Every finding on record at Hansford Manor

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items were properly stored, labeled, and dated.2. The facility failed to the kitchen was free of expired foods.These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Findings included: In an observation and interview of the kitchen with the DM and the RD on 9/8/25 at 10:10 AM the following was observed in the freezer:1. large plastic bag of French fries, open to air, not in original box2. 3 brown bags of a food item, no label, not in original boxIn an interview during the observation of the freezer on 9/8/25 at 10:12 am the DM stated of the large bag of French fries Oh yes, it should be fastened. I will throw it out now. The DM stated the brown bags of food were French fries. She stated the facility only received brown bags with French fries in it. She stated the staff did not mark the brown bags because everyone knew the brown bags were French fries. The RD stated all frozen items should be labeled and dated when they are taken out of the box. She stated the French fries should have been marked when they were taken out of the box. She stated she trained the kitchen staff in the kitchen rules and regulations. She stated food borne illness were consequences of not labeling and storing foods properly.In an observation of the kitchen on 9/8/25 at 10:20 AM revealed a large container of Parsley spice with an expiration date of July 2025 on the spice shelf.In an observation and interview on 9/9/25 at 9:00 am, a plastic bag of cheese was observed in the cooler, open to air. The RD stated the package should have been closed to air.In an observation and interview on 9/10/25 at 9:05 am the RD was shown the expired Parsley spice container on the spice shelf. She stated the spice was expired and should have been thrown out. Record Review of the facility policy titled Food Safety Requirements (Use and Storage of Food and Beverage Items), dated 1/1/2023, revealed: Proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses will be followed. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include storage of foods in a manner that helps prevent deterioration or contamination of the food including from growth of microorganisms. Practices to maintain safe storage include labeling, dating, and monitoring refrigerated foods including use by its use by date, discarded when expired and keeping foods covered in airtight containers

Based on observation, interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #25) of 24 residents reviewed for advanced directives. Resident #25 had a DNR in her record that was missing the date of when Resident #25 signed the DNR. This failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.Findings included: Record review of Resident #25's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include (idiopathic) normal pressure hydrocephalus (a neurological condition primarily affecting older adults characterized by enlarged ventricles in the brain and a specific triad of symptoms: difficulty walking, gait disturbances, cognitive decline, and urinary incontinence), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs). Resident 25 was listed in Advance Directives as being a DNR. Record review of Resident #25's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of being independent with most of her ADL's. Record review of Resident #25's care plan with admission date of [DATE] revealed the following: Focus:In fulfilment of my rights and my desire to retain control and autonomy over my health care decisions, I have an OOH-DNR. Record review of the clinical record for Resident #25 revealed an Order Summary with Active Orders as of [DATE] with the following order: -DNR/DNI - Active [DATE] Record review of the clinical record for Resident #25 revealed a DNR dated [DATE] (signed by the physician) with the following:Section - A. Declaration of the Adult Person: -Resident #25 signed the form and printed her name. There was no date of when Resident #25 signed the form. During an interview on [DATE] at 1:39 PM LVN A (the nurse responsible for Resident #25 this shift) reported if a staff member reported to her Resident #25 did not have a pulse or was not breathing, she would check Resident #25's chart for her code status then she would get an RN if an RN was available and verify Resident #25's condition. If Resident #25 was a full code she would start CPR. LVN A reported that if Resident #25 was a DNR then she wound not start CPR and contact the primary physician. LVN A then checked Resident #25's chart and noted on the front of the chart a sticker that read DNR. LVN A reported that Resident #25 was a DNR and therefore she would not start CPR. LVN A reviewed Resident #25's DNR form in Resident #25's chart. LVN A reported that Resident #25 did not date when she signed the DNR. LVN A reported that she did not think the DNR was valid because it was an incomplete form. When asked again LVN A reported that she would treat Resident #25 as a full code at this time and start CPR. During an interview on [DATE] at 09:48 AM the DON with the ADON present reported the social worker was responsible for verifying the accuracy of the DNRs for each resident. The DON reported that if the person who implements the DNR such as with Resident #25 did not date when they sign the DNR then the DNR was not valid and if the DNR was not implemented validly then the DNR would not be carried out correctly. During an interview on [DATE] at 10:05 AM the SW reported that she did not verify the actual DNR for Resident #25. The SW reported that MR C was responsible for checking the DNRs and that MR C probably just missed that this one was not dated. The SW reported that she felt the DNR was still valid since the doctor and the two witnesses signed the DNR. During an interview on [DATE] at 10:09 AM MR C reported that Resident #25 was admitted with her DNR already completed and that was before she was in this position and the DNR was the responsibility of a prior employee no longer employed at the facility. MR C reviewed Resident #25 DNR, reported that Resident #25 did not date her signature, and that she did not feel it was an issue because the witnesses and the doctor signed the DNR. Record review of the facility provided policy titled Out-of-Hospital Do-Not Resuscitate Order date issued [DATE], revealed the following: Purpose: The purposed of this policy is to establish a process for informing, recording, educating, and implementing Out-of-Hospital Do-Not Resuscitate order (OOH-DNR) in compliance with state law. Procedure: C. Medical Records personnel will place a copy of the completed OOH-DNR form . Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following:- Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. - The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

Based on observation, interview, and record review; the facility failed to ensure a medication was labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication carts reviewed for medication storage. The Hall 2 medication cart had a inulin pen that had been used that was not marked with the date of when it was opened/accessed or when it should expire. This failure could result in ineffective treatment resulting in exacerbation of resident's disease processes.Findings include: During an observation on [DATE] at 8:48 AM of the Hall 2 medication cart with LVN A present, an Insulin Glargine Pen was not marked with the date of when it was opened or when it would expire. During an interview on [DATE] at 8:50 AM LVN A (the nurse administering medication from the Hall 2 medication cart that shift) reported the Insulin Glargine Pen was not marked with a date of when it was opened/accessed and when it would expire. LVN A reported that the insulin appeared to have been used and reported she had not used the insulin this shift, it was a pm administration. LVN A reported if an insulin was not marked when it is opened/accessed or when it would expire then the insulin could be expired and can potentially affect the residents blood sugars. LVN A reported she had been trained on insulin storage by the DON, and she marks all insulins when she open/access's them and this insulin was not opened/accessed by her. During an interview on [DATE] at 09:42 AM the DON with ADON present reported per investigation they determined an agency nurse had accessed the Insulin Glargine Pen the previous evening and was responsible for not marking the insulin pen found in the medication cart. The DON reported per the facility policy all insulins are to be marked when they are opened/accessed and when they are to be expired/discarded. The DON reported using an insulin that has not been labeled correctly could result in the medication not being effective and the ADON reported the medication could loose its efficacy. The ADON reported that it was the floor staff nurses responsibility to check their carts and make sure all medications were marked correctly. The ADON reported LVN A probably had not had time to check her cart the morning of this surveyor's review. Record review of the facility provided policy titled Usage, Storage, and Re-entry of Multi dose Vials date issued [DATE], revealed the following: Procedure:b. The product is to be disposed of within 28 days after initially opening.c. The product is to be clearly labeled with the date opened and initials of the nurse who opened the product.

Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #12) of 15 residents reviewed for respiratory care. -Resident #12 was not receiving oxygen at the correct dose. This failure could place residents at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings include: Record review of Resident #12's admission record dated 09/08/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), chronic respiratory failure (a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly), dementia (a group of thinking and social symptoms that interferes with daily functioning), and dependence on supplemental oxygen. Record review of Resident #12's clinical record revealed her last MDS was a quarterly completed 6/13/25 listing her with a BIMS score of 03 indicating she was severely cognitively impaired, and she had a functionality of being independent with most of her ADL's. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #12 was marked as having oxygen While a Resident. Record review of Resident #12's Order Summary Report with Active Orders as of 9/09/25 revealed the following order:- Oxygen administered @ 2L/NC Continuous every morning and at bedtime related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (J44.9) Prescriber Written Active 04/12/2025. Record review of Resident #12's care plan with admission date of 2/20/23 revealed the following: Focus:- I have COPD. Revised on 6/24/25. Intervention:- Give oxygen therapy as ordered by the physician. Revised on 6/24/25. During an observation on 09/08/2025 at 10:56 AM Resident #12 was in her room sleeping in her recliner wearing her O2 via NC. Noted her oxygen was at 4.5L/min. Resident #12 did not wake to knocking or introduction. During an observation and interview on 09/09/2025 at 1:18 PM Resident #12 was sitting in the main lobby with her oxygen on via a portable pump. This surveyor attempted to interview Resident #12, but she became uncomfortable and did not want to answer questions. Resident #12 stated, everything was fine and mumbled an incoherent response to any further questions. During an observation on 09/10/2025 at 8:18 AM Resident #12 was not in her room. This surveyor observed Resident #12's oxygen concentrator set at 3.5L/min. During an interview on 09/10/2025 at 8:21 AM LVN B (the nurse providing medications for Resident #12 this shift) reviewed Resident #12 orders and reported Resident #12 was ordered to be on 2l/min of oxygen. LVN B entered Resident #12's room, checked her concentrator, and reported the resident was on approximately 3L/min of oxygen. When asked if this was the correct dose of oxygen medication, LVN B reported it was not but the resident often would adjust the medication to what she felt would address her difficulty breathing. LVN B set the concentrator to the ordered dose of 2L/min. LVN B was asked three times if the oxygen medication was given correctly or if the medicator not being given at the correct dose would affect the resident and each time LVN B repeated the resident would change the dose herself. During an interview on 09/10/2025 at 09:52 AM the DON with ADON present reported Resident #12 had dementia and was supposed to have her oxygen set at 2L/min but Resident #12 will often change it. The DON reported a resident not receiving a medication at the ordered dose was an issue and she did not know what to do about this situation with Resident #12. The DON reported Resident #12 did have COPD and if a resident had compromised lungs and they get to much oxygen then it can compromise their condition. The ADON reported the nurses on the floor were responsible for taking care of the residents oxygen. Record review of the facility provided policy's titled, Physician Services and Charting Errors and/or Omissions revealed no information related to ensuring resident medication orders are implemented accurately.

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 15 Residents reviewed for comprehensive care plans. -The facility failed to include a care plan for Resident #1's wounds. This failure could result in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #1's face sheet dated 9/08/2025 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and pressure ulcer of right ankle (damage to an area of the skin caused by constant pressure on the area for a long time). Record review of Resident #1's annual MDS completed 8/01/25 listed him with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of being independent with most of his ADL's. Resident #1 was listed with one unhealed stage 3 pressure ulcer, one unstageable pressure ulcer, and diabetic foot ulcers. Record review of Resident #1's order summary reports revealed the following:- Active orders as of 9/10/25:Rt anterior ankle: .change daily in the morning related to PRESSURE ULCER OF RIGHTANKLE (L89.51) Phone Active 08/06/2025 Rt medial Ankle: .change daily in the morning related to PRESSURE ULCER OF RIGHT ANKLE (L89.51) Phone Active 08/28/2025 - Active orders as of 8/01/25:Rt anterior ankle: .change daily in the morning related to PRESSURE ULCER OF RIGHT ANKLE (L89.51) Phone Active 07/28/2025 Rt medial Ankle: .change daily in the morning related to PRESSURE ULCER OF RIGHT ANKLE (L89.51) Phone Active 07/28/2025 - Active orders as of 7/01/25:Right medial ankle: .Change daily. in the morning for Pressure ulcer Phone Active 06/23/2025 Record review of Resident #1's care plan with admission date 11/18/21 and last revision 8/13/25 revealed no care plan for pressure ulcers, diabetic foot ulcers, or wound care. During an observation on 09/08/2025 at 10:34 AM Resident #1 was observed in his room in his wheelchair with his head placed on the edge of his bed sleeping. He did not wake to knocking or introduction. During an interview on 09/08/2025 at 4:00 PM the DON reported Resident #1 refused to allow this surveyor to observe his wounds and his wound care. The DON reported Resident #1 would often refuse care for example he would leave the dining room if a certain person was serving meals, and he only allows one staff member to purchase his cigarettes. During an interview on 09/10/2025 at 9:58 AM the DON with the ADON present reported that Resident #1 has had a wound to his ankles/feet for approximately a year that have healed, worsened, and healed. Resident #1 recently had MRSA in one of his wounds. The DON reported Resident #1 was a diabetic, smoked, was not compliant, and refuses to stay of his wounds to prevent the pressure. The ADON reported Resident #1 has had a small wound on his foot that has always been there. The ADON reported that any wound to include Resident #1 should always be care planned and that she did not know if Resident #1 wounds were care planned. The ADON reported she would have to contact the wound nurse to find out if they were in his care plans. During an interview on 09/10/2025 at 11:12 AM the DON reported that she talked with the MDS Coordinator (who was responsible for completed the care plans) and the MDS Coordinator reported Resident #1 had frequent changes in the condition his wounds and that his care plan for his wounds had been resolved out which meant they had removed it from his care plan. The DON reported Resident #1's wound care had not been added back to his care plan and that the current care plan should address his wound care needs. The DON reported if a care plan was not updated with the resident care and condition then orders will not be followed, care will not be done, the resident could be at risk for infection, and they could have a worsening of the wound. During an interview on 09/10/2025 at 11:19 AM the MDS RN reported Resident #1's wound care should be in his current care plans and his wound care plans were resolved/cancelled on 4/23/25 and never reentered. The MDS RN reported Resident #1's wound care should have been reentered into Resident #1's care plans a couple of months ago. The MDS RN reported that if the care plans do not reflect the resident condition, then the resident would not receive the appropriate care. Record review of the facility provided policy titled Care Plans date issued 1/09/19, revealed the following: Procedure:-The Interdisciplinary Team (IDT), .develops and implements a comprehensive, person, centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.-The comprehensive, person-centered care plan will:b. describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #28 and Resident #101) of 14 residents reviewed for care plans. The facility failed to include bed rail use in the care plans of Resident #28 and Resident #101. These failures could place residents at risk of harm due to incorrect care and/or lack of monitoring. Findings Included: 1. Record review of Resident #28's admission record dated 08/19/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), osteoarthritis (degenerative joint disease), muscle weakness, hallucinations (sensory experiences that appear real but are created by your mind), and repeated falls. Record review of Resident #28's quarterly MDS completed on 08/01/24 revealed the following: Section C: Resident #28 had no BIMS score but staff assessment of resident indicated severely impaired cognition. Section GG: Resident #28 used a w/c and was dependent on staff for all ADLs. Section I: Resident #28's primary medical condition was non-traumatic brain dysfunction. Section J: Resident #28 had one fall with no injury since his previous assessment. Section N: Resident #28 received antipsychotic, antianxiety, antidepressant, and opioid medications. Section O: Resident #28 received hospice services while a resident. Record review of Resident #28's care plan completed on 07/30/24 revealed he had impaired cognitive function and was at high risk for falls. The care plan made no mention of bed rails. Record review of Resident #28's Admit/Readmit Screener dated 04/14/23 revealed it was a reentry and right and left side half rails would be used. Side Rails are indicated and serve as an enabler to promote independence. Record review of Resident #28's order tab in his EHR revealed the following order: Resident may use enabler for bed mobility dated 04/14/23. Record review of Resident #28's Consent for Side Rails form revealed it was signed and dated by his family member on 01/31/20. During an observation on 08/19/24 at 10:57 AM Resident #28 was lying in his bed with eyes closed. He had a bed rail in the upright position on the top left side of the bed. During an observation on 08/20/24 at 01:55 PM Resident #28 was in his bed on his back with eyes closed. HOB was raised almost to sitting. Bed rail on the left side of the bed was in upright position. The bed was against the wall on the right side of the bed. 2. Record review of Resident #101's admission record dated 08/20/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (problems falling and staying asleep), and muscle weakness. Record review of Resident #101's MDS face sheet in the EHR revealed and admission MDS in progress. When this record was viewed Section C was completed and indicated a BIMS score of 3 which indicated severely impaired cognition. Record review of Resident #101's care plan initiated on 08/13/24 revealed he used antianxiety medication and had limited physical mobility due to weakness. Record review of Resident #101's order summary report dated 08/20/24 revealed the following order: Resident may use enabler for bed mobility dated 08/12/24. Record review of Resident #101's Admit/Readmit Screener dated 08/13/24 revealed 1/4 rails would be utilized for bed mobility. Record review of Resident #101's Consent for Side Rails form revealed he signed and dated the form on 08/12/24. During an observation on 08/19/24 at 10:57 AM Resident #101 was lying on his back in bed with his eyes closed. Bilateral bed rails were in upright position on the top half of the bed. During an observation on 08/20/24 at 06:49 AM Resident #101 was lying on his back in bed. Bilateral bed rails were in upright position on the top half of the bed. During an observation and interview on 08/20/24 at 08:57 AM Resident #101 was seated in his w/c next to his bed. He had a friend seated on end of his bed visiting with him. Bilateral bed rails were in upright position on the top half of Resident #101's bed. When asked if he used the bed rails for mobility, Resident #101 stared at the bed rail nearest him for approximately 10 seconds. When his friend patted the rail and asked if Resident #101 used it, Resident #101 said, There could be a better one, but it is okay. When asked if the bedrail helped him move around in his bed, Resident #101 said, Yes. During an interview on 08/21/24 at 12:05 PM MDS Coordinator stated she was responsible for putting nursing information in the care plan including information regarding bed rails. She stated bed rails utilized in the facility were for mobility. She stated a possible negative outcome of not having bed rails listed in the care plan was that staff would not know they were used for mobility. During an interview on 08/21/24 at 12:15 PM ADM stated MDS Coordinator was responsible for putting bed rail use in the care plans of residents who used bed rails. She stated residents could die or could get hung up in the bed rails if they were not care planned for bed rail use. ADM stated having bed rail use in the care plan was important because, We want to keep them (residents) safe. Record review of facility policy titled Proper Use of Bed Rails and dated 10/02/24 revealed in part: . The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. Direct care staff will be responsible for care and treatment in accordance with the plan of care. The interdisciplinary team will make decisions regarding when the bed rail will be use [sic] or discontinued, or when to revise the care plan to address any residual effects of the bed rail. Record review of facility policy titled Care Plans and dated 04/12/23 revealed in part: . It is the policy of [NAME] Manor to provide care and services to each resident based on a plan of care. The plan o care is developed through the collaborative assessment of an interdisciplinary team, in conjunction with the resident, the resident's family or representative, and the attending physician. A. Baseline care plan will be: . Include the minimum healthcare information necessary to properly care for a resident including . 2. Physician orders . 3. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, . physician orders . The comprehensive care plan: 1. RAPs (Resident Assessment Protocol) provide criteria that trigger review of possible problem conditions to ensure that staff has identified the problems in a consistent and systematic manner. D. The care plan must include but is not limited to: . The care plan will attempt to manage resident risk Factors [sic] . Services that are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. E. The care plan will be periodically reviewed and revised as the resident's status changes, and services provided must be in accordance with each resident's written plan of care. Record review of facility policy title Care plans-Interdisciplinary Team and dated 01/09/18 revealed in part: . [NAME] Manor Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 48161

