Every finding on record at Hertford Rehabilitation and Healthcare Center

Based on record review, resident, and staff interviews, the facility failed to document and provide written information to residents/representatives regarding their right to refuse medical/surgical treatment or to formulate an advance directive for 7 of 13 residents reviewed for advance directives (Residents #5, #8, #15, #40, #58, #72, and #80). Findings included: a. Resident #72 was admitted to the facility on [DATE]. Resident #72 had a Full Code physician order dated 10/6/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact. An interview was conducted with Resident #72 on 7/29/26 at 9:30 AM. Resident #72 stated that he did not recall receiving written education regarding advance directives. There was no documentation in Resident #72's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. b. Resident #80 was admitted to the facility on [DATE]. Resident #80 had a Full Code Physician order dated 7/27/26. An in-progress Medicare 5-day MDS assessment dated [DATE] revealed Resident #80 was cognitively intact. During an interview with Resident #80 on 7/29/26 at 9:24 AM she stated that she did not recall receiving written education regarding advance directives. There was no documentation in Resident #80's medical record for education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. c. Resident #58 was originally admitted to the facility on [DATE]; he was readmitted on [DATE]. Resident #58 had a Do Not Resuscitate (DNR) physician order dated 3/12/25. A quarterly MDS assessment dated [DATE] revealed Resident #58 was moderately cognitively impaired. There was no documentation in Resident #58's medical record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. Attempts to contact the Resident Representative (RR) were unsuccessful. d. Resident #40 was admitted to the facility on [DATE]. Resident #40 had a Full Code physician order dated 12/26/16. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was assessed as having severe cognitive impairment. There was no documentation in Resident #40's medical record that education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. Attempts to contact the Resident Representative (RR) were unsuccessful. e. Resident #5 was admitted to the facility on [DATE]. Resident #5 had a Full Code physician order dated 5/19/26. An admission MDS assessment dated [DATE] revealed Resident #58 was cognitively intact. During an interview with Resident #5 on 7/27/26 at 3:00 PM he stated that he did not recall receiving written education regarding advance directives. There was no documentation in Resident #5's medical record that education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. f. Resident #8 was admitted to the facility on [DATE]. Resident #8 had a Full Code physician order dated 2/27/26. A quarterly MDS assessment dated [DATE] revealed Resident #8 was cognitively intact. During an interview with Resident #8 on 7/30/26 at 11:10 AM she stated that she did not recall receiving written education regarding advance directives. There was no documentation in Resident #8's medical record that education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. g. Resident #15 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] revealed Resident #15 had a moderate cognitive impairment. There was no documentation in Resident #15's medical record that education regarding formulation of advance directives and/or an opportunity to formulate advance directives was offered. Attempts to interview Resident #15 were not successful. An interview was conducted with the Social Worker (SW) on 7/30/26 at 10:17 AM. She stated she addressed advance directives during her initial conversation with the resident and/or the resident representative. She stated she read to them the facility's code status information and confirmed their initial code status. The SW stated she provided verbal explanation but no written material concerning advance directives was given. She stated she also informed the resident/ RR that they can change their code status at any time by contacting a staff member in the facility, and that staff member would contact her. The SW stated that advanced directives were also reviewed with the resident and/or RR during care plan meetings at which time their current code status was reviewed and either confirmed or changed as requested. The SW further stated she had not been documenting what education she was reviewing with residents and/or their RR regarding advance directives, however, moving forward she would be. An interview was conducted on 7/30/26 at 10:30 AM with the Director of Nursing (DON). The DON stated her expectation was that advance directives were discussed at the time of admission, code status was reviewed and confirmed, and the resident's wishes were followed. She stated the SW was responsible for providing written documentation of advance directives to the resident/RR and the DON was not aware that written documentation was not being provided. The DON further stated advance directives were also discussed and documented with any changes from baseline in a resident's health, as well as during quarterly care meetings. During an interview on 7/30/26 at 11:10 AM with the Administrator, she stated advance directives were discussed with a resident and/or their RR on admission and an acknowledgement form was signed confirming their code status. The Administrator further stated code status was also addressed with any change in condition of a resident, and at quarterly care plan meetings. She further stated the SW should document all advance directives/code status discussions within the social service progress note or the care plan meeting note. An interview was completed on 7/30/26 at 11:20 AM with the Regional Clinical Director. She stated upon admission and during quarterly care meetings a resident should be educated about the full advance directives, not just code status, and the SW should document any written materials and verbal education provided to residents and/or their RR in a progress note or interdisciplinary team care plan note.

Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 1 of 34 days reviewed for sufficient staffing. The findings included: A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 5/01/25 through 6/03/25 was conducted. A review of the daily census posting sheets for 5/25/25 revealed no RN coverage for eight consecutive hours on 5/25/25. In an interview on 6/05/25 at 2:52 PM the Director of Nursing (DON) stated for staff call out, they would call the staffing agency for a nurse to fill an open position. She indicated as it was the Memorial holiday weekend, no facility or agency staff were available to fill the position on 5/25/25. In an interview on 6/05/25 at 11:54 AM the Clinical [NAME] President revealed they did not have a RN on 5/25/25 due to call out.

Based on staff interview and review of the Facility Assessment, the facility failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required and failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies which had the potential to affect 64 of 64 residents. The findings included: Review of the Facility Assessment revealed that the staffing plan listed the number of Nurses (Registered Nurse or Licensed Practical Nurse) and Certified Nursing Assistants (CNAs) noted as the desired number FTE (full-time equivalent, the total number of full-time employees working in an organization) of staff and the professional requirement for those staff members. However, the staffing plan did not address staffing needs for each shift and weekends, or address staffing needs in these areas based on changes to the resident population as required. In addition, the Facility Assessment did not note if a contract or other agreement was in place related to the provider who was responsible for the provision of goods, facility management services, emergency services, transportation, and dialysis services for the facility. An interview was conducted with the Administrator on 6/05/25 at 2:24 PM who indicated she was not aware of the requirement to specifically address the nurse staff shift information according to each unit. She reported she was not aware they needed to list the contract services used at the facility in the Facility Assessment. She indicated she would expect all the contract services to be listed and reviewed annually.

Based on observations, record review, and resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of flies that affected resident rooms 5 of 12 rooms observed on the 300 Hall (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The findings included: Review of the pest control service inspection report dated 5/14/25 revealed the interior and exterior of the facility for general pests as well as spreading granular around the exterior of the foundation of the building. The service inspection report further noted that rodent stations were inspected and baited, the attic was baited for roaches, and a wasp nest was removed on the exterior of the building. There was no mention of a fly program service. a. An observation of room [ROOM NUMBER] on 6/02/25 at 10:41 am was conducted. Multiple flies were visible in the room and were observed landing on the residents beds, over bed tables, heads and arms. The three residents present at the time of the observation were able to swat the flies away. An observation of room [ROOM NUMBER] on 6/03/25 at 12:30 pm was conducted and flies were visible in the room on resident beds and overbed tables. Resident #4, who had moderate cognitive impairment, stated the flies were horrible. b. An observation of room [ROOM NUMBER] on 6/02/25 at 10:52 am was conducted. Many flies were visible in the room on resident beds, residents head, upper body, and bedside table. The two residents present at the time of the observation were able to swat the flies away. c. An observation of room [ROOM NUMBER] on 6/02/25 at 11:11 am was conducted. Many flies were visible in the room and were observed to land on the residents head and arms. The two residents present at the time of the observation were able to swat the flies away. d. An observation of room [ROOM NUMBER] was conducted on 6/02/25 at 11:28 am and flies were observed landing on the blanket, hands, face, and head. Two of the three resident present during the observation were able to swat the flies away. Resident #1 was observed waving his hands by his head to remove flies. Resident #1, who was cognitively intact, reported the flies were always in the room and bothered him. An observation of room [ROOM NUMBER] on 6/03/25 at 2:45 pm was conducted and flies were observed around the resident's head and face. One of the two residents present during the observation was able to swat the flies away. e. An observation of room [ROOM NUMBER] on 6/05/25 at 11:24 am was conducted. The resident was observed in bed sleeping with multiple flies on his legs, back, head, and arms. The resident was able to swat away the flies. An observation of the smoking area was conducted on 6/05/25 at 3:45 pm with the Maintenance Director. The Residents were observed to be sitting outside the smoking exit door under a gazebo with a raised garden bed to the right of the exit door. The smoking area was clean and without debris or garbage. The Maintenance Director lifted the insect trap located at the smoking entrance and it was observed to have some flies attached to the glue strips but the glue strips were not completely covered. The smoking exit door was opened by the Maintenance Director and the blower fan, located on the wall at the smoking exit door, turned on automatically when the door was opened. No flies were observed to enter the facility at the time of the observation when the door was opened and the blower fan was on. During an interview with Nurse Aide (NA) #2 on 6/03/25 at 2:45 she revealed flies have been pretty bad and she stated they are in most rooms on the 300 Hall. NA #2 stated she believed the flies got in by the smoking door area because the residents go out so often to smoke. An interview was conducted on 6/05/25 at 11:26 am with Housekeeper #1 who revealed he did not spray any chemicals for flies at the facility. He stated the Maintenance Director was responsible for the treatment of flies. An interview was conducted with the Director of Nursing (DON) on 6/05/25 at 1:04 pm who revealed the flies had never been as bad as they were right now. The DON stated she believed the flies were entering the facility from the smoking area door because the door was opened for extended periods of time to allow for all the residents to exit and enter. The DON stated the smoking exit door had a blower that would turn on when the door opened to reduce the amount of flies and an insect trap (a wall-mounted fixture with a blue light and glue strips that attracted and trapped flies) was right at the smoking area entrance. She stated the flies were still getting in the facility because of the amount of time it took to get the residents in the door. An interview was conducted with the Maintenance Director on 6/05/25 at 3:24 pm. The Maintenance Director revealed that he was responsible to maintain the insect traps in the facility by changing out the light bulbs and replacing the glue traps. He stated the facility had 6 large wall mounted insect traps in the resident halls and he had started to place smaller insect traps in resident rooms but had not yet gotten to the 300 Hall. The Maintenance Director stated he changed the insect traps by the smoking entrance about every 2 weeks and the other insect traps lasted longer, like once a month. The Maintenance Director stated he did not maintain documentation for how often he changed the glue traps and lights for the insect traps. During an interview on 6/05/25 at 4:31 pm with the Administrator she revealed the facility had identified the need for insect traps in resident rooms and the facility had been working on getting insect traps ordered and installed. The Administrator stated with the weather warming up the number of flies in the facility had increased.

Based on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of use of anticonvulsant medication (Resident #55) and use of anticoagulant medication (Resident #55 and Resident #26) for 2 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses which included convulsions, stroke, and nontraumatic intracranial hemorrhage. Resident #55 had a physician order dated 12/17/24 for levetiracetam (anticonvulsant medication) oral tablet 1000 milligram (mg) give one tablet twice a day for seizure disorder. The Medication Administration Record for March 2025 and April 2025 revealed Resident #55 was administered the levetiracetam as ordered. Review of Resident #55's current and discontinued physician order for March 2025 through April 2025 revealed no orders for an anticoagulant medication. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and was not coded for the use of anticonvulsant medication. The assessment further noted that Resident #55 was coded for the use of an anticoagulant medication. An interview was conducted on 6/04/25 at 12:02 pm with the MDS Nurse who confirmed Resident #55 did not have a physician order for an anticoagulant medication. The MDS Nurse revealed she must have mistakenly clicked anticoagulant medication instead of anticonvulsant medication for Resident #55 when she completed the assessment. During an interview on 6/05/25 at 4:20 pm with the Administrator she stated the MDS Nurse was responsible to ensure that Resident #55's MDS assessment was accurately coded. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses which included stroke. Review of Resident #26's current and completed physician orders for February 2025 through March 2025 revealed no orders for anticoagulant medication. The Minimum Data Set (MDS) end of Medicare Part A assessment dated [DATE] revealed Resident #26 had moderate cognitive impairment and was coded for use of an anticoagulation medication. During an interview on 6/04/25 at 12:02 pm with the MDS Nurse she confirmed Resident #26 was not prescribed an anticoagulant medication. The MDS Nurse stated she must have incorrectly coded Resident #26's MDS assessment in the area of anticoagulant medication. An interview was conducted on 6/05/25 at 4:20 pm with the Administrator. She stated the MDS Nurse was responsible to ensure that Resident #26's MDS assessment was accurately coded.

Based on observations, record review, staff interviews, and Responsible Party (RP) interview, the facility failed to provide an ongoing resident centered activities program that included one on one (1:1) activities to meet the interests of a resident who did not participate in group activities for 1 of 1 resident reviewed for activities (Resident #55). The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit and nontraumatic intracranial hemorrhage (bleed in the brain tissue that occurs without any trauma). The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and no speech. Resident #55's assessment of daily and activity preferences revealed it was important for family or significant other to be involved in the care discussion and he enjoyed listening to music. There were no other activity preferences noted. Resident #55's care plan last reviewed on 4/09/25 revealed Resident #55 was dependent on staff for meeting emotional and social needs with a goal to maintain involvement in cognitive stimulation and social activities. The care plan had interventions which included providing the resident with materials for individual activities as desired, invite the resident to scheduled activities, and ensuring that the activities the resident is attending were compatible with physical and mental capabilities. Review of the Kardex (resident care guide) revealed Resident #55's activities were to include one to one (1:1) program, group events, group programs, and self-directed activity. Review of the activity participation record for the month of May 2025 revealed no documentation that Resident #55 participated in any facility activity. Review of the 1:1 program record for the month of May 2025 revealed no documentation that Resident #55 had participated in any 1:1 activity. Review of the group events, group programs, and self-directed activity record for the month of May 2025 revealed no documentation that Resident #55 had participated in any group events, group programs, or self-directed activity. Observations were conducted on 6/02/25 at 10:32 am and 11:28 am revealed Resident #55 was in bed with his head turned toward the window and the wall mounted television was turned on. Resident #55 turned and made eye contact with the surveyor upon entering the room but he was unable to participate in an interview. There was no radio observed in Resident #55's room. A telephone interview was conducted on 6/02/25 at 11:26 am with Resident #55's RP who revealed she was concerned that the facility did not include the resident in activity programs. The RP stated that Resident #55 was only in the room in bed when she or other family visited the facility and was not observed to be engaged in any activities. The RP stated Resident #55 enjoyed watching football and basketball and listening to music before he was admitted to the facility. The RP stated she did not recall being asked by anyone at the facility what Resident #55's interests were. Observations were conducted on 6/03/25 at 9:39 am, 12:37 pm, and 2:53 pm revealed Resident #55 was in bed with the wall mounted television turned on. There was no radio observed in Resident #55's room. An interview was conducted with Nurse Aide (NA) #1 on 6/03/25 at 12:37 pm who revealed she did not observe Resident #55 in any facility group activities or any activity staff in the room with him when she worked. NA #1 stated she was not aware of any particular activity that Resident #55 enjoyed but she stated the television in the room was on all the time. During an interview on 6/03/25 at 2:47 pm NA #2 revealed she did not see Resident #55 participate in any facility activities. NA #2 stated she believed he liked to listen to the television so she left the television on for him. The Activity Director was interviewed on 6/03/25 at 2:53 pm who reported that resident 1:1 activities were documented in the electronic health record when the activity was completed and she attempted to complete resident 1:1 activities at least once weekly for 10 minutes. The Activity Director stated Resident #55 had been to one facility activity that she was aware of in the past, but he had not been taken to any activities during the last few months. She was unable to recall when Resident #55 participated in a 1:1 visit, group activity, or group event. The Activity Director stated Resident #55 had a television in his room and she believed he had a radio in the room as well that could be turned on by her or floor staff when he wanted. An interview was conducted with the Director of Nursing (DON) on 6/05/25 at 1:06 pm who revealed the Activity Director was responsible for determining what 1:1 activities would be appropriate for Resident #55. During an interview with the Administrator on 6/05/25 at 4:24 pm she revealed the Activity Director was responsible to provide Resident #55 with activities that addressed the needs of the resident.

Based on record review, and staff and Consultant Pharmacist interviews, the facility failed to have effective systems in place for the return of discontinued controlled medications to the pharmacy which resulted in the controlled medication being diverted from the medication storage cart for 1 of 2 residents reviewed for misappropriation of residents' property (Resident #44). The findings included: Review of the Disposal of Medications Policy dated 1/24 read in part: Discontinued medications and/or medications left in the nursing care center, are identified and removed from current medication supply in a timely manner according to state and federal regulations for disposition. Resident #44 was admitted to the facility on [DATE]. Review of a physician's order for Resident # 44 dated 11/15/24 read, Oxycodone (a narcotic pain medication) 5 milligrams (mg) by mouth every six hours as needed for pain. The order was discontinued on 11/29/24. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact and was on a scheduled pain medications regimen. He received opioid medication during the lookback period. A review of the December 2024 narcotic/control substance count sheet revealed on 12/9/24 Medication Aide #1 received the medication cart with 22 narcotic cards, and the count was validated by Nurse #3. Review of the pharmacy packing slip dated 11/26/24 revealed the facility received 8 doses of Oxycodone/Acetaminophen 5/325 mg for Resident #44. Review of the November 2024 MAR revealed no doses of Oxycodone/Acetaminophen 5/325 mg were administered to Resident #44 before it was discontinued on 11/29/24. A review of the initial allegation report dated 12/9/24 revealed the facility became aware of the misappropriation of facility property on 12/9/24 at 2:45 PM when the Director of Nursing (DON) reconciled the narcotic medications and found that the counts were not correct as documented. An allegation of misappropriation of resident property was submitted for Resident #44 and Medication Aide #1 was suspended pending the outcome of the investigation. The initial report was submitted by the previous Administrator. A review of the 5-day investigation report dated 12/13/24 revealed the allegation of misappropriation of facility property was substantiated. Medication Aide #1 was terminated on 12/10/24. The DON noted the number of narcotic sheets, and the number of narcotic cards was off by two. Resident #44 was found to be missing a medication card containing 8 Oxycodone/Acetaminophen 5/325 (milligram) mg tablets. This medication had been discontinued and the medication card had not been removed by the Nursing Administration from the medication cart. An attempt to interview Medication Aide #1on 6/5/25 at 3:45 PM was unsuccessful. An attempt to contact Nurse #3 on 6/5/25 at 3:48 PM was unsuccessful. An interview was conducted with the facility Pharmacist on 6/5/25 at 4:04 PM. The Pharmacist verified Resident #44's Oxycodone had not been returned to the pharmacy. The Pharmacist stated the facility was supposed to remove the medication from the medication cart and return the medication back to the pharmacy. The Pharmacist stated a medication disposition was sent back with all medications returned for pharmacy disposal. She added that narcotic medications were placed in a bag and sealed in addition to their being locked in the plastic bin they were sent back in. The Pharmacist stated the facility had a contract with the pharmaceutical company and they did monthly checks of the medication carts to include checking for discontinued medications. An interview was conducted with the previous Director of Nursing (DON) on 6/5/25 at 4:47 PM. She confirmed she was the DON at the time of the medication diversion incident. The DON stated she had come out of the clinical meeting and checked her mailbox outside her door. The previous DON indicated she noticed there was one individual controlled drug record placed in her mailbox on her office door. The previous DON stated she became suspicious because the controlled drug record appeared randomly. The previous DON stated she immediately went to the medication cart to reconcile the narcotics. The previous DON stated the count was off by two narcotic count cards on the 200 Hall Medication Cart on 12/9/24. The previous DON stated one of the two missing narcotic count cards was located during the audit of the 200 Hall medication cart. The previous DON indicated there were 21 narcotic control sheets documented instead of 22 which were verified at the beginning of the shift by Nurse #3. The previous DON further stated she determined the narcotic medication card that belonged to Resident #44 which contained 8 Oxycodone/Acetaminophen 5/325 mg tablets was missing. The previous DON stated at the time of the incident that Nursing Administration was to remove the narcotic medication from the medication cart when the medication were discontinued but there was no specific time frame as to when the discontinued medications were removed from the medication cart. Two nurses were to verify and sign off the amount of medication that was left on the medication card that was being returned to the pharmacy. The amount being returned was documented on to the return medication disposition document (a document that tracks the final location of a medication). The previous DON stated the medication was placed in a sealed pharmacy bag and the sealed bag was then placed in a locked tote with the pharmacy return medication disposition. The previous DON stated the transporter picked up the medication and documentation of the receipt of medication was handed to the nurse for the return. The previous DON stated Medication Aide #1 was terminated on 12/13/24 and charges were filed related to the allegation. An interview was conducted with the Administrator on 6/5/25 at 6:08 PM. The Administrator stated the previous Administrator submitted the investigation report. She stated she had no concerns about misappropriation of resident property since becoming Administrator of the facility.

