Every finding on record at Hillcrest Home

Based on observations, interviews, facility documents, and policy review, it was determined that the facility failed to provide adequate supervision to prevent elopement for one (Resident #1) of three sample residents who were reviewed for accident and supervision. Specifically, facility staff failed to respond to an exit door alarm on a kitchen exit door, which allowed Resident #1, a cognitively impaired resident with a known history of wandering, to exit the facility unattended into an unsecured area without staff knowledge. The IJ began on 12/24/2025 at 6:14:PM, when Resident #1 eloped through the unsecure kitchen door without staff knowledge. The facility's failure to monitor alarmed exits and to supervise wandering, at-risk residents placed Resident #1 at immediate risk for serious bodily injury, harm, or death due to an altered mental status and exposure to external environmental hazards. The Immediate Jeopardy was removed on 12/26/2025 at 5:28 PM, prior to survey entry. This correction date was verified through a comprehensive review of the facilities plan of correction, including review of mandatory training logs regarding door alarm training protocols. Verification of monitoring logs, revision of policies and procedures, 15-minute check monitoring logs, visual verification of facility equipment changes and verification of retraining through staff interviews. Because the facility identified the deficiency, implemented systemic corrective actions, and achieved substantial compliance prior to the start of the current survey, the deficiency constitutes Past-Noncompliance at a Scope and Severity level of J. The Administrator was notified of the Past Non-Compliance (PNC) Immediate Jeopardy on 6/17/2026 at 4:57 PM. The findings include: A review of the admission Record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, unsteadiness on feet, and difficulty in walking. A review of the quarterly Minimum Data Set [MDS] assessment with an Assessment Reference Date [ARD] of 10/22/2025 indicated Resident #1 had a Brief Interview for Mental Status [BIMS] of 00, indicating severe cognitive impairment. A review of the annual MDS with an ARD of 04/15/2026 indicated Resident #1 had a Staff Assessment for Mental Status [SAMS] assessment of 3 which indicated the resident was severely impaired for daily decision making. A review of the Care Plan Report for Resident #1 revealed the following: Resident #1 had impaired cognitive function (07/22/2023) and independent with ambulation (03/21/2024). Resident #1 was care planned as a high risk for wandering (initiated 01/17/2023). A corresponding entry reported Resident #1 liked to walk in the halls independently and all staff were aware of the risk of elopement (initiated 03/05/2024). Diversional Interventions included engagement in purposeful activities, 1:1 time, family visits, supervised walks outside, pet therapy and television (initiated 01/17/2023). Additional interventions included enjoying walks outside in the courtyard and offering walks outside when Resident #1 was restless (initiated 11/05/2024). Resident #1 had a wander alert bracelet device that was placed 01/27/2023. A review of an Order Summary Report for Resident #1 revealed a physician's order dated 03/10/2025 instructing staff to monitor the resident for episodes of rummaging, wandering, and pacing. A separate physician's order dated 02/13/2024 directed staff to monitor for side effects of antipsychotic medications, including tremors, rigidity, confusion, weakness, and sedation. A review of a facility Wandering Risk Assessment dated 10/21/2025 indicated Resident #1 was at high risk for wandering and had a documented history of wandering behaviors. An internet search of local historical weather data for the municipality on 12/24/2025 revealed the following environmental conditions at the time of the incident. At 5:53 PM the temperature was 69.1 degrees Fahrenheit with winds out of the south at 6.90 miles per hour and clear skies. At 6:53 PM the temperature dropped to 66.0 degrees Fahrenheit. During an interview on 6/16/2025 at 1:44 PM, CNA [certified nursing assistant] #1 reported that they joined the search immediately upon completing care with another resident. CNA #1 reported they were informed a door to the kitchen had been propped open, that the door was usually closed and only assessable with a keypad. CNA #1 reported checking the specific door in the kitchen listed on the facility communication device and found it shut. CNA #1 investigated a knocking sound coming from the old dining room and visualized Resident #1 standing outside the back door of the room. CNA #1 entered the keycode into the electronic keypad, brought Resident #1 back into the facility, and escorted them back to their home unit. CNA #1 reported Resident #1 did not appear to have any injury and was ambulating as usual upon return. CNA #1 confirmed that when an alert was activated, the provided phones display photos of at-risk elopement residents along with their physical descriptions. During an interview on 6/17/2026 at 10:14 AM, CNA #2 indicated that upon reporting for duty on 12/24/2025 at approximately 6:15 PM, the facility communication device was actively alarming. CNA #2 reported that the device had been sounding for approximately two minutes and indicated that the alarm originated from the big kitchen door. CNA #2 entered the kitchen through an interior door that required a keycode for entry and proceeded to the exterior door facing the parking lot that was found partially open. CNA #2 stood in the doorway, looked outside, and observed no one in the vicinity. CNA #2 then entered the keypad code to deactivate the alarm. CNA #2 reported that approximately three minutes later, upon re-entering the home unit of Crestview, they were notified Resident #1 was missing and a facility search was underway. CNA #2 further reported that following Resident #1's elopement on 12/24/2025, they received remedial training on abuse and elopement protocols. CNA #2 reported that the elopement training protocol was modified to require staff to conduct physical searches outside the facility until the precise cause of a door alarm was determined. CNA #2 also reported that the facility communication device dashboard was updated to include photographs of high-risk residents and to require more frequent checks by staff. During an interview on 6/17/2026 at 12:28 PM the Administrator's retrospective review of the facility's electronic alarm log verified that the alarm sounded in the main kitchen on 12/24/2025 at 6:14:47 PM, when Resident #1 eloped from the facility unattended. The Administrator reported that based on the facility's internal investigation, Resident #1 exited the kitchen door, traveled up the uneven ground to the parking lot, walked around the back of the kitchen across uneven pavement to a grassy area and re-entered the facility through the old dining room door. The Administrator reported that the path walked by Resident #1 was approximately 225 ft from the point of exit to the point of re-entry. A joint physical tour of the area occurred on 06/17/2026, observation of the outdoor path traveled by Resident #1 during the elopement was conducted by the surveyor accompanied by the Administrator. The following environmental hazards were observed: -The designated area consisted of uneven, steep terrain covered in small, shallow pits. -The path sat approximately 90 feet from a frequently traveled public roadway. -The exterior entrance to the old dining room door required an individual to ascend three concrete steps to reach the door handle. A review of an untimed OLTC [Office of Long-Term Care] Witness Statement Form dated 12/24/2025 and signed by CNA #3 revealed CNA #3 received a message regarding Resident #1 on 12/24/2025 at 6:16 (PM), at which time they initiated a physical search for the resident. A review of an untimed OLTC [Office of Long-Term Care] Witness Statement Form dated 12/24/2025 and signed by CNA #1 revealed the following timeline: -CNA #1 wrote they were informed Resident #1 was missing. They [CNA #1] were informed by CNA #2 they had cleared the