Based on interview and record review, the facility failed to complete an assessment that accurately reflected the resident's status for 1 of 14 residents (Resident #4) reviewed for accuracy of MDS assessments. The facility failed to complete an accurate assessment for Resident #4, the assessment indicated she received insulin and did not. This failure could affect residents by placing them at risk for not receiving adequate care and services. Findings included: Record review of Resident #4's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses to include but not limited to hereditary motor and sensory neuropathy (nerve damage in the arms and legs), bipolar disorder, type 2 diabetes mellitus (high blood sugar levels), and chronic pain. Record review of Resident #4's Annual MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 13 out of 15 which indicated that she was cognitively intact. The MDS indicated in Section N0300 (Injections) that Resident #4 received 1 insulin injection from the 7 days during the MDS look back period. Record review of Resident #4's physician orders revealed no order for insulin injections. Orders for Ozempic .5 mg given subcutaneously in the afternoon every Wednesday related to type 2 diabetes mellitus dated 04/24/2024. Record review of Resident #4's Care plan dated 06/27/2024 indicated resident had Diabetes Mellitus with interventions of dietary consult for nutritional regimen and ongoing monitoring. No insulin injections were identified in the care plan. Record review of Resident #4's Medication Administration Record for June 2024 did not indicate any insulin injections were administered. During an interview on 08/20/2024 at 11:05 AM, Resident #4 stated that she does not take any insulin but was taking a medication called Ozempic for weight loss and that she was pre diabetic. Resident #4 stated that she does not get a lot of exercise being in a wheelchair, so the Ozempic was helping her lose weight. During an interview on 08/21/2024 at 9:14 AM, the ADM stated that she looked at the MDS Assessment for Resident #4 and stated that she saw where the MDS Coordinator marked insulin injections and stated that it must have been a typo. The ADM stated she could not argue that it was a mistake. During an interview on 08/21/2024 at 9:34 AM, the DON stated the MDS Coordinator was responsible for putting information in the MDS Assessment and that if that information was wrong it could affect the payrate and care of a resident. During an interview on 08/21/2024 at 9:43 AM, LVN A stated the MDS Coordinator was responsible for putting information in the MDS Assessment. LVN A stated that a possible negative outcome for putting wrong information in the MDS Assessment would be that a resident could get insulin instead of the accurate medication. During an interview on 8/21/2024 at 9:44 AM, the ADON stated the negative outcome for wrong information being in the MDS Assessment would be that the payrate for CMS would be wrong. During an interview on 08/21/2024 at 9:51 AM, the MDS Coordinator stated that the look back period for medication was 7 days for the MDS Assessment and she used the Resident Assessment Instrument for guidance. The MDS Coordinator stated that she was responsible for putting the information in the MDS Assessment and stated that she made a mistake by indicating that the resident was taking insulin when she was not. Record review of Resident Assessment Instrument (RAI) via CMS website. Section N: Medications Intent: The intent of the items in this section is to record the number of days, during the last 7 days that any type of injection, insulin, and or select medication were received by the resident. Steps for Assessment: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care locations where the resident may have received injections while a resident of the nursing home (e.g., flu vaccine in a physician's office, in the emergency room - as long as the resident was not admitted ). 3. Determine if any medications were received by the resident via injection. If received, determine the number of days during the look-back period they were received.

Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for 2 (Resident #4 and Resident #101) of 14 residents reviewed for bed rails. The facility placed bed rails on the beds of Resident #4 and Resident #101 on the day the residents were admitted without attempting other interventions. These failures could place residents at risk of entrapment or injury due to bed rails. Finding included: 1. Record review of Resident #4's admission record dated 08/20/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hereditary motor and sensory neuropathy (nerve damage that can cause pain, weakness, numbness, or tingling as well as motor symptoms like muscle weakness and loss of mass in different parts of the body characterized by impact on both afferent nerve cells [carry sensory information to the central nervous system] and efferent nerve cells [carry motor information away from the central nervous system]), bipolar disease (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), macular degeneration (medical condition resulting in blurred or no vision in the center of the visual field), and insomnia (problems falling and staying asleep). Record review of Resident #4's annual MDS completed on 06/20/24 revealed the following: Section B: Resident #4 required corrective lenses. Section C: Resident #4 had a BIMS score of 13 which indicated intact cognition. Section GG: Resident #4 had functional limitation in range of motion in both legs and utilized a w/c. She was independent in eating and required substantial/maximal assistance or was dependent across all other ADLs. Section I: Resident #4's primary medical condition was non-traumatic brain dysfunction. Section N: Resident #4 received antianxiety, antidepressant and opioid medications. Record review of Resident #4's care plan completed on 06/18/24 revealed Resident #4 was a moderate risk for falls, used an electric w/c, and had side rails for safety during care provision, to assist with bed mobility. Record review of Resident #4's Admit/Readmit Screener dated 06/28/23 revealed right and left half rails would be in use. Side rails are indicated and serve as an enabler to promote independence. Record review of Resident #4's order summary report dated 08/20/24 revealed the following order: Resident may use enabler for bed mobility dated 06/26/23. Record review of Resident #4's Consent for Side Rails form revealed she signed and dated the form on 06/28/23. During an observation on 08/19/24 Resident #4's bed had bilateral bed rails in upright position on the top half of the bed. During an observation on 08/20/24 at 11:05 AM Resident #4's bed had a bed rail in upright position on the right side of the top half of the bed. 2. Record review of Resident #101's admission record dated 08/20/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (problems falling and staying asleep), and muscle weakness. Record review of Resident #101's MDS face sheet in the EHR revealed and admission MDS in progress. When this record was viewed Section C was completed and indicated a BIMS score of 3 which indicated severely impaired cognition. Section GG was not yet complete. Record review of Resident #101's care plan initiated on 08/13/24 revealed he used antianxiety medication and had limited physical mobility due to weakness. Record review of Resident #101's order summary report dated 08/20/24 revealed the following order: Resident may use enabler for bed mobility dated 08/12/24. Record review of Resident #101's Admit/Readmit Screener dated 08/13/24 revealed 1/4 rails would be utilized for bed mobility. Record review of Resident #101's Consent for Side Rails form revealed he signed and dated the form on 08/12/24. During an observation on 08/19/24 at 10:57 AM Resident #101 was lying on his back in bed with his eyes closed. Bilateral bed rails were in upright position on the top half of the bed. During an observation on 08/20/24 at 06:49 AM Resident #101 was lying on his back in bed. Bilateral bed rails were in upright position on the top half of the bed. During an interview on 08/20/24 at 08:22 AM Resident #101's family member stated she did not remember signing anything regarding consent for bedrails for Resident #101. During an observation and interview on 08/20/24 at 08:57 AM Resident #101 was seated in his w/c next to his bed. He had a friend seated on end of his bed visiting with him. Bilateral bed rails were in upright position on the top half of Resident #101's bed. When asked if he used the bed rails for mobility, Resident #101 stared at the bed rail nearest him for approximately 10 seconds. When his friend patted the rail and asked if Resident #101 used it, Resident #101 said, There could be a better one, but it is okay. When asked if the bedrail helped him move around in his bed, Resident #101 said, Yes. During an interview on 08/21/24 at 10:38 AM LVN B stated the RNs were responsible for bed rail assessments at admission. During an interview on 08/21/24 at 10:43 AM RN C stated RNs did monthly bed rail assessments as part of the regular monthly assessment of each resident. RN C said RN D did initial bed rail assessments prior to or at admission. During an interview on 08/21/24 at 10:46 AM RN D stated when she admitted a resident, she encouraged families and residents strongly to forego bed rails. She stated the other nurses who worked with families at admission did the same. She stated they educated families and residents on the risks of bed rails. She stated families often wanted bed rails because they felt the bed rails would keep their loved ones from falling. She stated the facility tried to follow family wishes. RN D stated alternatives to bed rails would include a concave mattress, fall mats, bed alarms, and ensuring items of importance are within reach. RN D said, I feel like if they (families and residents) have been educated properly and they still choose them (bed rails) it is their prerogative. RN D did not respond with any possible negative outcome to residents of installing bed rails prior to trying alternatives. During an interview on 08/21/24 at 11:07 AM DON stated residents could be negatively impacted if bed rails were installed prior to attempting alternatives. She said, There are a lot of negative outcomes; limits mobility, potential for entrapment, risk of them climbing out of bed over the rails and getting injured. She stated residents and their families often wanted bed rails if they came from a hospital setting where bed rails were used. During an interview on 08/21/24 at 11:28 AM ADM stated residents could be injured if bed rails were installed prior to attempting alternatives. Record review of facility policy titled, Proper Use of Bed Rails and dated 10/02/23 revealed in part: . Appropriate alternative approaches are attempted prior to using be rails. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. 48161

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 14 of 49 residents (Resident #7 and the 13 residents residing on the north end of hall 1) reviewed for accident hazards. 1. Resident #7 was allowed to keep his cigarettes and lighter with him. 2. Three 200 mg tablets of Amiodarone were found on the floor of the north end of hall 1. These failures could place residents at risk of injury. Findings included: 1. Record review of Resident #7's face sheet, dated 06/19/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with behavioral disturbance (a group of thinking and social symptoms that interfere with daily functioning), unspecified mood disorder (a disorder with symptoms that cause distress or impairment in social and/or occupational function), nicotine dependence, anxiety disorder (mental disorder characterized by significant and uncontrollable feelings of anxiety and fear), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #7's Quarterly MDS, dated [DATE], revealed a BIMS of 5, which indicated severely impaired cognition. Section G of the MDS revealed Resident #7 required supervision and set up help with bed mobility, transfer, and walking. He required extensive assistance by one staff person for dressing, toilet use, and personal hygiene. Resident #7 was independent and required set up help only when eating. Record review of Resident #7's care plan dated, 04/26/23, revealed a focus area of impaired cognitive function/dementia or impaired thought processes r/t Dementia, impaired decision making. One of the interventions listed next to this focus area was I need supervision and assistance with all decision making. The care plan revealed a focus area of I smoke cigarettes. The goal for this focus area read, I will continue to be safe while smoking as evidenced by . turning my cigarettes and lighter in to the nurse after I smoke and out of reach of other residents. Included in the interventions listed for this goal were, I will comply with the smoking policy of [NAME] Manor. I will turn my lighter and extra cigarettes into the nurse or can keep out of the reach of other residents. Record review of Resident #7's Smoking Assessment, dated 04/04/23, revealed Resident #7 had cognitive loss and needed the facility to store his lighter and cigarettes. The smoking assessment further noted that Resident #7's care plan would be used to assure he was safe while smoking. An observation on 06/20/23 at 08:32 AM, revealed Resident #7 walking down the hall with his cigarettes and a black lighter in the wire basket of his walker. During an observation and interview on 06/20/23 at 08:40 AM, Resident #7 was sitting on the edge of his bed with his walker next to the bed. The wire basket of the walker contained a pack of cigarettes and a black lighter. Resident #7 stated he goes outside to smoke on his own. During an observation and interview on 06/20/23 at 08:48 AM, Resident #7 was lying on his left side in his bed. His walker was near the bed and the wire basket of the walker still contained a pack of cigarettes and a black lighter. When asked if he keeps his own cigarettes and lighter, Resident #7 stated, I have been. I'm not supposed to, but they don't care. During an observation on 06/21/23 at 09:50 AM, Resident #7 was lying in his bed asleep on his left side with his walker nearby. A black lighter was in the wire basket of the walker. During an interview on 06/21/23 at 11:23 AM, the DON stated smoking assessments were done at admission. She stated the RN's were responsible for the smoking assessments. The DON stated a negative outcome of allowing Resident #7 to keep his smoking paraphernalia rather than turn it into the nurses was, They could light the building on fire, I guess. When asked who is responsible to ensure Resident #7 turns in his lighter and cigarettes after smoking, the DON stated it is the charge nurse but activities staff tends to watch the smoking residents as they smoke outside the activities room. She said Resident #7 usually turned his lighter and cigarettes in to the nurse at the window (of the nurse's station in hall 1). During an interview on 06/21/23 at 11:39 AM, the ADM stated a possible negative outcome of allowing Resident #7 to keep his smoking paraphernalia rather than turn it in to the nurses was, It could cause some accidents and be detrimental to the health of the resident and other residents. When asked who was responsible to ensure Resident #7 turned in his smoking paraphernalia after smoking, the ADM said, Whoever sees him coming in. The charge nurse watches for it and whoever is there. 2. Observation on 06/19/23 at 10:47 AM, revealed a round white pill on the floor in the doorway of room [ROOM NUMBER] of hall 1. The pill had a capital A on one side and other side it had a B and a 4. During an interview on 06/19/23 at 10:48 AM, CNA C was shown the pill from the floor and offered to turn it in to the nurses' station. She stated if she ever found a pill on the floor, she would put it in her pocket and turn it in to a nurse. Observation on 06/19/23 at 10:52 AM, revealed two more round white pills on the floor in the hallway close to the wall between room [ROOM NUMBER] and room [ROOM NUMBER] and closer to room [ROOM NUMBER]. These pills had a capital A on one side and a B and a 4 on the other side. During an interview on 06/19/23 at 10:54 AM, RN A was given the three pills with a description of where they were found on the floor. During an interview on 06/19/23 at 10:58 AM, RN A stated the medication found on the floor of hall 1 came from a respite resident. She stated she spoke to the LVN doing medicine pass and discovered the LVN dropped the bottle of medication and it spilled. During an interview on 06/19/23 at 11:24 AM, RN A stated the nurse she spoke to regarding the spilled medication was LVN B. She stated, [First name of LVN B] is the little LVN in training. During an interview on 06/19/23 at 11:24 AM, LVN B stated, This morning I was trying to close the bottle and it slipped on me and fell on the floor and spilled. I picked up the ones that I could. I thought I got them all, but I guess some escaped me. During an interview on 06/19/23 at 02:14 PM, LVN B stated the medication she spilled on the floor was Amiodarone (medication used to treat certain types of serious irregular heartbeat to restore and maintain a regular steady heartbeat). During an interview on 06/21/23 at 11:33 AM, the DON stated her expectation of her staff when a bottle of medication was spilled was that they locate them all. She stated there was no way for LVN B to count the pills to determine if she had found all of the pills because the facility did not keep a record of how many pills came in with the respite resident. The DON stated a possible negative outcome of medication lying on floor was, Well, I guess any resident could eat them if they bent over and got them. During an interview on 06/21/23 at 11:39 PM, the ADM stated a possible negative outcome of medication lying on the floor of the facility was, If a resident were to pick it up and take it, they could have an adverse reaction. During an interview on 06/21/23 at 11:42 AM, RN A stated the facility would not count the medication a respite resident brought to the facility unless the medication was a narcotic. When asked for a possible negative outcome of medication lying on the floor of the facility, RN A stated, Someone could pick it up and ingest it. Record review of Midnight Census Report, dated 06/19/23, revealed the following residents resided on the north end of hall 1: Resident #1, Resident #11, Resident #19, Resident #20, Resident #27, Resident #28, Resident #31, Resident #33, Resident #41, Resident #44, Resident #46, Resident #97, and Resident #99 Record review of an undated, typed facility paper titled, Smokers revealed the following: .[first and last name of Resident #7] No designated Times Designated Area is outside of Activity Room Record review of an undated facility policy titled, Resident Smoking Policy revealed the following: The purpose of this policy is to establish reasonable precautions for residents' smoking safety, to the extent possible. c. Independent (Low Risk): Resident is capable of smoking independently with no more risk than the average smoker. May not retain personal smoking materials. Record review of facility policy titled, Medication Storage and dated 03/23/23 revealed the following: . The purpose of this policy is to ensure all medications housed on our premises will be stored in the pharmacy, medication rooms, and/or medication carts. It is the policy of [NAME] Manor that all drugs will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #3 and #40) and 1 of *(Nutrition Aide-(NA D) observed for infection control practices. NA D failed to use proper hand hygiene techniques when providing feeding assistance between Resident #3 and Resident #40. This failure may place resident at an increased risk for transmissible diseases. Findings include: Record review of Resident #3's face sheet dated 6/19/23 revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia (decreased ability of memory, thinking, activities of daily life), Unspecified Protein-Calorie Malnutrition (not enough protein or calories taken into body for normal metabolism), Cerebral Infarction (damage to tissues in the brain due to a loss of oxygen/blood to the area), Lack of Coordination (Difficulty with body movements, not purposeful), Need for Assistance with Personal Care. Record review of Resident #3's last quarterly MDS dated [DATE] revealed a BIMS score of 00 out of 15 which indicated he was severely impaired. Resident #3 required extensive assist with 2 persons assist with all ADL's. Resident #3 utilized a wheelchair for ambulation with limited assist with 1 person assist. Record review of Resident #3's care plan dated 5/3/23, revealed in part: Problem: Resident has ADL Self Care Performance Deficit related to Confusion, Dementia, Activity Intolerance. Goal: Resident will maintain current level of function in eating Interventions: Eating requires one staff participation to eat. Record review of Resident #40 face sheet dated 6/20/23 revealed a 71year old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia (decreased ability of memory, thinking, activities of daily life), Schizophrenia (a mental disorder characterized by delusions, hallucination, disorganized thoughts, speech and behavior), Vascular Dementia (Describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), Apraxia Following Other Cerebrovascular Disease (A neurological syndrome characterized by difficulty in performing daily tasks even if the instructions are understood. The person affected finds it difficult to tie shoelace, button the shirt, difficulty in making certain facial expressions) Record review of Resident #40's last quarterly MDS dated [DATE] revealed a BIMS score of 03 out of 15 which indicated he was severely impaired. Resident #40 required extensive assist with 2 persons assist with all ADL's. Resident #40 utilized a wheelchair for ambulation with limited assist with 1 person assist. Record review of Resident #40's care plan dated 5/16/23, revealed in part: Problem: Resident has ADL Self Care Performance Deficit related to Confusion, Dementia, Impaired Balance. Goal: Resident will maintain current level of function in eating Interventions: Resident requires supervision assistance to eat. Requires setup staff participation to eat. Observation on 6/19/2023 at 11:55 AM, during lunch dining, NA D did not change gloves when she picked up utensil of Resident #40 and cut up food. She walked over to Resident #3, picked up his utensils, walked to Resident #40, picked up his utensils and continued to feed Resident #40. She walked back and fed Resident #3. NA D did not change gloves or wash hands between feeding multiple residents. Interview on 6/19/2023 at 12:50PM, NA D stated, I know that it was my mistake. Referring to not washing her hands when going from one resident to another during dining observation. NA D stated possible negative outcome is Germs from one place to another place. Interview on 6/20/2023 at 08:22 AM with DON stated, The Nutrition Aide D should not have been wearing gloves to feed residents. She should have hand sanitized before going from one resident to another. DON stated possible negative outcome(s) could be Cross contamination. Record review of NA D employee file indicated she had been employed as a paid feeding attendant for twelve years. She has a Certification of Achievement for completed eight hours of Nutrition Aide Training Dated November 21, 2011. Record review of care plans for Resident #3 and Resident #40, both are designated as needing feeding. Record review of facility policy titled, Hand Hygiene dated 10/02/2023, stated the following: Policy Statement It is the policy to follow Standard Precautions, which includes hand hygiene to prevent the spread of infection and for the safety of our residents. Policy Interpretation and Implementation A. Hand washing must be used: 1. Before donning and after doffing PPE. Anytime hands become soiled. 4. Before and After Resident care involving body fluids, substances, and mucus membranes. B. Hand rubs: 1. May be used between glove changes if hands are not soiled. 2. Between care of each patient. 48221