Based on record reviews, and staff interviews, the facility failed to notify the resident and Resident Representative in writing of the reason for transfer/discharge to the hospital. The deficient practice affected 5 of 5 residents reviewed for hospitalization (Resident #28, Resident #24, Resident #2, Resident #47, and Resident #8). The following included: a.Resident #28 was admitted to the facility on [DATE]. A review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. A review of Resident #28's nursing progress note dated 5/26/25 revealed she was discharged to the hospital on 5/26/25 due to a critical low hemoglobin and altered mental status. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident for 5/26/25. b. Resident #24 was admitted to the facility on [DATE]. A review of Resident #24's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of Resident #24's nursing progress notes revealed she was discharged to the hospital on 4/10/25 gastrointestinal bleeding and returned on 4/16/25. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident for 4/10/25. c. Resident #2 was admitted to the facility on [DATE]. A review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. A review of Resident #2's nursing progress notes revealed he was discharged to the hospital on 8/8/24 to have a tunneled catheter inserted for antibiotic administration and returned on 8/9/24. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident for 8/8/24. d. Resident #47 was admitted to the facility on [DATE]. A review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed he had moderate cognitive impairment. A review of Resident #47's nursing progress notes revealed he was discharged to the hospital on 7/13/24 due to increases shortness of breath with difficulty breathing and returned on 7/17/24. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident for 7/13/24. e. Resident #8 was admitted to the facility on [DATE]. A review of Resident # 8's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of Resident #8's nursing progress notes revealed she was discharged to the hospital on 8/16/24 due to vomiting up blood and returned on 8/19/24. Review of the medical record revealed no written notification of transfer for the Responsible Party or the resident for 8/16/24. An interview conducted with the Social Worker on 6/4/25 at 3:35 PM revealed she had not been sending a written notification of transfer/discharge to the resident or Resident Representative. The Social Worker stated she had been placing a follow-up phone call about the transfer to hospital and notifying the Resident Representative verbally. The Social Worker further stated she sometimes documented the conversation in her personal notebook or in the resident chart. An interview conducted with the Administrator on 6/5/25 at 06:08 PM revealed she was aware a follow-up phone call was to be made to the resident or Resident Representative to inform them of the transfer to the hospital. The Administrator stated she expected that written notification of transfer/ discharge would be sent to the resident and Resident Representative when residents discharge to the hospital. The Administrator further stated that going forward all hospital discharges would be reviewed each day during the morning meeting to make sure the written notifications were sent out.

Based on record reviews and staff interviews, the facility failed to document accurate information on the daily nurse staffing sheets for 34 of 34 days (5/01/25 through 6/03/25) reviewed. The findings included: A review of the Staff Schedule/Assignment Sheets and daily Posted Nurse Staffing Information sheets for 5/01/25, 5/02/25, 5/03/25, 5/04/25, 50/5/25, 5/06/25, 5/07/25, 5/08/25, 5/09/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/24, 6/01/25, 6/02/25 and 6/03/25 revealed discrepancies in the areas of number of unlicensed staff (including Medication Aides (MAs) actual hours worked and actual nursing staff who worked. The Daily Posted Staffing for licensed staff and unlicensed staff documented staff were scheduled to work 2 twelve-hour shifts, when the actual hours worked by unlicensed staff were 3 eight-hour shifts. The number of unlicensed staff and actual hours worked of unlicensed staff (including Medication Aides (MAs) on 1st shift (7:00 AM - 3:00 PM) were incorrect for the following days: for 5/01/25, 5/02/25, 5/03/25, 5/04/25, 50/5/25, 5/06/25, 5/07/25, 5/08/25, 5/09/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/24, 6/01/25, 6/02/25 and 6/03/25. The Daily Posted Staffing for licensed staff and unlicensed staff documented staff were scheduled to work 2 twelve-hour shifts, when the actual hours worked by unlicensed staff were 3 eight-hour shifts. The number of unlicensed staff and actual hours worked of unlicensed staff on 2nd shift (3:00 PM - 11:00 PM) (including MAs) were incorrect for the following days: for 5/01/25, 5/02/25, 5/03/25, 5/04/25, 50/5/25, 5/06/25, 5/07/25, 5/08/25, 5/09/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/24, 6/01/25, 6/02/25 and 6/03/25. The Daily Posted Staffing for licensed staff and unlicensed staff documented staff were scheduled to work 2 twelve-hour shifts, when the actual hours worked by unlicensed staff were 3 eight-hour shifts. The number of unlicensed staff and actual hours worked of unlicensed on 3rd shift (11:00 PM - 7:00 AM) were incorrect for the following days: for 5/01/25, 5/02/25, 5/03/25, 5/04/25, 50/5/25, 5/06/25, 5/07/25, 5/08/25, 5/09/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/26/25, 5/27/25, 5/28/25, 5/29/25, 5/30/25, 5/31/24, 6/01/25, 6/02/25 and 6/03/25. The Daily Posted Staffing for licensed staff and unlicensed staff documented staff were scheduled to work 2 twelve-hour shifts, when the actual hours worked by unlicensed staff were 3 eight-hour shifts. An interview was conducted with the Staffing Scheduler on 6/05/25 at 2:53 PM who revealed she was responsible for completing the Daily Staffing Hours data sheets and confirmed the assignment data sheets were the actual staff that worked on a specific date. She reported she was trained to document the staffing hours for licensed and unlicensed staff for 2 twelve-hour shifts for all licensed and unlicensed staff. In an interview on 6/05/25 at 2:27 PM the Clinical [NAME] President stated the daily staffing information was documented as 2 twelve-hour shifts versus 3 eight-hour shifts for unlicensed staff. In an interview on 6/05/25 at 2:24 PM the Administrator reported with the way the daily staffing was listed, it looked like the actual unlicensed staff hours were off.

Based on record review and staff interviews, the facility failed to have a Registered Nurse (RN) on duty at least 8 hours a day with a facility census of greater than 60 residents for 6 of 91 days reviewed (6/11/2023, 6/18/2023, 6/22/2023, 6/25/2023, 6/28/2023, and 6/29/2023). The findings included: A record review of the schedules for June 2023, revealed there was no RN who worked at least 8 hours on 6/11/2023, 6/18/2023, 6/22/2023, 6/25/2023, 6/28/2023, and 6/29/2023. The daily nurse staff postings revealed the census was 67 on 6/11/2023, 70 on 6/18/2023, 70 on 6/22/2023, 68 on 6/25/2023, 68 on 6/28/2023, and 69 on 6/29/2023. During an interview with the Director of Nursing (DON) on 5/16/2024 at 9:25 a.m. she revealed she was the scheduler at the facility. She revealed she had scheduled an RN for 6/11/2023, 6/18/2023, 6/22/2023, 6/25/2023, 6/28/2023, and 6/29/2023 but the RN called out and she was not able to find coverage. An interview was conducted with the Administrator on 5/16/2024 at 10:22 a.m. He revealed there should be an RN scheduled with a census of more than 60 residents.

Based on observations and staff interviews the facility failed to remove expired medication, date open medications, and failed to refrigerate medication according to the manufacturer's recommendations for 1 of 2 medications cart reviewed (Hall 300). The findings included: During an observation of the Hall 300 medication cart with the Director of Nursing (DON) and Nurse #1 on [DATE] at 1:44 pm the following was observed. The DON and Nurse #1 confirmed all findings before the removal of the items. One glargine insulin injector pen with an expiration date of [DATE] written on the label. One glargine insulin injector pen open, with no open date noted and approximately 60 units of the 100 units of insulin remaining. The manufacturer's recommendations for insulin glargine (a long-acting insulin) recommended should be discarded 28 days after first use. One glargine insulin injector pen unopened with 100 units of the 100 units of insulin remaining. The sticker on the bag which held the unopened glargine insulin injector pen noted, keep in refrigerator. The manufacturer's recommendations for insulin glargine recommended that unopened insulin be stored in the refrigerator at approximately 36 to 46 degrees Fahrenheit. One vial of haloperidol (an antipsychotic medication) 5 milligram/milliliter per injection open, with no open date noted on the vial. One tube of nystatin antifungal cream open, with no open date noted on the on the tube. One tube of ketoconazole antifungal cream open, with no open date noted on the tube. An interview was conducted with Nurse #1 on [DATE] at 1:46 pm who revealed she was agency staff, that was her first day back at the facility and she would clean the cart after her medication pass was completed. A telephone interview was conducted on [DATE] at 8:35 am with Nurse #4, who was assigned to Hall 300 medication cart during the overnight shift prior to the observation, revealed she did not go through the medication cart to look for expired or undated items. Nurse #4 stated she would remove items from the medication cart if she saw they were expired when she passed medications, but she was not aware she was supposed to go through the entire cart. An interview was conducted with the Unit Manager who reported she tried to go through the medication carts weekly to look for expired and undated medications and she stated she would remove any identified items from the medication carts. The Unit Manager stated she believed the Hall 300 medication cart was last checked about a week ago. During an interview on [DATE] at 1:47 pm the DON stated the medication carts were to be checked for expired and undated medications every night by the nurse assigned to the medication cart during the overnight shift. She stated the Unit Manager and the pharmacy consultant completed monthly audits of the medication carts and she had not received information about issues with the medication carts.

Based on observation, record review, and staff interviews, resident interviews, Responsible Party (RP) interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 2/24/22 focused infection control and complaint survey, and the 10/26/21 and 1/31/23 recertification and complaint survey. This was for 7 recited deficiencies on the current complaint and recertification survey of 5/16/24 in the areas of Care Plan Timing and Revision (F657), Activities of Daily Living Care Provided for Dependent Residents (F677), Respiratory/Tracheostomy Care and Suctioning (F695), Registered Nurse (RN) 8 hours/7 Days a Week, Full Time DON (F727), Posted Nurse Staffing Information (F732), Label and Store Drugs and Biologicals (F761), and Infection Prevention and Control (F880). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F657: Based on observations, record review, and staff interviews, the facility failed to update the care plan in the area of contracture management for 1 of 1resident reviewed for limited range of motion (Resident #39). During the recertification and complaint investigation survey of 1/31/23, the facility failed to update a resident's individualized care plan related to discharge and failed to hold a quarterly care plan meeting for residents reviewed for care plans. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the previous administrative team completed the education and auditing and resolved the plan of correction for the deficient practice. The Administrator stated the nursing department was responsible for the initial care plan, but the MDS Nurse was responsible for updating the care plan when the splint was ordered. F677: Based on observation, record review, staff interviews, Resident interview, and Responsible Party (RP) interview, the facility failed to provide incontinence care to residents that were incontinent and dependent on staff for activities of daily living (ADLs) for 2 of 5 residents reviewed (Resident #10 and Resident #217). During the focused infection control and complaint survey of 2/24/22, the facility failed to provide incontinence care for residents reviewed for Activities of Daily Living (ADL). During the recertification and complaint investigation survey of 1/31/23, the facility failed to provide nail care to residents who needed extensive assistance and/or were dependent for Activities of Daily Living (ADL) care. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the previous administrative team completed the education and auditing and resolved the plan of corrections for the deficient practices. The Administrator stated the Director of Nursing was ultimately responsible for ensuring care was provided, but he stated the facility needed a more robust plan of education and thorough monitoring to ensure the deficient practice did not occur again. F695: Based on observation, record review, Resident interview, and staff interviews, the facility failed to obtain a physician order for a continuous positive airway pressure (CPAP) machine for 1 of 1 resident reviewed for respiratory care (Resident #7). During the recertification and complaint investigation survey of 1/31/23, the facility failed to ensure emergency equipment was present at the bedside for residents with tracheostomies. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the previous administrative team completed the education and auditing and resolved the plan of correction for the deficient practice. The Administrator stated he expected that the deficient practice remained resolved, however it was clear the facility needed a more solid plan to ensure compliance. F727: Based on record review and staff interviews, the facility failed to have a Registered Nurse (RN) on duty at least 8 hours a day with a facility census of greater than 60 residents for 6 of 91 days reviewed (6/11/2023, 6/18/2023, 6/22/2023, 6/25/2023, 6/28/2023, and 6/29/2023). During the recertification and complaint investigation survey of 1/31/23, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 53 days of 135 days reviewed for staffing. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the previous administrative team completed the education and auditing and resolved the plan of correction for the deficient practice. The Administrator stated the Director of Nursing (DON) was currently the acting staffing coordinator, but he stated the previous staffing coordinator should have informed her of the need for RN coverage. F732: Based on observations and staff interviews the facility failed to post nurse staffing information in a location that was readily accessible to residents and visitors on 4 of 4 days during the survey (5/13/2024, 5/14/2024, 5/15/2024, and 5/16/2024). During the recertification and complaint investigation survey of 1/31/23, the facility failed to post accurate nurse staffing information for Registered Nurses (RN) for 23 of 43 days reviewed and observed for posted staffing. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the prior deficient practice was resolved by the previous administrative team and the posted nursing staffing location was an area he identified but he did not follow up with the location of the nurse staff posting. F761: Based on observations and staff interviews the facility failed to remove expired medications, date open medications, and failed to refrigerate medications according to the manufacturer's recommendations for 1 of 2 medications cart reviewed (Hall 300). During the recertification and complaint investigation survey of 1/31/23, the facility failed to discard expired medication, date opened insulin and store medication per manufacturers recommendation. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the previous administrative team completed the education and auditing and resolved the plan of correction for the deficient practice. The Administrator stated the DON was responsible for ensuring the carts were checked, but he stated he was not aware of any concerns prior to the current survey. F880: Based on observations, record review, and staff interviews, the facility failed to implement infection prevention program policies and procedures when Nurse Aide (NA) #3 failed to perform hand hygiene after performing incontinence care for 1 of 1 resident observed for incontinence care (Resident #10), and NA #1 failed to perform hand hygiene between resident rooms when passing meal trays (room [ROOM NUMBER] and room [ROOM NUMBER]) for 1 of 1 NA observed during meal tray delivery. During the recertification and complaint investigation survey of 10/26/21, the facility failed to use an approved procedure to clean and disinfect a shared glucometer used for residents reviewed for fingerstick blood glucose tests. The facility also failed to ensure staff performed hand hygiene when passing trays to resident rooms. During the recertification and complaint investigation survey of 1/31/23, the facility failed to maintain a sterile field while performing tracheostomy care. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed the previous administrative team completed the education and auditing and resolved the plan of correction for the deficient practice and the facility had not identified any concern prior to the current survey.

Based on observation, record review, staff interviews, Resident interview, and Responsible Party (RP) interview, the facility failed to protect a resident's right to be free from neglect for 2 of 2 resident reviewed for neglect (Resident #10 and Resident #217). The findings included: This tag is cross-referenced to: F677: Based on observation, record review, staff interviews, Resident interview, and Responsible Party (RP) interview, the facility failed to provide incontinence care to residents that were incontinent and dependent on staff for activities of daily living (ADLs) for 2 of 5 residents reviewed (Resident #10 and Resident #217).

Based on observation, record review, staff interviews, Resident interview, and Responsible Party (RP) interview, the facility failed to provide incontinence care to residents that were incontinent and dependent on staff for activities of daily living (ADLs) for 2 of 5 residents reviewed (Resident #10 and Resident #217). The findings included: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (MS-a chronic disease of the nervous system), and stroke with right sided hemiplegia (paralysis). The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 was cognitively intact, was coded with limited range of motion function of the upper and lower extremities, and the skin was intact. Resident #10 was coded as always incontinent of bowel and bladder and was dependent on staff for activities of daily living (ADLs). Review of the care plan last revised on 4/29/24 revealed Resident #10 had an ADL self -care performance deficit related to MS and stroke with interventions that included the resident was dependent upon staff for bathing, bed mobility, dressing, and personal hygiene. A care plan was in place for bowel and bladder incontinence related to MS and stroke with interventions which included checking frequently and as required for incontinence, and to change frequently. An interview was conducted on 5/13/24 at 12:17 pm with Resident #10 who reported she had asked Nure Aide (NA) #3 to change her brief and clothing at 8:30 am and the care had not yet been provided. Observations and interviews conducted with Resident #10 on 5/13/24 at 1:15 pm, 1:45 pm, and 2:00 pm revealed Resident #10 was still in the same shirt, and she reported she had not been provided personal care or incontinence care as requested in the morning. An interview was conducted with NA #3 on 5/13/24 at 2:07 pm who revealed she was prepared to provide incontinence care for Resident #10 at this time. NA #3 stated she left Resident #10 until this time because she was not a heavy wetter, and she knew Resident #10 could wait until the end of the shift. She stated she did introduce herself in the morning, but she did not provide any care at that time, and she was unable to remember if Resident #10 reported she needed care. NA #3 reported she assisted Resident #10 with the lunch meal but had not provided any other care during her shift. She stated she was assigned to provide care to ten residents on her shift and she was able to get her work done by the end of the shift. NA #3 stated she worked slow and had not had time to provide care to Resident #10 until the end of the shift but stated Resident #10 would be okay to wait until the end of the shift. An observation of Resident #10's incontinence and personal care was conducted on 5/13/24 at 2:10 pm with NA #3. Resident #10's yellow incontinence brief was noted to be saturated and dark in color from the groin to midway up the brief toward the waistline in the front. Resident #10 was turned on her right side by NA #3 and the bottom of the yellow incontinence brief was noted to be dark in color and saturated from groin area up to mid buttock area. An interview was conducted on 5/16/24 at 11:23 am with the Director of Nursing (DON) who revealed Resident #10 should have had the incontinence care and personal care provided when she asked NA #3 in the morning. The DON stated incontinence care should be provided every two hours and as needed throughout a shift. The DON reported NA #3 had not reported she did not have time to complete Resident #10's care or that she was unable to manage her assignment. During an interview on 5/16/24 at 1:49 pm the Administrator revealed the DON was responsible to ensure that Resident #10's care was provided. 45789 2. Resident #217 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, and pneumonitis. Review of the baseline care plan initiated on 5/8/2024 revealed Resident #217 had an ADL self -care performance deficit related to limited range of motion of lower extremities. The care plan revealed Resident #217 required extensive assistance to total care by staff. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #217 was cognitively impaired. He was coded with limited range of motion function of the lower extremities. Resident #217 was coded as always incontinent of bowel and bladder and was dependent on staff for ADLs. During an interview with Resident #217's Representative on 5/13/2024 at 11:56 a.m. she stated she found Resident #217 in bed in a urine soaked brief and blanket when she visited on 5/8/2024 at about 1:27 p.m. In an interview with Nurse #4 on 5/14/2024 3:39 p.m. she revealed she was approached by Resident #217's Representative to provide incontinence care for Resident #217 about 1:30 p.m. on 5/8/2024. She further revealed Resident #217 had last been changed during the morning nursing rounds but was not sure of the time. Nurse #4 stated incontinence care should be provided every two hours and as needed throughout a shift. An interview with Nurse Aide (NA) #4 on 5/14/2024 at 3:16 p.m. revealed on 5/8/2024 she worked on both 100 and 400 halls when she was called by Nurse #4 at 1:30 p.m. to change Resident #217. NA #4 revealed she had 20 residents assigned to her which delayed incontinent care for Resident #217. NA #4 revealed she found Resident #217's brief and linen saturated in urine when she provided incontinence care to him. She further revealed the facility was short-staffed at that time. A review of the daily nurse staff assignment sheet dated 5/8/2024 revealed NA #4 was assigned a total of 14 residents on halls 100 and 400. During an interview with NA #5 on 5/15/24 8:34 a.m. she revealed she was pulled from her assignment on hall 300 on 5/8/2024 at 1:33 p.m. by Nurse #4 to help provide incontinence care for Resident #217. She further revealed Resident #217's brief, bed pad and the bed linen were soaked in urine. During an interview on 5/15/2024 at 11:01 a.m. the Administrator revealed he observed Resident #217 receiving incontinence care before 8:30 a.m. on 5/8/2024. He further revealed Nurse #4 was responsible for ensuring that Resident #217's care was provided.

Based on observation, record review, Resident interview, and staff interviews, the facility failed to ensure that a resident with reported hearing difficulties was evaluated for 1 of 1 resident reviewed for vision and hearing (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with diagnoses which included stroke. Review of Resident #24's care plan last reviewed on 4/24/24 revealed no care plan related to hearing difficulty. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 was cognitively intact and was coded for adequate hearing without the use of a hearing aid. Review of the nursing progress notes revealed no documentation regarding Resident #24's reported hearing difficulties. Review of the active physician orders revealed no orders for an evaluation of Resident #24's reported hearing difficulty. An interview and observation were conducted on 5/13/24 at 2:05 pm with Resident #24. This surveyor had to move close and speak loudly within one to two inches of the right ear for Resident #24 to hear questions. Resident #24 reported to staff that she had a hearing problem and she needed people to get close and talk loudly so she could hear, but she stated no one had checked to see if she needed a hearing aid. An interview was conducted on 5/15/24 at 12:16 pm with Nurse Aide (NA) #2 who revealed she often provided care to Resident #24, and she stated in order to communicate with Resident #24 she needed to get close to her ear or she could read her lips. She stated Resident #24 would put her hand up to her ear and tell you she could not hear and that you needed to be closer, but she did not think that meant she was hard of hearing. NA#2 stated she just thought that was normal that she needed to speak a little louder and get close to communicate with Resident #24. An interview was conducted on 5/16/24 at 9:20 am with the Unit Manager who revealed Resident #24 did not report she had hearing difficulty, but the Unit Manager stated she did need to get close to Resident #24 when she spoke. A telephone interview was conducted with the Nurse Practitioner (NP) on 5/16/24 at 12:49 pm who revealed she was not aware of Resident #24's reported hearing difficulties until she was notified by the Director of Nursing (DON) today while at the facility. The NP stated she saw Resident #24 today and an otolaryngologist (ear, nose, and throat) consultation was ordered. During an interview on 5/15/24 at 12:03 pm with the DON she revealed that she was unable to locate any further documentation regarding audiology consultations for Resident #24. She stated Resident #24 would always say to come closer because she could not hear but she stated she never put it together to have her seen by the audiologist. The DON stated Resident #24 would tell you to come closer when talking so she could hear us, but she did not ask for a hearing aid. An interview was conducted on 5/16/24 at 1:49 pm with the Administrator who revealed he was able to communicate with Resident #24 without difficulty and he was not aware of the reported hearing difficulties, but it will be addressed.