active electronic door alarm. -CNA #1 conducted a physical search of the facility's interior hallways and returned to the kitchen area to continue the investigation. -Upon entering the kitchen, CNA #1 heard knocking sounds originating from the old dining room exterior door, proceeded to investigate, and observed Resident #1 standing outside the facility unattended. -CNA #1 immediately brought Resident #1 back into the facility and escorted the resident to their assigned home unit. A review of an untimed OLTC [Office of Long-Term Care] Witness Statement Form dated 12/24/2025 and signed by CNA #2 revealed the following documented facts: -CNA #2 reported for duty on 12/24/2025 and observed that the Big Kitchen door was actively sounding. -CNA #2 proceeded to the kitchen area and cleared the active alarm. -CNA #2 explicitly documented that they deactivated the alarm system without checking the outside grounds or exterior perimeter of the door. A review of a facility policy titled Elopements and Wandering Residents with a revised date of 12/21/2025 revealed the following operational mandates: -The facility would ensure residents who exhibit wandering behavior or are at risk for elopement received adequate supervision. Residents would receive care according to their personalized plan of care that specifically addressed their unique behaviors contributing to a wandering or elopement risk. -Every staff member would be responsible for the physical location of residents. Wandering was defined as a random or repetitive locomotion that may or not be goal directed. - Elopement was defined as when a resident left the premises or safe area without the proper authorization or supervision. -Policy directives included utilization of door alarms, locking mechanisms, and wander alert devices to prevent elopements. -The Policy mandated the ongoing monitoring of safety devices, monthly door alarm drills with response time audits, structured outside search protocols, and the utilization of internal communication systems. The policy explicitly required that the outside area of an alerting exit must be searched immediately. Review of the facility's Action Plan following the elopement incident on 12/24/2025 revealed the following interventions had been enacted prior to the survey team entering the facility: -The removal of the doorstop from the kitchen door immediately to prevent it from being propped open, to avoid residents having unimpeded access to the kitchen. -The facility placed highly visible signage on the kitchen door instructing staff and visitors to keep the door closed at all times. -Increased monitoring through visual and electronic communication device and the facility placed Resident #1 on formal 15-minute safety checks daily. These checks begin at 4:00 PM and continue until the resident is safely in bed for the night. -Resident #1's care plan was updated to mandate that staff-to-staff communication addressing Resident #1's specific location whenever they were away from their home unit. -The intra-facility communication plan implemented a structured communication plan for staff to share real-time updates when wandering residents were observed in their respective areas, specifically identifying individuals designated as high wander risks. -Alarm system auditing with scheduled monthly monitoring and testing of the electronic alarm system staff's reaction times. -Mandated an immediate outside search protocol for any facility alarm that is activated without a known or obvious cause. -Conducted a comprehensive facility assessment of residents for elopement risk, ensuring any resident assessed as an elopement risk was added to the intra-facility communication plan. A review of an Elopement training document verified that mandatory staff training was initiated 12/26/2025. The education program provided targeted instruction on elopement procedures, execution of structured elopement drills and specific parameters for outdoor search methods.

Based on interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse were reported to the Administrator and the State Survey Agency (SSA) within the required timeframe for one (Resident #2) of three residents reviewed for abuse. Specifically, the facility received a report of alleged abuse involving Resident #2 on 10/23/2025 (reported by LPN #10 to the Administrator) but did not report the allegation to the SA until 06/19/2026. Additionally, it was revealed by the Clinical Coordinator that the facility received a report of abuse for Resident #2 on 11/17/2025, which was reported to LPN #9, who failed to report the allegation to the Administrator until 11/18/2025. The findings include: Review of the undated facility policy titled, Abuse, Neglect and Exploitation revealed requirements for reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies immediately, but not later than two hours after the allegations is made, if the events that caused the allegations involve abuse or result in serious bodily injury. Review of a county law enforcement Dispatch Call Detail revealed that on 10/23/2025 at 2:19 PM the dispatch received a call from the facility. A narrative of the ensuing encounter revealed law enforcement was informed Resident #2 had reported being sexually assaulted by an employee of the facility, and that the facility was conducting an internal investigation. Review of an OLTC (Office of Long-Term Care) Incident and Accident (I&A) Report for Resident #2, with a Date of I&A and Discovery Date of 10/23/2025 and a Submitted Date of 06/18/2026, revealed the resident alleged on 10/23/2025 at 11:15 AM that they had been sexually assaulted by a tall guy, and said they were kissed by the big, tall guy [this allegation was] reported to the Unit Manager. Review of an OLTC I&A Report for Resident #2, with a Date of I&A of 11/17/2025 at 9:30 PM and a Submitted Date of 11/18/2025 at 3:02 PM, revealed Resident had made a second allegation of sexual assault by the tall guy. Review the Advanced Practice Registered Nurse (APRN) progress note dated 10/23/2025 revealed Resident #1 was seen for a body audit due to an allegation of abuse with no negative findings. Review of a progress note dated 11/17/205 and authored by LPN #9 indicated Resident #1 alleged being raped. No indication of reporting the allegation to the Administrator. Review of the quarterly Minimum Data Set (MDS) dated [DATE] with an Assessment Reference Date of 10/15/2025 indicated Resident #2 had a Brief Interview of Mental Status score of 03, which indicated severe cognitive impairment. Review of Resident #2's Care Plan revealed a focus, modified on 11/19/2025, that indicated the potential to demonstrate physical behaviors towards others, make accusations of spouse cheating and others raping me and occasional nightmares. Interventions for agitation, guide away from sources of distress, engage calmly in conversations, if response is aggressive [toward] staff to walk calmly away and approach later. Review of an Order summery indicated resident was on palliative care, and was monitored for episodes of verbal outburst, disruptiveness, accusations of spouse having an affair, or saying other raped them. During an interview on 06/16/2026 at 1:30 PM, the Clinical Coordinator indicated LPN #9 was unaware of the facility reporting requirements and did not report the allegation of sexual abuse. The Clinical Coordinator became aware of the sexual abuse allegation by reading the documentation from the night before, then immediately reporting it to the Administrator. During an interview on 06/18/2026 at 11:33 AM, the Administrator confirmed the allegation of abuse alleged to have occurred on 10/23/2025 was not reported to the SSA, stating, Resident #2 did not identify the alleged perpetrator at this time, if we had identified the person, we would have suspended the alleged perpetrator. During a follow-up interview on 06/16/226 at 12:25 PM, the Administrator indicated when completing the report to the State Agency for the 11/17/2025 incident, it was discovered that there was a gap in timely notifications to the required staff due to lack of a standard process and a checklist to ensure all items are done timely.

Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure adequate supervision was provided, and the alert alarm system was monitored and tested per manufacturer ' s recommendation to prevent elopement for 1 (Resident #55) of 3 sampled residents reviewed for accidents/supervision. The findings are: An Admission Record was reviewed and revealed Resident #55 had diagnoses that included Alzheimer's disease, dementia with behavioral disturbances, and anxiety. A quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of April 23, 2025, was reviewed and revealed resident #55 had a Brief Interview for Mental Status [BIMS] of 02 [indicated severely cognitively impaired]. Section GG indicated the resident was able to walk at least 150 feet independently. An undated Care Plan Report was reviewed and indicated that Resident #55 was a high risk for wandering, identified 01/17/2023. Care plan interventions included engagement with purposeful activities (1/17/2023), supervised walks (11/05/2024), pet therapy (3/06/2025), looking out windows, outside with supervision (3/10/2025), independent ambulation but is an elopement risk (3/05/2024), loud noises can be a trigger for the resident, supervise during and after a fire drill (2/27/2024), provide care in a calm reassuring manner, clear simple instructions, [brand name] watch (1/27/2023). A Wander Risk Assessment for Resident #55 dated 1/21/2025 was reviewed and indicated that Resident #55 was a moderate risk for wandering. An Office of Long-Term Care incident document with a submitted date of 3/01/2025 at 8:50 AM was reviewed and revealed that during the facility staff video review, on 2/28/2025 at 5:18 PM, Resident #55 was observed standing by the front entrance door. Resident #55 wore a safety device that automatically locked the door when Resident #55 approached the door. A visitor attempted to open the door from the outside, activating the alarm. After the 15 second wait time, the door lock deactivated and the visitor who was standing on the other side of the door then opened the door and let Resident #55 outside. At 5:20 PM the review indicated a visitor was seen on the video, coming to the front door, then returned to the parking lot, then the visitor was observed returning to the building with Resident #55 without difficulty. Progress notes dated for a late entry 2/28/2025 were reviewed and revealed while Resident #55 was standing at the front door of the facility, a pharmacy delivery driver approached the door. The door was locked due to the resident guard bracelet setting the door alarm. Once the door alarmed for 15 seconds, the door released, the driver held the door open for Resident #55 to exit the facility. Resident #55 was placed on 30-minute checks and the pharmacy was notified regarding the door alarm system and residents safety. Progress notes dated 7/26/2024 were reviewed and revealed that during a care plan meeting Resident #55 had one elopement within the look back period where Resident #55 made it outside. A Behavior Progress note dated 7/21/2025 was reviewed and revealed a follow-up from an elopement from 7/20/2025. A progress note dated 7/20/2024 was reviewed and indicated that Resident #55 was found outside of the facility in a grassy area by the Administrator and returned to the facility. Progress notes dated 9/29/2024 were reviewed and revealed Resident #55 was observed out of the facility with the door alarm activated. Resident #55 made it out of the facility to the parking lot past the first row of cars, more than 40 feet from the front entrance. During an interview on 5/06/2025 at 8:47 AM, the Information Technology [IT] #1 staff was interviewed and indicated that the IT department was responsible for setting up the alert alarm system, the units are provided after setting up to the nursing staff to place on the residents person. IT #1 denied routinely checking the door alarm system to determine if it was performing as expected, indicating the system was only checked when a new bracelet was being set up. IT #1 stated that if the door wasn't working then someone would notice when it didn't lock when a resident wearing a bracelet got close to the doors, and it didn't lock, confirming that unless a staff member was with the resident when a resident with a guard bracelet on their person went close to the door, if the door wasn't functioning properly, the resident could exit the facility without staff being aware. IT #1 was asked what the manufacturers recommendations for routine monitoring of the alarm system were. IT #1 denied any knowledge of the manufacturing recommendations for monitoring the system. IT #1 confirmed that the last time the alert alarm system was checked was a month or two ago. IT #1 confirmed that there was not any alert to IT if the system wasn't functioning properly. IT #1 confirmed that the facility would not know there was an issue with the system until a resident got out the doors. IT #1 denied having any knowledge of the facility performing any drill for elopement for the system. IT #1 confirmed that the installation company doesn't provide routine onsite checks, only when the facility requests a check of the system. IT #1 remarked that the last time the installation company checked the system was the end of last year, November or December, due to an issue with the door not functioning properly after a resident was able to get the door open part of the way and the alarm not activating. IT #1 stated that after facility staff reviewed the video, Resident #55 was observed pushing the door open partway and the alarm didn't activate. The installation company was notified and when they checked the system, it was determined that a sensor wasn't functioning properly and the wiring had to be reworked. On 05/06/2025 at 8:57 AM, the facility door downstairs at Brookside was activated with a tag provided by IT #1, the door locked, and the alarm sounded, 6 staff members responded to the alarm within 42 seconds, and no phone alerts were received by the staff. On 05/06/2025 at 9:36 AM, the facility front entry door was tested with a tag provided by IT #1, when the door was approached within 5 feet the door locks were activated, the door handle was depressed once and the alarm sounded, after the 15 second wait time, the door locks released and the surveyor was able to get out of the door and stand in the portico prior to the first employee on the scene. The first unit staff approached the door at 1 minute and 22 seconds after the initial activation of the guard system. During an interview with the Administrator on 5/06/2025 at 1:00 PM, it was revealed that the residents are assessed for elopement on admission and quarterly. The Administrator confirmed that the facility had a door alarm system, staff education, elopement policies and care planning intervention for residents who are high elopement risks. The Administrator confirmed that the staff were in-serviced annually for elopement and thought the drills were conducted annually with the skills fair. When asked if Resident #55 had eloped prior to the elopement in February 2025, the Administrator confirmed that the resident had eloped in July of 2024. The Administrator was asked how Resident #55 exited the facility on 2/28/2025, he confirmed that an outside vendor delivery person held the door open for Resident #55 allowing the resident to exit the facility. The Administrator confirmed that the door alarm system was a [name brand] guard. Explaining that when the system detects the guard bracelet, the door automatically locks, but if the resident pushes on the door an alarm sounds and the phone alerts go out to staff who are expected to respond immediately and redirect the resident. If the door alarm sounds for 15 seconds, then the door lock releases, allowing the door to be opened. During an interview on 05/06/2025 with the visitor who returned the resident to the facility, it was confirmed that on 2/28/2025 between 5:00pm and 5:30pm they observed the resident outside the facility. When the visitor arrived, they recognized a person walking in the parking lot as a resident that resides at the facility. The visitor confirmed that they approached the resident, the resident happily took their hand, and they walked back inside the facility. An undated vendor letter included with the facility reported incident was reviewed and revealed the facility requesting assistance from the vendors to please wait for staff assistance if the alarm had been activated and not allow anyone to exit prior to checking with staff. A System Maintenance and Testing instruction sheet for the electronic elopement/monitoring system was reviewed and revealed the recommendation was system testing at least monthly and periodic testing of these critical performance functions could help prevent undetected security system failures. For a properly functioning system, when a guard tag approaches a monitored door zone equipped with locks, the lock should engage. Test results should be written down and kept in a log. The Elopement-Prevention and Search policy was reviewed and revealed the alarm systems must be maintained and monitored for accurate operation. The vendors and staff should be educated annually on the elopement policy. When the door alarm had been activated, step outside and scan the area for residents or identify the reason for the alarm.