Based on observation, interview and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests for 1 of 8 residents (Resident #1) reviewed for COVID-19 testing. Resident #1 was exposed to COVID-19 from NA A and was not tested for COVID-19 after known exposure. This failure could place residents at risk for exposure and transmission of COVID-19. The findings included: Record review of Resident #1's face sheet, dated 09/26/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 9 out of 15 which indicated her cognition was moderately impaired. She required extensive, two-person assistance with bed mobility and transferring, extensive one-person assistance with dressing, toilet use, personal hygiene and locomotion on the unit and was independent with set-up help only with eating. Record review of Resident #1's care plan, dated 07/26/22, revealed, in part, .Focus .Covid 19 .I [Resident #1] wish to continue my communal dining experience with out [sic] feeling isolated. Record review of Resident #1's immunization record, undated, revealed she received one dose of a COVID-19 vaccine on 02/23/21 and a second dose on 03/24/21 and refused any subsequent COVID-19 boosters. Record review of Resident #1's electronic chart from May 2022 to September 2022 revealed no positive COVID-19 tests with the last 90 days. During an interview on 09/26/22 at 10:13 AM, the DON stated a staff member, NA A, tested positive for COVID-19 on 09/12/22. She stated NA A started having allergy symptoms on 09/10/22 while working that she continued to have while working on 09/11/22. She stated NA A was tested for COVID-19 on both of those days which was negative however on 09/12/22, NA A tested COVID-19 positive. NA A was not working on 09/12/22. The DON stated the facility response to the COVID-19 positive result was to monitor the residents NA A was in contact with for any signs or symptoms of COVID-19. The DON stated NA A was around two residents while working on 09/10/22 and 09/11/22; Resident #2 and another resident the DON could not initially remember. The DON stated they would only test the residents for COVID-19 if they were symptomatic, even if they were exposed to COVID-19. During an interview on 09/26/22 at 2:28 PM, the ADON, who was also the facility ICP, stated Resident #1 was the other resident who was exposed to NA A. She stated NA A passed meal trays and assisted with feeding the residents during mealtime. The ADON stated NA A may also have helped pass hydration cups and snacks to residents during the day, but she was not sure. The ADON stated NA A was not working on 09/12/22 when she tested COVID-19 positive. The ADON stated Resident #1 and Resident #2 were the only two residents NA A was around when she had worked the two days prior to testing COVID-19 positive. The ADON stated NA A probably was around the residents longer than 15 minutes. The ADON stated there was no COVID-19 testing performed on Resident #1 and Resident #2 after known exposure to COVID-19. When asked why they were not tested for COVID-19, the ADON stated she did not know why. She stated she felt like the federal guidelines regarding COVID-19 stated people would not test COVID-19 positive until two days after being exposed to COVID-19 exposure. The ADON stated at one time, she knew the facility had to COVID-19 test everyone but now she did not think so, especially since Resident #1 and Resident #2 recently had COVID-19 within the last 90-days. She stated Resident #1 was COVID-19 positive in late July 2022 and Resident #2 was COVID-19 positive around that time, as well. During an interview on 09/26/22 at 3:07 PM, the ADON stated Resident #1 and Resident #2 were not COVID-19 tested after known COVID-19 exposure from a staff member because they were within their window after being COVID-19 positive within 90 days. The ADON stated there was some confusion on when residents need to be tested for COVID-19 since staff were not required to undergo routine COVID-19 testing when within their 90-day window after they were COVID-19 positive. The ADON was not sure if residents were required to be COVID-19 tested or not. When asked what the facility would do if a resident had not had COVID-19 within 90 days and were exposed to a COVID-19 positive staff member, the ADON stated they would have waited 24 hours and tested the resident for COVID-19. The ADON stated she was not at work during the time NA A tested COVID-19 positive and Resident #1 and Resident #2 were exposed but the DON was. During an interview on 09/26/22 at 3:43 PM, the ADON stated Resident #1 had actually not been positive for COVID-19 within the last 90 days. The ADON stated Resident #1 should have been tested for COVID-19 after known exposure to a COVID-19 positive staff member and she was not sure why she was not tested . The ADON stated the only one that could answer that was the DON because the ADON was not at work during that time. The ADON stated a negative resident outcome to not testing residents for COVID-19 after exposure was there could have been a bigger COVID-19 outbreak. During an attempted telephone interview on 09/26/22 at 3:45 PM, the DON was called and there was no answer. A voicemail was left to return call. The DON had left the facility earlier in the day. During an observation and interview on 09/26/22 at 4:00 PM, Resident #1 was in her room, lying in her bed. She appeared well-groomed and in no distress. Resident #1 was unsure how long she had been at the facility. She stated she was able to feed herself but there was a staff member that sat with her during mealtimes, though she was unsure who it was, and it was not always the same person. When asked if she had been having a fever, cough, shortness of breath, or loss of taste or smell, she stated when she was young, they thought she had [NAME] fever. When asked if she had any of those symptoms recently, she stated she did not know. When asked if she had any COVID-19 vaccinations, she stated she was not sure. During an interview on 09/26/22 at 4:32 PM, the ADM stated resident COVID-19 testing post-exposure depended on if the resident had COVID-19 themselves recently. She stated Resident #1 should have been tested for COVID-19 after being exposed to NA A. She stated there were potential negative resident outcomes for not testing Resident #1 for COVID-19, but she declined to say what they were. During an attempted telephone interview on 09/26/22 at 4:21 PM, the DON was called and there was no answer. A voicemail was left to return call. During an interview on 09/26/22 at 4:40 PM, the ADON stated the DON was typically responsible for overseeing COVID-19 testing. During a telephone interview on 09/27/22 at 9:28 AM, NA A returned the missed phone call and stated she tested COVID-19 positive on 09/12/22. She stated she worked at the facility the prior two days, 09/10/22 and 09/11/22. She stated she started having allergy symptoms on 09/11/22 and told the DON who tested her for COVID-19 which was negative at that time. She stated she did not work on 09/12/22 and re-tested that day and was COVID-19 positive. NA A stated she helped feed the residents during meals time while at work, but she stated she did not remember who she fed on 09/10/22 and 09/11/22. She stated she assisted with feedings in the dining hall. She stated she also helped pass out hydration cups to both resident halls in the facility. She stated while thinking about it, she believed she only helped feed one resident during breakfast and lunch but did not remember who the resident was. NA A stated she was probably around the resident for about 35 minutes per meal. Record review of the facility's policy titled, Coronavirus Testing, dated April 2022, revealed, in part, .Definitions: .Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period .Policy Explanation and Compliance Guidelines: .3. Individuals with signs and symptoms of COVID-19 should be prioritized first when tested , then perform testing triggered by an outbreak investigation as follows: Table 1. Testing Summary .Testing Trigger .Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts .Residents .Test all residents, vaccinated and unvaccinated, that had close contact with a COVID-19 positive individual Testing of Staff and Residents in Response to an Outbreak .1. A new COVID-19 infection in any staff or any nursing home onset COVID-19 infection in a resident will trigger an outbreak investigation .2. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing will begin immediately .3. Outbreak testing will be performed either through contact tracing or broad-based (e.g. facility-wide) testing .Routine Testing of Staff .7. Routine testing of asymptomatic residents will not be performed unless prompted by a change in circumstances, such as an identification of a confirmed COVID-19 case in the facility.

Based on observation, interview and record review the facility failed to ensure all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident # 1) reviewed for abuse. The facility failed to report to the State Survey Agency an allegation of abuse which involved Resident #1 within 2 hours of the allegation. This failure could place residents at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and the state survey agency which could place residents at risk of continued and/or unrecognized abuse, neglect or exploitation. Findings include: Record review of an anonymous complaint intake, received 07/22/22, revealed [Resident #1] was physically assaulted by staff at the facility. Around 7/20/22, the incident occurred in the isolation unit. [Resident #1] and [Resident #2] are confirmed positive with COVID-19 and sharing a room in the isolation unit. [Resident #2] is the parent of a dietary aide (unknown) that works in the kitchen during the dayshift.[Resident #1] was going through [Resident #2's] belongings. [Resident #1] has dementia. The dietary aide slapped [Resident #1] on the hand. It is uncertain if injuries were sustained. This incident was reported to the D.O.N. and the Administrator. The facility failed to [MEDICATION(S)]. Record review of Resident #1's face sheet, dated 8/4/2022, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 2 out of 15, which indicated her cognition was severely impaired and she required supervision and/or physical assistance from 1 staff member in most ADLs. Record review of Resident #2's face sheet, dated 8/4/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 7 out of 15, which indicated her cognition was moderately impaired and she was totally dependent on 2 or more staff in most ADLs. During an observation and attempted interview with Resident #1 on 08/04/2022 at 10:55 AM, revealed she was in the TV room, sitting in her wheelchair, holding a doll in her arms. Resident #1 was dressed for the day and her hair was neatly brushed. She had no visible injuries on her hands. She didn't answer any questions, but just smiled. During an observation and interview with Resident #2 on 08/04/2022 at 9:42 AM, revealed she was in her room, sitting in her wheelchair, watching TV. She was dressed for the day. She stated she had a roommate while she had COVID-19 but when their quarantine was over, the roommate moved out and back into her previous room. Resident #2 stated the roommate was Resident #1. She stated her daughter worked for the facility, in the kitchen. She s her daughter was KA-A. She denied any incident between her daughter and her previous roommate, Resident #1. She denied seeing her daughter slap Resident #1's hand. During an interview on 08/04/2022 at 9:54 AM with the ADM, she said she remembered someone came to her and said KA-A slapped away the hand of a resident. She said she didn't remember who reported this to her. The ADM said the DON investigated it and KA-A was sent home. She said the DON was off today, but she would call her and ask her where the investigation report was. During an interview on 08/04/2022 at 10:52 AM, the ADM said the DON didn't have anything written down concerning the allegation of abuse. The ADM said the DON investigated the incident and interviewed KA-A. KA-A denied any abuse and Resident #2 denied the incident even happened. She said Resident #1 wasn't interviewable but was assessed for injuries and didn't have any. The ADM said neither she nor the DON thought this was a reportable incident since there were no injuries and no evidence to substantiate the allegation. Record review of the facility's Prevention of Resident Abuse, Neglect, and Mistreatment policy, dated 08/07/2017, revealed the following: .G. Reporting and Response 1. Reporting of Incident: All incidents and allegations must be reported IMMEDIATLEY by the Administrator, DON or designee to the Department of Aging and Disability Services (DADS).

Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 13 (Resident #4) residents reviewed for PASRR. Resident #4 was not referred for PASRR Level II assessment when a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services. Finding include: Record review of Resident #4's clinical record face sheet dated 4-28-2022 revealed she is a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's last completed MDS was an annual dated 1-28-2022 revealed she had a BIMS of 6 indicating she is severely cognitively impaired, and she had a functionality of requiring one-person assistance with most of her activities of daily living. Further review of section A1500 revealed the following: Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a relation condition.-Answer was 0: No. Record review of Resident #4's clinical record face sheet dated 4-28-2022 revealed she has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's PASRR Level 1Screening with date of assessment 9-10-2019 revealed the following: C0100 Mental Illness-No C0200 Intellectual Disability-No C0300 Developmental Disability-No There were no other PASRR Level 1 Screenings in Resident #4's chart. During an observation on 04/27/22 at 01:25 PM Resident #4 was in bed sleeping but awoke to knocking. Resident #4 was dressed well, wearing her glasses, and was laying on top of her covers. Resident #4 reported her lunch was good. She was limited with her answers and became confused easily. Resident #4 believed she was admitted to this facility this morning. She became increasingly confused with further questions and was unable to answer effectively. During an interview on 04/29/22 at 09:16 AM HR A verified that Resident #4 was PASSR negative with a Level 1 Screening date of 9-10-2019. HR A reviewed Resident #4's chart and verified that another PASRR Level 1 had not been done on this resident. HR A verified that Resident #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned HR A stated, If there is a change in the resident's condition then we would do another PASRR. HR A then reported that SS B from Social Services was supposed to complete the PASRRs. During an interview on 04/29/22 at 09:19 AM SS B verified that Resident #4 did have a negative PASRR, and a qualifying diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned if Resident #4 should have had the PASRR updated when the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned if there could be negative consequences from not having PASRR Level II services when the resident qualifies SS B stated, The main thing is they will not receive the extra services provide by TMHP like counseling and stuff like that. They will not receive what PASRR will provide. Both HR A and SS B verified that once a PASRR is in the system then the DON follows up if it is positive. HR A checked the system and reported that she could not find any follow-up for Resident #4. During an interview on 04/29/22 at 09:32 AM the DON when questioned about the PASRR Level II services for Resident #4 stated, I can't tell you any answers on that . I don't remember the last Resident I called on.: When questioned if any consequences could arise from a resident not receiving level II services that they should qualify for from PASRR the DON stated, We do everything for them so they really wouldn't miss something. If there is anything the PASRR would provide we would provide it anyway. Record review of the facility provided policy titled Preadmission Screening (PASRR) dated 12-16-2016 revealed the policy contained no information to address a resident with a newly added qualifying diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 04/29/22 at 10:36 AM the DON stated, Ya that is the only PASRR policy that we have.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 Employees (NA A, HK B and LVN C) reviewed for infection control and prevention practices. - During the COVID-19 pandemic: NA A was observed donning PPE in the hallway, entering Resident #1's COVID-19 positive room, leaving Resident #1's COVID-19 positive room and doffing PPE in the same hallway. HK B stated she cleaned Resident #1's room just like she does all the other rooms and does not have dedicated cleaning supplies in his room. LVN C stated she donned and doffed her PPE when caring for Resident #1, who was COVID-19 positive, in the hallway outside of his room. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, including but not limited to COVID-19, by exposing them due to improper donning and doffing and disinfecting procedures. The evidence is as follows: Record review of Resident #1's clinical record revealed an admitted [DATE], was [AGE] years old with the following Diagnoses: [REDACTED]. -Care Plan: at risk for infection, signs/symptoms of COVID19 - monitor and report headache, fever, body aches, sore throat, cough, sob, and resp difficulty. Observe for psychosocial and mental status changes . Document and report- social service consult as needed. Provide alternative methods of communications with family , visitors- activities. Provide support and allow resident to express feelings, fears, and concerns. Temp checks TID. -Nurses Notes: 11/5/2020 3:42 p.m. - Resident transferred to covid unit at this time. 11/9/2020 at 4:15 p.m. - Received pt. back to room [ROOM NUMBER] per services of facility physician for covid infection. Patient reoriented to room unsuccessfully. Patient remains confused with agitation. No signs or symptoms of respiratory difficulty or complaints voiced at time of admission. vital signs obtained as charted. Assessment completed as charted. During an interview on 11/13/2020 at 9:20 a.m., the DON stated Hall 1 South was the hallway that the hospital took over and got that licensed as the hospital and they ran the COVID-19 unit when they had the severe outbreak. The DON stated the hospital staff took over the care of the residents who were positive. The DON stated there were three residents on that hallway but they were not counted in the nursing home census because they are in the care of the hospital. The DON stated on Hall 1 North they have one COVID-19 positive resident (Resident #1) who was in a room by himself with the door closed. The DON stated she had a huge problem with that positive resident being on that hallway because staff doff PPE in the hallway. An observation on 11/13/2020 at 9:30 a.m. of Hallway 1 South revealed there were double fire doors closed with a sign on it that documents: - KEEP OUT! COVID HALLWAY. -Entrance Only. -Once you are on the unit you cannot exit through this door. You must go outside the South door and go around. -Airborne Precautions An observation on 11/13/2020 at 9:35 a.m. of room [ROOM NUMBER] located on Hallway 1 North revealed there were two signs: -COVID POSITIVE ROOM -MUST WEAR FULL PPE An observation on 11/13/2020 at 9:37 a.m., of Hallway 1 North revealed there two red bins which were located in the hallway across from room [ROOM NUMBER] (COVID-19 positive room). Both bins had red hazard bags in them with the lids closed. In between the two bins was a tall yellow cart full of PPE. The double fire doors at the beginning of the hallway were open and a sign posted documented: Doors must be kept shut to all rooms at all times. Observations of rooms located on this hallway revealed 7 doors open at this time. During an interview on 11/13/2020 at 9:40 a.m., Resident #2 stated the girls take great care of her and said I don't wear a mask and I thank God I don't have to wear what you are wearing. (Investigator was wearing hazmat suit with face shield, N95 mask and hair covering) Resident #2 was sitting in the doorway of room [ROOM NUMBER] located next door to the COVID-19 positive room [ROOM NUMBER]. An observation on 11/13/2020 at 10:00 a.m. revealed NA A donned PPE in the hallway on 1 North outside of room [ROOM NUMBER]. NA A put on a gown, shoe covers, face shield, mask and gloves and entered room [ROOM NUMBER]. Within a minute or two, NA A was back outside of room [ROOM NUMBER] and doffed PPE in the hallway and discarded the contaminated PPE in the bins that were in the hallway. NA A then sprayed her shoes off and her body off with a disinfectant. During an interview on 11/13/2020 at 10:20 a.m., NA A stated she removed the PPE like that in the hallway because that was the way she was taught to doff PPE. NA A stated she was required to wear full PPE when caring for the COVID-19 positive resident. During an interview on 11/13/2020 at 10:40 a.m., HK B was interviewed using AD who was interpreting for HK B who only spoke Spanish. HK B stated she cleans all rooms the same. HK B stated she cleans room [ROOM NUMBER] just like she does all the others. HK B stated she takes the equipment she needs off of her cart, goes into the room and cleans it and puts everything back on the cart to do the next room. HK stated she wears full PPE when cleaning. During an interview on 11/13/2020 at 11:15 a.m., LVN C stated when she cares for Resident #1, the person in room [ROOM NUMBER] who is COVID-19 positive, she had to be completely gowned up with full PPE. LVN C stated she would donn the PPE in the hallway, go into room [ROOM NUMBER], then come out and doff and take all the PPE off, dispose of the PPE and then spray herself off with a disinfectant. During an interview on 11/13/2020 at 11:45 a.m., the Administrator stated the South hallway was their COVID-19 positive unit and the hospital was running that. The Administrator confirmed they do have one resident (Resident #1), who tested COVID-19 positive on Hallway 1 north at this time. Record review of document titled, Designated COVID unit, dated 5/13/2020, documented the following: I. PURPOSE: It is the policy of this facility to prepare an outline for a possible COVID-19 outbreak inside the nursing facility. II. POLICY: A. If a resident tests positive for COVID-19 and the facility was unable to admit to the hospital they will be transferred to the designated COVID wing of the facility (rooms 15 - 26). B. Resident will be transferred to wing with a facial covering in place and staff will have appropriate PPE on during transfer. Doors to all other resident rooms will be closed and the staff and all other residents will be removed from hallways to prepare for transfer of COVID positive resident. D. COVID unit is the designated Hot zone in the facility and will be closed off from the Warm zone with Fire Doors and a plastic insert with zipper that acts as 2nd door to Hot zone. Record review of document by CMS titled COVID-19 Long-Term Care Facility Guidance, dated 04/02/2020, and accessed at https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf, revealed in part: To provide critical, needed leadership for the Nation's long-term care facilities to prevent further spread of COVID-19, CMS and CDC are now recommending the following immediate actions to keep patients and residents safe: 1. Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control. Record review of web page by CDC titled Preparing for COVID-19 in Nursing Homes, dated 06/25/2020, and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed in part: Core Practices Identify Space in the Facility that Could be Dedicated to Monitor and Care for Residents with COVID-19. Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. Record review of web page by CDC titled Responding to COVID-19 in Nursing Homes: Considerations for the Public Health Response to COVID-19 in Nursing Homes, dated 04/30/2020, and accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, revealed in part: Resident Cohorting Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 Nurse Aides (NA A) . -NA A provided care to multiple residents and failed to maintain proper PPE or hand hygiene. This deficient practice has the potential to affect all residents in the facility by exposing them to care that could lead to the spread of [MEDICAL CONDITION] infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: During an observation on 10-5-2020 at 09:37 AM, NA A was noted entering a resident's room with a glass of liquid. NA A was observed assisting the resident with taking a drink. NA A was not wearing gloves. NA A had been noted previously delivering drinks to several rooms on this hall without using gloves or washing her hands. When entering the room, NA A did not perform hand hygiene before assisting the resident. During an observation on 10-5-2020 at 09:42 AM, NA A and one other staff member were observed delivering prefilled drink cups to the 100 Hall. Both NA A and the other staff member delivered to all but two residents (who were receiving incontinent care at the time). Both NA A and the other staff members did not wear any gloves and never washed their hands or used ABHR during the process. During an interview on 10-5-2020 at 09:43 AM when questioned concerning infection control NA A stated, we have to wash our hands on a regular basis and use hand sanitizer on ourselves and the residents. When asked if NA A had completed delivery of water to the resident on the 100 Hall with the assistance of another staff member NA A stated, Yes we completed this hall. When asked if NA A washed her hands or used ABHR between each resident's delivery she stated, We washed out hands before we started delivering the water and picking up their used water bottles. After we are done we will wash out hands again. We will wash our hands on a regular basis. When questioned when NA A was last tested for COVID-19 she stated, last Wednesday 9-30-2020. During continued observation on 10-5-2020 at 09:58 AM NA A and the other staff member were observed delivering water to the remaining two halls without washing their hands. They were noted entering a resident's room, delivering a water pitcher, leaving the room and proceeding to the next resident's room. They did not perform hand hygiene between rooms. They were not wearing gloves between room. During an interview on 10-5-2020 at 08:49 AM when questioned concerning current infection control procedures the administrator reported that masks are worn at all times, handwashing and ABHR are expected with providing resident care, and gloves are to be worn when providing resident care. During an interview on 10-5-2020 at 2:11 PM when questioned if staff who were providing resident care should wash their hands between each resident's room the administrator stated, Yes, they should. During an interview on 10-5-2020 at 2:51 PM when asked if she felt staff should wash their hands between resident rooms especially with providing resident care the ICP stated, Yes, they should clean their hands. Record review of facility provided policy titled Hand Hygiene dated 6/2012 revealed the following: Purpose: The purpose of this policy is to provide guidelines to personnel for proper hand hygiene to prevent the spread of infection. B. Hand rubs to be used: 2.Between care of each patient.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. - DA D was observed preparing food in the kitchen with a mask down around her chin - DA E was observed preparing food in the kitchen with a mask not covering her nose. - CNA C was observed not wearing a mask while sitting at the nursing station- - RN A was observed not wearing a mask while sitting at the nursing station - LVN B was observed not wearing a mask while sitting at the nursing station These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings include: During an observation of the kitchen on 9-4-2020 at 10:30 AM, DA D was seen with her mask down around her chin. The mask was not covering her nose and mouth as she was preparing food. During an observation of the kitchen on 9-4-2020 at 10:30 AM, DA E was seen preparing food with her mask down not covering her nose. During an observation on 9-4-2020 at 12:56 PM, CNA C was seen with her face mask down around her chin while sitting at the nurse's station. During an observation on 9-4-2020 at 1:05 PM both RN A was observed not wearing a face mask at all while sitting at a nurse's station. LVN B was seen sitting at the same nurse's station with her mask down around her chin. During an interview with KM on 9-4-2020 at 10:40 AM, she was asked if it was her expectation that all her kitchen staff wear masks while working in the kitchen. KM replied that it was her expectation that all staff wear their masks while in the kitchen. KM was asked if it was her expectation that all kitchen staff wear their masks to cover both their nose and mouths. KM confirmed that it was her expectation that all staff wear their masks to cover their nose and mouths. During an interview with DA D on 9-4-2020 at 10:44 AM, DA D was asked why she was not wearing her mask correctly when the surveyor entered the kitchen. DA D replied that she was hot. DA D confirmed that she knew that it was required to wear a mask while working in the kitchen. DA D was asked what problems could arise if she was not wearing a mask while preparing food. DA D stated that she could get people sick. During an interview with DA E on 9-4-2020 at 10:47 AM, DA E was asked why she was not covering her nose with her mask. DA E replied that it slipped down. DA E was asked if it was the expectation to wear a mask that covered both her nose and mouth while working in the kitchen, and she responded that it was the expectation. During an interview with ADM, DON and ADON on 9-4-2020 at 10:53 AM, they were all asked if it was their expectation to wear a mask while in the building. All confirmed that it was the expectation that staff wear a mask while in the facility. During an interview on 9-4-2020 at 1:07 PM, DON and ADON were asked if it was their expectation that nursing staff wear masks while at the nurse's station. Both DON and ADON replied that it was their expectation to wear a mask while in the building. ADON confirmed the importance of wearing a mask was to help prevent the spread of COVID 19 or other infections. During an interview on 9-4-2020 at 1:13 PM, LVN B was asked why she was not wearing a mask at the nurse's station. She replied that it slipped down. LVN B confirmed that masks were being worn to help prevent the spread of COVID-19 and that it was the facility's expectation to wear a mask while working. During an interview on 9-4-2020 at 1:15 PM, RN A was asked why she was not wearing a mask while sitting at the nurse's station. She stated that she had polio when younger and it affected her lungs. During an interview on 9-4-2020 at 1:58 PM, CNA C was asked why she was not wearing a mask while sitting at the nurse's desk. CNA C stated that she sometimes just gets tired of the mask and takes it off. CNA C was asked why facility staff were required to wear a mask while working. She stated it was to help stop the spread of COVID. Record review of facility provided policy titled COVID-19 Response Plan dated 8-27-2020, reflected in part: E. HYGIENE AT WORK Wear masks. F. KEEP THE MANOR CLEAN Wear masks. Record review of Executive Order GA 29, dated 7-2-2020, reflected in part: NOW, THEREFORE, I, Greg Abbott, Governor of Texas, by virtue of the power and authority vested in me by the Constitution and laws of the State of Texas, do hereby order the following on a statewide basis effective at 12:0 1 p.m. on July 3, 2020: Every person in Texas shall wear a face covering over the nose and mouth when inside a commercial entity or other building or space open to the public, or when in an outdoor public space, wherever it is not feasible to maintain six feet of social distancing from another person not in the same household; Record review of Nursing Facility COVID-19 Response Emergency Rule, not dated, reflected in part: (k) All nursing facility staff must wear facemasks while in the facility. (m) If an executive order or other direction is issued by the Governor of Texas, the President of the United States, or another applicable authority, that is more restrictive than this rule or any minimum standard relating to a nursing facility, the nursing facility must comply with the executive order or other direction.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 5 (Resident #23, Resident #24, Resident #28, Resident #44, Resident #45) of 24 residents reviewed for advance directives Resident #23's qualified relative did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #24's legal guardian did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #28's qualified relative did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #44's legal guardian did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #45 is a male resident. His OOH-DNR is checked that he is female. This could place the resident at risk due to Emergency Medical Services not honoring the DNR because of not being able to identify the correct resident. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care, could place residents at risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #23 Record review of the clinical record for Resident #23 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's Quarterly MDS, dated [DATE], showed a BIMS score of 8, revealing moderate cognitive impairment. Record review of the resident's Quarterly MDS, dated [DATE], showed the resident's functional status as independent for most ADLs, with supervision for walking. Record review of Resident #23's OOH-DNR revealed Resident #23's qualified relative did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #24 Record review of the clinical record for Resident #24 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's Quarterly MDS, dated [DATE], showed a BIMS test that could not be completed. Staff assessed Resident #24 as severely impaired. Record review of the resident's Quarterly MDS, dated [DATE], showed the resident's functional status as needing extensive two-person assistance with every ADL. Record review of Resident #24's OOH-DNR revealed Resident #24's legal guardian did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #28 Record review of the clinical record for Resident #28 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's Quarterly MDS, dated [DATE], showed a BIMS score of 11, showing mild to moderate cognitive impairment. Record review of the resident's Quarterly MDS, dated [DATE], showed the resident's functional status as needing extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. She needed limited assistance with walking, and supervision with locomotion. Record review of Resident #28's OOH-DNR revealed Resident #28's qualified relative did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #44 Record review of the clinical record for Resident #44 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's Annual MDS, dated [DATE], showed a BIMS score of 13, showing mild to no cognitive impairment. Record review of the resident's Annual MDS, dated [DATE], showed the resident's functional status as needing extensive two-person assistance with nearly all ADLs. Record review of Resident #44's OOH-DNR revealed Resident #44's legal guardian did not sign on the Guardian/Agent/Proxy/Relative signature line, and instead signed on the Person's signature line. Resident #45 Record review of the clinical record for Resident #45 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the resident's MDS Annual Assessment, dated 09-16-2019, showed a BIMS score of 10, showing mild cognitive impairment. Record review of the resident's MDS Annual Assessment, dated 09-16-2019, showed the residents functional status as needing extensive assistance with all ADLs except eating. Record review of Resident #45's clinical record revealed Resident #45 is a male resident. His OOH-DNR is checked that he is female. This could place the resident at risk due to Emergency Medical Services not honoring the DNR because of not being able to identify the correct resident. During an interview with MR on 10-17-2019 at 9:50 AM, she confirmed that several Advance Directives were not completed correctly. She confirmed that several resident's legal representative's did not sign the OOH-DNR form in the correct place. During an interview with the ADM, DON and MR, on 10-17-2019 at 10:25 AM, it was confirmed that several Advance Directives were not completed correctly. They confirmed that several residents' legal representatives did not sign the OOH-DNR form in the correct place. It was also confirmed that Resident #45, who is a male resident, was marked as a female on the OOH-DNR form. Record review of facility provided policy titled Advanced Directives in Hansford Manor, dated 7-27-2016, reflected in part: III. Procedure: G. The care plan team will review advance directives annually with the resident and/or the responsible party to ensure the they are still the wishes of the resident. Such reviews will be made during the annual assessment and recorded on the resident assessment instrument (MDS). The Care Plane Coordinator is responsible for seeing to it that this (is) carried out.

Based on interview and record review, the facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 1 of 24 residents (Resident #46) reviewed for PASRR compliance. - The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #46 prior to admission to the facility. This failure had the potential to affect all residents by placing them at risk of not receiving specialized and/or habilitative services as needed to meet her needs and as required by law due to an inability to identify potential mental disorders or intellectual disabilities. Findings include: Record review of the clinical record for Resident #46 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #46's MDS Quarterly Assessment, dated 09-20-2019, showed that the resident could not complete the BIMS test. Staff assessed the resident as severely cognitively impaired. Record review of Resident #46's MDS Quarterly Assessment, dated 09-20-2019, showed the resident's functional status as near completely dependent on all ADLs Record review of facility provided PASRR screening for Resident #46 titled PASRR Level 1 Screening indicates that the assessment was completed on 4-12-2019, 15 days after the resident had been admitted to the facility. During an interview with the DON on 10-17-2019 at 11:15 AM, the DON was asked what her expectation was for when PASRR level 1 screenings should be done. HShe stated that PASRR level 1 screenings should be completed on or before admission. DON was shown the PASRR level 1 for Resident #46 and confirmed that it was completed 15 days after admission. During an interview with the DON on 10-17-2019 at 2:30 PM, the DON stated that she remembered during PASRR training that if a person was admitted on hospice, a PASRR did not have to be done. The DON was then asked to provide the training in which she was referring to. During an interview 10-17-2019 at 2:36 PM, the DON brought the training packet she was referring to. The training packet stated that an individual may receive an exception for admission into the facility from the State PASRR representative if the individual meets the following: Terminal Illness, as defined for hospice. DON was then asked if she had documentation from the state PASRR representative excluding Resident #46. She stated she did not. During an interview with the ADM on 10-17-2019 at 3:04 PM, she stated that according to the facility policy Resident #46 met criteria to be exempt from PASRR level 1 screening, since the hospice doctor noted that death was thought to be imminent upon admission. She also stated that according to their policy Resident #46 was admitted from a hospital where she received acute care treatment, making her exempt from a PASRR level 1 screening. The policy states The state may choose not to apply the PASRR requirements if: (1) the individual is admitted directly to the facility from a hospital where he/she received acute inpatient care; (2) he/she requires facility services for the condition for which he/she received care in the hospital; and (3) the attending physician has certified (prior to admission) that the individual will likely need less than 30 days care at the facility. The resident did not meet all three criteria for possible exemption from the PASRR level 1 screening since when the resident was taken off of [MEDICATION NAME] she became more responsive and progressed to eating over the next few days. ADM was shown the training packet brought by the DON and was asked if, as stated in the training packet, a state PASRR representative exempted Resident #46 from a PASRR level 1 screening. The ADM stated that there had not been a state PASRR representative out to see Resident #46. Record review of facility provided policy titled Preadmission Screening (PASRR), dated 12-16-2016, reflected in part: II. Policy Hansford Manor will ensure that all new admissions are appropriately screened prior to admission to determine that the individual requires nursing facility level of care and to identify any specialized services that may be necessary. A form PL1 will be completed and submitted, as required, for every individual prior to admission regardless of funding source or diagnosis. b. The State may choose not to apply the PASRR requirements if: : (1) the individual is admitted directly to the facility from a hospital where he/she received acute inpatient care; (2) he/she requires facility services for the condition for which he/she received care in the hospital; and (3) the attending physician has certified (prior to admission) that the individual will likely need less than 30 days care at the facility. Record review of facility training packet titled Preadmission Screening and Annual Resident Review (PASARR), not dated, reflected in part: e. Exemptions 1. Based upon the PASARR screen process an individual may receive an exception for admission into the facility from the State PASARR representative if the individual meets the following: d. Terminal illness, as defined for hospice e. Severe physical illnesses such as coma, ventilator dependence, functioning at a [DIAGNOSES REDACTED] level, or [DIAGNOSES REDACTED]., amyotrophic lateral [MEDICAL CONDITION], and [MEDICAL CONDITION] which results in a level of impairment so severe that the individual could not be expected to benefit from specialized services;

Based on interview and record review, the facility failed to ensure that each resident was properly screened for a mental disorder or intellectual disability prior to admission for 3 of 15 residents (Resident # 37, Resident # 50, and Resident # 57) reviewed for PASRR compliance. - The facility failed to complete a PASRR level 2 on Resident # 37 after her PASRR level 1 screening was positive for mental illness. - The facility failed to ensure that an initial PASRR screening (Level I) was completed for Resident # 50 and Resident # 57 prior to admission to the facility. This failure could place all future, newly admitted residents at risk of not receiving specialized and/or habilitative services as needed to meet their needs and as required by law due to an inability to identify potential mental disorders or intellectual disabilities. Findings Include: Resident # 37 Record review of Resident # 37's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her last MDS was a quarterly completed on 11-23-2018 with a BIMS score of 15 out of 15 indicating she is cognitively intact and that she requires set up assistance with all her activities. Record review of facility provided PASRR with a completion date of 10/25/2016 revealed Resident # 37 was positive for mental illness. A PASRR level 2 could not be located in the resident's paper or electronic health records. During an interview with SSA A on 1-9-2019 at 10:18, when asked if Resident # 37 had a level 2 PASRR completed, she replied, No, a level 2 was never done. I remember talking with the daughter about Resident # 37's PASRR, and I think she didn't want her mother to have anything, but we didn't document it. I know the system triggered for it when we put the level 1 in, but it didn't come up and we didn't follow up on it. Resident # 50 Record review of Resident # 50's face sheet revealed a [AGE] year-old male with a current admitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident # 50's quarterly MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate cognitive impairment. The MDS indicated active [DIAGNOSES REDACTED]. The MDS also indicated that Resident # 50 received antipsychotic medication on a routine basis. Record review of facility provided initial PASRR screening for Resident # 50 titled PASRR Level 1 Screening indicates that the assessment was completed on 12/01/2018, 81 days after the resident had been admitted to the facility. During an interview on 01/09/19 at 9:22 AM with MRD B, she stated that they did not have a PASRR I completed on Resident # 50 prior to 12/01/2018 because the hospital had not completed one when they discharged the resident to the facility. MRD B reported that the facility had the PASRR I completed after the resident was admitted and they realized it had not been done yet. Resident # 57 Record review of Resident # 57's face sheet revealed a [AGE] year-old female with a current admitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 57's MDS dated [DATE] revealed a BIMS score of 04 out of 15 indicating severe cognitive impairment. The MDS indicated active [DIAGNOSES REDACTED]. Record review of facility provided initial PASRR screening for Resident # 57 titled PASRR Level 1 Screening indicates that the assessment was completed on 03/29/2018, 1 day after the resident had been admitted to the facility. During an interview on 01/09/19 at 9:38 AM with MRD B, she reported that there was no PASRR Level I completed on Resident # 57 before 03/29/2018. Record review or facility provided policy titled Preadmission Screening (PASRR), dated 12/15/2016, revealed in part: Policy Hansford Manor will ensure that all new admissions are appropriately screened prior to admission to determine that the individual requires nursing facility level of care and to identify any specialized services that may be necessary. A form PL1 will be completed and submitted, as required, for every individual prior to admission regardless of funding source or diagnosis.