Based on observation, record review, Resident interview, and staff interviews, the facility failed to obtain a physician order for a continuous positive airway pressure (CPAP) machine for 1 of 1 resident reviewed for respiratory care (Resident #7). The findings include: Review of Resident #7's hospital discharge oxygen therapy order requisition dated 11/15/21 revealed an order for non-invasive ventilation CPAP. Resident #7 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea (when the throat muscles relax and block the airway during sleep causing your breathing to be interrupted). Review of Resident #7's care plan last reviewed on 3/7/24 revealed no care plan for the CPAP machine. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact and was not coded for CPAP use. A record review conducted on 5/13/25 of Resident #7's active physician orders revealed there was no order for his CPAP. An interview and observation were conducted on 5/13/24 at 11:15 am with Resident #7 who had a CPAP machine on his bedside table. Resident #7 stated his CPAP machine was used every night, but he stated he thinks he needs a new one because it was blowing a lot of air. A telephone interview was conducted on 5/16/24 at 8:16 am with Nurse #3 who revealed she often provided care for Resident #7 during the 7:00 pm-7:00 am shift. Nurse #3 stated Resident #7 used the CPAP machine every night and that he was able to put on the mask independently and he would ask her to turn it on. Nurse #3 stated she could not recall if there was a physician order for the CPAP, but she stated she thought the order was there. During an interview on 5/16/24 at 9:17 am with the Unit Manager she revealed she was aware Resident #7 had a CPAP machine and that he used it at night. She stated the CPAP machine required a physician order which would at least include when to put it on and when to take it off. The Unit Manager stated physician orders were reviewed during the morning clinical meeting, but she was unable to state why Resident #7 did not have a physician order for his CPAP machine. A telephone interview was conducted with the Nurse Practitioner (NP) on 5/16/24 at 12:45 pm who revealed she was aware Resident #7 used a CPAP machine at night. She stated he did report to her today that he needed to have his CPAP checked so she wrote an order for a new CPAP machine and equipment for Resident #7. The NP stated Resident #7's CPAP machine should have had a physician order. An interview was conducted on 5/16/24 at 9:46 am with the Director of Nursing (DON) who revealed Resident #7 had used his CPAP for a long time and she thought the order was there. The DON stated the physician order for Resident #7's CPAP may have fallen off during a monthly physician order recapitulation (summary) and was missed during the review by nursing. The DON stated a physician order was required for Resident #7's CPAP but she was unable to state how it was missed. An interview was conducted with the Administrator on 5/16/24 at 1:49 pm who revealed the DON was responsible to ensure Resident #7 had a physician order for his CPAP machine.

Based on observations, record review, and staff interviews, the facility failed to implement infection prevention program policies and procedures when Nurse Aide (NA) #3 failed to perform hand hygiene after performing incontinence care for 1 of 1 resident observed for incontinence care (Resident #10), and NA #1 failed to perform hand hygiene between resident rooms when passing meal trays (room [ROOM NUMBER] and room [ROOM NUMBER]) for 1 of 1 NA observed during meal tray delivery. The findings included: The facility policy titled Infection Prevention Program last revised in 2009 revealed the Infection Prevention Program was a comprehensive program that addresses detection, prevention, and control of infections among residents and personnel. The facility policy titled Handwashing/Hand Hygiene last revised in August 2019 revealed that hand hygiene was the primary means to prevent the spread of infections and that all staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy further stated that hand hygiene was to be performed before and after assisting a resident with meals, and before moving from a contaminated body site to a clean body site during resident care. 1. An observation on 5/13/24 at 2:10 pm revealed NA #3 prepared to provide incontinence care to Resident #10. NA #3 donned her gloves and prepared a water basin and wash cloths and proceeded to clean Resident #10 on the front side and then turned the resident on her left side and cleaned her back side and in between her buttocks. NA #3 then placed a clean brief and a clean shirt on Resident #10 without removing her gloves and performing hand hygiene. NA #3 removed her gloves and performed hand hygiene before exiting the room with the trash and linen bags in her hand. An interview was conducted with NA #3 on 5/13/24 at 2:25 pm who reported she did not realize she did not change her gloves after cleaning Resident #10. She stated she normally would put on several pairs of gloves and after cleaning a resident she would remove the dirty gloves and then use the clean gloves that were under the ones she just took off to put on the clothes. NA #3 stated she should have washed up and changed her gloves before she put the new brief and clothes on Resident #10. During an interview on 5/16/24 at 11:23 am with the Infection Preventionist (IP) she revealed NA #3 should have removed the soiled gloves and performed hand hygiene after Resident #10's incontinence care was completed. The IP stated NA #3 should have performed hand hygiene and put on clean gloves before she put the clean brief and clothing on Resident #10. 2. During a continuous observation on 5/15/24 from 8:13 am through 8:24 am on Hall 300, Nurse Aide (NA) #1 was observed to remove a meal tray from the meal cart and enter room [ROOM NUMBER]. She placed the breakfast tray on the overbed table next to the bed and exited the room without performing hand hygiene. A hand sanitizer dispenser was located on the wall to the left of the door frame of room [ROOM NUMBER] upon exiting the room and a bathroom was located in the room. NA #1 was observed to walk to the linen cart, which was down the hall from room [ROOM NUMBER], lift the linen cart cover and obtain a clothing protector and re-enter room [ROOM NUMBER]. NA #1 was not observed to perform hand hygiene by use of the hand sanitizer dispenser on the wall prior to entering room [ROOM NUMBER] with the clothing protector. She was then observed to place the clothing protector on the Resident, reposition the Resident in bed, she touched, and operated the bed control device to raise the head of the bed, and moved the overbed table close to the Resident. NA #1, without performing hand hygiene with soap and water in the bathroom or hand sanitizer located on the wall outside of the room, was then observed to pick up a slice of toast from the meal tray with her bare hands and proceeded to spread butter on the toast and then placed the toast on the meal tray for the Resident to eat. NA #1 then exited the room; she was not observed to have performed hand hygiene with soap and water in the bathroom or use the hand sanitizer dispenser on the wall outside of room [ROOM NUMBER] and retrieved a meal tray from the meal cart and entered room [ROOM NUMBER]. She was observed to place the meal tray on the overbed table for the Resident in room [ROOM NUMBER]and exited the room without performing hand hygiene with soap and water in the bathroom or by the hand sanitizer dispenser which was located on the right side of the door frame on the wall outside of room [ROOM NUMBER]. NA #1 was observed to walk down the hall out of sight of this surveyor. An interview was conducted with NA #1 on 5/15/24 at 11:19 am who revealed she was new to the facility, and she felt busy trying to get the meals out and just forgot to use hand sanitizer or wash her hands. She stated she should have used hand sanitizer between rooms when passing out trays, and she should not have picked up the toast with her hand. She stated she had received education on hand hygiene and when it needed to be done, but she just forgot. During an interview with the Director of Nursing/Infection Preventionist (IP) on 5/16/24 at 11:30 am she revealed NA #1 was new to the facility but had been provided with education regarding hand hygiene. The IP stated NA #1 should have performed hand hygiene between each meal tray, and she should not have touched the resident's food with her hand.

Based on record review and staff interviews, the facility failed to provide written notice of discharge or transfer to the Responsible Party (RP) for 1 of 3 residents reviewed for hospitalization (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. The change in condition assessment dated [DATE] revealed Resident #1 was sent to the hospital due to chest pain. Record review of the nursing progress notes revealed there was no documentation that the Responsible Party (RP) received written notice of discharge or transfer when the resident was sent to the hospital. Review of the progress notes revealed Resident #1 returned to the facility on [DATE]. In an interview with the RP on 5/16/2024 at 1:06 p.m. he revealed he did not receive a written notice of discharge or transfer for Resident #1 for the hospitalization that occurred on 4/13/2024. During an interview with the Social Worker (SW) on 5/16/2024 at 9:44 a.m. she revealed she could not remember if the written notice of discharge or transfer was sent to the RP. She revealed she would usually provide the notice of discharge or transfer to the resident during a discharge or transfer. During an interview with the Administrator on 5/15/2024 at 9:32 a.m. he revealed it was the responsibility of the SW to send a written notice of discharge or transfer to the RP when there is a discharge or transfer.

Based on observations, record review, and staff interviews, the facility failed to update the care plan in the area of contracture management for 1 of 1 resident reviewed for limited range of motion (Resident #39). The findings included: Resident # 39 was admitted to the facility on [DATE] with diagnoses which included stroke with hemiplegia (paralysis) of the right side. Review of the care plan last revised on 3/05/24 revealed Resident #39 had an activities of daily living (ADLs) self-care deficit related to hemiplegia with interventions which included physical and occupational therapy evaluation and treatment. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #39 had severe cognitive impairment and had functional limitations of range of motion of the upper and lower extremities. A physician order dated 4/01/24 revealed occupational therapy splinting hand roll to right hand. A physician order dated 4/01/24 indicated to remove splint (hand roll) right hand at 2:00 pm. Skin checks around area of splint after removal one time a day for contracture management. A physician order dated 4/02/24 stated to apply splint (hand roll) to right hand at 10:00 am. Skin checks around area of splint prior to application one time a day for contracture management. Resident #39's care plan did not reflect the use of hand splint for contracture management. Observations on 5/14/24 at 1:44 pm and 5/15/24 at 2:14 pm revealed Resident #39 was observed with a hand roll in the right hand. An interview was conducted on 5/15/24 at 12:16 pm with Nurse Aide (NA) #2 who revealed Resident #39 used the hand roll in the right hand and it was placed in her hand after morning care was completed. A telephone interview was conducted with the MDS Nurse on 5/16/24 at 11:47 am who reported she received an email (unsure of the date) from the Therapy Manager with a list of residents that used splints to develop a care plan, but she stated she may not have gotten to Resident #39's yet. The MDS Nurse confirmed Resident #39 was listed on the email from the Therapy Manager regarding the right-hand splint for contracture management, but she just had not gotten the care plan done yet. An interview was conducted with the Therapy Manager on 5/16/24 at 12:35 pm who revealed he sent the MDS Nurse information regarding Resident #39's right-hand splint when the order was placed so a care plan could be developed. An interview was conducted on 5/16/24 at 9:46 am with the Director of Nursing (DON) who reported the MDS Nurse was responsible to develop Resident #39's care plan for the right-hand splint. During an interview on 5/16/24 at 1:49 pm the Administrator revealed the MDS Nurse was responsible for development of the care plan for Resident #39's contracture management.

Based on observations and staff interviews the facility failed to post nurse staffing information in a location that was readily accessible to residents and visitors on 4 of 4 days during the survey (5/13/2024, 5/14/2024, 5/15/2024, and 5/16/2024). The findings included: During an initial observation on 5/13/2024 at 10:16 a.m., the Daily Nursing Staff posting could not be located at the lobby and all nursing halls. A further observation on 5/13/2024 at 1:17 p.m., and on 5/13/2024 at 3:17 p.m. revealed the daily nursing staff posting could not be located either in the nursing halls or the lobby. During an observation on 5/14/2024 at 11:42 a.m., the daily nursing staff posting could not be located either in the nursing halls or the lobby. An observation on 5/15/2024 at 9:40 a.m. revealed the daily nurse staff posting was hung on the wall past the nursing station on hall 200 by the Rehab Service entrance which was accessible for staff and residents on hall 200 only. The daily nurse staffing sheet was a white, landscaped 8x10-inch piece of paper inside a folder strapped to the wall. The daily nurse staff posting was not visible or accessible for all residents or visitors to view. Additional observations on 5/16/2024 at 10:15 a.m. and on 5/16/2024 at 12:35 p.m. of the facility's daily nurse staff posting revealed it was hung on the wall past the nursing station on hall 200 by the Rehab Service entrance which was accessible for staff and residents on hall 200 only. The daily nurse staffing sheet was a white, landscaped 8x10-inch piece of paper inside a folder strapped to the wall. The daily nurse staff posting was not visible or accessible for all residents or visitors to view. In an interview with the Director of Nursing (DON) on 5/15/2024 at 9:40 a.m. she revealed she is the scheduler and thought the daily nursing staff posting was in the right location. She stated it should have been posted in a more visible place. She revealed she will move the daily nursing staff posting to an area where all residents and visitors can access it. An interview with the Administrator on 5/16/2024 at 1:20 p.m. revealed the facility's daily staff posting was to be placed in an area that was visible for all residents and visitors to view. He revealed he was aware it was placed in Hall 200 past the nursing station.