Based on observation, interview, and record review, the facility failed to ensure that 2 (Residents #44, #78) sampled residents had facial hair and nails trimmed and re-polished. This has the ability to affect 16 residents who reside on 300 Hall. The findings are: 1. On 03/25/2024 at 11:48 AM, the Surveyor observed Resident #78 with chipped nail polish on the fingernails of both hands. The Surveyor ask Resident #78, Do you like your nails painted? Resident #78 stated, Yes, but they need repainted. 2. On 03/25/2024 at 03:09 PM, the Surveyor observed Resident #78 with chipped nail polish on both hands. 3. On 03/26/2024 at 09:19 AM, the Surveyor observed Resident #78 with chipped nail polish on both hands. 4. On 03/25/2024 at 11:40 AM, the Surveyor observed Resident #44 with 0.5-0.75-inch-long nails with chipped nail polish, and 0.5-0.75-inch-long chin and neck hair. 5. On 3/25/2024 at 03:09 PM, the Surveyor observed Resident #44 with 0.5-0.75-inch-long fingernails with chipped polish on both hands, and 0.5-0.75-inch-long facial chin and neck hair. 6. On 03/26/2024 at 09:09 AM, the Surveyor observed Resident #44 up in recliner in room with 0.5-0.75-inch-long fingernails with chipped polish on both hands and 0.5-0.75-inch-long facial chin and neck hair. 7. On 03/27/2024 at 11:46 AM, the Surveyor asked Certified Nursing Assistant, (CNA) #1, Who is responsible for trimming and polishing resident's fingernails? CNA #1 stated, The CNAs are, unless they are diabetic then the nurses do. The Surveyor asked, How often do the residents get their nails trimmed and polish reapplied? CNA #1 stated, Weekly or earlier if needed. CNA #1 confirmed Residents #44 and #78 needed their nails trimmed and repolished. 8. On 03/27/2024 at 11:50 AM, the Surveyor asked CNA #1, Why should a resident be free of facial hair? CNA #1 stated, Dignity, and they feel better about themselves. The Surveyor asked, How often should a female resident's facial hair be trimmed? CNA #1 confirmed, Whenever it is noticeable, weekly, or as needed. CNA #1 confirmed that Resident #78 had long facial and neck hair. 9. On 03/27/2024 at 11:54 AM, the Surveyor asked the Assistant Director of Nurses (ADON), Who is responsible for making sure nails are trimmed and polished? The ADON stated, The CNAs are, unless they (the residents) are diabetic, then the nurses trim them, but the CNAs polish the nails. The Surveyor asked, How often do the Residents get their nails polished? The ADON stated, Weekly, unless it is chipped and they need to do it sooner, as needed. The ADON observed the fingernails of Residents #44 and #78 and confirmed that both residents need their nails trimmed and re-polished. The Surveyor asked, Why should a female resident be free of facial hair? The ADON stated, For their dignity. The Surveyor asked, How often should a female Resident have their facial hair removed? The ADON confirmed, As needed and with showers. The ADON observed Resident #78 and stated, Oh my, yes it needs done and we will make sure it is removed this afternoon. 10. On 03/26/2024 at 12:40 PM, a policy was received titled, Activities of Daily Living (ADLs) which documented, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview, and record review, the facility failed to ensure adequate supervision was provided to prevent burns for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who received speech therapy resulting in past noncompliance. The findings are: a. A Physician's Order dated 04/27/23 documented, .Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to Left later [lateral] thigh topically every day shift for burn to left thigh . until healed . b. A Nurses Note dated 04/27/23 at 1:42 PM documented, .Quarter sized area with red edges appearing like a burned area noted to left thigh. Resident reported to staff he had a hot hand in his pocket. Called his wife [Name] and asked her if she knew anything about it. [Name] stated she would never bring anything like that up and she didn't know what that was. She stated she did let him sleep on a heating pad all night one night but could not remember what night that was. Educated [Name] on only applying heat for 15 minutes at a time and with a barrier in between. She stated she didn't know that and was good to know. Will apply treatment to resident's thigh as ordered and educate resident and wife again on discharge . c. An Incident assessment dated [DATE] at 1:50 PM documented, .Resident burned his leg . Resident placed something hot in his pocket . Someone, in which the resident cannot remember who, gave resident something hot to put in his pocket to keep him warm . Resident was cold and spoke to someone that he had difficulty staying warm. Said person gave him something hot to put in his pocket resulting in a burn on his thigh . d. A Skin & Wound Evaluation dated 04/27/23 at 1:51 PM documented, .Type: Burn .Degree: First Degree .Location: Left thigh (Lateral) .Acquired: In-House Acquired .New .Length: 2.4cm [centimeters]; Width: 2.0cm; Depth: Not Applicable .% slough: 10% . e. A Nurses Note dated 04/27/23 at 2:06 PM by Licensed Practical Nurse (LPN) #1 documented, .Therapy staff reports to nurse that while resident was changing out pants for the morning a large red spot was noted on resident's left lateral thigh. Upon nursing assessment, burn like area was noted. Resident reports that area felt like it burned a little bit. Stated that someone gave him a hot hand like warmer and told him to stick it in his pocket to keep him warm. Also stated that he could not remember who it was that gave it to him. Notified family, CC [Clinical Coordinator], and provider. Applied treatment as ordered to wound . f. On 05/31/23 at 9:32 AM, Resident #1's spouse could not remember who gave him the hot pack at first. She stated, After he went home, he described the person and remembered it was the speech therapist that he had been working with at the nursing home. He said she had given it to him because he was cold and told him to put it in his pocket. They found it in the laundry. Resident #1's spouse denied ever bringing any type of heating pad to the facility and explained she had used one on him at home prior to the nursing home stay. g. A document titled, Speech Therapy Retraining, provided by the Administrator on 05/31/23 at 10:11 AM stated, .Date - April 28, 2023 . Discussed SLP [Speech Language Pathologist] giving a hot pack of any kind to residents. Educated on the risks of hot packs including burns, skin irritation, and circulation complications to residents. Also discussed the risks of giving hot packs to resident with Dementia as they do not always remember being given these items. Educated SLP on reporting to the nurse if a resident reports feeling cold or hot and the nurse can assess the resident. SLP was in agreement and voiced understanding of education . h. On 05/31/23 at 10:34 AM, the Surveyor asked the Speech Therapist what incident occurred during Resident #1's last stay at the nursing facility. She stated, I gave him a hot hand and he