Based on observation, interview and record review; it was determined the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 2 of 2 medication carts. 1 insulin medication vial in the Hall 1 medication cart was marked with an open date of [DATE], and still in use 58 days after having been opened. 1 insulin medication vial in the Hall 2 medication cart was marked with an open date of [DATE], and still in use 71 days after having been opened. 1 insulin medication vial in the Hall 2 medication cart was open and had been used twice with no open date marked or label on the it. The facility's failure to ensure medications were labeled in accordance with currently accepted professional principles could place residents at risk for exposure to medication that is expired or ineffective; resulting in exacerbation of the disease being treated, exposure to contaminated products capable of causing infection, and other adverse reactions. Findings include: During an observation on [DATE] at 11:53 AM, the Hall 1 medication cart was inspected with LVN E. In one of the drawers, there was a multidose vial of [MEDICATION NAME] labeled with the name of Resident #3 and an open date of [DATE]. LVN E verified that the date written on the vial was [DATE] and stated, I bet the nurse marked it with the wrong date because Resident #3 uses this medication a lot. During an observation on [DATE] at 11:40 AM of Hall 2 medication cart with LVN F, inside a drawer of the cart was a multidose vial of [MEDICATION NAME] R insulin labeled with the name of Resident #13 and the open date of [DATE]. There was also a multidose vial of [MEDICATION NAME] labeled with the name of Resident #13 and an open date that was marked out with a black marker. The date could not be discerned. When questioned, LVN F reported that Resident #13's [MEDICATION NAME] R insulin should have been discarded. LVN F reported that the insulin would not return to the drawer. LVN F then stated, concerning Resident #13's [MEDICATION NAME], I don't know when that was opened because it is marked out. LVN F then discarded both insulin vials in the trash receptacle of the medication cart. Also noted in the drawer of the medication was a new multidose vial of [MEDICATION NAME] that was unopened and labeled with the name of Resident #13 and a fill date of [DATE]. In another drawer of the medication cart was a Tresiba Insulin Flex Pen labeled with the name of Resident #12 and a fill date of [DATE]. The Tresiba pen was unmarked as to what date it had been opened. When questioned, LVN F stated Somebody hasn't been dating them. Looks like two doses have been administered out of this pen but it is not marked with an open date. Per interview with the DON on [DATE] at 1:52 PM, when questioned concerning the handling of insulin medication, she stated, The insulin should be dated when it is opened. When questioned as to when insulin should be discarded after having been opened the DON stated, We all know that there is a specific amount of time insulin can be kept after it's opened and must be thrown away. When asked what that specific amount of time is, the DON replied, 28 days. Record review of facility policy revealed: Policy Title: Usage, Storage, and Re-entry of Multi dose Vials Distribution: Hansford Manor Date issued: [DATE] Purpose: The purpose of this policy is to establish guidelines for the use of a multi dose vial that contain more than one dose of medication. Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect [MEDICAL CONDITION] and does not protect against contamination when healthcare personnel fail to follow safe infection practices. Use of a multi does vial for different patients pose a risk of spreading or transferring infection should the vial become contaminated. Procedure: b. The product is to be disposed of within 28 days after initially opening or discarded upon expiration date if unopened or medication vial should be discarded whenever sterility is compromised or questionable. c. The product is to be clearly labeled with the date opened and the initials of the nurse who opened the product.

Based on record review, observation and interviews, the facility failed to implement their policies and procedures to prevent neglect for 3 of 10 residents (Residents #1, 2 and 5) who were transferred by means of a mechanical stand-up lift. Residents #1, 2 and 5 were transferred by way of a mechanical "stand" lift rather than a mechanical "total body" lift, despite not meeting criteria for the "stand" lift in accordance with manufacturer's operating instructions. Manufacturer's directions for the "stand" lift required that residents be able to follow simple directions, otherwise a "total body" lift should be used. Failure to ensure Resident #1 was transferred with the appropriate mechanical lift likely resulted in Resident #1 sustaining a fractured right shoulder. On 07/10/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/11/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed Residents #1, 2 and 5 at risk of injury and/or death. The evidence was as follows: 1.) Resident #1: - Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time her injury was incurred. [DIAGNOSES REDACTED]. - Review of the MDS quarterly resident assessment instrument dated 05/23/14 documented Resident #1 rarely or never understood verbal interaction. It documented severely impaired cognitive skills and fluctuating psychomotor [MEDICAL CONDITION]. It documented Resident #1 required extensive assistance by two staff for transfers and most ADLs. - Review of Resident #1's computer generated nursing progress notes documented: 06/30/14, 17:05 (5:05 p.m.), bruise noted to right upper arm, 3 cm in diameter. DON notified and examined bruise. DON said the standing lift could have attributed to the bruising and should not be used on resident again. - Review of the x-ray report dated 07/03/14, 09:32 (9:32 a.m.), documented a displaced [MEDICAL CONDITION] humerus at the level of the surgical neck and soft tissue swelling. - Review of Manufacturer's operating instructions for the EZ Way "stand" mechanical lift documented if patients were unable to follow simple commands (for example where to place their arms and legs in order to ensure a safe transfer by means of the "stand" lift), the EZ Lift "total body" mechanical lift must be used. The directions documented three specific criteria should be met for safe use of the "stand" lift: 1. able to follow simple commands. 2. able to bear some weight. 3. have upper body strength - Observation on 7/10/14 at 11:30 a.m. revealed Resident #1 sitting in a wheelchair, wearing a sling on her right arm. Resident #1 was unable to converse or follow simple commands. - Review of the facility provided Provider Investigation Report dated 07/03/14, Attachment "A", a written statement by the DON, documented Resident #1 had been transferred by means of a mechanical "stand" lift which had an under arm sling. It documented all direct care staff were in-serviced regarding Resident #1's need to be transferred by means of a "total body" mechanical lift. 2.) Resident #2: - Review of Resident #2's MDS Quarterly assesment dated 5/23/14, documented the resident was rarely or never able to understand or be understood by others. It documented Resident #2 required extensive 2-person physical assistance for transfers. - During an interview on 07/10/14 at 11:15 a.m., Charge Nurse LVN "E" said Resident #2 was transferred by means of a mechanical stand lift. - Observation on 07/10/14 at 1:40 p.m. revealed two CNAs ("C" and "D") transferred Resident #2 by means of the mechanical "stand" lift. Resident #2 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #2 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. 3.) Resident #5: - Review of Resident #5's MDS Quarterly assessment dated [DATE], documented the resident was rarely or never able to understand or be understood by others. It documented Resident #5 required extensive 2-person physical assistance for transfers. - During an interview on 07/10/14 at 12:00 p.m., CNA "A" said Resident #5 was transferred by means of a mechanical "stand" lift. - Observation on 07/10/14 at 12:50 p.m. revealed two CNAs ("A"and "B") transferred Resident #5 by means of the mechanical "stand" lift. Resident #5 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #5 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. - During a subsequent interview on 07/10/14 at 3:40 p.m., CNA "A" said she attended a 07/03/14 in-service following Resident #1's fractured shoulder during which time she was instructed by the DON not to use the mechanical "stand" lifts when transferring residents who were unable to follow simple commands. When asked why she was observed transferring Resident #5 by means of the mechanical "stand" lift despite the resident's inability to follow simple commands, CNA "A" replied "Well I thought he (Resident #5) was ok to transfer with that lift and I didn't want to lie because we use that lift all the time with Resident #5." 4.) During an interview on 07/10/14 at 12:10 p.m., CNA "F" identified on the facility provided CMS Form 802 dated 07/10/14, 10 residents who were transferred by means of the mechanical "stand lift", to include Residents #2 and #5. 5.) During an interview on 07/10/14 at 2:15 p.m., the MDS Coordinator said she did not feel Residents #2 or #5 were appropriate for transfers by means of the mechanical "stand" lift based on their MDS assessments for cognitive and mental functioning. 6.) During an interview on 07/10/14 at 2:40 p.m., the DON said she instructed all staff to not use mechanical "stand" lifts when transferring residents who were unable to know they need to hold on to the grip bar. The DON said Residents #2 and #5 could not be lifted with the mechanical stand lifts due to cognitive impairment. - During a subsequent interview on 07/11/14 at 2:10 p.m, the DON said she felt she was ultimately responsible for placing residents at risk for injury because although she had initiated the in-service regarding which residents were appropriate for transfer by means of the mechanical "stand" lift, she failed to complete the process. The DON said "I in-serviced everybody that came in to work for the next day or two, but then I left town and I never finished the in-service." 7.) Review of the staff in-service attendance log following the incident documented 16 staff (CNAs) were educated regarding which residents were appropriate for use of the mechanical stand lift for transfers. 8.) Review of the facility provided staff roster documented 32 CNAs were employed at the facility. 9.) During an interview on 07/11/14 at 2:45 p.m., the Administrator said " I really had no idea we were using the mechanial "stand" lifts with residents who were not appropriate for transfer by means of the "stand" lifts." 10.) Review of the facility policy titled Prevention of Resident Abuse, Neglect and Mistreatment, dated 01/26/2005, documented: I. Purpose: It is the purpose of his policy to prohibit and prevent any form of resident abuse, neglect, involuntary seclusion, and misappropriation of property by an employee, another resident, or other person. This shall be referred to collectively as "mistreatment" in this policy. II. Policy: A. It is the policy of Hansford Manor to implement procedures for preventing the mistreatment of [REDACTED]. 2. Training staff in interventions, reporting, detection and prevention. 3. Prevention through identificaion of and intervention for at-risk residents. 4. Identification of events and occurrences that may constitute or contribute to mistreatment. 6. Protection for individuals from mistreatment during investigations of allegations. 8. Prevention of recurrence of identified resident mistreatment. III. Procedure: C. 10. Prevention of neglect in particular shall be addressed through several strategies: a. Licensed Vocational Nurses in charge are responsible for making rounds of residents and documenting care and condition both on a regularly scheduled basis at least once per shift each day on a random basis to check that resident care has been done. E. 3. Conditions which may raise a concern for mistreatment include but are not limited to: a. Unexplained skin tears or bruises, especially when these are located on parts of the body that are unlikely to be injured accidentally (inner aspect of forearms), or having a suspicious pattern, or any injury which is not consistent with the description of the occurrence. K. The Director of Nursing is responsible for ensuring that residents are monitored and that staff is adequately trained, informed, and supported. He/she is responsible for ensuring that orientation and training of nursing staff is effective in preventing and addressing resident mistreatment. On 07/10/14 at 5:15 p.m., the Administrator and DON were notified the IJ had been identified. On 07/11/14 at 12:07 p.m., the facility submitted the following plan of removal: Plan of Removal of Immediate Jeopardy for Complaint Investigation of 07/10/14 1. Corrective Action for those residents found to be affected: a. Three residents were potentially at risk due to use of a standing lift for transfers. These residents have been assessed for weight bearing, upper body strength, and ability to follow instructions, and found to be inappropriate for the standing lift. b. Residents who CAN use the standing lift will be listed on a covered card attached to the standing lift(s), which will be updated by the DON or MDS Nurse as soon as a resident needs to be taken off the list, due to change in condition, or new admission. c. All available staff on all shifts have been inserviced on the specific residents who can and who cannot use the standing lift(s). In addition, all staff will be instructed to immediately report cognitive and physical changes to the charge nurse, who will alert the RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to insrtuction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in he amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. d. Any staff who have not been inserviced due to absence will not be allowed to work on the floor until they have completed the inservice (see attached Inservice Agenda and sign-in sheet). e. All staff will recieve a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. f. All mechanical lifts will receve monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 2. Corrective action for those residents with the potential to be affected: a. All residents with transfer problems have been assessed for weight bearing , upper body strength, and ability to follow instructions, and those for whom the standing lift is appropriate according to the assessment will be added to the list of residents who may be transferred with the standing lift, which is attached to the standing lift. (See attached assessment form and list of Standing Lift residents). b. In addition to the inservice described in 1.c all staff will receive a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. c. All mechanical lifts will receive monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 3. Measures to ensure on-going compliance: a. All staff is inserviced, and must pass a test supplied by the manufacturer of the standing lift, on use of the standing and Maxi lifts immediately, annually thereafter, and for new staff, before working on the floor. In addition, all staff will be instructed to immediatley report cognitive and physical changes to the charge nurse, who will alert RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to instruction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in the amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. b. All staff is inserviced on how to find which residents are approved for standing lift use, the location of the list attached to the standing lift(s), and how the list will be updated, immediately, annually, and before working on the floor for new staff. c. The DON or designated RN wil lupdate the Standing-Lift list whenever a resident has a change in condition, or a new resident is admitted who is not appropriate for the standing lift. d. For one month, all nursing staff will be questioned at random by the DON or designated RN regarding the information presented at the inservice to test comprehension and retention. Observations will be done by the DON or designated RN to ensure that staff is complying. Any new hires during this period will be included in the questioning and observation. 4. Monitors to prevent recurrence: a. The DON or designated RN will monitor standing lift use through questioning of 5 CNA and 2 LVN staff per week regarding which residents may or may not use the standing lift; what criteria are used to determine appropriateness; how to find out which residents are on the list; and if the staff have encountered any problems in this regard. b. Monitor results will be turned in to Performance Improvement Committee each month until 100% compliance is reached. Failure to meet 100% compliance will require a written plan of correction and further monthly reporting of new measures by the DON to the Performance Improvement Committee. c. On-going compliance will be monitored as part of all CNA and LVN annual performance reviews. d. The MDS nurse/care plan coordinator will check the Standing-Lift list at the beginning of each month to ensure the list has been kept up to date. 11.) Observations and interviews with CNA staff on 07/11/14 revealed understanding that Residents #1, 2 and 5 were not appropriate for use of the mechanical "stand" lift, and had been trained regarding where to locate information regarding which residents were appropriate for a specific type of mechanical lift ("stand" lift or "total body" lift). On 07/11/14 at 3:02 p.m. the IJ was removed. The CMS Form 802 dated 07/10/14 documented 65 residents.20.)

Based on record review, observation and interviews, the facility failed to implement their written policies and procedures to prevent neglect for 3 of 10 residents (Residents #1, 2 and 5) reviewed for neglect. Residents #1, 2 and 5 were transferred by way of a mechanical "stand" lift rather than a mechanical "total body" lift, despite not meeting criteria for the "stand" lift in accordance with manufacturer's operating instructions. Manufacturer's directions for the "stand" lift required that residents be able to follow simple directions, otherwise a "total body" lift should be used. Failure to ensure Resident #1 was transferred with the appropriate mechanical lift likely resulted in Resident #1 sustaining a fractured right shoulder. On 07/10/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/11/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed Residents #1, 2 and 5 at risk of injury and/or death. The evidence was as follows: 1.) Review of the facility policy titled Prevention of Resident Abuse, Neglect and Mistreatment, dated 01/26/2005, documented: I. Purpose: It is the purpose of his policy to prohibit and prevent any form of resident abuse, neglect, involuntary seclusion, and misappropriation of property by an employee, another resident, or other person. This shall be referred to collectively as "mistreatment" in this policy. II. Policy: A. It is the policy of Hansford Manor to implement procedures for preventing the mistreatment of [REDACTED]. 2. Training staff in interventions, reporting, detection and prevention. 3. Prevention through identificaion of and intervention for at-risk residents. 4. Identification of events and occurrences that may constitute or contribute to mistreatment. 6. Protection for individuals from mistreatment during investigations of allegations. 8. Prevention of recurrence of identified resident mistreatment. III. Procedure: C. 10. Prevention of neglect in particular shall be addressed through several strategies: a. Licensed Vocational Nurses in charge are responsible for making rounds of residents and documenting care and condition both on a regularly scheduled basis at least once per shift each day on a random basis to check that resident care has been done. E. 3. Conditions which may raise a concern for mistreatment include but are not limited to: a. Unexplained skin tears or bruises, especially when these are located on parts of the body that are unlikely to be injured accidentally (inner aspect of forearms), or having a suspicious pattern, or any injury which is not consistent with the description of the occurrence. K. The Director of Nursing is responsible for ensuring that residents are monitored and that staff is adequately trained, informed, and supported. He/she is responsible for ensuring that orientation and training of nursing staff is effective in preventing and addressing resident mistreatment. 2.) Resident #1: - Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time her injury was incurred. [DIAGNOSES REDACTED]. - Review of the MDS quarterly resident assessment instrument dated 05/23/14 documented Resident #1 rarely or never understood verbal interaction. It documented severely impaired cognitive skills and fluctuating psychomotor [MEDICAL CONDITION]. It documented Resident #1 required extensive assistance by two staff for transfers and most ADLs. - Review of Resident #1's computer generated nursing progress notes documented: 06/30/14, 17:05 (5:05 p.m.), bruise noted to right upper arm, 3 cm in diameter. DON notified and examined bruise. DON said the standing lift could have attributed to the bruising and should not be used on resident again. - Review of the x-ray report dated 07/03/14, 09:32 (9:32 a.m.), documented a displaced [MEDICAL CONDITION] humerus at the level of the surgical neck and soft tissue swelling. - Review of Manufacturer's operating instructions for the EZ Way "stand" mechanical lift documented if patients were unable to follow simple commands (for example where to place their arms and legs in order to ensure a safe transfer by means of the "stand" lift), the EZ Lift "total body" mechanical lift must be used. The directions documented three specific criteria should be met for safe use of the "stand" lift: 1. able to follow simple commands. 2. able to bear some weight. 3. have upper body strength - Observation on 7/10/14 at 11:30 a.m. revealed Resident #1 sitting in a wheelchair, wearing a sling on her right arm. Resident #1 was unable to converse or follow simple commands. - Review of the facility provided Provider Investigation Report dated 07/03/14, Attachment "A", a written statement by the DON, documented Resident #1 had been transferred by means of a mechanical "stand" lift which had an under arm sling. It documented all direct care staff were in-serviced regarding Resident #1's need to be transferred by means of a "total body" mechanical lift. 3.) Resident #2: - Review of Resident #2's MDS Quarterly assesment dated 5/23/14, documented the resident was rarely or never able to understand or be understood by others. It documented Resident #2 required extensive 2-person physical assistance for transfers. - During an interview on 07/10/14 at 11:15 a.m., Charge Nurse LVN "E" said Resident #2 was transferred by means of a mechanical stand lift. - Observation on 07/10/14 at 1:40 p.m. revealed two CNAs ("C" and "D") transferred Resident #2 by means of the mechanical "stand" lift. Resident #2 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #2 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. 4.) Resident #5: - Review of Resident #5's MDS Quarterly assessment dated [DATE], documented the resident was rarely or never able to understand or be understood by others. It documented Resident #5 required extensive 2-person physical assistance for transfers. - During an interview on 07/10/14 at 12:00 p.m., CNA "A" said Resident #5 was transferred by means of a mechanical "stand" lift. - Observation on 07/10/14 at 12:50 p.m. revealed two CNAs ("A"and "B") transferred Resident #5 by means of the mechanical "stand" lift. Resident #5 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #5 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. - During a subsequent interview on 07/10/14 at 3:40 p.m., CNA "A" said she attended a 07/03/14 in-service following Resident #1's fractured shoulder during which time she was instructed by the DON not to use the mechanical "stand" lifts when transferring residents who were unable to follow simple commands. When asked why she was observed transferring Resident #5 by means of the mechanical "stand" lift despite the resident's inability to follow simple commands, CNA "A" replied "Well I thought he (Resident #5) was ok to transfer with that lift and I didn't want to lie because we use that lift all the time with Resident #5." 5.) During an interview on 07/10/14 at 12:10 p.m., CNA "F" identified on the facility provided CMS Form 802 dated 07/10/14, 10 residents who were transferred by means of the mechanical "stand lift", to include Residents #2 and #5. 6.) During an interview on 07/10/14 at 2:15 p.m., the MDS Coordinator said she did not feel Residents #2 or #5 were appropriate for transfers by means of the mechanical "stand" lift based on their MDS assessments for cognitive and mental functioning. 7.) During an interview on 07/10/14 at 2:40 p.m., the DON said she instructed all staff to not use mechanical "stand" lifts when transferring residents who were unable to know they need to hold on to the grip bar. The DON said Residents #2 and #5 could not be lifted with the mechanical stand lifts due to cognitive impairment. - During a subsequent interview on 07/11/14 at 2:10 p.m, the DON said she felt she was ultimately responsible for placing residents at risk for injury because although she had initiated the in-service regarding which residents were appropriate for transfer by means of the mechanical "stand" lift, she failed to complete the process. The DON said "I in-serviced everybody that came in to work for the next day or two, but then I left town and I never finished the in-service." 8.) Review of the staff in-service attendance log following the incident documented 16 staff (CNAs) were educated regarding which residents were appropriate for use of the mechanical stand lift for transfers. 9.) Review of the facility provided staff roster documented 32 CNAs were employed at the facility. 10.) During an interview on 07/11/14 at 2:45 p.m., the Administrator said " I really had no idea we were using the mechanial "stand" lifts with residents who were not appropriate for transfer by means of the "stand" lifts." On 07/10/14 at 5:15 p.m., the Administrator and DON were notified the IJ had been identified. On 07/11/14 at 12:07 p.m., the facility submitted the following plan of removal: Plan of Removal of Immediate Jeopardy for Complaint Investigation of 07/10/14 1. Corrective Action for those residents found to be affected: a. Three residents were potentially at risk due to use of a standing lift for transfers. These residents have been assessed for weight bearing, upper body strength, and ability to follow instructions, and found to be inappropriate for the standing lift. b. Residents who CAN use the standing lift will be listed on a covered card attached to the standing lift(s), which will be updated by the DON or MDS Nurse as soon as a resident needs to be taken off the list, due to change in condition, or new admission. c. All available staff on all shifts have been inserviced on the specific residents who can and who cannot use the standing lift(s). In addition, all staff will be instructed to immediately report cognitive and physical changes to the charge nurse, who will alert the RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to insrtuction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in he amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. d. Any staff who have not been inserviced due to absence will not be allowed to work on the floor until they have completed the inservice (see attached Inservice Agenda and sign-in sheet). e. All staff will recieve a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. f. All mechanical lifts will receve monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 2. Corrective action for those residents with the potential to be affected: a. All residents with transfer problems have been assessed for weight bearing , upper body strength, and ability to follow instructions, and those for whom the standing lift is appropriate according to the assessment will be added to the list of residents who may be transferred with the standing lift, which is attached to the standing lift. (See attached assessment form and list of Standing Lift residents). b. In addition to the inservice described in 1.c all staff will receive a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. c. All mechanical lifts will receive monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 3. Measures to ensure on-going compliance: a. All staff is inserviced, and must pass a test supplied by the manufacturer of the standing lift, on use of the standing and Maxi lifts immediately, annually thereafter, and for new staff, before working on the floor. In addition, all staff will be instructed to immediatley report cognitive and physical changes to the charge nurse, who will alert RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to instruction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in the amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. b. All staff is inserviced on how to find which residents are approved for standing lift use, the location of the list attached to the standing lift(s), and how the list will be updated, immediately, annually, and before working on the floor for new staff. c. The DON or designated RN wil lupdate the Standing-Lift list whenever a resident has a change in condition, or a new resident is admitted who is not appropriate for the standing lift. d. For one month, all nursing staff will be questioned at random by the DON or designated RN regarding the information presented at the inservice to test comprehension and retention. Observations will be done by the DON or designated RN to ensure that staff is complying. Any new hires during this period will be included in the questioning and observation. 4. Monitors to prevent recurrence: a. The DON or designated RN will monitor standing lift use through questioning of 5 CNA and 2 LVN staff per week regarding which residents may or may not use the standing lift; what criteria are used to determine appropriateness; how to find out which residents are on the list; and if the staff have encountered any problems in this regard. b. Monitor results will be turned in to Performance Improvement Committee each month until 100% compliance is reached. Failure to meet 100% compliance will require a written plan of correction and further monthly reporting of new measures by the DON to the Performance Improvement Committee. c. On-going compliance will be monitored as part of all CNA and LVN annual performance reviews. d. The MDS nurse/care plan coordinator will check the Standing-Lift list at the beginning of each month to ensure the list has been kept up to date. 11.) Observations and interviews with CNA staff on 07/11/14 revealed understanding that Residents #1, 2 and 5 were not appropriate for use of the mechanical "stand" lift, and had been trained regarding where to locate information regarding which residents were appropriate for a specific type of mechanical lift ("stand" lift or "total body" lift). On 07/11/14 at 3:02 p.m. the IJ was removed. The CMS Form 802 dated 07/10/14 documented 65 residents.