Based on observations, record review, staff, Wound Care Physician, and Medical Director interviews, the facility failed to provide ongoing skin assessments, monitor consistently, and ensure treatments and interventions were implemented to prevent pressure ulcer development and worsening for a resident at risk for pressure ulcers who was admitted to the facility without pressure ulcers. On 10/02/22 Resident #67 was identified with a stage 2 pressure ulcer on his sacrum that worsened to a stage 4 pressure ulcer on 11/9/22. On 12/25/22 Resident #67 was diagnosed with osteomyelitis on admission to the hospital. In addition, the facility had a lower level of deficient practice when the facility failed to provide ongoing skin assessments, consistent wound monitoring, and to implement interventions of a low air-loss mattress and turning and repositioning as recommended by the wound care physician for Resident #5. This deficient practice affected 2 of 3 residents reviewed for pressure ulcers (Resident #67 and #5). Immediate Jeopardy began on 11/09/22 when the facility failed to assess and identify a stage 4 sacral pressure ulcer for Resident #67. The immediate jeopardy was removed on 1/28/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the education and the monitoring systems put in place are effective and to address deficient practice for Resident #5. Findings included: 1. Resident #67 was admitted to the facility on [DATE] with diagnoses which included traumatic brain dysfunction and respiratory failure. The head-to-toe skin assessment dated [DATE] at 8:28 AM revealed Resident #67 had no pressure ulcers present on the 7/11/22 admission. Resident #67's care plan initiated on 7/13/22 had a focus for potential impairment to skin integrity related to fragile skin, immobility, and incontinence. The interventions included weekly skin assessments and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. A pressure sore scale for predicting pressure sore risk dated 7/18/22 at 4:28 PM assessed the resident was at high risk. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #67 had severe cognitive impairment and was totally dependent on staff for all activities of daily living including bed mobility. The assessment noted no pressure ulcers, always incontinent of bowel and bladder, was on a scheduled pain medication regimen, received no as needed pain medication, had no weight gain or loss and received 100% nutrition through a feeding tube. The resident had no behaviors or refusal of care. He was coded to have a pressure reducing device for bed. The weekly skin assessments from 7/11/22 through 8/30/22 revealed no pressure ulcers present. The weekly skin assessment dated [DATE] revealed a stage 2 neck pressure ulcer which was treated and resolved on 9/28/22. The weekly skin assessment completed by Nurse #10 dated 9/28/22 revealed moisture associated skin damage to the sacrum. The September 2022 Treatment Administration Record (TAR) revealed the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks three times per day. The weekly skin assessment completed by Nurse #2 dated 10/02/22 revealed a stage 2 pressure ulcer to the sacrum. An interview on 1/27/23 at 2:04 PM with Nurse #2 revealed she was not currently employed at the facility but had been assigned to provide care for Resident #67 three nights per week for the three months she worked at the facility. She stated that wound care treatments were completed during the day and did not remember completing the weekly skin assessment. The care plan was not updated when the sacral pressure ulcer was identified. The quarterly MDS dated [DATE] revealed Resident #67 had severe cognitive impairment and was totally dependent on staff for all activities of daily living including bed mobility. The assessment noted one unstageable pressure ulcer which was not present on admission, always incontinent of bowel and bladder, was not on a scheduled pain medication regimen, received no as needed pain medication, had no weight gain or loss and received 100% nutrition through a feeding tube. The resident had no behaviors or refusal of care. He was coded to have a pressure reducing device for bed, received pressure ulcer/injury care, and application of ointments/medications to other than feet. The October 2022 TAR revealed a continuation of the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks three times per day. An additional treatment order dated 10/14/22 read in part for Collagenase (used to remove dead tissue) ointment applied to sacrum every day. This treatment was not signed as completed on 10/19/22 and 10/22/22. An interview on 1/27/23 at 8:52 AM with Nurse #9 revealed she had obtained the order dated 10/14/22 for Collagenase. She stated she did not remember if the physician assessed the sacral wound or if she called him. She stated she observed the wound when assisting the Nursing Assistant (NA) with resident care on 10/14/22. Nurse #9 also stated she did not complete wound measurements or notify management about this wound. She stated that if she completed the wound care treatments, she signed the TAR. There were no weekly skin checks or pressure ulcer assessment notes after 10/02/22 until 11/09/22. Resident #67 was first assessed and treated by the Wound Care Physician for his sacral pressure ulcer on 11/09/22. His wound evaluation and management summary dated 11/09/22 read, in part, that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 6.5 centimeters (cm) by 5.0 cm by 0.1 cm. The ulcer had moderate serous exudate with 80% necrotic tissue and 20% granulation tissue. His ulcer detail note read, in part, that the resident was seen for initial evaluation and management of recent development of unstageable necrosis pressure injury of the sacrum. His plan of care recommendations included to off-load wound, turn side to side and front to back in bed every 1-2 hours if able, and a low air-loss mattress. His dressing treatment plan recommendations were for an absorbent, antimicrobial dressing applied daily for 30 days and Collagenase ointment applied daily for 30 days. Resident #67's wound evaluation and management summary dated 11/16/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.5 cm. The ulcer had moderate serous exudate with 60% necrotic tissue, 30% slough, and 10% granulation tissue. Resident #67's wound evaluation and management summary dated 11/23/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.9 cm. The ulcer had moderate serous exudate with 70% necrotic tissue, and 30% slough. Resident #67's wound evaluation and management summary dated 11/30/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.8 cm. The ulcer had moderate serous exudate with 20% necrotic tissue, 50% slough, and 30% granulation tissue. Resident #67's wound evaluation and management summary dated 12/07/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.8 cm. The ulcer had moderate serous exudate with 70% necrotic tissue and 30% slough. Resident #67's wound evaluation and management summary dated 12/14/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.9 cm. The ulcer had moderate serous exudate with 60% necrotic tissue and 40% slough. Resident #67's wound evaluation and management summary dated 12/21/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.9 cm with undermining of 4.3 cm at 3 o'clock. There was a deep tissue injury (DTI) noted within the wound bed area. The ulcer had moderate serous exudate with 60% necrotic tissue, 30% slough, and 10% granulation tissue. An interview with the Wound Care Physician on 1/11/23 at 3:00 PM revealed he made recommendations in his wound care notes. He stated he had recommended a low air-loss mattress for Resident #67 on his 11/09/22 recommendations. He also stated that a low air-loss mattress and turning and repositioning were vital to wound healing. Another interview with the Wound Care Physician on 1/27/23 at 11:44 AM revealed he was consulted by the facility to see Resident #67. He stated he could not say how the resident's wound developed, but confirmed it was a stage 4 sacral pressure ulcer when he initially assessed it on 11/09/22. He stated the resident was at high risk for wound development due to his medical comorbidities. The Wound Care Physician stated that he followed the resident weekly and when he saw him on 12/21/22 he noted no signs or symptoms of infection, but the resident had a high biofilm (thin, slimy film of bacteria that adheres to a surface) and necrotic burden (dead tissue that is a physical barrier and is a medium for bacterial growth), so he was at high risk of developing an osteomyelitis infection. The November 2022 TAR revealed a continuation of the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks three times per day. The treatment order dated 10/14/22 for Collagenase to the sacrum was discontinued on 11/09/22. This treatment was not signed as completed on 11/2/22 and 11/4/22. The November 2022 TAR also had an order dated 11/09/22 for Collagenase ointment with an absorbent, antimicrobial dressing to be applied every day. This order was discontinued on 11/16/22. This treatment was not signed as completed on 11/11/22. The November 2022 TAR had an order dated 11/16/22 for Collagenase ointment with an absorbent, antimicrobial dressing to be applied every day. This treatment was not signed as completed on 11/18/22, 11/23/22, and 11/26/22. Resident #67's care plan was updated on 11/29/22 with an additional focus area notation that the resident had a pressure wound to inner buttocks. The goals and interventions were not updated. The weekly skin assessment completed by Nurse #11 dated 12/07/22 revealed a stage 4 pressure ulcer to the sacrum. The wound measurements were 7.0 cm x 5.0 cm x 1.8 cm. An interview with the Nurse #11 on 1/27/23 at 11:23 AM revealed she was an agency nurse and had worked at the facility for a couple of months mostly as the wound care nurse. She stated she rarely saw the resident in a different position and did not feel he was turned or repositioned as he should have been to prevent his pressure ulcers from getting worse or not healing. She stated the hall nurse was responsible for completing the residents' weekly skin assessments. She also stated that they were responsible for completing the residents' wound care treatments if there was no wound care nurse. The Wound Care Physician's wound evaluation and management summary dated 12/21/22 did not indicate concerns about infection and noted moderate serous drainage. The wound was debrided to remove necrotic tissue and biofilm and health bleeding tissue was observed. The wound measurements were 7.0 cm x 5.0 cm x 1.9 cm. The December 2022 TAR revealed a continuation of the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks every shift which was three times per day. This treatment order was discontinued on 12/30/22. The December 2022 TAR had an order dated 11/16/22 for Collagenase ointment with an absorbent, antimicrobial dressing to be applied every day. This order was discontinued on 12/20.22. This treatment was not signed as completed on 12/01/22, 12/09/22, 12/13/22, and 12/17/22. The December 2022 TAR had an order dated 12/20/22 for Collagenase ointment and collagen powder with an absorbent, antimicrobial dressing to be applied every day. This order was discontinued on 12/21/22. The December 2022 TAR had an order dated 12/21/22 for Collagenase ointment and collagen powder and to pack the wound with wound cleanser moistened gauze with an absorbent, antimicrobial dressing every day. This order was discontinued on 12/30/22. This treatment was not signed as completed on 12/23/22. Review of nurses' progress note completed by Nurse #12 dated 12/22/22 revealed Resident #67 tested positive for COVID. Review of nurses' progress note completed by Nurse #2 dated 12/25/22 revealed the resident was sent to the hospital for fever and respiratory distress. Resident #67's care plan initiated on 12/30/22 had a focus for multiple pressure injuries related to incontinence and decreased mobility and was at risk for worsening of wounds and additional breakdown. The interventions included to reposition and/or turn at frequent intervals to provide pressure relief and complete a full body check weekly and document. Review of Resident #67's hospital discharge summary dated 1/05/23 included admission diagnoses of Covid pneumonia and stage 4 decubitus ulcer with osteomyelitis. He was treated with intravenous (IV) antibiotics with a discharge medication list to continue two antibiotics for 32 days. Resident #67's admission skin assessment dated [DATE] indicated he had a stage 4 sacrum pressure ulcer which measured 6.4 cm by 4.0 cm by 2.1 cm. Multiple observations were made on 1/10/23 at 10:00 AM, 11:15 AM, 12:27 PM and 1:09 PM. Resident #67 was observed to lie in the same position with the head of bed at about 45 degrees, face to the right, lying on his back, pillow under left arm, pillow under right side arm/side, feet wearing protective boots, and legs straight. The resident was not observed to make any independent movements and was not interviewable. The resident was observed to be on a low air-loss mattress. An interview with Nursing Assistant (NA) #3 on 1/10/23 at 2:13 PM revealed she was assigned to provide care for Resident #67. She also revealed she was scheduled to work from 7:00 AM until 3:00 PM. She stated she had turned him one time that day during his bath right before lunch. She stated that the resident did not get turned every 2 hours today because she was trying to give other residents their baths. She stated she was familiar with the resident, and she knew he was supposed to be turned every 2 hours. An interview with NA #6 on 1/26/23 at 3:11 PM revealed she was regularly assigned to provide care for Resident #67. She stated she did not turn him completely on his side but used pillows or wedges under his buttocks to reposition him. She also stated she turned him as often as possible but was unable to always turn him every 2 hours. An interview with NA #4 on 1/27/23 at 9:51 AM revealed she had been assigned to provide care for Resident #67 occasionally. She stated that she tried to turn and reposition the resident every 2 hours but that was not always possible if she got busy. An interview with Nurse #8 on 1/10/23 at 1:36 PM revealed she was the assigned nurse for Resident #67. She stated she was his assigned nurse frequently but had only been employed at the facility a short time. She did not provide wound care as there was a wound care nurse. She stated she had never seen him fully turned from one side to the other. She stated she saw pillows placed under one hip then the other to offload pressure on the sacral wound. She stated that he coughed more if turned onto his side. An interview with Nurse #10 on 1/27/23 at 12:02 PM revealed she had been employed at the facility as the wound care nurse for approximately 1 year and no longer worked at the facility. She stated when she first started working at the facility, she often worked 7 days per week, but then worked 3-5 days per week. She stated she completed weekly assessments and provided wound care treatments to Resident #67. She stated that if the TAR wasn't signed, then the treatment had not been done. She stated when she was the wound care nurse, she completed the weekly skin assessments and wound assessments. A wound care observation was completed with Nurse #11 and the Wound Care Physician on 1/11/23 at 3:17 PM revealed Resident #67's sacrum pressure ulcer was 6.5 cm (centimeters) x 4.4 cm x 1.9 cm with moderate serosanguinous exudate. The wound had 3.4 cm undermining (when the wound edges become eroded and a pocket forms beneath the wound edge) at the 3 o'clock position and contained 40% slough and 60% granulation. An interview with the Medical Director on 1/12/23 at 11:11 AM revealed he believed lack of turning and repositioning could contribute to pressure ulcer decline. He also stated he relied on the facility to ensure the wound physician recommendations in their notes were completed. A further interview with the Medical Director on 1/27/23 at 7:58 PM, he revealed he had seen and assessed Resident #67's sacral wound when it was a stage 2 but did not specify a date. He stated that the resident had multiple comorbidities which included his cerebrovascular disease, chronic respiratory failure, and tube feeding nutrition but that the lack of care he received played a part in his sacral wound development. He specified the lack of care as the resident not being turned or repositioned as frequently as necessary to prevent the sacral pressure ulcer from developing and worsening and noted that the resident did not have a pressure ulcer on admission. He also felt that weekly skin checks were important. An interview with the [NAME] President of Clinical Operations on 1/12/23 at 1:45 PM revealed the facility should adhere to the standards of wound management which included turning and repositioning. She also revealed that Resident #67 had significant comorbidities for pressure ulcer development. The Administrator was notified of the immediate jeopardy on 1/27/23 at 1:10 PM. The facility provided the following plan for immediate jeopardy removal: - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Inconsistent nursing leadership led to the compliance failure. The [NAME] President of Quality Assurance completed this root cause analysis on 1/12/2023. Resident #67's skin assessment was completed on 01/27/2023 by the Unit Manager. The braden scale assessment was completed on 01/13/2023 by staff Registered Nurse and scores a 10, which indicates at risk for skin breakdown. Skin assessment shows sacrum stage IV and left heel deep tissue injury. Orders were entered for weekly skin assessments and weekly pressure wound observations, that were not previously in place. Assessments were scheduled for weekly skin and weekly pressure wound observations, that were not previously in place. Turning and repositioning as needed, not previously in place, was added to plan of care tasks, to be signed by Nursing Assistants, indicating the completion of turning and repositioning task occurred each shift. Resident continues on an air mattress. These updates were entered by the Director of Nursing 1/20-1/27/23. Interventions are in place to address pressure ulcers for Resident #67. - Heel protector boots-1/19/23 ordered, Occupational Therapy 1/5/23, turning and positioning, as needed 01/20/23, air mattress- 11/9/22, the facilty's wound care provider's recommendations were reviewed entered as physician's orders on 01/26/23, by the Director of Nursing. Residents with a high risk braden score, were audited on 01/27/2023 by the Director of Nursing. Interventions will be reviewed and implemented, as appropriate. No new residents were identified. Braden assessments were audited for residents triggering to be at risk for skin breakdown. Plans of care will be reviewed for those residents that trigger at risk, by the Director of Nursing, Unit Manager and MDS nurse on 01/27/23, to ensure interventions are current and appropriate. - Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Nurses are being educated by the Unit Manager, regarding documentation of skin assessments, and braden assessments upon admission, with ongoing weekly skin assessments, weekly pressure wound observations, and quarterly braden assessments. Nurses not currently available for education, will receive education by the Unit Manager or Wound Care Nurse prior to assuming their next shift assignment. Nursing education was completed on 1/27/23, and included staff nurses and agency nurses, that are on our current schedules. New hires will receive this education by the Nursing Management team, as part of their nursing orientation. The wound nurse is responsible for the wound management, Monday- Friday, and a nurse will be scheduled on the weekends, for wound care continuity. Should the wound nurse be absent, then the Unit Manager will assume responsibility for wound care. A staff nurse has been identified as the primary wound care nurse effective January 27, 2023 and has been enrolled in a wound care certification program. Date of alleged IJ removal: 01/28/2023 The credible allegation of immediate jeopardy removal was validated by onsite verification on 1/31/23. Interviews conducted with nursing staff revealed they had attended training on Wound Management- Skin and Wound Protocol. The education included Braden scale, weekly skin review which was to be completed by the licensed nurse for each resident weekly. Weekly pressure wound observation tool- to be completed by clinical managers/designee when the weekly assessment is not completed by the Wound NP. Weekly non-pressure wound observation tool -for diabetic ulcers, arterial or vascular ulcers, surgical wound, excoriations, lacerations, abrasions, bruises , or skin tears- to be completed weekly by Clinical Manager/designee if the Wound NP did not access the area. The education also included steps to take if there were changes to the resident's skin integrity or wound outside the scheduled observations. Inservice forms were reviewed and indicated the dates, topics discussed, and the trainer, and included attending staff signatures. A review of the weekly wound observation dated 1/25/23 revealed the resident was seen by the facility's wound clinic and new orders provided. A review of the physician's orders for the month of January 2023 revealed that new orders and recommendations were included on the MAR. A review of the plan of care NA task list report last updated 1/27/23 included skin care, positioning, and skin integrity. A review of the Braden scale audit and verification log revealed 100 % of the residents were reviewed on 1/27/23. The facility had appointed a nurse as Wound Nurse Monday thru Friday and the individual has been signed up for a 2-part wound care certification program effective 1/27/23. An Interview conducted with new wound nurse on 1/31/23 revealed that his schedule would be from 11AM-7PM Monday through Friday. The wound nurse stated when he was not present, there was a backup nurse or another agency nurse that would complete the treatments/wounds. He stated his job entailed being responsible for all the treatments, weekly skin checks, weekly wound assessments, and Braden scales. An interview was conducted with the Director of Nursing (DON) on 1/31/23 at 3:00 PM. The DON stated that the wound care nurse would be responsible for wound care management documentation and validation. An observation of Resident #67 on 1/31/23 at 12:35 PM revealed that he was wearing heel protector boots and a pressure relieving mattress was in place. The facility's Immediate Jeopardy removal date of 1/28/23 was validated. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident and seizure disorder. The baseline care plan dated 8/29/22 had a focus for pressure ulcers present upon admission 8/26/22 and is at risk for further pressure injury development. Resident #5 was initially evaluated and treated by the Wound Care Physician on 8/31/22 for three deep tissue injuries (DTI) and one unstageable sacral pressure ulcer. The Wound Care Physician's evaluation and management summary dated 8/31/22 included recommendations to off-load wound, turn side to side and front to back in bed every 1-2 hours if able, and a low air-loss mattress. Review of Resident #5's electronic medical record census indicated he was sent to the hospital on 9/01/22 and returned to the facility on [DATE]. Review of Resident #5's head to toe skin check dated 9/14/22 revealed the resident returned to the facility with an additional wound and changes to the previous wounds. The Wound Care Physician's evaluation and management summary dated 9/21/22 had additional wound detail which read in part that the resident returned to the facility after hospitalization for sepsis due to presumed endocarditis complicated by wound infection and strong suspicion for osteomyelitis underlying stage 4 pressure wound of the sacrum. Resident's overall prognosis is poor. There were no weekly skin checks or pressure ulcer assessment notes from 10/06/22 until 10/26/22. Resident #5's quarterly MDS dated [DATE] revealed he had 1 stage 3 pressure ulcer which was present on admission. He had 3 stage 4 pressure ulcers, 2 of which were present on admission. He had 2 unstageable pressure ulcers, none of which were present on admission. He also had 8 unstageable suspected deep tissue injury pressure ulcers, 1 of which was present on admission. Review of Resident #5's head to toe skin check dated 12/30/22 revealed he had eleven pressure areas. The Wound Care Physician's Wound Evaluation and Management Summary note dated 1/04/23 for Resident #5 included staging, measurements, notations of exudate, etiology and the treatment plan for each wound. The summary included that the resident returned to the facility after hospitalization for sepsis likely secondary to urinary tract infection/possible aspiration pneumonia complicated by heart attack likely secondary to sepsis/acute on chronic anemia, acute hypoxic respiratory failure likely secondary to aspiration pneumonitis and acute deep vein thrombosis (DVT) of left subclavian vein. As such, resident has returned to facility with deterioration in surface area and/or depth, and/or increase DTI/slough/necrosis in several wound. Multiple observations were made on 1/10/23 at 10:02 AM, 12:27 PM and 1:09 PM. Resident #5 was observed lying in the same position with the head of bed about 30 degrees, facing upright, lying on his back, arms crossed over lower body, towel under left arm, legs contracted with knees bent. The resident was not interviewable. The was no low air-mattress observed on the resident's bed. An interview with Nursing Aide (NA) #3 on 1/10/23 at 2:13 PM revealed she was assigned to provide care for Resident #5. She stated she had turned him one time that day during his bath right before lunch. She stated that the resident did not get turned every 2 hours today because she was trying to give other residents their baths. She stated she was familiar with the resident, and she knew he was supposed to be turned at least every 2 hours. An interview with Nurse #8 on 1/10/23 at 1:36 PM revealed she was assigned to the hall for Resident #5. She did not provide wound care as there was a wound care nurse. She stated he did not like to be moved and she did not know if the physician was aware of this. She confirmed that Resident #5 did not have a low air-loss mattress and stated his low air-loss mattress was on order and did not know the status. An interview with the Supply Clerk on 1/11/23 at 1:59 PM revealed she ordered a low air-loss mattress when she received a physician's order. She stated she had received an order today for a low air-loss mattress. An interview with the Wound Care Physician on 1/11/23 at 3:00 PM revealed he made recommendations in his wound care notes. He stated he had recommended a low air-loss mattress for Resident #5 and did not know why he did not have one at this time. He also stated that a low air-loss mattress and turning and repositioning were vital to wound healing. He also stated that the resident had multiple medical comorbidities and contractures which contributed to his pressure ulcers. An interview with the Medical Director on 1/12/23 at 11:11 AM revealed he relied on the staff to obtain the low air-loss mattress. He also revealed that Resident #5 had contractures and general decline which contributed to his pressure ulcers. An interview with the [NAME] President of Clinical Operations on 1/12/23 at 1:45 PM revealed the facility should adhere to the standards of wound management which includes turning and repositioning. She also revealed that Resident #5 had significant comorbidities for pressure ulcer development.

Based on record review and staff, and physician interviews the facility failed to obtain and administer Oxycodone/acetaminophen (a controlled substance medication ordered to treat pain) as ordered for a resident who was newly admitted to the facility with a recent fracture of the upper and lower left humerus (a long bone located in the upper arm between the shoulder joint and elbow joint). The resident was transferred to the Emergency Department (ED) for unmanaged pain on two occasions (12/24/22 and 12/30/22) where he was provided with Oxycodone/acetaminophen as ordered which was effective in relieving the resident's pain. The resident reported a pain level on 12/24/22 at an 8 out of 10 (with 10 representing the worst pain imaginable) and on 12/30/22 a 10 out of 10 and he expressed he felt like he was being hit with a hammer. This was for 1 of 1 residents reviewed for pain management. Findings included: Resident #66 was admitted to the facility on [DATE]. His active diagnoses included fracture of the upper and lower left humerus. The hospital discharge summary dated 12/22/22 revealed he was ordered Oxycodone/acetaminophen 5-325 milligrams (a medication which is a combination of oxycodone and acetaminophen) every 4 hours as needed for pain. Resident #66's admission note dated 12/22/22 completed by Nurse #1 revealed he was alert and oriented and admitted for a fracture to the left arm due to a fall. Resident #66 had bruising noted to arms and chest, left flank area. During an interview on 1/10/23 at 2:15 PM Nurse #1 stated Resident #66 was admitted late on 12/22/22 around 7:00 PM. This was when her shift ended and Unit Manager #1 the took over for her when he arrived at the facility. She concluded that all she did was write the admitting note and did not put the resident's orders into their electronic medical records system. She stated this facility did not allow orders to be entered until the resident physically arrived in the facility, so the unit manager put Resident #66's orders in. Resident #66's orders revealed on 12/22/22 he was ordered Oxycodone/acetaminophen 5-325 milligrams by mouth every 4 hours for pain. Review of a text conversation between Physician #1 and Unit Manager #1 on 12/22/22 from 6:06 PM to 6:14 PM revealed the unit manager notified the physician via text message that Resident #66 had admitted from the hospital and the hospital had not sent any hard script for Resident #66's Oxycodone/acetaminophen 5-325 milligrams by mouth every 4 hours as needed. Unit Manager #1 faxed a hard script to be signed to Physician #1 and Physician #1 texted and indicated he would send the hard script to the pharmacy. During an interview on 1/10/23 at 2:39 PM Unit Manager #1 stated when Resident #66 arrived at the facility on 12/22/22 the first question the resident asked was if his pain medication had arrived at the facility yet. Unit Manager #1 explained to him that the medications had not been entered into their system yet, therefore the pharmacy had not filled any of his prescription at that time. He informed the resident that if there was a medication due for him, they had a backup system in the facility to pull the medication for him to cover the break between the hospital and arrival of the medications from the pharmacy to the facility. After speaking with the resident, the Unit Manager began to enter the resident's orders on their electronic records system. He noted Resident #66's order for Oxycodone/acetaminophen 5-325 milligrams required a hard script at their pharmacy since it was a controlled substance, and a hard script was not sent from the hospital. At that point, on 12/22/22, he texted the physician to explain the situation and informed him that they needed the hard script. The doctor sent the order to the pharmacy that evening. The Medication Administration Record (MAR) indicated no Oxycodone/acetaminophen was administered to Resident #66 on 12/22/22. Resident #66's baseline care plan dated 12/23/22 revealed he was care planned for pain. The interventions included to evaluate the effectiveness of pain interventions, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, and notify physician if interventions are unsuccessful or if current complaint is a change from past experience of pain. Review of a text conversation between Physician #1 and Unit Manager #1 on 12/23/22 from 4:35 PM to 5:34 PM revealed Unit Manager #1 again texted the physician regarding Resident #66's pain medication not yet being received. The resident was noted to be complaining of pain as well as the family complaining on his behalf. During an interview on 1/10/23 at 2:39 PM Unit Manager #1 stated on 12/23/22 he was made aware by Resident #66 that he had not received his pain medication. He then sent Physician #1 another text requesting the hard script for the pain medication for Resident #66. Resident #66's MAR for 12/23/22 revealed he received Oxycodone/acetaminophen 5-325 milligrams by mouth on 12/23/22 at 4:51 PM and again at 10:30 PM. These medications were pulled from the facility emergency backup medicine supply machine. A nursing note dated 12/24/22 at 3:32 AM revealed Nurse #2 documented Resident #66 had complaints of pain in his left shoulder which he rated an 8 out of 10. Nurse #2 called the pharmacy for Oxycodone/acetaminophen 5-325 milligrams as the medication for Resident #66 from the facility emergency backup medicine supply machine had run out. Physician #1 was messaged for other options. The pharmacy told the nurse that the Oxycodone/acetaminophen was on the way. A nursing note dated 12/24/22 at 5:00 AM revealed Nurse #2 documented Resident #66 stated he wanted to go to the hospital because he was in pain and couldn't wait for his pain medication to arrive. He was sent to the emergency department. During an interview on 1/11/23 at 8:03 AM Nurse #2 stated in the early morning on 12/24/22, Resident #66 requested pain medication and she identified the Oxycodone/acetaminophen 5-325 milligrams had not arrived at the facility yet. She indicated when she informed Resident #66 that his pain medication had not arrived, the resident requested to be sent to the hospital for pain management as his pain level was 8 out of 10. She stated she sent him to the hospital as he requested for pain management. A nursing note dated 12/24/22 at 10:42 AM revealed Nurse #3 documented Resident #66 returned to facility around 9:15 AM. Resident #66 was alert and oriented with no signs or symptoms of distress and he was ambulatory in his room. The hospital sent 2 Oxycodone/acetaminophen 5-325 milligrams via emergency medical services. During an interview on 1/11/23 at 9:07 AM Nurse #3 stated Resident #66 had a blister pack of Oxycodone/acetaminophen 5-325 milligrams in the medication cart during her shift when he returned from the hospital on 12/24/22. She reported his pain medication was available and provided as needed per orders during her shift and his pain was under control at that time. During an interview on 1/10/23 at 9:45 AM Physician #1 stated Resident #66 was prescribed Oxycodone/acetaminophen 5-325 milligrams every 4 hours as needed for pain on admission to the facility. He indicated on 12/23/22 he was made aware by a nurse that Resident #66 did not have a hard script, there was no Oxycodone/acetaminophen in the building available for him, and they did not have an emergency kit to pull the medication from. Physician #1 sent the hard script to the pharmacy via fax on 12/23/22 which was a Friday. On the morning of 12/24/22 Physician #1 was notified that Resident #66 had not received his pain medication from the pharmacy and had been in enough pain that he requested to be sent to the hospital due to pain. He indicated the resident received his pain medication at the hospital and returned to the facility the same day. During an interview on 1/11/23 at 10:32 AM the Director of Nursing stated the resident came to the facility on [DATE]. She verified there was an issue with obtaining a hard script for Oxycodone/acetaminophen which resulted in this medication not arriving from the pharmacy until 12/24/22. She indicated prior to the arrival of the Oxycodone/acetaminophen 5-325 milligrams from the pharmacy, in the early morning of 12/24/22 Resident #66 requested pain medication and was told the medication was on the way. Resident #66 requested to be sent to the hospital for pain management as his pain level was 8 out of 10. He was sent to the hospital and during the time he was at the hospital, a blister pack with 18 Oxycodone/acetaminophen arrived at the facility. When he returned from the hospital his pain was under control. Resident #66's MAR for December 2022 revealed he received Oxycodone/acetaminophen 5-325 milligrams by mouth on the following dates and times: - 12/24/22 at 11:42 AM, 3:43 PM, and 9:13 PM - 12/25/22 at 4:30 AM, 3:55 PM, and 10:04 PM. - 12/26/22 at 3:03 AM, 8:26 AM, and 6:07 PM - 12/27/22 at 12:46 AM, 5:09 AM, 3:30 PM, and 8:23 PM - 12/28/22 at 1:20 AM, 5:30 AM, 9:31 AM, and 2:23 PM - 12/29/22 at 1:21 AM A nursing note dated 12/29/22 written at 7:43 PM as late entry for 12/29/22 at 10:00 AM revealed Nurse #4 documented Resident #66 was upset that his Oxycodone/acetaminophen 5-325 milligrams was not available at the time requested. Nurse #4 informed Resident #66 they were waiting on the delivery of medication from the pharmacy. As needed Acetaminophen was offered, however, Resident #66 refused. Resident #66's family member arrived at bedside around 10:00 AM and started demanding medication for the resident related to left shoulder pain. During an interview on 1/12/23 at 8:56 AM Nurse #4 stated on 12/29/22 she was informed during change of shift when she came to work that Resident #66's pain medication had run out, but the refill was expected that morning. Resident #66 requested pain medication at some point that morning, but she did not know what time it was. It was later in the morning she believed as therapy was coming to work with the resident, and he stated he would not do therapy without his pain medications. She offered him Acetaminophen which he refused. She indicated he was agitated which she stated was understandable as he indicated his pain was at a 10 out of 10. His medication did not arrive that morning, so the nurse requested the Director of Nursing's assistance to contact the physician and pharmacy. A nursing note dated 12/29/22 at 12:05 PM revealed the Director of Nursing documented Resident #66 had complaints of pain. Resident #66 was noted with no more narcotics in the medication cart or available in the facility emergency backup medicine supply machine. A phone call was made to Physician #1 with a request for a new order for Oxycodone/acetaminophen 10-325 milligrams as 2 tabs were available in the facility emergency backup medicine supply machine and would be available to dispense until his prescription refill arrived that evening. An order dated 12/29/22 revealed Resident #66 was ordered Oxycodone/acetaminophen 10-325 milligrams by mouth every 4 hours for pain. Resident #66's MAR revealed he received Oxycodone/acetaminophen 10-325 milligrams by mouth on 12/29/22 at 12:00 PM and 4:00 PM. Resident #66's Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. His active diagnoses included unspecified fracture of upper and end of left humerus. He was assessed to have frequent pain that had not disrupted his sleep in the past five days but had, over the past 5 days, limited his day-to-day activities because of pain. The worst pain he had experienced in the past 5 days had been a 7 out of 10. He received an opioid 7 of the 7 day look back period. A progress note dated 12/30/22 at 12:38 AM revealed Nurse #2 documented Resident #66 had complaints of severe pain and he no longer had any Oxycodone/acetaminophen 5-325 milligram or 10-325 milligram tablets available in the facility. Resident #66 reported 10 out of 10 pain in left arm and shoulder and current pain management was insufficient at that time. Resident #66 requested to go to the hospital for pain management. A nursing note dated 12/30/22 at 3:48 AM revealed Nurse #2 documented Resident #66 arrived back in facility from the hospital with his pain under control. The medical record indicated Resident #66 discharged home on 12/30/22. During an interview on 1/11/23 at 8:03 AM Nurse #2 stated in the early morning on 12/30/22, Resident #66 requested pain medication and she did not have any Oxycodone/acetaminophen 5-325 milligrams or 10-325 milligrams. She stated she informed the resident she had Acetaminophen and was going to seek other options with the physician as well, and the resident requested to be sent to the hospital for pain management again as his pain level was at a 10 out of 10 and he told her it felt like he was being hit with a hammer. She stated she sent the resident to the hospital and notified the physician. During an interview on 1/10/23 at 9:45 AM Physician #1 stated on 12/29/22 he was called by the Director of Nursing, and she informed him that his 18 Oxycodone/acetaminophen pills had run out. She informed him she had two 10-325 milligram Oxycodone/acetaminophen in the facility, and she requested an order to give the resident this dose of the Oxycodone/acetaminophen while waiting for the pharmacy to deliver the medication. He indicated around 3:00 AM on 12/30/22 a nurse called to inform him that Resident #66 was back in the emergency department due to pain because his Oxycodone/acetaminophen still had not arrived at the facility. Physician #1 reported he was working at the hospital that night and called the emergency department to discuss the resident and the emergency department gave the resident pain medication and sent him back to the facility. The resident was scheduled to discharge home that day and he did discharge home as planned. He stated it was not acceptable to let a resident go without his pain medication. During an interview on 1/11/23 at 10:32 AM the Director of Nursing stated it was not acceptable for a resident to be in severe pain at the facility due to the lack of ordered pain medication in the facility. She revealed this was why they sent him to the hospital both times as there were no other options and his pain needed to be controlled in that moment.