got burned. The Surveyor asked, Why did you give him a hot hand? She stated, He was cold, so I gave him some blankets and he was still complaining of being cold, so I gave him a hot hand. The Surveyor asked, At what point in your session did you give it to him? She stated, Close to the end of the session. The Surveyor asked if she had ever given a hot hand to any other resident. She stated, No, I don't know what I was thinking. I use them for myself. I didn't mean to hurt anyone. I've learned my lesson. The Surveyor asked if she could explain the type of Hot Hands that she provided to Resident #1. She stated, It was a four hour one. A small one. It was a little larger than a matchbox. The Surveyor asked if she remembers what day this occurred. She stated, The day before he was being discharged , I believe. It may have been on Wednesday. Our session was right before dinner somewhere between 4:00 and 5:00 PM because he was about to have dinner. The Surveyor asked if she knew where the Hot Hands was when she left Resident #1. She stated, He had it in his pocket and he said it felt warm. i. On 05/31/23 at 3:10 PM, the ADON provided a document titled, Performa Hot and Cold Gel Packs. She stated, This is the Manufactures Guidelines to the heat packs we use here. We don't use hot hands for heat application, and we only apply heat when we have a doctor's order. She handed the Surveyor an example template of the Physician's Order they use when heat application is ordered by the Physician. The Manufacturer's Guidelines for the Hot Packs documented, .Use as heat therapy to soothe muscle aches, stiffness, cramps, and tension . Do not place pack directly on skin. Without protection, skin could be severely burned by heat . Before application, wrap the gel pack with several thicknesses of a towel for heat therapy . Never sleep, lie or sit on the pack. Take extra care when applying on infants, young or elderly patients who may be more sensitive to heat . Monitor carefully when used with anyone whose skin could burn or freeze easily such as children and the elderly . Do not leave the pack on the skin more that 20-25 minutes . Do not use on patients who have sensitive skin, nerve damage or poor circulation . The Physician Order Template documented, .Heat pack to (_____) 10-15 minutes at a time, as tolerates with quarterly review . The Surveyor asked the ADON if Resident #1 had a Physician's Order for heat application. She stated, No, he didn't. j. On 06/01/23 at 10:56 AM, the Surveyor asked LPN #1 to explain what happened when it was discovered that Resident #1 had been burned. He stated, The therapist was in the room helping the resident get dressed and saw the area. They came and got me to come and look at the red area. The APN [Advance Practice Nurse] looked at it and said it looked like a burn. The resident stated someone gave him something hot and told him to put it in his pocket and it would keep him warm. He wasn't sure who it was who gave it to him. The wife suggested that it may have been the Speech Therapist. The CNAs were later questioned, and they said they had found a hot hands in the laundry. The resident left a day or two later. The Speech Therapist was questioned and admitted she had given it to him.

Based on interview, and record review, the facility failed to ensure full time Nursing Assistants (NA) did not work more than 4 months in the facility without completing the necessary certification requirements. This failed practice had the potential to affect 87 residents who currently resided in the home according to the Resident Census and Conditions of Residents provided by the Administrator on 02/14/23 at 8:50 AM. The findings are: 1. On 02/15/23 at 2:25 PM, the Human Resource (HR) Director provided a list of 16 Nursing Assistants who were currently employed by the facility. The Surveyor asked the HR Director if all of the Nursing Assistants listed had completed their testing within the specified 4 month time frame. She stated, No. The HR Director then provided a list of the 10 Nursing Assistants who had not completed a portion of their training requirements with the last day of their 4 month training period as follows: a. NA #1 - 12/21/22. b. NA #2 - 12/21/22. c. NA #3 - 12/21/22. d. NA #4 - 02/01/23. e. NA #5 - 02/01/23. f. NA #6 - 02/02/23. g. NA #7 - 02/02/23. h. NA #8 - 02/09/23. i. NA #9 - 02/09/23. j. NA #10 - 02/09/23. The Surveyor asked the HR Director if these employees were continuing to work past their 4-month training period despite having not completed their program of study within the specified time frame. She stated, Yes. 2. On 02/15/23 at 2:25 PM, the HR Director provided a copy of the nursing schedule from December 18, 2022, to the present. The HR Director had highlighted 10 Nursing Assistants currently on the schedule, 9 of which had provided services to the residents during this period of time. 3. On 02/16/22 at 12:15 PM, the Administrator provided a list of Nursing Assistants who had provided nursing services to residents after the end of their four-month training period. The employee and their time worked are as follows: a. NA #1 - 41 shifts for a total of 373.0501 hours. b. NA #2 - 36 shifts for a total of 341.766 hours. c. NA #3 - 38 shifts for a total of 375.6166. d. NA #4 - 12 shifts for a total of 98.45 hours. e. NA #5 - 11 shifts for a total of 90.1667 hours. f. NA #6 - 11 shifts for a total of 90.7501 hours. g. NA #7 - 11 shifts for a total of 97.9834. h. NA #8 - out of town. i. NA #9 - 3 shifts for a total of 26.1 hours. j. NA #10 - 4 shifts for a total of 34.3 hours. Total number of hours - 1528.1835. 4. On 02/16/23 at 1:00 PM, the Surveyor asked the Administrator if the facility had a policy concerning staffing. At 1:10 PM, the Administrator provided a policy titled, Nursing Services & [and] Sufficient Staff. The policy stated: .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill set to assure resident safety . 5. On 02/16/22 at 1:42 PM, the Surveyor asked the Unit Coordinator if the facility had a job description for a Nursing Assistant or a Certified Nursing Assistant (CNA). He stated, .We don't really have anything like that . 6. On 2/17/23 at 8:10 AM, the Surveyor asked the Director of Nursing (DON), How long can a Nursing Assistant work before they complete the certification process? She stated, .Four months . The Surveyor asked, What should take place at the end of that four months if they have not completed the certification process? She stated, .I know before there was a wavier and they could just continue to work. I guess now they shouldn't work . 7. The Certified Nursing Assistant Job Description provided by the Unit Coordinator on 02/17/23 at 8:33 AM documented, .Basic Core Competencies . 11. Clinical skills sufficient to meet all the primary responsibilities identified above; meets state licensing and all other appropriate regulations for position, as well as organization's expectations of position clinically (direct nursing, return demonstration, supervision and guidance) .