Based on record review, observation and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for 3 of 10 residents (Residents #1, 2, and 5) reviewed for accident hazards: Residents #1, 2 and 5 were transferred by means of a mechanical "stand" lift rather than a mechanical "total body" lift, despite not meeting criteria for the "stand" lift in accordance with manufacturer's operating instructions. Manufacturer's directions for the "stand" lift required that residents be able to follow simple directions, otherwise a "total body" lift should be used. This practice likely resulted in Resident #1 sustaining a fractured right shoulder. On 07/10/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/11/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed Residents #1, 2 and 5,the residents at risk of injury and/or death. The evidence was as follows: 1.) Resident #1: - Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time her injury was incurred. [DIAGNOSES REDACTED]. - Review of the MDS quarterly resident assessment instrument dated 05/23/14 documented Resident #1 rarely or never understood verbal interaction. It documented severely impaired cognitive skills and fluctuating psychomotor retardation. It documented Resident #1 required extensive assistance by two staff for transfers and most ADLs. - Review of Resident #1's computer generated nursing progress notes documented: 06/30/14, 17:05 (5:05 p.m.), bruise noted to right upper arm, 3 cm in diameter. DON notified and examined bruise. DON said the standing lift could have attributed to the bruising and should not be used on resident again. - Review of the x-ray report dated 07/03/14, 09:32 (9:32 a.m.), documented a displaced fracture of the proximal humerus at the level of the surgical neck and soft tissue swelling. - Review of Manufacturer's operating instructions for the EZ Way "stand" mechanical lift documented if patients were unable to follow simple commands (for example where to place their arms and legs in order to ensure a safe transfer by means of the "stand" lift), the EZ Lift "total body" mechanical lift must be used. The directions documented three specific criteria should be met for safe use of the "stand" lift: 1. able to follow simple commands. 2. able to bear some weight. 3. have upper body strength - Observation on 7/10/14 at 11:30 a.m. revealed Resident #1 sitting in a wheelchair, wearing a sling on her right arm. Resident #1 was unable to converse or follow simple commands. - Review of the facility provided Provider Investigation Report dated 07/03/14, Attachment "A", a written statement by the DON, documented Resident #1 had been transferred by means of a mechanical "stand" lift which had an under arm sling. It documented all direct care staff were in-serviced regarding Resident #1's need to be transferred by means of a "total body" mechanical lift. 2.) Resident #2: - Review of Resident #2's MDS Quarterly assesment dated 5/23/14, documented the resident was rarely or never able to understand or be understood by others. It documented Resident #2 required extensive 2-person physical assistance for transfers. - During an interview on 07/10/14 at 11:15 a.m., Charge Nurse LVN "E" said Resident #2 was transferred by means of a mechanical stand lift. - Observation on 07/10/14 at 1:40 p.m. revealed two CNAs ("C" and "D") transferred Resident #2 by means of the mechanical "stand" lift. Resident #2 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #2 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. 3.) Resident #5: - Review of Resident #5's MDS Quarterly assessment dated [DATE], documented the resident was rarely or never able to understand or be understood by others. It documented Resident #5 required extensive 2-person physical assistance for transfers. - During an interview on 07/10/14 at 12:00 p.m., CNA "A" said Resident #5 was transferred by means of a mechanical "stand" lift. - Observation on 07/10/14 at 12:50 p.m. revealed two CNAs ("A"and "B") transferred Resident #5 by means of the mechanical "stand" lift. Resident #5 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #5 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. - During a subsequent interview on 07/10/14 at 3:40 p.m., CNA "A" said she attended a 07/03/14 in-service following Resident #1's fractured shoulder during which time she was instructed by the DON not to use the mechanical "stand" lifts when transferring residents who were unable to follow simple commands. When asked why she was observed transferring Resident #5 by means of the mechanical "stand" lift despite the resident's inability to follow simple commands, CNA "A" replied "Well I thought he (Resident #5) was ok to transfer with that lift and I didn't want to lie because we use that lift all the time with Resident #5." 4.) During an interview on 07/10/14 at 12:10 p.m., CNA "F" identified on the facility provided CMS Form 802 dated 07/10/14, 10 residents who were transferred by means of the mechanical "stand lift", to include Residents #2 and #5. 5.) During an interview on 07/10/14 at 2:15 p.m., the MDS Coordinator said she did not feel Residents #2 or #5 were appropriate for transfers by means of the mechanical "stand" lift based on their MDS assessments for cognitive and mental functioning. 6.) During an interview on 07/10/14 at 2:40 p.m., the DON said she instructed all staff to not use mechanical "stand" lifts when transferring residents who were unable to know they need to hold on to the grip bar. The DON said Residents #2 and #5 could not be lifted with the mechanical stand lifts due to cognitive impairment. - During a subsequent interview on 07/11/14 at 2:10 p.m, the DON said she felt she was ultimately responsible for placing residents at risk for injury because although she had initiated the in-service regarding which residents were appropriate for transfer by means of the mechanical "stand" lift, she failed to complete the process. The DON said "I in-serviced everybody that came in to work for the next day or two, but then I left town and I never finished the in-service." 7.) Review of the staff in-service attendance log following the incident documented 16 staff (CNAs) were educated regarding which residents were appropriate for use of the mechanical stand lift for transfers. 8.) Review of the facility provided staff roster documented 32 CNAs were employed at the facility. 9.) During an interview on 07/11/14 at 2:45 p.m., the Administrator said " I really had no idea we were using the mechanial "stand" lifts with residents who were not appropriate for transfer by means of the "stand" lifts." On 07/10/14 at 5:15 p.m., the Administrator and DON were notified the IJ had been identified. On 07/11/14 at 12:07 p.m., the facility submitted the following plan of removal: Plan of Removal of Immediate Jeopardy for Complaint Investigation of 07/10/14 1. Corrective Action for those residents found to be affected: a. Three residents were potentially at risk due to use of a standing lift for transfers. These residents have been assessed for weight bearing, upper body strength, and ability to follow instructions, and found to be inappropriate for the standing lift. b. Residents who CAN use the standing lift will be listed on a covered card attached to the standing lift(s), which will be updated by the DON or MDS Nurse as soon as a resident needs to be taken off the list, due to change in condition, or new admission. c. All available staff on all shifts have been inserviced on the specific residents who can and who cannot use the standing lift(s). In addition, all staff will be instructed to immediately report cognitive and physical changes to the charge nurse, who will alert the RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to insrtuction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in he amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. d. Any staff who have not been inserviced due to absence will not be allowed to work on the floor until they have completed the inservice (see attached Inservice Agenda and sign-in sheet). e. All staff will recieve a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. f. All mechanical lifts will receve monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 2. Corrective action for those residents with the potential to be affected: a. All residents with transfer problems have been assessed for weight bearing , upper body strength, and ability to follow instructions, and those for whom the standing lift is appropriate according to the assessment will be added to the list of residents who may be transferred with the standing lift, which is attached to the standing lift. (See attached assessment form and list of Standing Lift residents). b. In addition to the inservice described in 1.c all staff will receive a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. c. All mechanical lifts will receive monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 3. Measures to ensure on-going compliance: a. All staff is inserviced, and must pass a test supplied by the manufacturer of the standing lift, on use of the standing and Maxi lifts immediately, annually thereafter, and for new staff, before working on the floor. In addition, all staff will be instructed to immediatley report cognitive and physical changes to the charge nurse, who will alert RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to instruction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in the amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. b. All staff is inserviced on how to find which residents are approved for standing lift use, the location of the list attached to the standing lift(s), and how the list will be updated, immediately, annually, and before working on the floor for new staff. c. The DON or designated RN wil lupdate the Standing-Lift list whenever a resident has a change in condition, or a new resident is admitted who is not appropriate for the standing lift. d. For one month, all nursing staff will be questioned at random by the DON or designated RN regarding the information presented at the inservice to test comprehension and retention. Observations will be done by the DON or designated RN to ensure that staff is complying. Any new hires during this period will be included in the questioning and observation. 4. Monitors to prevent recurrence: a. The DON or designated RN will monitor standing lift use through questioning of 5 CNA and 2 LVN staff per week regarding which residents may or may not use the standing lift; what criteria are used to determine appropriateness; how to find out which residents are on the list; and if the staff have encountered any problems in this regard. b. Monitor results will be turned in to Performance Improvement Committee each month until 100% compliance is reached. Failure to meet 100% compliance will require a written plan of correction and further monthly reporting of new measures by the DON to the Performance Improvement Committee. c. On-going compliance will be monitored as part of all CNA and LVN annual performance reviews. d. The MDS nurse/care plan coordinator will check the Standing-Lift list at the beginning of each month to ensure the list has been kept up to date. 10.) Observations and interviews with CNA staff on 07/11/14 revealed understanding that Residents #1, 2 and 5 were not appropriate for use of the mechanical "stand" lift, and had been trained regarding where to locate information regarding which residents were appropriate for a specific type of mechanical lift ("stand" lift or "total body" lift). On 07/11/14 at 3:02 p.m. the IJ was removed. The CMS Form 802 dated 07/10/14 documented 65 residents.

Based on interview and record review it was determined the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 of 13 sampled residents: The DON failed to ensure residents were properly assessed for use of the appropriate type of mechanical lift, and failed to ensure CNA staff were trained regarding which residents were appropriate for a specific type of mechanical lift. Tha Administrator failed to ensure the DON thoroughly assessed residents for use of specific types of mechanical lifts, and failed to ensure the DON effectively trained staff regarding specific residents' needs for different types of mechanical lifts. Residents #1, 2 and 5 were transferred by way of a mechanical "stand" lift rather than a mechanical "total body" lift, despite not meeting criteria for the stand lift in accordance with manufacturer's operating instructions. Manufacturer's directions for the "stand" lift required that residents be able to follow simple directions (for example where to place their arms and legs in order to ensure a safe transfer by means of the "stand" lift), otherwise a "total body" lift should be used. Failure to ensure Resident #1 was transferred with the appropriate mechanical lift likely resulted in Resident #1 sustaining a fractured right shoulder, and placed Residents #2 and 5 at risk for potential injury or death. On 07/10/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/11/14, the facility remained out of compliance at a scope of "isolated" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all direct care staff regarding special considerations for residents with specific medical conditions when using mechanical lifts. This failure placed Residents #1, 2 and 5 at risk of injury and/or death. The evidence was as follows: 1.) Review of the facility policy titled Prevention of Resident Abuse, Neglect and Mistreatment, dated 01/26/2005, documented: I. Purpose: It is the purpose of his policy to prohibit and prevent any form of resident abuse, neglect, involuntary seclusion, and misappropriation of property by an employee, another resident, or other person. This shall be referred to collectively as "mistreatment" in this policy. II. Policy: A. It is the policy of Hansford Manor to implement procedures for preventing the mistreatment of [REDACTED]. 2. Training staff in interventions, reporting, detection and prevention. 3. Prevention through identificaion of and intervention for at-risk residents. 4. Identification of events and occurrences that may constitute or contribute to mistreatment. 6. Protection for individuals from mistreatment during investigations of allegations. 8. Prevention of recurrence of identified resident mistreatment. III. Procedure: C. 10. Prevention of neglect in particular shal be addressed through several strategies: a. Licensed Vocational Nurses in charge are responsible for making rounds of residents and documenting care and condition both on a regularly scheduled basis at least once per shift each day on a random basis to check that resident care has been done. E. 3. Conditions which may raise a concern for mistreatment include but are not limited to: a. Unexplained skin tears or bruises, especially when these are located on parts of the body that are unlikely to be injured accidentally (inner aspect of forearms), or having a suspicious pattern, or any injury which is not consistent with the description of the occurrence. K. The Director of Nursing is responsible for ensuring that residents are monitored and that staff is adequately trained, informed, and supported. He/she is responsible for ensuring that orientation and training of nursing staff is effective in preventing and addressing resident mistreatment. 2.) Review of the record of admission (Face Sheet) documented Resident #1 was admitted to the facility on [DATE]. She was [AGE] years of age at the time her injury was incurred. [DIAGNOSES REDACTED]. 3.) Review of the MDS quarterly resident assessment instrument dated 05/23/14 documented Resident #1 rarely or never understood verbal interaction. It documented severely impaired cognitive skills and fluctuating psychomotor [MEDICAL CONDITION]. It documented Resident #1 required extensive assistance by two staff for transfers and most ADLs. 4.) Review of Resident #1's computer generated nursing progress notes documented: 06/30/14, 17:05 (5:05 p.m.), bruise noted to right upper arm, 3 cm in diameter. DON notified and examined bruise. DON said the standing lift could have attributed to the bruising and should not be used on resident again. 5.) Review of the x-ray report dated 07/03/14, 09:32 (9:32 a.m.), documented a displaced [MEDICAL CONDITION] humerus at the level of the surgical neck and soft tissue swelling. 6.) Review of Manufacturer's operating instructions for the EZ Way "stand" mechanical lift documented if patients were unable to follow simple commands (impaired cognitive skills), the EZ Lift "total body" mechanical lift must be used. 7.) Review of the facility provided Provider Investigation Report dated 07/03/14, Attachment "A", a written statement by the DON, documented Resident #1 had been transferred by means of a mechanical stand lift which had an under arm sling. It documented all direct care staff were in-serviced regarding Resident #1's need to be transferred by means of a total body mechanical lift. 8.) Review of the staff in-service attendance log following the incident documented 16 staff (CNAs) were educated regarding which residents were appropriate for use of the mechanical stand lift for transfers. 9.) Review of the facility provided staff roster documented 32 CNAs were employed at the facility. 10.) Observation on 7/10/14 at 11:30 a.m. revealed Resident #1 sitting in a wheelchair, wearing a sling on her right arm. Resident #1 was unable to converse or follow simple commands. 11.) Review of Resident #2's MDS Quarterly assesment dated 5/23/14, documented the resident was rarely or never able to understand or be understood by others. It documented Resident #2 required extensive 2-person physical assistance for transfers. 12.) Review of Resident #5's MDS Quarterly assessment dated [DATE], documented the resident was rarely or never able to understand or be understood by others. It documented Resident #5 required extensive 2-person physical assistance for transfers. 13.) Observation on 07/10/14 at 12:50 p.m. revealed two CNAs ("A"and "B") transferred Resident #5 by means of the mechanical stand lift. Resident #5 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #5 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. 14.) Observation on 07/10/14 at 1:40 p.m. revealed two CNAs ("C" and "D") transferred Resident #2 by means of the mechanical stand lift. Resident #2 was observed to be unable to follow simple commands to better assist the aides with the stand-up lift transfer. Resident #2 was unable to lean forward for sling placement, and was unable to grip the hand bar or place both feet on the lift platform when asked to do so. 15.) During an interview on 07/10/14 at 11:15 a.m., Charge Nurse LVN "E" said Resident #2 was transferred by means of a mechanical stand lift. 16.) During an interview on 07/10/14 at 12:00 p.m., CNA "A" said Resident #5 was transferred by means of a mechanical stand lift. During a subsequent interview at 3:40 p.m., CNA "A" said she attended the 07/03/14 in-service following Resident #1's fractured shoulder during which time she was instructed by the DON not to use the mechanical stand lifts when transferring residents who were unable to follow simple commands. When asked why she was observed transferring Resident #5 by means of the mechanical stand lift despite the resident's inability to follow simple commands, CNA "A" replied "Well I thought he was ok to transfer with that lift and I didn't want to lie because we use that lift all the time with Resident #5." 17.) During an interview on 07/10/14 at 12:10 p.m., CNA "F" identified on the facility provided CMS Form 802 dated 07/10/14, 10 residents who were transferred by means of the mechanical stand lift, to include Residents #2 and #5. 18.) During an interview on 07/10/14 at 2:15 p.m., the MDS Coordinator said she did not feel Residents #2 or #5 were appropriate for transfers by means of the mechanical stand lift based on their MDS assessments for cognitive and mental functioning. 19.) During an interview on 07/10/14 at 2:40 p.m., the DON said she instructed all staff to not use mechanical stand lifts when transferring residents who were unable to know they need to hold on to the bar. The DON said Residents #2 and #5 could not be lifted with the mechanical stand lifts due to cognitive impairment. During a subsequent interview on 07/11/14 at 2:10 p.m, the DON said she felt she was ultimately responsible for placing residents at risk for injury because although she had initiated the in-service regarding which residents were appropriate for transfer by means of the mechanical stand lift, she failed to complete the process. The DON said "I in-serviced everybody that came in to work for the next day or two, but then I left town and I never finished the in-service." 20.) During an interview on 07/11/14 at 2:45 p.m., the Administrator said she felt herself to be ultimately responsible for placing residents at risk for injury because "I am responsible for everything that happens here." The Administrator continued, " I really had no idea we were using the mechanial stand lifts with residents who were not appropriate for transfer by means of the stand lifts." On 07/10/14 at 5:15 p.m., the Administrator and DON were notified the IJ had been identified. On 07/11/14 at 12:07 p.m., the facility submitted the following plan of removal: Plan of Removal of Immediate Jeopardy for Complaint Investigation of 07/10/14 1. Corrective Action for those residents found to be affected: a. Three residents were potentially at risk due to use of a standing lift for transfers. These residents have been assessed for weight bearing, uper body strength, and ability to follow instructions, and found to be inappropriate for the standing lift. b. Residents who CAN use the standing [MEDICATION NAME] be listed on a covered card attached to the standing lift(s), which will be updated by the DON or MDS Nurse as soon as a resident needs to be taken off the list, due to change in condition, or new admission. c. All available staff on all shifts have been inserviced on the specific residents who can and who cannot use the standing lift(s). In addition, all staff will be instructed to immediately report cognitive and physical changes to the charge nurse, who will alert the RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to insrtuction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in he amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. d. Any staff who have not been inserviced due to absence will not be allowed to work on the floor until they have completed the inservice (see attached Inservice Agenda and sign-in sheet). e. All staff will recieve a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. f. All mechanical lifts will receve monthly preventative maintenance bythe Maintenance Department, according to manufacturer's instructions. 2. Corrective action for those residents with the potential to be affected: a. All residents with transfer problems have been assessed for weight bearing , upper body strength, and ability to follow instructions, and those for whom the standing lift is appropriate according to the assessment will be added to the list of residents who may be transferred with the standing lift, which is attached to the standing lift. (See attached assessment form and list of Standing Lift residents). b. In addition to the inservice described in 1.c all staff will receive a copy of the policy and procedure for use of mechanical lift (standing lift), and sign a statement that they have read and understand it's contents. c. All mechanical lifts will receive monthly preventative maintenance by the Maintenance Department, according to manufacturer's instructions. 3. Measures to ensure on-going compliance: a. All staff is inservicd, and must pass a test supplied by the manufacturer of the standing lift, on use of the standing and Maxi lifts immediately, annually thereafter, and for new staff, before working on the floor. In addition, all staff will be instructed to immediatley report cognitive and physical changes to the charge nurse, who will alert RN on duty to conduct an assessment for lift use, as applicable. They are instructed that cognition affecting lift use is the ability to follow instructions in the performance of any ADL, such as being able to pay attention to instructions, alertness, being able to move body parts in response to instruction, and being able to communicate to the caregiver if they are experiencing pain, weakness, or any distress during ADLs. A change in the amount of self-performance and support needed (limited, extensive, etc.) must be reported to the charge nurse. b. All staff is inserviced on how to find which residents are approved for standing lift use, the location of the list attached to the standing lift(s), and how the list will be updated, immediately, annually, and before working on the floor for new staff. c. The DON or designated RN wilupdate the Standing-Lift list whenever a resident has a change in condition, or a new resident is admitted who is not appropriate for the standing lift. d. For one month, all nursing staff will be questioned at random by the DON or designated RN regarding the information presented at the inservice to test comprehension and retention. Observations will be done by the DON or designated RN to ensure that staff is complying. Any new hires during this period will be included in the questioning and observation. 4. Monitors to prevent recurrence: a. The DON or designated RN will monitor standing lift use through questioning of 5 CNA and 2 LVN staff per week regarding which residents may or may not use the standing lift; what criteria are used to determine appropriateness; how to find out which residents are on the list; and if the staff have encountered any problems in this regard. b. Monitor results will be turned in to Performance Improvement Committee each month until 100% compliance is reached. Failure to meet 100% compliance will require a written plan of correction and further monthly reporting of new measures by the DON to the Performance Improvement Committee. c. On-going compliance will be monitored as part of all CNA and LVN annual performance reviews. d. The MDS nurse/care plan coordinator will chck the Standing-Lift list at the beginning of each month to ensure the list has been kept up to date. Observations and interviews with CNA staff on 07/11/14 revealed understanding that Residents #1, 2 and 5 were not appropriate for use of the mechanical "stand" lift, and had been trained regarding where to locate information regarding which residents were appropriate for a specific type of mechanical lift ("stand" lift or "total body" lift). Observations and interviews with CNA staff on 07/11/14 revealed understanding that Residents #1, 2 and 5 were not appropriate for use of the mechanical "stand" lift, and had been trained regarding where to locate information regarding which residents were appropriate for a specific type of mechanical lift ("stand" lift or "total body" lift). On 07/11/14 at 3:02 p.m. the IJ was removed. The CMS Form 802 dated 07/10/14 documented 65 residents.