Based on record review and staff, pharmacy, and physician interviews the facility failed to obtain Oxycodone/acetaminophen (a controlled substance medication ordered to treat pain) from their pharmacy for a resident who was newly admitted to the facility with a recent fracture of the upper and lower left humerus (a long bone located in the upper arm between the shoulder joint and elbow joint). The resident was transferred to the Emergency Department (ED) for unmanaged pain on two occasions (12/24/22 and 12/30/22) due to the facility not having Oxycodone/acetaminophen available to the resident in the facility. The resident reported a pain level on 12/24/22 at an 8 out of 10 (with 10 representing the worst pain imaginable) and on 12/30/22 a 10 out of 10 and he expressed he felt like he was being hit with a hammer. This was for 1 of 1 resident reviewed for pharmacy services. Findings included: Resident #66 was admitted to the facility on [DATE]. His active diagnoses included fracture of the upper and lower left humerus. The hospital discharge summary dated 12/22/22 revealed he was ordered Oxycodone/acetaminophen 5-325 milligrams (a medication which is a combination of oxycodone and acetaminophen) every 4 hours as needed for pain. Resident #66's admission note dated 12/22/22 completed by Nurse #1 revealed he was alert and oriented and admitted for a fracture to the left arm due to a fall. Resident #66 had bruising noted to arms and chest, left flank area. During an interview on 1/10/23 at 2:15 PM Nurse #1 stated Resident #66 was admitted late on 12/22/22 around 7:00 PM. This was when her shift ended and Unit Manager #1 the took over for her when he arrived at the facility. She concluded that all she did was write the admitting note and did not perform any assessments and did not put the resident's orders into their electronic medical records system. She stated this facility did not allow orders to be entered until the resident physically arrived in the facility, so the unit manager put Resident #66's orders in. The unit manager would take the orders and put them in their system to order the medications from their pharmacy which would arrive on the next day, and they would use their backup medication system to bridge the gap. Resident #66's physician orders revealed on 12/22/22 he was ordered Oxycodone/acetaminophen 5-325 milligrams by mouth every 4 hours for pain. During an interview on 1/10/23 at 2:39 PM Unit Manager #1 stated when a new admission came into the facility, he waited until the resident arrived with his discharge summary from the hospital. He waited for the resident to arrive from the hospital and utilized the physical discharge summary because there was always a chance that the medication was changed last minute by the hospital. He stated he took the physical paperwork including the discharge summary provided by emergency medical services upon the resident's arrival. He further stated once he had the orders in the discharge summary, he entered the orders in and once they are saved the order is automatically sent to the pharmacy. He stated if they had a medication that was due but had not arrived from the pharmacy or if the resident was asking for an as needed medication which they were able to receive at that time, they would go to the facility emergency backup medicine supply machine system which was a large, locked emergency medications kit. He stated when Resident #66 arrived at the facility on 12/22/22 the first question the resident asked was if his pain medication had arrived at the facility yet. Unit Manager #1 explained to him that the medications had not been entered into their system yet, therefore the pharmacy had not filled any of his prescription at that time. He informed the resident that if there was a medication due for him, they had a backup system in the facility to pull the medication for him to cover the break between the hospital and arrival of the medications from the pharmacy to the facility. After speaking with the resident, the Unit Manager began to enter the resident's orders on their electronic records system. He noted Resident #66's order for Oxycodone/acetaminophen 5-325 milligrams required a hard script at their pharmacy since it was a controlled substance, and a hard script was not sent from the hospital. At that point, on 12/22/22, he texted the physician to explain the situation and informed him that they needed the hard script. The physician sent the order to the pharmacy that evening. Review of a text conversation between Physician #1 and Unit Manager #1 on 12/22/22 from 6:06 PM to 6:14 PM revealed the unit manager notified the physician via text message that Resident #66 had admitted from the hospital and the hospital had not sent any hard script for Resident #66's Oxycodone/acetaminophen 5-325 milligrams by mouth every 4 hours as needed. Unit Manager #1 faxed a hard script to be signed to Physician #1 and Physician #1 texted and indicated he would send the hard script to the pharmacy. The Medication Administration Record (MAR) indicated no Oxycodone/acetaminophen was administered to Resident #66 on 12/22/22 or on 12/23/22 until 4:51 PM. Review of a text conversation between Physician #1 and Unit Manager #1 on 12/23/22 from 4:35 PM to 5:34 PM revealed Unit Manager #1 again texted the physician regarding Resident #66's pain medication not yet being received. The pharmacy had told Unit Manager #1 they had not received the hard script for Oxycodone/acetaminophen, and the resident was complaining of pain. Unit Manager #1 requested the physician send the hard script to a pharmacy nearby for staff to pick up the medication quickly. The physician replied that he would send the script directly to the main pharmacy again and that there had not been a hard script on his fax machine that morning (faxed from Unit Manager #1 the evening prior). During a follow-up interview on 1/10/23 at 2:39 PM Unit Manager #1 stated on 12/23/22 he was made aware by Resident #66 that he had not received his pain medication. He then sent Physician #1 another text requesting the hard script for the pain medication for Resident #66. He asked if this could be sent to a backup local pharmacy nearby to be picked up. Physician #1 asked him where the patient was and if someone had faxed him the hard script. The unit manager told the doctor he had faxed the hard script last night but could fax it to him again. The doctor physician said there wasn't a hard script on his fax machine that morning. Physician #1 sent the script directly to the pharmacy himself. Resident #66's MAR for 12/23/22 revealed he received Oxycodone/acetaminophen 5-325 milligrams by mouth on 12/23/22 at 4:51 PM and again at 10:30 PM. These medications were pulled from the emergency backup medicine supply machine. A nursing note dated 12/24/22 at 3:32 AM revealed Nurse #2 documented Resident #66 had complaints of pain in his left shoulder which he rated an 8 out of 10. Nurse #2 called the pharmacy for Oxycodone/acetaminophen 5-325 milligrams as the medication for Resident #66 from the facility emergency backup medicine supply machine had run out. Physician #1 was messaged for other options. The pharmacy told the nurse that the Oxycodone/acetaminophen was on the way. A nursing note dated 12/24/22 at 5:00 AM revealed Nurse #2 documented Resident #66 stated he wanted to go to the hospital because he was in pain and couldn't wait for his pain medication to arrive. He was sent to the emergency department. During an interview on 1/11/23 at 8:03 AM Nurse #2 stated in the early morning on 12/24/22, Resident #66 requested pain medication and the nurse identified the Oxycodone/acetaminophen 5-325 milligrams had not arrived at the facility yet and did not know why. She called the pharmacy and was told the medication was on the way and would arrive sometime that morning. She indicated when she informed Resident #66 that his pain medication had not arrived yet, the resident requested to be sent to the hospital for pain management as his pain level was 8 out of 10. She stated she sent him to the hospital as he requested for pain management. A nursing note dated 12/24/22 at 10:42 AM revealed Nurse #3 documented Resident #66 returned to facility around 9:15 AM. Resident #66 was alert and oriented with no signs or symptoms of distress and he was ambulatory in his room. The hospital sent 2 Oxycodone/acetaminophen 5-325 milligrams via emergency medical services. During an interview on 1/10/23 at 9:45 AM Physician #1 stated Resident #66 was prescribed Oxycodone/acetaminophen 5-325 milligrams every 4 hours as needed for pain on admission to the facility. He indicated on 12/23/22 he was made aware by a nurse that Resident #66 did not have a hard script, there was no Oxycodone/acetaminophen in the building available for him, and they did not have an emergency kit to pull the medication from. Physician #1 sent the hard script to the pharmacy via fax on 12/23/22 which was a Friday. On the morning of 12/24/22 Physician #1 was notified that Resident #66 had not received his pain medication from the pharmacy and had been in enough pain that he requested to be sent to the hospital due to pain. He indicated the resident received his pain medication at the hospital and returned to the facility the same day. He indicated he saw the resident on 12/26/22 and the resident was fine and did not complain of pain. During an interview on 1/11/23 at 9:40 AM the Director of Client Services for the pharmacy stated the pharmacy received an order for Oxycodone/acetaminophen 5-325 milligrams by mouth every 4 hours as need for pain on 12/23/22 ordered by Physician #1. This order requested 20 pills and two pills had been pulled from the facility emergency backup medicine supply machine so the pharmacy dispensed 18 pills to the facility on [DATE] and this order arrived at the facility on 12/24/22 after the resident went to the hospital. On 12/23/22, after they had received the first order, they also received an order for Oxycodone/acetaminophen 5-325 milligrams by mouth every 4 hours as need for pain, but this order requested 180 pills and was ordered by Physician #1. Because the pharmacy could only fill one of the prescriptions as it was a controlled substance, they filled the 20 pills prescription which had arrived first and did not fill the 180 pills prescription. He stated when a nurse requested to refill any prescription through their electron medical records system at the facility, it would send the request to the pharmacy. Oxycodone/acetaminophen required a hard script for the prescription to be filled so the Pharmacy would request a new order from the facility and then fill the prescription. During an interview on 1/11/23 at 10:32 AM the Director of Nursing stated the resident came to the facility on [DATE]. She verified there was an issue with obtaining a hard script for Oxycodone/acetaminophen which resulted in this medication not arriving from the pharmacy until 12/24/22. She indicated prior to the arrival of the Oxycodone/acetaminophen 5-325 milligrams from the pharmacy, in the early morning of 12/24/22 Resident #66 requested pain medication and was told the medication was on the way. Resident #66 requested to be sent to the hospital for pain management as his pain level was 8 out of 10. He was sent to the hospital and during the time he was at the hospital, a blister pack with 18 Oxycodone/acetaminophen arrived at the facility. When he returned from the hospital his pain was under control. Resident #66's MAR for December 2022 revealed he received Oxycodone/acetaminophen 5-325 milligrams by mouth in the following dates and times: - 12/24/22 at 11:42 AM, 3:43 PM, and 9:13 PM - 12/25/22 at 4:30 AM, 3:55 PM, and 10:04 PM. - 12/26/22 at 3:03 AM, 8:26 AM, and 6:07 PM - 12/27/22 at 12:46 AM, 5:09 AM, 3:30 PM, and 8:23 PM - 12/28/22 at 1:20 AM, 5:30 AM, 9:31 AM, and 2:23 PM - 12/29/22 at 1:21 AM A nursing note dated 12/29/22 written at 7:43 PM as late entry for 12/29/22 at 10:00 AM revealed Nurse #4 documented Resident #66 was upset that his Oxycodone/acetaminophen 5-milligrams was not available at time requested. Nurse #4 called the Pharmacy to inquire on status of medication delivery. Nurse #4 informed Resident #66 they were waiting on the delivery of medication from the pharmacy. As needed Acetaminophen was offered, however, Resident #66 refused. During an interview on 1/12/23 at 8:56 AM Nurse #4 stated on 12/29/22 she was informed during change of shift when she came to work that Resident #66's pain medication had run out, but the refill was expected that morning. Resident #66 requested pain medication at some point that morning, but she did not know what time it was. It was later in the morning she believed as therapy was coming to work with the resident, and he stated he would not do therapy without his pain medications. She offered him Acetaminophen which he refused. She indicated he was agitated which she stated was understandable as he indicated his pain was at a 10 out of 10. His medication did not arrive that morning, so the nurse requested the Director of Nursing's assistance to contact the physician and pharmacy. A nursing note dated 12/29/22 at 12:05 PM revealed the Director of Nursing documented Resident #66 had complaints of pain. Resident #66 was noted with no more narcotics in the medication cart or available in the facility emergency backup medicine supply machine. The Director of Nursing called the pharmacy and discovered the hospital initially sent a prescription for Oxycodone/acetaminophen 5-325 milligrams for a quantity of 20 tablets. Physician #1 also sent a prescription for 180 tablets. The pharmacy only sent the 20 tablets as they could not fill both prescriptions. The other prescription was available at the pharmacy and was now filled and will be delivered that evening. A phone call was made to Physician #1 with a request for a new order for Oxycodone/acetaminophen 10-325 milligrams as 2 tabs were available in the facility emergency backup medicine supply machine and would be available to dispense until his prescription refill arrives this evening. Normally an order would be refilled by the nurse when it ran out and she did not have a way to show if a refill was requested or not by the nurse. She stated the only answer she got from the pharmacy of why the refill had not arrived was because they had two orders and only filled one. An order dated 12/29/22 revealed Resident #66 was ordered Oxycodone/acetaminophen 10-325 milligrams by mouth every 4 hours for pain. Resident #66's MAR revealed he received Oxycodone/acetaminophen 10-325 milligrams by mouth on 12/29/22 at 12:00 PM and 4:00 PM. A progress note dated 12/30/22 at 12:38 AM revealed Nurse #2 documented Resident #66 had complaints of severe pain and he no longer had any Oxycodone/acetaminophen 5-325 milligram or 10-325 milligram tablets available in the facility. Resident #66 reported 10 out of 10 pain in left arm and shoulder and current pain management was insufficient at that time. Resident #66 requested to go to the hospital for pain management. A nursing note dated 12/30/22 at 3:48 AM revealed Nurse #2 documented Resident #66 arrived back in facility from the hospital with his pain under control. The medical record indicated Resident #66 discharged home on 12/30/22. During an interview on 1/11/23 at 8:03 AM Nurse #2 stated in the early morning on 12/30/22, Resident #66 requested pain medication and she did not have any Oxycodone/acetaminophen 5-325 milligrams or 10-325 milligrams. She stated she informed the resident she had Acetaminophen and was going to seek other options with the physician as well, and the resident requested to be sent to the hospital for pain management again as his pain level was at a 10 out of 10 and he told her it felt like he was being hit with a hammer. She stated she sent the resident to the hospital and notified the physician. During an interview on 1/10/23 at 9:45 AM Physician #1 stated on 12/29/22 he was called by the Director of Nursing, and she informed him that his 18 Oxycodone/acetaminophen pills had run out. She informed him she had two 10-325 milligram Oxycodone/acetaminophen in the facility, and she requested an order to give the resident this dose of the Oxycodone/acetaminophen while waiting for the pharmacy to deliver the medication. He indicated around 3:00 AM on 12/30/22 a nurse called to inform him that Resident #66 was back in the emergency department due to pain because his Oxycodone/acetaminophen still had not arrived at the facility. Physician #1 reported he was working at the hospital that night and called the emergency department to discuss the resident and the emergency department gave the resident pain medication and sent him back to the facility. The resident was scheduled to discharge home that day and he did discharge home as planned. He stated it was not acceptable to let a resident go without his pain medication. During an interview on 1/11/22 at 9:40 AM the Director of Client Services for the pharmacy stated on 12/29/22 the Director of Nursing called the pharmacy to check why the prescription had not been filled. The pharmacy explained that because they had filled the order for the 20 pills, they did not fill the order for 180 pills. The Director of Nursing informed the pharmacy that Resident #66 did not have any Oxycodone/acetaminophen 5-325 milligrams available in the facility and the pharmacy indicated they would fill the 180 pill order at that time. The medication would be on the 9 PM run from the pharmacy which meant it would arrive sometime in the early morning. The order for the 180 pills was dispensed on 12/29/22 and arrived at the facility on the morning of 12/30/22. During an interview on 1/11/23 at 10:32 AM the Director of Nursing stated it was not acceptable for a resident to be in severe pain at the facility due to the lack of ordered pain medication in the facility. She concluded this was why they sent him to the hospital both times as there were no other options and his pain needed to be controlled in that moment.