Based on record review, and interview, the facility failed to ensure a comprehensive, person-centered Care Plan was developed to address the necessary care and monitoring related to the administration of Insulin to enable staff to determine the effectiveness of the medication and promptly identify any potential adverse effects for 1 (Resident #46) of 1 sampled resident who had a Physicians Order for Insulin and resided on the 300 Hall. The findings are: Resident #46 had a diagnosis of Type II Diabetes Mellitus. The Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received insulin injections during the last 7 days. a. The Physicians Orders documented, .A1C Q [every] 3 months in the morning every 3 month(s) starting on the 18th for 1 day(s) related to Type 2 Diabetes Mellitus with Unspecified Complications . Order Date 12/18/2022 . HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML [Milliliters] Insulin Lispro (1 Unit Dial)) Inject as per sliding scale: if 0 - 70 = 0 units Give 4oz [ounces] of juice and notify MD [Medical Doctor]; 71 - 139 = 0 units; 140 - 180 = 3 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units Administer insulin and notify MD, subcutaneously two times a day . Order Date 01/06/2021 . Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 24 unit subcutaneously at bedtime . Order Date 12/20/2021 . b. The Care Plan with a revision date of 12/21/22 documented, .I currently receive a NCS [No Concentrated Sweets] diet related to my diabetes. with regular texture as ordered by my physician. I also take Humalog and Lantus. I have a libre sensor to take my BS [Blood Sugar]. At times it does not work, and I need my finger pricked. The Care Plan did not address or contain interventions related to monitoring for hyperglycemia, hypoglycemia and /or for obtaining lab work. c. On 02/16/23 at 9:32 AM, the Surveyor asked Registered Nurse (RN) #1, Who develops the resident's Care Plan? RN #1 stated, I do or any Clinical Coordinator that admits the resident. The Surveyor asked, Is [Resident #46] on insulin? RN #1 stated Yes. The Surveyor asked, Is this medication supposed to be monitored? RN #1 stated, Yes. The Surveyor asked, What should the resident be monitored for? RN #1 stated, For signs and symptoms [s/s] of hyper and hypo glycemia. The Surveyor asked, Should [Resident #46] be care planned for being a diabetic receiving insulin? RN #1 stated, Yes. The Surveyor asked RN #1 to review Resident #46's Care Plan. The Surveyor asked if Resident #46 was care planned for being on insulin. RN #1 stated, Yes. The Surveyor asked, Where is it documented in [Resident #46's] Care Plan for insulin and the interventions to monitor for s/s of hypo and hyper glycemia? RN #1 stated, We just look at her glucose numbers. The only thing the Care Plan mentions is to maintain her blood sugars. Interventions to monitor for s/s should be in her Care Plan. d. The Manufacturers Insert for Humalog provided by the Assistant Director of Nursing (ADON) on 02/16/23 at 12:57 PM documented, .HUMALOG may cause serious side effects that could lead to death, including . low blood sugar (hypoglycemia). Signs and symptoms of low blood sugar may include: dizziness . slurred speech . confusion . fast heartbeat . serious allergic reactions . Get medical help right away, if you have any of these signs or symptoms of a severe allergic reaction . a rash . trouble breathing . a fast heartbeat . e. The Manufacturers Insert for Lantus provided by the Assistant Director of Nursing (ADON) on 02/16/23 at 12:57 PM documented, .Lantus may cause serious side effects that could lead to death, including . low blood sugar (hypoglycemia). Signs and symptoms that may indicate low blood sugar include: dizziness . confusion . slurred speech . fast heartbeat . severe allergic reaction . Get medical help right away if you have any of these signs or symptoms of a severe allergic reaction . a rash . trouble breathing . fast heartbeat . or sweating .

Based on observation, record review, and interview, the facility failed to ensure the Plan of Care was revised to reflect the current needs of the resident to ensure appropriate care was provided for 1 (Resident #66) of 1 sampled resident who required extensive assistance with eating and resided on the 200 Hall. The findings are: Resident #66 had a diagnosis of Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and required extensive one person physical assistance with eating and was on a therapeutic diet. a. The Physicians Order dated 02/18/22 documented, .NCS [No Concentrated Sweets], NAS [No Added Salt] diet, Gound [Ground] meat texture . b. The Care Plan with a revision date of 03/22/22 documented, .I have an ADL [Activities of Daily Living] Self Care Performance Deficit r/t [related to] dementia . EATING: I require set up assistance to eat . c. On 02/13/23 at 12:07 PM, Resident #66 was sitting in the Sunroom, a family member was sitting next to her. The family member was spoon feeding Resident #66 her lunch. d. On 02/14/23 at 8:16 AM, Resident #66 was sitting in the Dining Room, a Certified Nursing Assistant (CNA) was sitting next to her spoon feeding Resident #66 her breakfast. e. On 02/16/23 at 10:04 AM, the Surveyor asked Register Nurse (RN) #2, Who revises the resident's Care Plans? RN #2 stated, [Nurse's Name] or me. The Surveyor asked, When should the resident's Care Plan be revised? RN #2 stated, 'With new orders, change of condition, any new adjustments, and quarterly. The Surveyor asked, What level of assistance does [Resident #66] require for eating? RN #2 stated. Ninety percent of the time she requires staff to feed her, she's an extensive assist for eating. The Surveyor asked, According to [Resident #66's] Care Plan, how much assistance does the resident require for eating? RN #2 stated, The Care Plan states she is set up assistant for meals. The Surveyor asked, Should [Resident #66's] Care Plan be revised? RN #2 stated, Yes. f. The facility policy titled, Care Plan Revisions Upon Status Change, provided by the Assistant Director of Nursing on 02/16/23 at 12:57 PM documented, .The purpose of this procedure is to provide a consistent process for reviewing and revisiting the care plan for those residents experiencing a status change . The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . Upon identification of a change in status, the nurse will notify the Clinical Coordinator, the physician and the resident representative, if applicable. The Clinical Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on interventions options . The care plan will be updated with the new or modified interventions . Care plans will be modified as needed by the Clinical Coordinator or other designated staff member .