Based on interviews and record review, it was determined that for 1 of 11 sampled residents (Resident #1), the facility failed to notify the physician after health changes when the resident continued to experience nausea and vomiting for over 48 hours. This failure resulted in the physician not being afforded the opportunity to alter Resident #1's treatment. Resident #1 experienced clinical complications ([MEDICAL CONDITION] infarction), which resulted in her death. This failure had the potential to affect all residents in the facility who could experience a change of condition. The facility census was 54. The evidence is as follows: 1) Review of Resident #1's clinical record documented the following: - The computerized information system, "Healthland", no date, documented Resident #1 was admitted to the facility on [DATE]. Her date of expiration was [DATE]. - The MDS quarterly assessment dated [DATE], documented Resident #1 was independent with ambulation (used no mobility devices), transfers, toileting and all ADLs. The resident was steady at all times and had no functional limitations with ROM. Resident #1 was continent of bowel and bladder at all times. [DIAGNOSES REDACTED]. - The Comprehensive Resident Assessment and Care Plan, last updated [DATE], documented Resident #1 had short and long-term memory deficit, no communication difficulties, was independent with regards to decision-making skills, and was a low risk for falls. She was a DNR. - Computerized Nurse progress notes dated [DATE] at 1602 (4:02 p.m.), by LVN "C", documented Resident #1 received a new order for [MEDICATION NAME] (used for prevention of nausea and vomiting, according to the Geriatric Dosage Handbook, 12th edition, copyright 2007, pg. 1142), 4 mg. every 6 hours PRN by Physician "A". Further review revealed the next entry dated [DATE] at 6:45 a.m., by LVN "D", documented Resident #1 was found beside bed by an unidentified CNA. Resident #1 was cold, blue in color and with no viable vital signs. 2) The 31 Day PRN MAR, dated [DATE], documented Resident #1 was administered the [MEDICATION NAME] 3 times, [DATE] at 2:00 p.m.,[DATE] at 7:00 p.m., and [DATE] at 6:00 p.m.(Thursday, Friday and Saturday). 3) Review of facility provided witness statements documented the following: - LVN "H", no date - On Friday ([DATE]), Resident #1 was spitting into a trash can while sitting in recliner. [MEDICATION NAME] given at 1900 (7:00 p.m.), no further complaints until 2100 (9:00 p.m.), when Resident #1 requested something to help her sleep. Resident #1 denied any pain or discomfort at that time, and was encouraged to use call light if any further assistance was needed. - CNA "F", [DATE] - On Friday, [DATE], CNA "F" worked the 6:00 p.m. - 6:00 a.m. shift. CNA "F reported to charge nurse (no name), that Resident #1 was complaining of nausea. CNA "F" obtained vitals (not documented), for the nurse. After the charge nurse administered something for nausea, CNA "F" returned to check on Resident #1, at which time resident reported feeling better, ate some crackers and drank a Coke. - LVN "G", [DATE] - Worked 6:00 p.m. - 6:00 a.m. on Saturday [DATE]. LVN "G" was told Resident #1 was nauseated. LVN "G" administered [MEDICATION NAME] (at 6:00 p.m.), and obtained vitals (vitals not documented). LVN "G" remembered thinking the vitals were almost "text book" perfect, with a BP of ,[DATE], and a pulse rate of 65. LVN "G"offered Resident #1 food, which the resident declined. Resident #1 denied vomiting, and reported feeling "queasy". At 2000 (8:00 p.m.), Resident #1 ate a few crackers and a few sips of Coke, and reported feeling somewhat better. Resident #1 replied "No", when asked if experiencing any pain. 4) Review of the 24 hour report sheets from [DATE] through [DATE], revealed no documentation regarding Resident #1 experiencing nausea and vomiting. 5) Review of the Quality Assurance Report dated [DATE], by LVN "E", documented Resident #1 was lying in a supine position on the floor, without respirations and cold to touch, face blue in color, and no palpable pulse. 6) Review of a prescription note photocopy dated [DATE], by Physician "B", documented Resident #1 expired from [MEDICAL CONDITION] infarction. 7) Review of the Provider Investigation Report dated [DATE], documented on [DATE] at 6:45 a.m., Resident #1 was found on the floor in the resident's room, deceased . 8) During an interview on [DATE] at 10:20 a.m., LVN "C" said on Thursday [DATE], between 1:00 p.m. and 2:00 p.m., Resident #1 reported feeling nauseous. LVN "C" called Physician "A" and obtained orders for [MEDICATION NAME]. LVN "C" said she gave Resident #1 the [MEDICATION NAME] at approximately 2:00 p.m. 9) During a telephone interview on [DATE] at 11:38 a.m., CNA "J" said she worked 2:00 p.m. -10:00 p.m. on Saturday [DATE]. CNA "J" said Resident #1 was vomiting that night at approximately 9:45 p.m. ( 55 hrs and 45 minutes after Resident #1 received her initial dose of [MEDICATION NAME]). CNA "J"continued, Resident #1 said she was nauseated and her face appeared reddened, flushed, and strained from vomiting in her trash can. CNA "J" gave Resident #1 a tissue to wipe her face, and some crackers to eat with a soda. 10) During a telephone interview on [DATE] at 12:30 p.m., LVN "K" said on Saturday, [DATE], while working 6:00 p.m. - 6:00 a.m., she last spoke with Resident #1 at 9:00 p.m., at which time Resident #1 looked okay, not really that sick, but she did get her some crackers and soda. LVN "K" continued, there had been a stomach bug going around and other residents were also vomiting. LVN "K" said she did not really know what to do. She said she did not think to contact the resident's physician regarding her continued vomiting. 11) During an interview on [DATE] at 4:35 p.m., LVN "G" said on Saturday [DATE], she was the "extra" nurse during the 6:00 p.m. - 6:00 a.m. shift, but was orienting a new nurse (LVN"K"), so she felt ultimately responsible as the charge nurse during the shift. LVN "G" said when she came on shift it was reported to her that Resident #1 was nauseated all that day. She continued, at 6:00 p.m., she gave Resident #1 [MEDICATION NAME]. LVN "G" said she saw Resident #1 hovering over her trash can, and she observed a scant amount of what appeared to look more like phlegm than bile in the resident's trash can. Resident #1 told her she felt queasy, but had not vomited at that time. Resident #1 declined her offer of food at that time. LVN "G" said she thought Resident #1's condition was nothing more than a little bug, and that [MEDICATION NAME] and crackers would help. LVN "G" Said she did not notify the physician of Resident #1's continued nausea and vomiting. She said to her knowledge no one went in to Resident #1's room to see about the resident after approximately 9:00 p.m., for the remainder of the shift, until the resident was found deceased in her room by the oncoming staff after 6:00 a.m. on Sunday [DATE]. During a subsequent interview at 5:00 p.m., LVN "G" said on Saturday, [DATE], she did look at Resident #1's chart, and saw that Resident #1 had been nauseous and vomiting for 2 days, and had not gotten any better from taking the [MEDICATION NAME] prescribed 2 days earlier. 12) During a telephone interview on [DATE] at 5:22 p.m., Physician "A" said he ordered [MEDICATION NAME] for Resident #1 on Thursday, [DATE], after it was reported the resident was feeling nauseous. Physician "A" continued, if Resident #1's symptoms persisted he would have expected to be notified again after ,[DATE] hours. The physician had not been consulted again after the initial order for [MEDICATION NAME] was obtained on [DATE].

Based on interviews and record review, it was determined that for 1 of 11 sampled residents (Resident #1), the facility failed to implement policies and procedures that prohibit neglect when the facility failed to regularly check on and assess the resident who was experiencing nausea and vomiting, and failed to notify the physician. Resident #1 was found lying on the floor in her room, cold, blue in color, and without a pulse, by oncoming day shift staff, after staff from the previous shift failed to check on and assess the resident during the night. This failure resulted in the facility not being able to reassess and intervene on the resident's behalf when the resident experienced a significant change of condition, and had the potential to affect the remaining 54 residents at the facility. The evidence is as follows: 1) Review of Resident #1's clinical record documented the following: - The computerized information system, "Healthland", no date, documented Resident #1 was admitted to the facility on [DATE]. Her date of expiration was [DATE]. - Computerized Nurse progress notes dated [DATE] at 6:45 a.m., by LVN "D", documented Resident #1 was found beside bed by a unidentified CNA. Resident #1 was cold, blue in color and with no viable vital signs. - The MDS quarterly assessment dated [DATE], documented Resident #1 was independent with ambulation (used no mobility devices), transfers, toileting and all ADLs. The resident was steady at all times and had no functional limitations with ROM. Resident #1 was continent of bowel and bladder at all times. [DIAGNOSES REDACTED]. - The Comprehensive Resident Assessment and Care Plan, last updated [DATE], documented Resident #1 had short and long-term memory deficit, no communication difficulties, was independent with regards to decision-making skills, and was a low risk for falls.She was a DNR. 2) The MAR indicated [REDACTED]. 1142), 4 mg. every 6 hours PRN. The 31 Day PRN MAR, dated [DATE], documented Resident #1 was administered the [MEDICATION NAME] 3 times, ,[DATE],5, and 6. 3) Review of the 24 hour report sheets from [DATE] through [DATE], failed to document any information regarding Resident #1 experiencing nausea and vomiting. 4) Review of the Provider Investigation Report dated [DATE], documented on [DATE] at 6:45 a.m., Resident #1 was found on the floor in the resident's room, deceased . 5) Review of a prescription note photocopy dated [DATE], by Physician "B", documented Resident #1 expired from [MEDICAL CONDITION] infarction. 6) During an interview on [DATE] at 10:30 a.m., the Administrator said CNAs were suppose to check on residents during the night, but Resident #1 did not want to be disturbed during the night hours, adding the resident was able to use her call light if she wanted assistance. Furthermore, the Administrator said LVN "C", assessed Resident #1 after lunch on [DATE], when the resident first complained of nausea. The Administrator continued, LVN "C" failed to document having assessed Resident #1 at that time. Lastly, the Administrator said staff failed to look in on Resident #1 during the night the resident died ([DATE]). 7) During a telephone interview on [DATE] at 11:38 a.m., CNA "J" said she worked 2:00 p.m. -10:00 p.m. on Saturday [DATE]. CNA "J" said Resident #1 was vomiting that night at approximately 9:45 p.m. ( 55 hrs and 45 minutes after Resident #1 received her initial dose of [MEDICATION NAME]). CNA "J"continued, Resident #1 said she was nauseated and her face appeared reddened, flushed, and strained from vomiting in her trash can. CNA "J" gave Resident #1 a tissue to wipe her face, and some crackers to eat with a soda. 8) During a telephone interview on [DATE] at 12:30 p.m., LVN "K" said on Saturday, [DATE], while working 6:00 p.m. - 6:00 a.m., she last spoke with Resident #1 at 9:00 p.m., at which time Resident #1 looked okay, not really that sick, adding she did get her some crackers and soda. LVN "K" continued, there had been a stomach bug going around and other residents were also vomiting. LVN "K" said she did not really know what to do. She said she did not think to contact the resident's physician regarding her continued vomiting, adding it had been 3 hours since Resident #1 was given her PRN [MEDICATION NAME] for vomiting, so it was not yet time to give the medication again. LVN "K" said LVN "C" checked Resident #1's vitals earlier in the day during the previous shift and they were WNL, so she did not see it necessary that she again check the resident's vitals during the night shift. Additionally, LVN "K" said she entrusted CNAs checked on residents every 2 hours during the night when rounds were made, and would have let her know if the resident's condition worsened. LVN "K" said she regretted not having done more for Resident #1 during the night of [DATE], adding she took the resident's independence for granted. 9) During an interview on [DATE] at 3:30 p.m., the ADON said LVN "G" last assessed Resident #1 on [DATE], adding LVN "G" failed to document the assessment because the resident's vitals were WNL. The ADON said LVNs "C", "G" and "H" all had taken Resident #1's vitals in the days prior to her death, but failed to document having done so because the vitals were WNL. She acknowledged lack of documentation resulted in lack of evidence assessments were performed. 10) During an interview on [DATE] at 4:35 p.m., LVN "G" said on Saturday [DATE], she was the "extra" nurse during the 6:00 p.m. - 6:00 a.m. shift, but was orienting a new nurse (LVN"K"), so she felt ultimately responsible as the charge nurse during the shift. LVN "G" said when she came on shift it was reported to her that Resident #1 was nauseated all that day. She continued, at 6:00 p.m., she gave Resident #1 [MEDICATION NAME]. LVN "G" said she saw Resident #1 hovering over her trash can, and she observed a scant amount of what appeared to look more like phlegm than bile in the resident's trash can. Resident #1 told her she felt queasy, but had not vomited at that time. Resident #1 declined her offer of food at that time. LVN "G" said she thought Resident #1's condition was nothing more than a little bug, and that [MEDICATION NAME] and crackers would help. LVN "G" Said she did not notify the physician of Resident #1's continued nausea and vomiting, even though 48 hours had passed with no relief of the resident's symptoms. She said to her knowledge no one went in to Resident #1's room to see about the resident after approximately 9:00 p.m., for the remainder of the shift, until the resident was found deceased in her room by the oncoming staff after 6:00 a.m., on Sunday [DATE]. During a subsequent interview at 5:00 p.m., LVN "G" said on Saturday, [DATE], she did look at Resident #1's chart, and saw that Resident #1 had been nauseous and vomiting for 2 days, and had not gotten any better from taking the [MEDICATION NAME] prescribed 2 days earlier. She said she had assessed Resident #1 at 6:00 p.m. on [DATE], but her vitals were WNL, so she did not document having done the assessment. 11) During an interview on [DATE] at 4:50 p.m., CNA "M" said she worked the 6:00 p.m. - 6:00 a.m. shift on [DATE], adding she was aware at 10:00 p.m. that evening Resident #1 had been given [MEDICATION NAME] for nausea and vomiting, and went to bed. CNA"M" said she never checked on Resident #1 during her shift because Resident #1 was independent and did not like to be disturbed during the night, adding the resident was able to use her call light and was even known to walk to the nurse's station to ask for PRN medications. 12) During a telephone interview on [DATE] at 5:22 p.m., Physician "A" said he ordered [MEDICATION NAME] for Resident #1 on Thursday, [DATE], after it was reported the resident was feeling nauseous. Physician "A" continued, if Resident #1's symptoms persisted he would have expected to be notified again after ,[DATE] hours. 13) During an interview on [DATE] at 5:42 p.m., CNA "F" said she worked the 6:00 p.m.- 6:00 a.m. shift on [DATE]. CNA "F" said she had not been checking on independent residents during the night because the independent residents were able to use their call lights, adding "I hate that (Resident #1), just layed there like that all night." 14) During an interview on [DATE] at 5:55 p.m., LVN "H" said she frequently worked the night shift, adding CNAs usually never checked on the independent residents during the night hours. LVN "H" said some of the residents, including Resident #1, did not want to be disturbed during the nights. LVN "H" said staff during the night shift only focused on residents who were heavier care and who required assistance with toileting during the nights. 15)Review of the facility policy and procedure titled Prevention of Resident Abuse, Neglect, and Mistreatment, dated [DATE], documented: - II-A-3- Prevention through identification of and intervention for at-risk residents. 16) Review of the facility policy and procedure titled Nursing Rounds, dated [DATE], documented: - III-A-: Recent changes of condition or concerns shall be passed on in report at the beginning of each nurse's shift. The oncoming nurse is responsible for conducting nursing assessments of those residents identified as needing close monitoring due to a recent change. Any unusual findings by CNAs shall be followed up by the LVN's observation or assessment. - III-B-1: CNAs are required to conduct rounds on all residents assigned to them by the charge nurse every two hours. - III-B-2-o: Ask resident if he/she needs anything, needs assistance, is feeling OK. - III-B-2-p: Observe resident for any injuries, expression of pain or distress, or change in condition. 17) Review of the facility policy and procedure titled Physician Communications, dated [DATE], documented: - III-A-2- Any abnormal findings, observations, and lab results as soon as possible.