Based on observation, staff interview and record review the facility failed to implement effective systems for administration to ensure that all staff were educated and competent to clean and disinfect a shared glucometer for 2 of 2 medication aides observed to perform fingerstick blood glucose tests with the use of a shared glucometer (Med Aide #1 and Med Aide #2). Immediate Jeopardy began on 10/19/21 when administration did not ensure effective protocols or systems were in place to ensure medication aides were educated and competent to clean and disinfect a shared glucometer. This was evident for 2 of 2 medication aides observed to perform fingerstick blood glucose tests (Med Aide #1 and Med Aide #2). There was no protocol in place to ensure this training and competency and there was not a protocol in place to orient new medication aides. The facility was not able to show that a skills checklist was completed for the 2 medication aides. Immediate Jeopardy was removed on 10/22/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (No actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure the monitoring of systems put into place and to complete facility employee and agency staff in-service orientation and training. The findings included: This tag is cross referenced to: F880 - Based on observations, staff interviews and record review the facility failed to use an approved procedure to clean and disinfect a shared glucometer used for 5 of 5 residents (Resident #15, #2, #50, #38 and #1). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA) approved disinfectant in accordance with the manufacturer of the glucometer increased the likelihood of the spread of blood borne infections between residents. Failure to disinfect a shared glucometer was observed when 2 of 2 medication aides were observed to perform a fingerstick blood glucose test on residents and did not disinfect the glucometer per manufacturer ' s specifications (Med Aide #1 and Med Aide #2). On 10/19/21 at 12:10 PM an interview was conducted with the Assistant Director of Nursing (ADON) who was also the Infection Control Nurse in the facility. The ADON stated she was also was responsible for staff training in the facility. The ADON stated that Med Aide #1 had recently received her certification and had just started working as a med aide. The ADON further stated that Med Aide #1 received orientation on the medication (med) cart for 2-3 days with a nurse until the Med Aide was comfortable. The ADON stated that Med Aide #2 was from an agency and was expected to be able to go straight to the med cart and do the job. The ADON further stated that agency staff received some general orientation to the facility but did not receive training related to medications or the glucometer. On 10/20/21 at 1:20 PM the ADON stated in an interview that Med Aide #1 started working as a Med Aide in the facility on 9/23/21 and had worked under the guidance of Nurse #1. The ADON further stated there was not a training protocol in place for the nurse that trained the Med Aide. The ADON stated Med Aide #1 had worked on the med cart most of the time she worked and would frequently use the glucometer during her shift. The ADON stated that Med Aide #2 had worked in the facility for at least several months and always worked on the med cart and would frequently use a glucometer during her shift to check a fingerstick blood glucose for the residents on her assigned hall. The ADON further stated that Med Aide #1 worked the 7 AM to 7 PM shift and Med Aide #2 worked mostly 7 AM to 7 PM but had worked some 7 PM to 7 AM shifts. On 10/21/21 at 2:20 PM an interview was conducted with Nurse #1 who stated she worked on the med cart with Med Aide #1 for 1-2 days. The Nurse further stated she did not have a protocol for this orientation and discussed things that came up during medication pass. The Nurse stated if they had a fingerstick blood glucose to do they did that. The Nurse stated she would physically wipe the glucometer for 3-5 minutes, then let it air dry. The Nurse further stated she observed Med Aide #1 to clean and disinfect the glucometer for 3-5 minutes while they were talking about other things related to the med pass but did not time her. On 10/20/21 at 11:15 AM the Nurse Consultant stated they had education records from the agency for Med Aide #2, but they did not address the cleaning or disinfecting procedures for the glucometer. On 10/20/21 at 11:42 AM the ADON stated in an interview that Med Aide #1 trained with Nurse #1 for 2-3 days when she first started as a med aide. The ADON further stated she had no documentation that Med Aide #1 was trained on cleaning and disinfecting the glucometer. On 10/20/21 at 10:45 AM the Administrator was notified of the Immediate Jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 10/21/21. The allegation of Immediate Jeopardy removal indicated: The problem identified was that licensed nurses and certified medication aides failed to use the appropriate procedure to clean and disinfect a shared glucometer used for five residents (#15, #2, #50, #38 and #1), required to have a blood sugar glucose. The facility Certified Medication Aides (#1 and #2) were observed not disinfecting the glucometer in between residents on 10/19/21. The administration team did not have adequate evidence of education and training provided prior to staff performing the task. Every resident that receives a fingerstick blood sugar check is at risk. The facility administration team, including the Administrator, Director of Nurses, Assistant Director of Nurses and Unit Manager failed to implement effective policy and procedure for the use of fingerstick blood glucose checks and failed to educate the licensed nurses and certified medication aides of these policies and procedures. The administration failed to ensure training was provided before tasks were assigned and failed to have a process in place to train new staff or agency staff over these policy and procedures for blood glucose management. The Medical Director was made aware and agreed with the steps taken as indicated in our plan of correction. The District Director of Clinical Services educated the administrative team, Administrator, DON, ADON and Unit Manager, over the Infection Control Manual-Glucometer Decontamination policy and procedures for the use of fingerstick blood glucose checks and the management of glucometers and cleaning requirements. This was completed on 10/20/21. The Infection Control Manual-Glucometer Decontamination policy was revised on 10/20/21 to reflect individual use glucometers will be used for each resident versus shared glucometers. The use of shared glucometers has been removed from our policy. On 10/20/21 the Administrator, Director of Nursing and the Assistant Director of Nursing worked with the District Director of Clinical Services and the county Health Department nurse to review the policy and procedure for the use of glucometers with residents, reviewed the manufacturer ' s recommendations for cleaning and disinfecting and developed a plan of action and an education tool for training nurses and certified medication aides over the facility ' s corrective action plan and over the proper management of the residents ' individual glucometer. The administrative corrective plan of action ensured that each resident that has a blood sugar glucose has been given an individually assigned glucometer that has been placed at their bedside as of 10/19/21 by the Director of Nursing (DON). The previously shared glucometers were removed from the med carts. Extra glucometers are available for staff that do the fingerstick blood sugar (FSBS) to ensure new admissions or residents with new orders for FSBS have their own glucometer. This was completed on 10/20/21. On 10/21/21, responsible parties (RP) for residents and those residents that receive fingerstick blood sugar checks have been notified by the Assistant Director of Nursing or Director of Nursing of the potential exposure of blood borne pathogens due to not properly disinfecting a shared glucometer. They were informed that we will be using individual glucometers for each resident. RPs and residents were informed that the local Health Department had been notified and we will be following any recommendations that they provide regarding the potential exposure to blood borne pathogens. The Health Department Nurse, on site 10/21/21, indicated that her recommendations would be completed and provided to the facility in approximately 1 week. The Administrator indicated to the Health Department Nurse that the facility would follow the Health Department recommendations. Current medication aides and licensed nurses have received training by the DON or ADON on the importance of cleaning and disinfecting the glucometer per manufacturer ' s guidelines using the blood glucose monitoring cleaning checklist. The training/education checklist covers the process of cleaning, it will include observation and return demonstration. This checklist indicates the facility will use the (name of) germicidal bleach wipes and the contact time required is 3 minutes. The education includes the purpose for following cleaning check list process for glucometers due to the likelihood of cross contamination and the spread of blood borne pathogens among residents. The education has been provided to all licensed nurses and certified medication aides regarding the procedure for cleaning and disinfecting glucometers, that they will continue to clean and disinfect the individually issued glucometers before and after use that are stored at the residents ' bedside. This education was completed on 10/20/21 by the Director of Nursing and the Assistant Director of Nursing. Effective 10/20/21, no medication aide or licensed nurse will do a fingerstick blood sugar check without the validation of the blood glucose monitoring checklist. This will include agency and new staff. The Director of Nursing will be responsible to ensure licensed nurses and certified medication aide staff are oriented and trained before performing the task of a fingerstick blood sugar check. Continued education will be performed by the DON, ADON or Unit Manager for any new facility nurses of certified med aides and agency staff before the fingerstick blood glucose checks are done. The training/education checklist covers the process of cleaning and will include observation and return demonstration. This checklist indicates the facility will use the (name of) germicidal bleach wipes and the contact time required is 3 minutes. The education includes the purpose for following cleaning check list process for glucometers due to the likelihood of cross contamination and the spread of blood borne pathogens among residents. The facility alleges removal of Immediate Jeopardy 10/22/21. On 10/26/21 from 10:00 AM to 12:45 PM, multiple staff members were interviewed. This included nurses and certified medication aides. All interviewed staff members validated they had attended in-service training regarding glucometers and infection control. Interviewed staff members were aware of the individual glucometers for each resident that required blood glucose checks. Staff stated each glucometer was stored in the resident ' s room with a supply of test strips. Three staff members were observed to perform blood glucose checks. Staff performed hand hygiene, cleaned the glucometer with a disinfecting wipe for the required amount of time and waited for the glucometer to air dry. After testing the resident ' s blood glucose, staff followed the same procedure to clean the glucometer. The glucometer was then returned to a storage case and stored in each resident ' s room. A resident who was cognitively intact reported the staff cleaned the glucometer prior to testing her blood glucose and again afterwards. The facility provided documentation of in-service training for the nurses and the med aides. The training/education checklist covered the process of cleaning and included observation and return demonstration. This checklist indicated the facility would use (name of) germicidal bleach wipes and the contact time required was 3 minutes. The education included the purpose for following the cleaning check list process for glucometers was due to the likelihood of cross contamination and the spread of blood borne pathogens among residents. The facility also had documented audits completed per their credible allegation of compliance. Staff from the local Health Department visited the facility on 10/21/21. During an interview with the Director of Nursing (DON) on 10/26/21 at 12:15 PM, the DON stated she had spoken with the local Health Department and they had no additional recommendations. She reported they had not received an official report from the Health Department. Review of the facility documentation revealed a policy that stated no staff would be allowed to perform blood glucose monitoring without the required training and a return demonstration. Training and return demonstration evidence for all licensed nurses and medication aides was reviewed. The facility ' s credible allegation was validated, and the Immediate Jeopardy was removed on 10/22/21.

Based on observations, staff interviews and record review the facility failed to use an approved procedure to clean and disinfect a shared glucometer used for 5 of 5 residents (Resident #15, #2, #50, #38 and #1) reviewed for fingerstick blood glucose tests. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA) approved disinfectant in accordance with the manufacturer of the glucometer increased the likelihood of the spread of blood borne infections between residents. Failure to disinfect a shared glucometer was observed when 2 of 2 medication aides were observed to perform a fingerstick blood glucose test on residents (Med Aide #1 and Med Aide #2). The facility also failed to ensure staff performed hand hygiene when passing trays to 8 of 8 resident rooms (Rooms #306, #204, #203, #210, #209, #212, #200, and #202). Immediate Jeopardy began on 10/19/21 when Med Aide #1 performed a fingerstick blood glucose test for a resident on her assigned hall using a shared glucometer and did not follow the manufacturer ' s instructions to disinfect the glucometer between residents. Immediate Jeopardy was removed on 10/22/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Example #2 was cited at a scope and severity of D. The findings included: Review of the facility policy titled Glucometer Decontamination dated 02/18 listed the purpose of the policy was to implement a safe and effective process for decontaminating glucometers after use on each resident. The policy statement read: In the event that glucometers are shared within a facility, the glucometer shall be decontaminated with the facility approved wipes following use on each resident. II Cleaning and disinfecting the glucometer: E. Wipe the monitor and ensure it is visibly wet (May wrap glucometer with wipe in order to ensure wet for entire time instructed. G. Allow the monitor to air dry. The manufacturer instructions for the glucometer used by the facility instructed the disinfection procedure as follows: To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. The disinfecting wipe used by the facility was included in the manufacturer ' s list. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe ' s directions for use. Wipe meter dry or allow to air dry. The directions on the container of germicidal bleach wipes used by the facility read: Apply pre-saturated towelette and wipe desired surface to be disinfected. The contact time listed on the container as the time required to kill all bacteria and viruses was 3 minutes. The blood glucose monitor cleaning skills checklist provided by the facility read as follows: 6. Wipe the monitor thoroughly, ensuring it is visibly wet and place on a clean surface. 7. Follow the wipe manufacturer ' s instructions for the length of time the monitor must remain wet. Wrap the monitor with an additional wipe, if necessary, to ensure it remains wet for the required time. 8. Once the appropriate length of time has elapsed, allow the monitor to air dry on a clean surface. 1. On 10/19/21 at 11:40 AM, Med Aide #1 was observed to check a fingerstick blood glucose for Resident #15. The Med Aide was observed to return to the medication cart and used a germicidal bleach wipe and wiped the glucometer front and back for approximately three seconds, disposed of the wipe, dried the glucometer with a tissue, wrapped the glucometer in the tissue and placed it back on the medication cart. During the observation, Med Aide #1 stated that the residents did not have their own glucometer and the one she used, was shared between other residents. The Med Aide stated that at this time she had no further blood glucose checks. A second interview was conducted with Med Aide #1 on 10/19/21 at 2:15 PM. The Med Aide stated she took a med aide class at a local college and they were taught to wipe off the glucometer before and after each resident. The Med Aide further stated the glucometer was supposed to be wet for 15-20 seconds and sit and dry for 3-5 minutes. On 10/19/21 at 4:00 PM, Med Aide #1 stated she knew how to clean the glucometer but was nervous when being observed to do the fingerstick blood glucose. A review of each resident ' s electronic medical record revealed the following: --In addition to the blood glucose level observed to be checked by Med Aide #1 on 10/19/21 at 11:40 AM, Resident #15 also had her blood glucose results documented by Med Aide #1 on 10/14/21 at 12 Noon and 4:00 PM. --In addition, Resident #2 had a blood glucose documented as checked by Med Aide #1 at 8:00 AM and prior to lunch on 10/19/21. A blood glucose was also documented for Resident #2 on 10/14/21 at 12 Noon and 4:00 PM by Med Aide #1. --In addition, Resident #50 had a blood glucose documented as checked by Med Aide #1 on 10/19/21 at 8:00 AM and on 10/14/21 at 12 Noon and 4:00 PM. On 10/19/21 at 12:10 PM the Assistant Director of Nursing (ADON) who was also the Infection Control Nurse stated in an interview that Med Aide #1 was oriented on the medication cart for 2-3 days by one of the nurses until the Med Aide felt comfortable. The ADON stated the staff was to disinfect the glucometer before and after use because the glucometer was shared between residents. The ADON further stated the staff were to use the wipes to clean the glucometer and wait for 5 minutes to dry. On 10/19/21 at 2:00 PM the Administrator provided the date that Med Aide #1 started on the medication cart as being 9/23/21. The Nurse Consultant stated in an interview on 10/19/21 at 2:10 PM, that the glucometer was supposed to be disinfected with the bleach wipe and the contact time was the time listed on the bleach wipe container which was 3 minutes. The Nurse Consultant further stated the glucometer was shared between residents. The Nurse Consultant stated they would begin in-services immediately to educate the staff on the proper way to disinfect the glucometer. The Nurse Consultant stated they had ordered and received individual glucometers for residents that required fingerstick blood glucose tests. 2. On 10/19/21 at 11:48 AM, Med Aide #2 (agency) was observed to do a fingerstick blood glucose on Resident #38. The Med Aide was observed to return to the medication cart and removed an approved wipe and wiped the glucometer for approximately 5 seconds, disposed of the wipe and wrapped the glucometer in a tissue and placed in a drawer on the medication cart. On 10/19/21 at 2:15 PM Med Aide #2 stated in an interview she had been a Med Aide for 7 years and had worked for the agency for 1 year. The Med Aide further stated she did not receive training on how to clean a glucometer from the agency but in some of the buildings she had worked, she was told to wipe off the glucometer with the bleach wipe and it needed to be wet for 2-3 minutes. On 10/20/21 at 8:26 AM, Med Aide #2 stated in an interview she knew the glucometer needed to stay wet for 3 minutes, but she had medications to pass and she did not do it. --In addition to the blood glucose level checked on 10/19/21 at 11:48 AM, Med Aide #2 documented a blood glucose for Resident #1 on 10/19/21 prior to lunch. There was also a blood glucose documented on Resident #1 by Med Aide #2 on 10/1/21 and 10/6/21 at 11:30 AM and 4:30 PM. On 10/19/21 at 12:10 PM the Assistant Director of Nursing (ADON) stated in an interview that Med Aide #2 was an agency Med Aide that had worked in the facility for several months. The ADON stated the staff was to clean the glucometer before and after use because they were using a shared glucometer. The ADON further stated the staff were to use the wipes to clean the glucometer and wait for 5 minutes to dry. The Nurse Consultant stated in an interview on 10/19/21 at 2:10 PM that the glucometer was supposed to be disinfected with the bleach wipe and the contact time was the time listed on the bleach wipe container which was 3 minutes. The Nurse Consultant further stated the glucometer was shared between the residents. The Nurse Consultant stated they would begin in-services immediately to educate the staff on the proper way to disinfect the glucometer. The Nurse Consultant stated they had ordered and received individual glucometers for residents that required a fingerstick blood glucose test but had not yet put them in the resident ' s rooms to be used. On 10/20/21 at 10:45 AM, the Administrator was informed of the Immediate Jeopardy. The facility provided a credible allegation of Immediate Jeopardy removal on 10/21/21. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: The facility failed to use the appropriate procedure to clean and disinfect shared glucometers used for 5 residents, #15, #2, #50, #38 and #1, required to have a blood sugar glucose. The facility failed to educate Med Aide #1 and Med Aide #2 on how to clean and disinfect a shared glucometer according to manufacturer ' s instructions when used for multiple residents. Med Aide #1 and #2 were observed not disinfecting the glucometer in between residents on 10/19/21. Each resident that has a blood sugar glucose has been given an, individually assigned glucometer that has been placed at their bedside as of 10/19/21 by the Director of Nursing (DON). The previously shared glucometers were removed from the medication carts. Extra glucometers are available for staff that do the fingerstick blood sugar (FSBS) to ensure new admissions or residents with orders for FSBS ' s have their own glucometer. Current medication aides and licensed nurses will receive training on the importance of cleaning and disinfecting the glucometer per manufacture ' s guidelines using the Blood Glucose Monitoring/Cleaning checklist. This checklist indicates the facility will use the (name of) germicidal bleach wipes and the contact time required is 3 minutes. Education ensures that staff understand, even though the residents have their own glucometers, they still have to clean and disinfect them after every use according to the manufacturer ' s instructions. The education includes the purpose for following cleaning check list process for glucometers due to the likelihood of cross contamination and the spread of blood borne pathogens among residents. This education was started on 10/19/21 by the Director of Nursing and the Assistant Director of Nursing. Effective 10/20/21 no medication aide or licensed nurse will do a fingerstick blood sugar check without the validation of the blood glucose monitoring checklist. This will include agency and new staff. The Director of Nursing will be responsible for keeping up the list of staff training completion of the blood glucose monitoring checklist. The Medical Director was informed by the District Director of Clinical services on 10/20/21 of the Immediate Jeopardy related to shared glucometers and the cleaning/disinfecting procedures required per manufacturer ' s guidelines were not followed. The Medical Director was informed that the Health Department Nurse recommended to proceed with the issuance of individually assigned glucometers. She was informed that this had already been put in place. She did indicate she was going to speak to her supervisor and would give an update of any additional recommendations. She was informed of the conversation with the Medical Director and that education will be provided to all licensed nurses and certified medication aides regarding the procedure for cleaning and disinfecting glucometers. The Health Department Nurse was informed by the Administrator that the facility will follow any recommendations made by the Health Department Nurse. Responsible parties of the affected residents have been notified as of 10/21/21 of the potential for exposure to blood borne pathogens through the use of shared blood glucose glucometers. The Health Department Nurse is on site as of 10/21/21 to evaluate the need for any testing for the affected residents. The Administrator has informed the Health Department Nurse that her recommendations will be followed. The facility alleges removal of Immediate Jeopardy on 10/22/21. On 10/21/21 at 1:55 PM the Health Department Nurse stated in an interview that she had looked at every chart to see who got fingerstick blood sugar (FSBS) test and no one that had orders for a FSBS had [CONDITION(S)] and there were no residents in the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse further stated she would pass her findings on to the city branch who would make the recommendations. The Nurse stated it would take up to a week at the most for her to get the recommendations back to the facility, but it would probably not take that long. On 10/26/21 from 10:00 AM to 12:45 PM multiple staff members were interviewed. This included nurses and medication aides. All interviewed staff members validated they had attended in-service training regarding glucometers and infection control. The interviewed staff members were aware of individual glucometers for each resident that required blood glucose checks. Staff stated the glucometer was stored in the resident ' s room in a case with a supply of test strips. Three staff members were observed to perform blood glucose checks. The staff performed hand hygiene, cleaned the glucometer the required amount of time and waited for the glucometer to air dry. After testing the resident ' s blood glucose, staff followed the same procedure to disinfect the glucometer. The glucometer was then returned to the storage case and stored in the resident ' s room. A resident who was cognitively intact reported staff cleaned her glucometer prior to testing her blood glucose and again afterwards. The facility provided documentation of in-service training for the nurses and medication aides. The training/education checklist covered the process of cleaning, observation and return demonstration. This checklist indicated the facility would use the (name of) germicidal bleach wipes and the contact time required was 3 minutes. The education included the purpose for following the cleaning check list process for glucometers was due to the likelihood of cross contamination and the spread of blood borne pathogens among residents. The facility also had documented evidence of audits completed per their credible allegation of compliance. The facility ' s credible allegation of immediate jeopardy removal was validated, and the Immediate Jeopardy was removed on 10/22/21. 2. During an observation of Nurse Aide (NA) #3 on 10/17/21 at 11:55 AM, she retrieved a meal tray from the food cart positioned in the middle of the resident hall, entered room [ROOM NUMBER] and set the food tray directly in front of the resident and uncovered the food. She then exited the room without washing her hands or using sanitizer. NA#3 returned to the food cart, retrieved another meal tray, entered room [ROOM NUMBER], placed the meal tray on the table beside the resident, and exited the room without performing hand hygiene. NA #3 returned to the food cart, retrieved another meal tray, entered rooms # 203, #209, #212, #200, and #202 and completed the same process without performing hand hygiene. During an interview with NA #3 on 10/17/21 at 12:42 PM, she stated she did not perform hand hygiene prior to or upon exiting resident rooms to deliver meal trays. She stated she waited until after she passed all meal trays and then performed hand hygiene. NA #3 stated that it was not necessary to perform hand hygiene between residents. During an interview with the Director of Nursing on 10/20/21 at 9:47 AM who stated staff are to perform hand hygiene before and after delivering each meal tray. An interview was conducted with the Assistant Director of Nursing on 10/20/21 at 10:52 AM and she stated that she was responsible for the facility's infection control program. She explained staff were instructed to use hand sanitizer every time they went in a resident's room and to wash their hands after direct care. She stated NA #3 should have performed hygiene before and after delivering each meal tray. During an interview with the Administrator on 10/20/21 at 3:38 PM he stated staff have been trained to perform hand hygiene when passing meal trays and NA #3 should have performed hand hygiene when passing resident meal trays.