Based on interviews and record review, it was determined that for 1 of 11 sampled residents (Resident #1), the facility failed to implement written policies and procedures that prohibit neglect when the facility failed to operationalize policies regarding 2 hour checks of all residents by CNAs, assessments by nursing staff, and physician notification. Resident #1 who had been complaining of nausea and vomiting for 3 days, was found lying on the floor in her room, cold, blue in color, and without a pulse, by oncoming day shift staff, after staff from the previous shift failed to check on and assess the resident during the night. This failure resulted in the facility not being able to reassess and intervene on the resident's behalf when the resident experienced a significant change of condition, and had the potential to affect the remaining 54 residents at the facility. The evidence is as follows: 1)Review of the facility policy and procedure titled Prevention of Resident Abuse, Neglect, and Mistreatment, dated [DATE], documented: - II-A-3- Prevention through identification of and intervention for at-risk residents. 2) Review of the facility policy and procedure titled Nursing Rounds, dated [DATE], documented: - III-A-: Recent changes of condition or concerns shall be passed on in report at the beginning of each nurse's shift. The oncoming nurse is responsible for conducting nursing assessments of those residents identified as needing close monitoring due to a recent change. Any unusual findings by CNAs shall be followed up by the LVN's observation or assessment. - III-B-1: CNAs are required to conduct rounds on all residents assigned to them by the charge nurse every two hours. - III-B-2-o: Ask resident if he/she needs anything, needs assistance, is feeling OK. - III-B-2-p: Observe resident for any injuries, expression of pain or distress, or change in condition. 3) Review of the facility policy and procedure titled Physician Communications, dated [DATE], documented: - III-A-2- Any abnormal findings, observations, and lab results as soon as possible. 4) Review of Resident #1's clinical record documented the following: - The computerized information system, "Healthland", no date, documented Resident #1 was admitted to the facility on [DATE]. Her date of expiration was [DATE]. - The MDS quarterly assessment dated [DATE], documented Resident #1 was independent with ambulation (used no mobility devices), transfers, toileting and all ADLs. The resident was steady at all times and had no functional limitations with ROM. Resident #1 was continent of bowel and bladder at all times. [DIAGNOSES REDACTED]. - The Comprehensive Resident Assessment and Care Plan, last updated [DATE], documented Resident #1 had short and long-term memory deficit, no communication difficulties, was independent with regards to decision-making skills, and was a low risk for falls. - Computerized Nurse progress notes dated [DATE] at 6:45 a.m., by LVN "D", documented Resident #1 was found beside bed by a unidentified CNA. Resident #1 was cold, blue in color and with no viable vital signs. 5) The MAR indicated [REDACTED]. 1142), 4 mg. every 6 hours PRN. The 31 Day PRN MAR, dated [DATE], documented Resident #1 was administered the [MEDICATION NAME] 3 times, ,[DATE],5, and 6. 6) Review of the 24 hour report sheets from [DATE] through [DATE], failed to document any information regarding Resident #1 experiencing nausea and vomiting. 7) Review of the Provider Investigation Report dated [DATE], documented on [DATE] at 6:45 a.m., Resident #1 was found on the floor in the resident's room, deceased . 8) Review of a prescription note photocopy dated [DATE], by DO "B", documented Resident #1 expired from [MEDICAL CONDITION] infarction. 9) During an interview on [DATE] at 10:30 a.m., the Administrator said CNAs were suppose to check on residents during the night, but Resident #1 did not want to be disturbed during the night hours, adding the resident was able to use her call light if she wanted assistance. Furthermore, the Administrator said LVN "C", assessed Resident #1 after lunch on [DATE], when the resident first complained of nausea. The Administrator continued, LVN "C" failed to document having assessed Resident #1 at that time. Lastly, the Administrator said staff failed to look in on Resident #1 during the night the resident died ([DATE]). 10) During a telephone interview on [DATE] at 11:38 a.m., CNA "J" said she worked 2:00 p.m. -10:00 p.m. on Saturday [DATE]. CNA "J" said Resident #1 was vomiting that night at approximately 9:45 p.m. ( 55 hrs and 45 minutes after Resident #1 received her initial dose of [MEDICATION NAME]). CNA "J"continued, Resident #1 said she was nauseated and her face appeared reddened, flushed, and strained from vomiting in her trash can. CNA "J" gave Resident #1 a tissue to wipe her face, and some crackers to eat with a soda. 11) During a telephone interview on [DATE] at 12:30 p.m., LVN "K" said on Saturday, [DATE], while working 6:00 p.m. - 6:00 a.m., she last spoke with Resident #1 at 9:00 p.m., at which time Resident #1 looked okay, not really that sick, adding she did get her some crackers and soda. LVN "K" continued, there had been a stomach bug going around and other residents were also vomiting. LVN "K" said she did not really know what to do. She said she did not think to contact the resident's physician regarding her continued vomiting, adding it had been 3 hours since Resident #1 was given her PRN [MEDICATION NAME] for vomiting, so it was not yet time to give the medication again. LVN "K" said LVN "C" checked Resident #1's vitals earlier in the day during the previous shift and they were WNL, so she did not see it necessary that she again check the resident's vitals during the night shift. Additionally, LVN "K" said she entrusted CNAs checked on residents every 2 hours during the night when rounds were made, and would have let her know if the resident's condition worsened. LVN "K" said she regretted not having done more for Resident #1 during the night of [DATE], adding she took the resident's independence for granted. 12) During an interview on [DATE] at 3:30 p.m., the ADON said LVN "G" last assessed Resident #1 on [DATE], adding LVN "G" failed to document the assessment because the resident's vitals were WNL. The ADON said LVNs "C", "G" and "H" all had taken Resident #1's vitals in the days prior to her death, but failed to document having done so because the vitals were WNL. She acknowledged lack of documentation resulted in lack of evidence assessments were performed. 13) During an interview on [DATE] at 4:35 p.m., LVN "G" said on Saturday [DATE], she was the "extra" nurse during the 6:00 p.m. - 6:00 a.m. shift, but was orienting a new nurse (LVN"K"), so she felt ultimately responsible as the charge nurse during the shift. LVN "G" said when she came on shift it was reported to her that Resident #1 was nauseated all that day. She continued, at 6:00 p.m., she gave Resident #1 [MEDICATION NAME]. LVN "G" said she saw Resident #1 hovering over her trash can, and she observed a scant amount of what appeared to look more like phlegm than bile in the resident's trash can. Resident #1 told her she felt queasy, but had not vomited at that time. Resident #1 declined her offer of food at that time. LVN "G" said she thought Resident #1's condition was nothing more than a little bug, and that [MEDICATION NAME] and crackers would help. LVN "G" Said she did not notify the physician of Resident #1's continued nausea and vomiting, even though 48 hours had passed with no relief of the resident's symptoms. She said to her knowledge no one went in to Resident #1's room to see about the resident after approximately 9:00 p.m., for the remainder of the shift, until the resident was found deceased in her room by the oncoming staff after 6:00 a.m. on Sunday [DATE]. During a subsequent interview at 5:00 p.m., LVN "G" said on Saturday, [DATE], she did look at Resident #1's chart, and saw that Resident #1 had been nauseous and vomiting for 2 days, and had not gotten any better from taking the [MEDICATION NAME] prescribed 2 days earlier. She said she had assessed Resident #1 at 6:00 p.m. on [DATE], but her vitals were WNL, so she did not document having done the assessment. 14) During an interview on [DATE] at 4:50 p.m., CNA "M" said she worked the 6:00 p.m. - 6:00 a.m. shift on [DATE], adding she was aware at 10:00 p.m. that evening Resident #1 had been given [MEDICATION NAME] for nausea and vomiting, and went to bed. CNA"M" said she never checked on Resident #1 during her shift because Resident #1 was independent and did not like to be disturbed during the night, adding the resident was able to use her call light and was even known to walk to the nurse's station to ask for PRN medications. 15) During a telephone interview on [DATE] at 5:22 p.m., Physician "A" said he ordered [MEDICATION NAME] for Resident #1 on Thursday, [DATE], after it was reported the resident was feeling nauseous. Physician "A" continued, if Resident #1's symptoms persisted he would have expected to be notified again after ,[DATE] hours. 16) During an interview on [DATE] at 5:42 p.m., CNA "F" said she worked the 6:00 p.m.- 6:00 a.m. shift on [DATE]. CNA "F" said she had not been checking on independent residents during the night because the independent residents were able to use their call lights, adding "I hate that (Resident #1), just layed there like that all night." 17) During an interview on [DATE] at 5:55 p.m., LVN "H" said she frequently worked the night shift, adding CNAs usually never checked on the independent residents during the night hours. LVN "H" said some of the residents, including Resident #1, did not want to be disturbed during the nights. LVN "H" said staff during the night shift only focused on residents who were heavier care and who required assistance with toileting during the nights.

Based on interviews and record review, it was determined the facility failed to ensure staff provided necessary care and services to maintain the highest practicable physical well-being for 1 of 11 residents (Resident #1), who after complaining of nausea and vomiting for 3 days, was found lying on the floor, cold and blue, without a pulse. Nursing and CNA staff failed to monitor and assess Resident #1 during the night shift, and failed to intervene and notify the physician when the resident's condition deteriorated. Resident #1 was found deceased by the oncoming day shift. This failure had the potential to effect the remaining 54 residents at the facility by placing them at risk of not receiving care and services to maintain their highest practicable well-being. The evidence is as follows: 1) Review of Resident #1's clinical record documented the following: - The computerized information system, "Healthland", no date, documented Resident #1 was admitted to the facility on [DATE]. Her date of expiration was [DATE]. - The MDS quarterly assessment dated [DATE], documented Resident #1 was independent with ambulation (used no mobility devices), transfers, toileting and all ADLs. The resident was steady at all times and had no functional limitations with ROM. Resident #1 was continent of bowel and bladder at all times. [DIAGNOSES REDACTED]. - The Comprehensive Resident Assessment and Care Plan, last updated [DATE], documented Resident #1 had short and long-term memory deficit, no communication difficulties, was independent with regards to decision-making skills, and was a low risk for falls. - Computerized Nurse progress notes dated [DATE] at 6:45 a.m., by LVN "D", documented Resident #1 was found beside bed by a unidentified CNA. Resident #1 was cold, blue in color and with no viable vital signs. 2) The MAR indicated [REDACTED]. 1142), 4 mg. every 6 hours PRN. The 31 Day PRN MAR, dated [DATE], documented Resident #1 was administered the [MEDICATION NAME] 3 times, ,[DATE],5, and 6. 3) Review of the 24 hour report sheets from [DATE] through [DATE], failed to document any information regarding Resident #1 experiencing nausea and vomiting. 4) Review of the Provider Investigation Report dated [DATE], documented on [DATE] at 6:45 a.m., Resident #1 was found on the floor in the resident's room, deceased . 5) Review of a prescription note photocopy dated [DATE], by DO "B", documented Resident #1 expired from [MEDICAL CONDITION] infarction. 6) During an interview on [DATE] at 10:30 a.m., the Administrator said CNAs were suppose to check on residents during the night, but Resident #1 did not want to be disturbed during the night hours, adding the resident was able to use her call light if she wanted assistance. Furthermore, the Administrator said LVN "C", assessed Resident #1 after lunch on [DATE], when the resident first complained of nausea. The Administrator continued, LVN "C" failed to document having assessed Resident #1 at that time. Lastly, the Administrator said staff failed to look in on Resident #1 during the night the resident died ([DATE]). 7) During a telephone interview on [DATE] at 11:38 a.m., CNA "J" said she worked 2:00 p.m. -10:00 p.m. on Saturday [DATE]. CNA "J" said Resident #1 was vomiting that night at approximately 9:45 p.m. ( 55 hrs and 45 minutes after Resident #1 received her initial dose of [MEDICATION NAME]). CNA "J"continued, Resident #1 said she was nauseated and her face appeared reddened, flushed, and strained from vomiting in her trash can. CNA "J" gave Resident #1 a tissue to wipe her face, and some crackers to eat with a soda. 8) During a telephone interview on [DATE] at 12:30 p.m., LVN "K" said on Saturday, [DATE], while working 6:00 p.m. - 6:00 a.m., she last spoke with Resident #1 at 9:00 p.m., at which time Resident #1 looked okay, not really that sick, adding she did get her some crackers and soda. LVN "K" continued, there had been a stomach bug going around and other residents were also vomiting. LVN "K" said she did not really know what to do. She said she did not think to contact the resident's physician regarding her continued vomiting, adding it had been 3 hours since Resident #1 was given her PRN [MEDICATION NAME] for vomiting, so it was not yet time to give the medication again. LVN "K" said LVN "C" checked Resident #1's vitals earlier in the day during the previous shift and they were WNL, so she did not see it necessary that she again check the resident's vitals during the night shift. Additionally, LVN "K" said she entrusted CNAs checked on residents every 2 hours during the night when rounds were made, and would have let her know if the resident's condition worsened. LVN "K" said she regretted not having done more for Resident #1 during the night of [DATE], adding she took the resident's independence for granted. 9) During an interview on [DATE] at 3:30 p.m., the ADON said LVN "G" last assessed Resident #1 on [DATE], adding LVN "G" failed to document the assessment because the resident's vitals were WNL. The ADON said LVNs "C", "G" and "H" all had taken Resident #1's vitals in the days prior to her death, but failed to document having done so because the vitals were WNL. She acknowledged lack of documentation resulted in lack of evidence assessments were performed. 10) During an interview on [DATE] at 4:35 p.m., LVN "G" said on Saturday [DATE], she was the "extra" nurse during the 6:00 p.m. - 6:00 a.m. shift, but was orienting a new nurse (LVN"K"), so she felt ultimately responsible as the charge nurse during the shift. LVN "G" said when she came on shift it was reported to her that Resident #1 was nauseated all that day. She continued, at 6:00 p.m., she gave Resident #1 [MEDICATION NAME]. LVN "G" said she saw Resident #1 hovering over her trash can, and she observed a scant amount of what appeared to look more like phlegm than bile in the resident's trash can. Resident #1 told her she felt queasy, but had not vomited at that time. Resident #1 declined her offer of food at that time. LVN "G" said she thought Resident #1's condition was nothing more than a little bug, and that [MEDICATION NAME] and crackers would help. LVN "G" Said she did not notify the physician of Resident #1's continued nausea and vomiting, even though 48 hours had passed with no relief of the resident's symptoms. She said to her knowledge no one went in to Resident #1's room to see about the resident after approximately 9:00 p.m., for the remainder of the shift, until the resident was found deceased in her room by the oncoming staff after 6:00 a.m. on Sunday [DATE]. During a subsequent interview at 5:00 p.m., LVN "G" said on Saturday, [DATE], she did look at Resident #1's chart, and saw that Resident #1 had been nauseous and vomiting for 2 days, and had not gotten any better from taking the [MEDICATION NAME] prescribed 2 days earlier. She said she had assessed Resident #1 at 6:00 p.m. on [DATE], but her vitals were WNL, so she did not document having done the assessment. 11) During an interview on [DATE] at 4:50 p.m., CNA "M" said she worked the 6:00 p.m. - 6:00 a.m. shift on [DATE], adding she was aware at 10:00 p.m. that evening Resident #1 had been given [MEDICATION NAME] for nausea and vomiting, and went to bed. CNA"M" said she never checked on Resident #1 during her shift because Resident #1 was independent and did not like to be disturbed during the night, adding the resident was able to use her call light and was even known to walk to the nurse's station to ask for PRN medications. 12) During a telephone interview on [DATE] at 5:22 p.m., Physician "A" said he ordered [MEDICATION NAME] for Resident #1 on Thursday, [DATE], after it was reported the resident was feeling nauseous. Physician "A" continued, if Resident #1's symptoms persisted he would have expected to be notified again after ,[DATE] hours. 13) During an interview on [DATE] at 5:42 p.m., CNA "F" said she worked the 6:00 p.m.- 6:00 a.m. shift on [DATE]. CNA "F" said she had not been checking on independent residents during the night because the independent residents were able to use their call lights, adding "I hate that (Resident #1), just layed there like that all night." 14) During an interview on [DATE] at 5:55 p.m., LVN "H" said she frequently worked the night shift, adding CNAs usually never checked on the independent residents during the night hours. LVN "H" said some of the residents, including Resident #1, did not want to be disturbed during the nights. LVN "H" said staff during the night shift only focused on residents who were heavier care and who required assistance with toileting during the nights.