Based on observations, record reviews, staff interviews, resident interview, and Medical Doctor (MD) interview, the facility failed to identify a hazardous construction area adjacent to the sidewalk leading to the 200 Hall entrance of the building used by one of one sampled resident (Resident #1). The area did not restrict access or have any visual caution signage. Resident #1 navigated his motorized wheelchair down the sidewalk. When he attempted to turn the motorized wheelchair around on the sidewalk, one wheel fell off the pavement. Resident #1 fell into a construction trench filled with rocks and the wheelchair fell on top of him. Resident #1 was unable to telephone for help and laid in the trench until a passerby found him. Resident #1 was airlifted to the hospital where he was treated for fractures to his left femur and tibia which required surgery. Immediate Jeopardy began on 3/7/21 when the facility failed to restrict resident access to an uneven sidewalk adjacent to a construction area and Resident #1 and his motorized wheelchair fell into a rock-filled construction trench. The resident was discovered by a passerby forty-five minutes after exiting the building and required emergency services and air lift to the hospital for treatment. The immediate jeopardy was removed on 3/26/2021 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure that the education and the monitoring systems put in place to remove the Immediate Jeopardy are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], lack of coordination, muscle weakness and muscle spasms. Review of Resident #1's annual Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact and required total dependence with 2-person physical assistance with transfers. Resident #1 had range of motion impairment of upper and lower extremities, both sides. Resident #1 used a wheelchair for mobility. A care plan initiated on 1/20/19 had a focus area of Resident #1 had limited physical mobility related to neurological deficits/[CONDITION(S)]/[CONDITION(S)] with a goal that Resident #1 will maintain current level of mobility. Has motorized wheelchair. The interventions included safe to leave grounds with reflector on wheelchair and educate on safety on grounds. A nurse note dated 3/7/21 revealed the nurse responded to a doorbell at the front entrance around 3:15PM. There was a young boy who told her a man turned over his wheelchair in the back of the building. The note further indicated the nurse went out to investigate, she found the resident off the pavement, in the rocks with the wheelchair on top of him. 911 had been dispatched at 3:33PM by the passerby, Emergency Medical Technician (EMT) arrived at 3:45PM. Four EMTs and fire department were needed to remove the wheelchair due to it weighing 400 pounds. The Fall Report dated 3/7/21 by Nurse #1 indicated the incident location was outside. The report indicated Resident #1 did not alert staff prior to leaving the building. It appeared resident was meeting someone outside due to fact that the resident had a case of water on him when he fell outside the building. Resident went out the back door and wheels went off pavement into rocks and wheelchair fell on top of resident. An observation, with the Administrator, on 3/22/21 at 2:50PM of the outside area where the fall occurred, revealed a sidewalk that was uneven which led to the side entrance (200-hall entrance) where Resident #1 had attempted to gain entrance into the facility. It was further observed there was a trench along the perimeter of the facility where construction was occurring. The trench was 2 feet in depth. An observation on 3/23/21 at 9:00AM revealed caution tape was placed across the sidewalk construction site which prevented access to this area. This was not in place on 3/22/21. An observation on 3/23/21 at 6:00PM of the location where the incident occurred revealed a sidewalk located 100' to the right of the main entrance. The sidewalk led to the 200-hall entrance. The concrete on the sidewalk was smooth for 35'. The concrete was uneven and jagged for 20' and then smooth for 10'. Along the inside perimeter of the uneven concrete, there were 2 pieces of [MEDICATION(S)] Chloride (PVC) pipe protruding 2' vertically from the ground. There was a drop off in this section of 2' which was layered with gravel. There was a caution tape at the beginning of the uneven concrete at 3' in height and another caution tape of the end of the uneven concrete at 1' in height. Resident #1 was found located in the trench 12' from the 200-hall entrance and 10' from the wire fencing gate which surrounded the 200-hall porch. The resident's wheelchair was resting partially on the PVC pipe and partially on the resident's right side. During an interview with Resident #1 on 3/22/21 at 12:50PM he revealed he had exited through the front door of the facility to visit with his family member. He further revealed he attempted to re-enter through the 200-hall door which had a keypad. The resident stated he knew the code to gain access independently. Resident #1 further stated the wheel of his wheelchair fell off the pavement into the ground and turned over. Resident #1 stated he went outside unaccompanied and indicated he was able to have outdoor visitation anytime he wanted without scheduling it. A subsequent interview with Resident#1 on 3/22/21 at 3:05PM revealed he had placed a call to his family member from his cell phone for the purpose of arranging a visit. When his family member arrived, an (Nursing Assistant) NA had let him out the front door. Resident #1 further stated he visited with his family member for 5-10 minutes. He stated the family member had provided him a case of water. After the visit, Resident #1 stated he decided to enter through the 200-hall entrance since his room was located just inside the door. Resident #1 stated when he started up the pavement, he observed the gate to the 200-hall to be closed, so he attempted to turn his wheelchair around. At that time, one wheel left the pavement and the wheelchair fell over onto him. Resident #1 stated he was unable to reach his cell phone to call for help. Resident #1 revealed he laid on the ground and waved his arms attempting to get the attention of a passerby, while yelling for help. Resident #1 indicated 4 cars had passed until someone saw him and stopped. Resident #1 revealed he was afraid he was going to lay out there and die. An interview with Nurse #2 on 3/22/21 at 12:59PM revealed she was unaware how Resident #1 exited the facility. Nurse #2 stated she was notified when a young boy rang the doorbell. The young boy informed Nurse #2 there was a gentleman lying on the ground outside. Nurse #2 assessed Resident #1, Emergency Management Services (EMS) arrived and proceeded to care for the resident. An interview on 3/22/21 at 8:20PM with Nurse #1, who was Resident #1's first shift nurse on 3/7/21, revealed she was notified by a co-worker that the resident was on the ground outside. She further stated EMS called the fire department to lift the wheelchair off the resident. She stated she observed a 32 pack of water and a bag of goodies on the ground. Nurse #1 revealed she was unaware Resident #1 was outside, nor was she aware how he got outside. Upon discovering the resident was on the ground outside, Nurse #1 revealed she had completed a mental assessment and stated he appeared to be his 'regular self'. Nurse #1 indicated the co-worker had completed vitals on Resident #1. She stated she observed the resident's leg was bent back. His head was lying in the rocks with the wheelchair laying on top of him. An interview with the Director of Nursing (DON) on 3/22/21 at 10:55AM revealed Resident #1 exited the facility without notifying staff. Resident #1 knew the code to the 200-hall door which was where he exited. The DON stated the resident had been expecting items which were dropped off outside the 200-hall door. The DON further stated when Resident#1 exited the facility, the wheel of his wheelchair got off the curb and Resident #1 fell . An interview on 3/23/21 at 11:30AM with NA #1 revealed she recalled Resident #1's family member was outside the facility when she was leaving at 3:00PM. NA #1 stated she let Resident #1 out the locked front entrance to an area between 2 doors as she was leaving for the day. She further stated the outer door didn't lock. A subsequent interview with NA #1 on 3/24/21 at 2:50PM revealed she did not think it was a problem to leave Resident #1 because he was meeting his family member outside. NA #1 stated she did not think about the fact that Resident #1 could not physically get back into the building. NA #1 stated Resident #1 had his cell phone on him and the resident never went anywhere without his phone. During an interview with Resident #1's family member on 3/23/21 at 12:00PM, she stated she had visited with Resident #1 on 3/7/21. She further stated she arrived at the facility around 2:50PM and visited for 15 minutes. The family member revealed Resident #1 came out the front door by himself to her car, which was parked along the side of the building, about midway down the sidewalk. She stated she had stopped to bring him water and snacks. She indicated there were no staff members outside during the time she visited with Resident #1. The family member expressed her concern that no one was there to assist Resident #1 in getting back into the building. She stated she had offered to assist Resident #1; however, he had declined, stating she was not permitted in the building. The family member stated when she left, Resident #1 was maneuvering his wheelchair toward the front entrance. During a telephone interview with the facility's Medical Director (MD) on 3/30/21 at 12:30PM, he revealed Resident #1 had functional [CONDITION(S)]. The MD stated Resident #1 had a fair amount of use of his arms as he was able to use his cell phone and to play video games. The MD stated he never saw Resident #1 outside other than in the designated smoking area. The MD stated Resident #1 required assistance from staff for all his care needs. The EMS report dated 3/7/21 at 4:05PM, stated, Resident found in isolation construction entrance in the gravel off the walkway, approximately 2 feet below the concrete walkway. The wheelchair was supported by blue [MEDICATION(S)] Chloride (PVC) pipe which was noted across right lower extremity. Left lower extremity was noted to be angulated backwards above the knee. Requested assist from Fire Department to safely remove wheelchair noted to be over 400lbs from patient. Visualized left leg, distal femur deformity, noted with crepitus, skin of lower extremity noted to be ashen in color. Resident was air-flighted to the hospital due to nature of injuries. A telephone interview with EMS #1 on 3/23/21 at 2:22PM revealed the wheelchair was partially off the walkway resting partially on the [MEDICATION(S)] Chloride pipe and Resident #1's right lower extremity. According to the hospital discharge summary record, Resident #1 was admitted on [DATE] with diagnoses that included closed nondisplaced spiral fracture of shaft of left tibia, closed displaced oblique fracture of shaft of left femur, and trauma. On 3/9/21, Resident #1 underwent an operative procedure which included an open treatment, fracture, femur, shaft, with retrograde intramedullary implant insertion, left retrograde femoral nail. The lower left fracture to the tibia was treated using a Rooke boot, a boot that provided complete offloading of the heel while naturally warming the limb. Resident #1 discharged on [DATE] from the hospital to the Nursing home. Discharge instructions included non-weight bearing lower left extremity for 12 weeks post-operatively, range of motion as tolerated, antibiotics and chemoprophylaxis for 6 weeks post-operatively. An interview with the Administrator on 3/24/21 at 12:13PM revealed the facility had no policy regarding blocking off construction areas. An interview with the Maintenance Manager on 3/23/21 at 11:23AM revealed the caution tape along the sidewalk had been blown away and not been replaced. The Administrator was notified of Immediate Jeopardy on 3/25/21 at 10:20AM. On 3/26/21 at 11:42AM the facility provided the following credible allegation of Immediate Jeopardy removal. The credible allegation of immediate jeopardy removal indicated: Hertford Health and Rehabilitation IJ Abatement Plan Hertford Health and Rehab IJ Credible Allegation for F 689 for removal of Immediate Jeopardy completed on March 25, 2021 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as result of noncompliance. Resident #1 was admitted on [DATE] with a diagnosis that included [CONDITION(S)], unspecified lack of coordination, muscle weakness and muscle spasms. On 3/7/21 a young boy rang the bell of the front entrance around 3:15 pm to alert the staff of a man that was turned over in his wheelchair on the facility grounds. The nurse immediately went to investigate and found resident #1 off the pavement, in the rocks with the wheelchair on top of him. 911 had already been dispatched by a passerby so EMT arrived onsite at 3:45 pm. With EMT and the Fire department assistance, they were able to safely remove the wheelchair and the resident was air flighted to the hospital where he was diagnosed with a fracture to the shaft of his left femur and a spiral fracture of the left tibia. The resident was admitted to the hospital where with orthopedic consultation underwent surgical procedures to repair the left leg fractures. He tolerated the procedures well and was readmitted to the facility on [DATE]. The resident's care and services were provided post-operative in the facility as ordered and on 3/23/21, the resident was discharged by Transport services to live with his mother. The facility failed to ensure that a construction area was visibly and adequately marked off as a danger zone and resident number 1 attempted to enter the 200-hall entrance since his room was just inside the door. The resident recognized that he was not going to be able to enter the 200-hall entrance and with an attempt to turn around his wheelchair, one wheel left the walkway and the wheelchair fell over on him. Every resident that is on the outside premises has the potential to be affected. Immediate action the Facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. The facility has developed a policy on 3/25/21 to ensure construction sites are properly marked to prevent access and ensure resident, staff and visitor safety. The maintenance workplace safety policy was amended to include the following: Make sure that construction sites or work areas are designated and properly marked as such to prevent access and to ensure safety. Construction areas or work sites must visibly and adequately be marked - as danger zones. An Ad-hoc QAPI was held on 3/25/21 to review the policy with department managers and the Medical Director. The Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Unit managers will utilize this policy in the all staff education as it relates to construction. Families and residents are being educated regarding the construction sites or work areas are designated and properly marked as such to prevent access and to ensure safety. Construction area or work sites will be visibly and adequately marked off as danger zones. VP of Quality and Customer experience, provided an in-service to the Administrator , Director of Nursing, the District Director of Operations and The District Director of clinical services on how to conduct root cause analysis so that effective interventions can be implemented to prevent reoccurrence on 3/25/21. The facility Maintenance man and the Construction company have marked off the construction sites so that the areas are visibly and adequately marked off as danger zones on 3/25/21. The social services director called the current residents' families on 3/25/21 to alert them of the continued construction on the grounds of the facility. The scripted conversation is as follows: The facility is calling to update you that we are still in the process of our construction project on the facility grounds. We have contractors that are trying to complete the projects outside to help improve the drainage system as soon as possible. When you come to the facility, please pay special attention to the marked off areas with caution tape and other danger zone signs for your safety. Due to the expansive construction projects at this time we will be temporarily suspending window visits, but we are committed to schedule indoor and outdoor visitation per CMS guidelines. Of course, visitation may change based on COVID cases, so when you call for a visit arrangement, we will discuss with you the options at the time. We appreciate your patience and support over the last year. Thank you in advance for paying close attention if you are on the premises for your safety. Please call the facility and ask to speak with our social worker, as we are eager for you to come and visit with us. A letter was also mailed to the responsible parties regarding the construction projects and safety advise, and of the ability to schedule visits by calling the facility. The Administrator, Director of nursing, Assistant Director of nursing started provided in-services to the current staff on 3/25/21. The in-service content is as follows: All staff have the responsibility to assist a resident as needed to exit the facility safely and remain in a safe location while outside of the facility. The facility will honor indoor and outdoor visitation per the CMS guidelines. No employee, Resident or resident Responsible Party / Visitor should enter any part of a construction area as identified by Caution tape, signs, ropes, gates or cones. All construction areas are off limits to all employees accept those assigned duties within a construction area by the Administrator or designated corporate manager. All construction areas are off limits to Residents and any visitor they may have. The scope of the construction area is around the entire facility perimeter where there has been a French drain and a down spout for roof/water runoff. Due to installation of new drain lines, all of the resident room windows are inside the construction danger zone area. An employee who becomes aware of any kind of potential for a breach of the construction areas as identified by caution tape, signs, ropes, barriers or cones should intervein as needed to prevent any safety concerns and or violation to our policy. Any concerns of any violation of employees, residents or visitors not complying with this guideline / policy is responsible to report the concern/incident to the Director of Nursing or Administrator immediately. The Director of Nursing, Assistant Director of nursing and Social worker informed all the residents on 3/25/21 that we are still in the process of our construction project on the facility grounds. We have contractors that are trying to complete the projects outside to help improve the drainage system as soon as possible. We have alerted your responsible part to please pay special attention to the marked off areas with caution tape and other danger zone signs for their safety. Due to the expansive construction projects at this time we will be temporarily suspending window visits but we can schedule outside and inside visitations with your families per the CMS guidelines .We are letting your families know about the visitation options and we are eager to provide you with an opportunity to visit with your loved one. The Facility alleges the removal of the immediate jeopardy on 3/26/2021. The credible allegation was verified on 3/27/21 at 11:00AM as evidenced by record review, observation, staff, resident, and responsible party interviews. Interviews were conducted with a sample of staff members to verify education was conducted for all employees regarding construction site safety, resident safety, and visitation during the construction. Interviews were conducted with a sample of residents to verify education was provided regarding on-going construction at the facility, to include construction site safety, supervision of residents when outside the facility, and visitation policy during the construction. Interviews were conducted with a sample of resident's responsible parties verified education was provided regarding construction site safety and visitation during the construction. The change in visitation affected window visits only which were temporarily suspended. Observation of the construction site revealed all construction areas were marked with 'caution, danger zone' signage, caution tape, construction barriers and orange barrier walls. Observation of notice posted inside the facility regarding construction sites. Documentation of in-service records were reviewed. Review of the letter sent to families and residents. Review of the updated policy on Maintenance Workplace Safety Policy revised March 2021 revealed all construction sites and designated work areas were to be properly marked as such to prevent access and to ensure safety. These areas must visibly and adequately be marked off as danger zones. Review of the QAPI Ad-Hoc Meeting and the Risk Assessment Tool revealed education of Administrative Staff and development of a Risk Assessment Tool. All of the evidence indicated the facility had removed the immediate jeopardy by March 26, 2021.

Based on record review, staff demonstrations and staff interviews, the facility failed to use a mechanical lift according to manufacturer's recommendations for 1 of 7 sampled residents (Resident #5) who had a fall from a mechanical lift while being transferred which resulted in multiple facial fractures. Immediate Jeopardy began on [DATE] for Resident #5. It was identified on [DATE] at 12:35 PM. The Immediate Jeopardy was removed on [DATE] at 6:45 PM and remained at a lower scope and severity of an "E" (Actual Harm that is not Immediate Jeopardy due to examples 2 through 5.) The facility failed to assess and implement interventions to preserve safety and mobility after bed rails were removed and also failed to pad bilateral side rails once the siderails were reapplied for 1 of 7 sampled residents (Resident #3) who experienced falls. The facility failed to implement interventions which were ordered or recommended by the interdisciplinary committee for 1 of 7 sampled residents (Resident #92) who experienced falls. The facility also failed to initiate appropriate fall prevention interventions for 2 of 7 sampled residents (Resident #81 and #83) who experienced falls. Findings include: 1. Resident #5 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. According to the section for positioning of the contour sling from the Manufacturer's (brand name mechanical lift) User's Manual, which was undated, the top edge of the sling fabric (nearest the head) should be slightly above the armpit level of the patient and the bottom edge of the sling fabric should be a few inches above the back of the patient ' s knee. Once the patient is properly positioned on top of the sling fabric, the 4 metal support bars are inserted into the sling pockets located on each end. The hole in the metal bar should be in the center of the pocket opening for the S-hook to be attached. Once the S-hooks are attached, the lift is moved into position to attach the sling hardware to the swivel bar. In the "Lifting the Patient" section of the Manufacturer's User's Manual for use of the (brand name mechanical lift), which was not dated, it was noted that "Chains, O-rings and D-Rings: After the chains, O-Rings or D-Rings are attached and the S-hooks are secured in both sides of the sling sections (open end facing outward), place the D-rings of the strap assemby or the O-ring and chain link of the chain assembly over the chain hooks of the swivel bar." It was noted in a diagram of the (brand name mechanical lift) that the top hooks were named "Strap Hooks" and the lower hook was named "Chain Hooks." A "WARNING" was noted in this section which indicated "When elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that all hardware is properly connected. Check each S-hook to make sure it is completely attached to the metal support bars of the sling. Check the attachment of the straps, O or D-rings to the swivel bar hooks. If any attachments are NOT properly in place, lower the patient back onto the bed and correct this problem." A picture diagram indicated that when the patient was clear of the bed (or chair) surface, a staff member would guide the patient to face the staff who was operating the lift. In detail "B" of the picture diagram, a staff member was holding onto the patient in the sling while the lift was being moved. According to information provided by the facility "FOR OTHER SLINGS WITH CHAINS ONLY" , which was undated, the 9th link of the chain should be hooked into the end of the swivel bar. "Check to see that links are hooked all the way into the swivel bar. " It was also noted that in the "FOR SLINGS/LIFTS WITH CHAINS" section of this document, "check chains and S-hooks to see that they are properly positioned." According to information provided by the facility for transferring with a hydraulic lift, revised [DATE], the hydraulic lift was used to lift the immobile patient in a comfortable and safe transfer. Two staff members were to be present during transfer to stabilize and support the patient. Another co-worker should guide the resident's body while the hydraulic lift was being moved with the resident suspended in the sling. An interdisciplinary team (IDT) note of [DATE] for Resident #5 indicated the nurse should monitor all transfers using the hoyer lift with 2 resident care specialists (RCS). According to a resident transfer evaluation, completed [DATE], Resident #5 was non-ambulatory, non weight bearing, was confused and unable to follow directions. This evaluation indicated the resident was unable to sit on the bedside without full back and head support and had contractures. The total score noted on this evaluation was 25 which indicated the caregiver would perform 100% of the transfer task using a total body sling and a mechanical lift device. An Annual (Minimum Data Set) MDS assessment of [DATE] indicated Resident #5 had long and short term memory problems as well as severely impaired decision making skills. She rarely understood and had no speech. She required total assistance from staff for all activities of daily living which included bed mobility and transfer. She was lifted mechanically. There were no falls documented. Accoring to Resident #5's resident care cardex worksheet, which was undated, the resident was to be transferred via mechanical lift. Resident #5's care plan, last reviewed on [DATE], identified a problem with fragile skin. An approach was to use special attention when moving her and she was to be transferred by hoyer mechanical lift with 2 (RCS) staff members. Another problem identified was potential for injury related to her non-ambulatory status. She required the use of a mechanical lift from the bed to the chair and from the chair to the bed. A hospital history and physical of [DATE] for Resident #5 indicated the resident fell 5 feet from a "hoyer lift" and sustained bilateral skin tears to both upper extremities, a skin tear to the right 2nd phalange (finger), skin tears with ecchymosis (bruising)and contusions bilaterally of the periorbital area (eye), a 3 centimeter laceration above the left brow and occult blood in the nares. Resident #5 also had a left zygomatic fracture, a left maxillary fracture, closed fracture of the nasal bones, and closed fractures of the left medial/lateral facial bones. Resident #5 was intubated for decreased level of consciousness (LOC) and diffuse facial edema. A nurse's note of [DATE] at 3:25 PM by Nurse #1 indicated Resident #5 was found on the floor in her room. She had fallen while being transferred via a mechanical lift with 2 person assist. She had a large laceration to the left eye. Her airway was maintained, suction was applied and staff were in the room with her awaiting the emergency medical services (EMS.) This note indicated she had a skin tear to the left hand. There was no mention of any other injuries. She was transported at 3:40 PM to the hospital for evaluation per the EMS. (There were no other notes in the chart regarding the incident.) Nurse #1 was interviewed on [DATE] at 3:00 PM about the nurse's note she wrote of [DATE] concerning Resident #5. Nurse #1 stated she was summoned to the room by RCS #2. She stated when she walked into the room, Resident #5 was facedown on the floor and was bleeding from a cut over one of her eyes. Nurse #1 stated she paged all staff to the room "STAT" (now) and everyone came running. She stated someone brought the crash cart but she did not remember who. Nurse #1 stated Resident #5 was a full code. She stated staff were suctioning Resident #5 to remove blood from her mouth. Nurse #1 stated Resident #5 was sent out for evaluation. She stated the incident occurred during shift change. Nurse #1 reported that Resident #5 was in the process of being transferred via use of a mechanical lift. Nurse #1 stated she was not aware of any past incidents using any of the mechanical lifts. Nurse #1 added that in-services were done immediately after the incident to ensure that staff were using the lifts properly. An Incident/Accident Report of [DATE] for Resident #5 indicated Resident #5 had an attended/injury fall with a head injury and possible laceration and was being sent out via EMS. There were no details as to what happened on this document. A statement from RCS #2 of [DATE] at 4:00 PM was included with the Incident/Accident Report. There were no statements from Staff Member #1 nor Nurse #2 included with this report. A typewritten statement from RCS#2 was dated [DATE] at 4:00PM and was not signed by RCS#2. RCS#2 retrieved the (brand name mechanical lift) lift and went into Resident #5's room to assist RCS#3. RCS# 3 was operating the lift. She positioned the (brand name mechanical lift) lift in front of the gerichair. She checked the position of sling pad and it was positioned properly underneath Resident #5. The top of the sling pad was below Resident #5's shoulders and the bottom of the sling pad was above her knees. RCS#2 hooked the short part of the chain to the top of the sling pad and the long part of the chain to the bottom of sling pad. While RCS#3 was connecting her chain onto the sling pad, the chain came off the mechanical lift bar hook on her side. She counted 10 links and hooked the chain back onto the lifter bar hook. She then hooked the short part of the chain to the top of the sling pad and the longer part of the chain to the bottom of the sling pad. Using the (brand name mechanical lift) controls, RCS#3 began to lift the sling pad with Resident #5 inside. As she was lifting, the sling pad got caught on the arm rest and the resident was lowered down slightly. RCS#2 pushed the sling pad inward towards the resident and the sling pad cleared the arm rest. RCS#3 lifted Resident #5 again and lifted her high enough to clear the armrests of the gerichair. RCS#2 pulled the gerichair from underneath the resident and RCS#3 moved the (brand name mechanical lift) lift toward the bed. As it was being moved, RCS#2 heard a loud pop and the sling and chain came loose from RCS#3's side and the resident landed on the floor. RCS#2 was interviewed on [DATE] at 4:55 PM. She stated Resident #5 fell out of the mechanical lift while being transferred. When questioned if the proper pad was used, she stated Resident #5 was up in the chair and the sling pad was already underneath her when she and RCS #3 went into the room. RCS#2 did state it was the correct sling. She stated they attached the chains (there was a hook located at the end of the chains for connecting into the metal slider bar on the sling pad) to the sling pad and hooked the chains onto the swivel lifter bar. When questioned about the chains, RCS#2 stated the chain on the side where RCS#3 was working came off the swivel bar. She stated that when the lifter bar was being lowered over the resident, the chain on the side where RCS#3 was working came off. She stated RCS#3 counted down 10 links and hooked the 10th link onto the lifter bar. RCS#2 stated while Resident #5 was being lifted up initially, the sling pad hook got caught on the armrest. She stated RCS#3 lowered her down enough for her to clear the sling. She stated RCS#3 continued to lift the resident up into the air above the gerichair. RCS#2 reported that RCS#3 was operating the mechanical lift while she moved the chair from between the legs of the lift. RCS#2 stated she was not sure what happened but the "strap" (chain) came off and the resident fell . RCS#2 stated that inservices had been provided to her as well as other staff members in the proper use of the mechanical lifts. RCS#2 also stated the (brand name mechanical lift) mechanical lift that she used to transfer Resident #5 was no longer in use and had been removed from the floor. There was a typewritten statement from RCS#3 dated [DATE] at 4:45 PM that was not signed by RCS#3. According to this statement, RCS#3 went into Resident #5's room to assist with a mechanical lift transfer along with RCS#2. RCS#2 brought the (brand name mechanical lift) lift into the room. The position of the sling pad was checked and found to be positioned properly underneath Resident #5. The top of the sling pad was positioned below Resident #5 ' s shoulders and the bottom of the sling pad was positioned above the knees. RCS#3 positioned the mechanical lifter bar over the gerichair where Resident #5 was sitting. RCS#3 was working the controls from the side of the lift. "When I lowered the lift to hook the chains up the chain came loose from my side and I counted 10 links and hooked it up on the 10th link." (The swivel lift bar was lowered overtop the resident.) She then hooked the short part of the chain to the top of the sling pad near the shoulders and then the other end of the chain to the bottom of the sling pad. RCS#3 began to lift Resident #5 using the hand controls. When she stated lifting the resident, the sling pad got hung on the armrest so she lowered her to allow RCS#2 to clear the side. Once the sling was cleared, RCS#3 relifted her to clear the sides of the gerichair. Once she cleared the chair, RCS#2 started to move the gerichair away from the mechanical lift and RCS#3 moved the lift with the lift legs out towards the bed. As RCS#3 was moving the mechanical lift towards the bed, there was a loud popping sound and the resident flipped out of the lift sling pad onto the floor. According to this statement, "..one side of the lift was not hooked up and it dangled on the floor." An interview was conducted with RCS#3 on [DATE] at 3:45 PM regarding the incident of [DATE]. RCS#3 stated what happened to Resident #5 was not intentional. RCS#3 stated RCS#2 brought the (brand name of mechanical lift) mechanical lift into Resident #5's room to assist with transferring her back to bed. RCS#3 stated the chains were already attached to the swivel lifter bar and the sling pad was already underneath Resident #5. RCS#3 stated Resident #5 was in a gerichair. She stated at times the chain would come off when they would be positioning the swivel lifter bar arm over the resident to connect the sling pad to the chains. RCS#3 stated there were metal slider bars that had to be placed in each of the 4 sides of the sling pad in order to connect the chains. She stated all the sides had slider bars but one. RCS#3commented one slider bar was on the table next to Resident #5's bed so she slid it into the corner of the sling pad. RCS#3 stated when she was lowering the mechanical lifter bar over the resident to connect the sling pad to the chain, the chain came off the bar and she had to reconnect it. RCS#3 stated she counted down 10 links and connected the 11th link onto the mechanical lifter bar hook. RCS#3 stated she connected the hooks into the slider bars on the 2 corners of the sling pad on her side. When asked her if she checked the chains before she lifted the resident, she stated she was sure she did. RCS#3 stated she began to raise Resident #5 up from the gerichair when the chain hook got caught on the chair arm so she lowered her so it could be cleared. Once the sling pad was cleared, RCS#3 raised her up in the air enough to clear the chair arm. While RCS#3 was lifting the resident up into the air, RCS#2 was moving the chair from underneath the resident. As RCS#3 began to move the mechanical lift towards the bed, she heard a pop and the resident toppled to the floor. She stated no one was actually touching the sling pad while Resident #5 was being moved. When questioned about the sound, she stated it sounded like a chain sound. RCS#3 reported they were no longer using the (brand name mechanical lift) lift and had an inservice on the proper use of hoyers after this incident. Review of the "Mechanical Lift Action Plan", dated [DATE], revealed that the two RCS staff members (RCS#2 and RCS#3) involved in the incident with Resident #5 were immediately in-serviced on the mechanical lift procedure along with a skills validation. In the outcome section of this document, both staff members were suspended pending further investigation. According to this action plan, a thorough investigation would be conducted. The lift that was involved in the incident was removed from the floor and secured. All mechanical lifts were removed from use until reviewed. On [DATE], the maintenance technician signed a statement indicating all lifts had been checked. All nursing staff were to be in-serviced on the mechanical lift procedure and a return demonstration would be required before using any of the mechanical lifts. The maintenance supervisor checked all mechanical lifts to ensure proper functioning on [DATE]. On [DATE] at 1:45 PM, Resident Care Specialist #1 (RCS #1) was interviewed about mechanical lift skills validation. She stated an in-service had been done recently on the use of the mechanical lift devices. RCS#1 stated she had been observed by nursing and was checked off on the use of the lifts. When questioned about the in-service, she stated the in-service was provided due to a "bad" accident involving use of one of the mechanical lifts. RCS#1 stated she had worked with that resident in the past and the resident was totally dependent on staff for all aspects of care. RCS#1 stated she was told that Resident #5 fell out of the mechanical lift and she had no further information regarding the incident as it happened on second shift. An interview was conducted with Nurse #2 on [DATE] at 11:30 AM. She reported when she arrived in Resident #5's room on [DATE], she was facedown on the floor in a large (maybe ,[DATE] inches around her head) pool of blood with one of her legs still draped across the leg of the mechanical lift. She stated she instructed the RCS (she did not remember which one) to move the hoyer out of the way so she could assess the resident. Nurse #2 reported that the right side chain with the green sling pad attached was dangling and the other side was still attached to the swivel bar. When questioned about the injuries, she reported Resident #5 was facedown so she rolled her over carefully to see where the blood was coming from. Nurse #2 stated there was blood on the right side of her body. Nurse #2 stated the resident was not conscious but had very loud noisy breathing. She stated there was clotted blood coming from her nose which was displaced to one side. Nurse #2 stated when she attempted to open her mouth to maintain her airway, she felt there were broken bones because of the way the mouth opened. Nurse #2 reported the injuries appeared to be serious and EMS was called. She stated the only explanation she had for the incident was that staff had connected the chains to the wrong brackets. Nurse #2 reported there were 2 different hooks on the swivel lifter bar. One looked almost like a rounded corkscrew (chain hook), was curled in a circular way and the other was a half loop bracket (strap hook) which was above the "curled" rounded hook (chain hook). Nurse #2 added that if staff hooked the chain onto the top brackets (strap hook) there would be nothing to hold it in place and it would slip off when the resident was moved. She stated the only way the chain would come off was if staff had placed it in the wrong position. Nurse #2 added that the curled hook (chain hook) was the proper place to connect the chains not the bracket over top the curled hook (chain hook). Nurse #2 commented that there was a nurse's note in Resident #5's chart that gave an account of the incident of [DATE]. There was no note from Nurse #2 found in the Resident #5's chart. On [DATE] at 11:50 AM, Nurse #2 reported that she was writing a "late entry" for the missing nurse's note from the [DATE] incident. According to this note, Resident #5 was prone in front of the bathroom door with her head slightly tilted with right cheek on the floor when she entered the resident's room. During an interview with the Administrator and the Director of Nurses (DON), on [DATE] at 10:30 AM, the Administrator stated the (brand name mechanical lift) lift that was used to transfer Resident #5 on [DATE] had 2 chains. She stated staff had been instructed to count up 10 links and hook that link onto the mechanical lifter swivel bar hook (chain hook). The Administrator stated the green sling pad had 4 corners and each end of the chain was connected to the sling pad on each corner. When questioned about her investigation into the incident, she stated the maintenance department had checked the (brand name mechanical lift) lift following the incident and found no mechanical problems with the unit. The Administrator reported that the last maintenance check performed on the (brand name mechanical lift) had been completed on [DATE]. She stated there were no concerns identified with the unit. She stated she and the DON had tried every possible way to get the chains to fall off and had not been successful. The Administrator stated it was an accident and was not sure what actually happened for the resident to fall. Both the Administrator and the DON stated RCS#2 and RCS#3 were brought into the office and asked to demonstrate what happened on [DATE]. The Administrator stated both of them demonstrated the proper way to use the (brand name mechanical lift) mechanical lift. The Administrator stated she immediately began inservices for all nursing staff and everyone's skills were validated to ensure that the mechanical lifts were being used properly. She stated the (brand name mechanical lift) the mechanical lift in question had been pulled off the floor and was no longer in use. The Administrator stated she had implemented an action plan to ensure no further incidents would occur with the use of the remaining mechanical lifts. When questioned about the [DATE] IDT note (interdisciplinary team), the DON remarked that the reason nurses were to monitor use of the lift was to make sure Resident #5 did not receive skin tears. She stated after a period of time, nurses did not need to observe due to no skin tears were received during transfers so the observations were discontinued. Training records were provided by the Administrator on [DATE] at 4:00 PM. According to the information provided, RCS#2 was checked off by the Safety Committee while using a mechanical lift (which lift was not specified) on [DATE]. The Administrator stated she did not know which mechanical lift was used for this observation. On [DATE], RCS#2 had watched the video for safe transfers on lifts. RCS#3 watched the safe transfers video on [DATE] and was checked off on use of the mechanical hoyer lift (which lift was not specified) on [DATE]. Nurse #8 was interviewed about the mechanical lift observations on [DATE] at 2:00 PM. She stated she was not sure what the reason was for the skills observations, but she was to observe staff using the mechanical lifts. She stated she thought it was for the annual skills checkoffs. On [DATE] at 12:00 PM, the Administrator stated that in-services for all staff had been conducted. She stated there was a mandatory transfer video for lifting and transfers that all staff were to view. The Administrator also stated skills check-offs (demonstrations) had been completed for all staff who were using the mechanical lift devices. She commented once again that she did not know what had transpired on [DATE] for Resident #5 to fall from the (brand name mechanical lift). The Administrator commented that the lift had been functioning properly on that day. Another interview with the Administrator was conducted on [DATE] at 1:00 PM. She reported that the safety committee performed 5 skills check-offs per month on employees. She stated the right side of the chain and sling pad was dangling when she arrived in Resident #5's room on [DATE]. She also stated Resident #5 was positioned on the floor. She commented she did not know how the incident occurred since the equipment (brand name mechanical lift) was in proper working condition. During an interview with RCS# 4, on [DATE] at 2:00 PM, she stated when she used the (brand name mechanical lift) she always used a green pad. She went to laundry to get a pad. She came back in 10 minutes and stated she couldn't find the pad but it was green, had 4 corners and had metal slider bars that fitted in each corner. She reported that she felt this particular lift was more stable for resident use. When questioned about the chain hook ups, she stated if staff did not hook the chains up properly they would slip off the lifter bar hook. RCS#4 commented that 2 staff members were always present during use of any of the mechanical lifts. Nurse #3 was interviewed on [DATE] at 2:50 PM. She stated she trained staff to use all of the mechanical lifts in the facility. She stated that included the (brand name mechanical lift) that was used on [DATE] with Resident #5. Nurse #3 stated if staff connected the chains properly the chains should not give way. She reported she could not determine what might have happened during the transfer of Resident #5 on [DATE]. At 4:00 PM on [DATE], Nurse #3 demonstrated the proper way to connect the chains to the (brand name mechanical lift) that was used on [DATE]. She stated she had trained staff on the use of this mechanical lift as well as the other lifts in the building but she could not say which machine staff were actually checked off on. Nurse #3 picked up one of the mechanical lift chains and counted down 10 hooks, hooked the 10th hook onto the chain hook located on the swivel lifter bar (chain hook) of the machine. She stated that the short end of the chain was to be connected to the top end of the green lifter (sling) pad for the upper body and the longer end was to be connected to the lower end of the lifter pad for the lower body. Nurse #3 stated the chain hook should be inserted into the pad away from the resident to prevent any injury during the lift. She then connected each chain hook into the 4 slider bars located within the sides of the lifter sling pad. Nurse #3 stated 2 staff were always used for the transfers to ensure safety for the resident. One staff member would help guide the resident's feet during the transfer and the other operated the machine. Nurse #3 stated the only way the chain would come off was if it was not properly positioned within the chain hook (the curled hook on the swivel lifter bar.) She stated she could not say what happened that day for the resident to fall. When questioned about skills checkoff, Nurse #3 stated she provided the new orientation skills training. She stated staff were observed and checked off for use of the mechanical lifts but she did not know which one each staff person had used. Nurse #3 added that the (brand name mechanical lift) in question had been included in the training. A telephone interview was conducted with a representative from (brand name mechanical lift manufacturer) on [DATE] at 1:35 PM. He stated the only way a chain would disconnect from the swivel lifter bar (chain hook) would be if it had not been properly engaged or the resident was tilted in the sling. He reported that the bracket on top of the swivel lifter bar could be used for the chains if needed for storage purposes. He stated if the facility was using a chain without an "O" ring, he could not say how safe the transfers would be since the purpose of the "O" ring was for balance and to stabilize the patient for lifting. A telephone interview to clarify the type of chains used on the mechanical lift in question was conducted with the Administrator on [DATE] at 1:40 PM. She stated as far as she knew, the chains used were the chains they had always used. She remarked there had never been an "O" ring type chain. On [DATE] at 12:45 PM, the Maintenance Supervisor (MS) stated when he performed maintenance checks on the mechanical lifts, he checked all the bolts to make sure they were tight. He stated he checked to make sure the hydraulic parts were clean and the base was secure and tight. The MS stated he checked to make sure the swivel lifter arm was centered and not bent as well as making sure all clips were in good shape and in good working condition. When questioned about the chains for the (brand name mechanical lift), he stated the chains they had were the only chains they had ever used and there was no O-ring on these chains. The MS reported checking the mechanical lift in question on [DATE] and found it be in proper working condition. He also stated he had checked it out again the Monday ([DATE]) following the incident with Resident #5 and found it to be functioning properly. The MS reported he had inspected the green pad and the lift chains and found nothing wrong with the sling pad nor the chains as they were in good working condition. The MS added that he was told that the hook in the bottom slider bar had come loose and dropped the resident. On [DATE] at 4:10 PM, the MS brought the (brand name mechanical lift) from storage. He stated he also had checked the unit out on [DATE] and found nothing to be functioning improperly. He reported that the only way for the chain to become disconnected would be due to operator error. The MS stated he had tried using his weight with the chains hooks up properly and the chains did not come off the chain hooks. At 4:20 PM on [DATE], RCS#2 was asked to demonstrate how she had connected the chains on the (brand name mechanical lift) on the day Resident #5 fell ([DATE].) She stated she counted down 10 links on the chain. RCS#2 hooked the 10th link onto the swivel bar chair hook (the curled one). She connected the 2 chain hooks into the metal slider bars on the 4 corners of the sling pad. When questioned about the possibility of the chair hitting the sling while the resident was being lifted, she stated no because the resident was high enough in the air that the chair was cleared and removed. When questioned about how the sling pad looked once the resident fell , she reported she did not remember if the chain was hooked in the chain hook or not. After RCS#2 finished her demonstration, the MS commented that Resident #5 had expired. At 4:30 PM on [DATE], RCS# 3 came into the room to demonstrate what she did on [DATE] when Resident #5 fell . She picked up the chains and counted down 10 links. She hooked that link onto the swivel lifter bar chain hook (not the top bracket hook). RCS#3 connected the S-hooks from each end of the chain into the slider bars on each of the 4 corners of the green pad. When asked to place the chains in the positions they were in on the day Resident #5 fell , RCS#3 unhooked the right side of the chain from the swivel bar chain hook and said that was the way it looked (the sling pad was still attached). The chain with the sling pad attached was dangling. RCS#3 stated she did not remember exactly how Resident #5 was positioned on the floor. RCS#3 added that there was not much room in Resident #5's room for using the mechanical lift as they had to move furniture around to transfer the resident. During an interview with the Administrator on [DATE] at 2:00 PM, she stated she did not know what actually happened when Resident #5 fell from the mechanical lift. She stated she did not know how to fix the problem if she didn't know what happened. The Administrator reported that the (brand name mechanical lift) would not be used again even if it checked out to be in good working condition. The maintenance technician assistant (MT#1) who checked the (brand name mechanical lift) shortly after the [DATE] incident with Resident #5 was interviewed on [DATE] at 9:15 AM. He stated when he got the (brand name mechanical lift) lift, the chain from the right side of the swivel bar was disconnected and dangling with the sling pad still attached. MT#1 stated the left side was still attached. He stated there was nothing wrong with the actual lift, the sling nor the chains. He stated in his opinion there was no way for the chain to pop off unless they had it connected improperly. MT#1 stated the fall was due to human error as the machine itself was working properly when he checked it out that da