Based on record review, and interview, the facility failed to ensure laboratory services were provided at the frequency ordered by the Physician, to assist the Physician with making treatment decisions for 1 (Resident #46) of 1 sampled resident who had a Physician Order for Hemoglobin (HgbA1C) levels. This failed practice had the potential to affect 1 resident who had a Physicians Order for HgbA1C levels and resided on the 300 Hall. The findings are: Resident #46 had a diagnosis of Type II Diabetes Mellitus. The Modified Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received insulin injections during the last 7 days. a. The Physicians Orders documented, .A1C Q [every] 3 months in the morning every 3 month(s) starting on the 18th for 1 day(s) related to Type 2 Diabetes Mellitus with Unspecified Complications . Order Date 12/18/2022 . HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML [Milliliters] Insulin Lispro (1 Unit Dial)) Inject as per sliding scale: if 0 - 70 = 0 units Give 4oz [ounces] of juice and notify MD [Medical Doctor]; 71 - 139 = 0 units; 140 - 180 = 3 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units Administer insulin and notify MD, subcutaneously two times a day . Order Date 01/06/2021 . Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 24 unit subcutaneously at bedtime . Order Date 12/20/2021 . b. The Care Plan with a revision date of 12/21/22 documented, .I currently receive a NCS [No Concentrated Sweets] diet related to my diabetes. with regular texture as ordered by my physician. I also take Humalog and Lantus. I have a libre sensor to take my BS [Blood Sugar] . c. On 02/15/23 at 3:13 PM, the Surveyor asked the Director of Nursing (DON) to provide documentation of the physician ordered HgbA1C results for December 18, 2022. The DON stated, The resident did not get her A1C drawn on 12/18/22. The person who updated the order, put the order in on 12/18/22, and the start date as 12/19/22, so it regenerated the order, and it was not drawn on 12/18/22 or 12/19/22. We are drawing it today. d. The Lab Report provided by the DON on 02/16/23 documented, .Collected: 02/15/23 at 1520 [3:20 PM] . Test HGB A1C Result 9.1 H [High] Reference 4.8-6.0 . e. The facility policy titled, Laboratory Services and Reporting, provided by the Assistant DON on 02/16/23 at 12:57 PM documented, .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law . The facility must provide or obtain laboratory services to meet the needs of its residents . The facility is responsible for the timeliness of the services . Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range . 47912

Based on observation and interview, the facility failed to ensure 4 of 4 working ice machines were maintained in clean, sanitary condition to prevent potential illness or infection for residents who received meals or ice from the main kitchen and 4 household kitchens. These failed practices had the potential to affect all 92 residents, as documented on a list provided by Registered Dietitian on 10/21/21. The findings are: 1. On 10/18/2021 at 12:27 P.M., Dietary Employee (DE) #1 took a white napkin and wiped the top of the internal curtain in the main kitchen's ice machine. A black substance transferred onto the napkin. Using another napkin, the employee wiped the back side of the curtain. The napkin returned with a slimy, pinkish substance on it. When asked to describe what she saw, DE #1 said, A little dirty. The Registered Dietitian (RD) said, I see mold. The RD was asked how often the machine was cleaned and stated, Every three months. When asked if residents received ice from the kitchen ice machine, the RD said, It's mostly used for food prep, such as when we make Jell-O. 2. On 10/18/2021 at 12:58 P.M., the RD wiped the back side of the internal curtain of the ice machine in the Crestview kitchen. A yellowish and brownish substance transferred onto the napkin. The RD was asked to describe what she saw. She stated, Typically I look for red or black. I can't really say what that is. 3. On 10/18/2021 at 1:03 P.M., there was a slight yellowish substance on a napkin used to wipe the back side of the internal curtain of the ice machine in the Terra Vista Kitchen. 4. On 10/18/2021 at 1:12 P.M., there was a small amount of a yellowish discoloration on a napkin used to wipe the back side of the internal curtain of the ice machine shared by the Pinnacle and Summit Kitchens. 5. On 10/20/21 at 9:33 A.M., the facility Manager was asked how often the facility's ice machines were cleaned. He stated, Three times per year. It's due this month. We clean it more often if we notice something. He was asked what the process was and stated, We follow the manufacturer's recommendations. We run a chemical through the system. We take the curtain out and clean it.

Based on observation, record review and interview, the facility failed to ensure expired medications were removed and placed into an area for destruction to prevent potential administration to residents and medications were labeled with the resident's name to prevent potential administration to other residents on 2 (Crestview Hall and Summit Hall) Halls of 6 (Crestview Hall, Summit Hall, Ridgemont Hall, Brookside Hall, Terra Vista Hall, and Pinnacle Hall) Halls. The findings are: 1. On 10/19/21 at 10:33 A.M., the Crestview nurse server (medication storage device) was inspected with the assistance of Licensed Practical Nurse (LPN) #1. An opened bottle of Earwax Removal Aid with an expiration date of 3/2021 was stored in the nurse server. LPN #1 was asked, Should expired medications be left in the nurse server? LPN #1 stated, No. 2. On 10/19/21 at 10:54 A.M., the Summit nurse server was inspected with Medication Assistant Tech (MAT) #1 and Registered Nurse (RN) #1. A bottle of Sore Throat Oral Relief with an opened date of 09/18/21 was in the nurse server and was not labeled with a resident name. RN #1 was asked, Is there a name on this bottle? RN #1 stated, No. RN #1 was asked, Should there be a name on it? RN #1 stated, Yes, it should have been left in their room. At 10:59 A.M., MAT #1 was asked, should the bottle have a name on it? MAT stated, It should have been labeled with a name. 3. On 10/21/21 08:30 A.M., the Director of Nursing (DON) was asked, Why should expired medications not be left in the nurse servers? The DON stated, The potential they could be given. The DON was asked, Why should medications be labeled with residents' names? The DON stated, So you can identify who the medication is for. 4. The facility's policy and procedure titled, Medication Storage, provided by the Director of Nursing (DON) on 10/19/21 at 1:54 P.M., documented, .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy .

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were coded accurately for 3 (Residents #47 #83 and #94) of 20 (Residents #64, #89, #94, #59, #73, #57, #11, #83, #42, #77, #75, #47, #28, #31, #60, #65, #52, #63, #1, and #24) sampled residents whose MDS assessments were reviewed. This failed practice had the potential to affect all 94 residents who resided in the facility, according to the Resident Census and Conditions of Residents form dated 7/7/2020. The findings are: 1. Resident #83 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment reference Date (ARD) of 6/17/2020 documented the resident scored 12 (8 - 12 indicates moderately intact) on a Brief Interview for Mental Status (BIMS); received an anticoagulant 7 days on the 7 day look back period. a. On 07/07/2020 at 09:52 AM, Resident #83's record review was completed with no anticoagulant found in physicians orders, or history. b. On 07/09/2020 at 02:06 PM, the Assistant Director of Nursing (ADON) was asked to provide documentation for Resident #83's anticoagulant. She stated, .I was unable to find any in the record . c. On 07/09/2020 at 02:19 PM, the last three MDSs with ARDs of 6/17/2020 (Quarterly), 5/22/2020 (Significant change), and 3/18/2020 (Annual) were reviewed, and all documented anticoagulant as being taken for the last 7 days. 2. Resident #47 had [DIAGNOSES REDACTED]. The MDS with an ARD of 5/20/2020 documented the resident's Brief Interview for Mental Status (BIMS) as not assessed, the Staff Assessment for Mental Status (SAMS) documented long and short term memory issues, and the Mood (PHQ-9) was documented as not assessed, staff completed with a score of 04 (1-4 indicates minimal depression), and Restraints used less than daily. a. The Care Plan dated 5/24/2020 didn't reference a restraint. b. Physician order [REDACTED]. No restraint assessment was found in the record. c. On 07/06/2020 at 1:55 PM, the resident was observed on a low bed. There was a fall mat at the bed side. d. On 07/08/2020 at 10:05 AM, Registered Nurse (RN) # 2 was asked if the resident had a restraint. She stated, No, I don't think so. He's on a low bed. But he is unable to walk. e. On 07/08/2020 at 10:40 AM, RN #2 stated, The MDS was incorrect . f. On 07/09/20 at 8:18 AM, CNA #1 was identified as the individual who completed the mental status and mood assessment and was asked, why was R#47 Quarterly MDS dated [DATE] BIMS & PHQ-9 marked as not assessed? CNA #1 stated, I really don't know why. Have you been trained on MDS completion? CNA #1 stated, Yes, by the person who's place I took. What are your job duties? The CNA stated, As house coordinator, I check rooms, check care, assist with families. So MDS' are last? CNA #1 stated Yes. g. At 2:00 PM, the Social Service Designee was asked what kind of training was provided for CNA#1? The Social Service Designee stated, I provided the initial training and recommended U-Tube training video. I trained him to always interview, it has to be offered. 3. Resident #94's Medicare 5 day/DRNA(Discharge Return Not Anticipated)/End of PPS (Prospective Payment System) Part A stay MDS with an ARD of 5/12/2020 documented discharge to acute care. a. The MDS progress note completed 5/19/2020 at 10:27 AM documented, (Name) entered (Name) on 5/6/2020 . (Name) discharged from (Name) to the community on 5/12/2020 and was completed by RN#1. b. On 7/9/2020 at 9:00 AM, RN#1 was asked to reference R#94's MDS note from 5/16/2020, and was asked, where does it say she was discharged to? RN #1 stated, community. When asked to review the discharge return not anticipated MDS with an ARD of 5/12/2020 to see where it identified she was sent, the RN stated, Oh, oops.

Based on record review and interview, the facility failed to ensure physician orders [REDACTED].#33) of 4 residents who had a physician order [REDACTED]. The findings are: 1. On 7/2/2020 the July 2020 Medication Administration Record [REDACTED]. **See orders for other directions** However, the blood sugar on 7/1/2020 was 65, the correct dosage should have been 38 units. b. On 7/3/2020 the [MEDICATION NAME] Solution 100 unit/ml (milliliter) inject 40 units subcutaneously in the morning the signature and the units were omitted the blood sugar from 7/2/2020 was 77. c. On 7/4/2020 the [MEDICATION NAME] Solution 100 unit/ml inject 42 units subcutaneously in the morning the signature and the units were omitted the blood sugar from 7/3/2020 was 54. d. On 7/6/2020 the MAR indicated [REDACTED]**See orders for other directions**. d. On 7/08/2020 at 7:24 PM, while completing the reconciliation of resident #33 orders, an order written [REDACTED]. e. On 7/09/2020 at 8:22 AM, Registered Nurse (RN) #2 was asked, How long had she been the unit manager? She stated, 2 weeks. She was asked, Do you review MAR's for omissions or errors? She hesitantly stated, Yes. She was asked, Are you aware of any insulin issues? She stated, Yes. She was asked, When were you made aware? She stated, This morning. She was asked, By whom? She stated, The DON. She was asked, Was it because of the request for the July 2020 MAR's? She stated, Yes. She was asked to provide any documentation related to the significant medication errors. f. On 7/9/2020 at 4:00 p.m., a review of the Medication Administration Policy and Procedure documented .Review MAR indicated [REDACTED].) to verify resident name, medication name, form, dose, route, and time. Sign MAR indicated [REDACTED]

Based on interview and record review, the facility failed to ensure the resident and the resident's representative were notified in writing of a transfer to the hospital for 1 (Resident (R) #65) of 4 (R #29, R #65, R #75, and R #89) sampled residents who were transferred to the hospital in the last 180 days. This failed practice had the potential to affect 9 total residents who were transferred, according to a list provided by the Admissions Coordinator on 7/09/2020 at 2:59 PM. The findings are: 1. Resident #65 had [DIAGNOSES REDACTED]. a. The MDS assessment dated [DATE] documented a Discharge Return Anticipated on 5/29/2020 and an Entry on 6/02/2020. b. On 07/09/2020 at 10:40 AM, the Admissions Coordinator was asked if the resident and the resident's representative were notified in writing of the transfer and the bed hold and he stated, We do that for the rehab residents but we don't for the long term care residents because they would panic thinking we were not going to hold their bed for them. So, no we are not completely compliant with that. Then he was asked, so am I understanding you correctly, you did not send the written notification of the hospitalization transfer and bed hold for Resident #65? He stated, No. We did not. c. On 7/10/2020 at 8:15 AM, a copy of the written notification of transfer was requested from the facility, the Admissions Coordinator stated that he didn't believe there was one.

Based on interview and record review, the facility failed to ensure the resident and the resident's representative were provided a bed hold policy prior to a transfer to the hospital for 1 (Resident (R) #65) of 4 (R #29, R #65, R #75, and R #89) sampled residents who were transferred to the hospital in the last 180 days. This failed practice had the potential to affect 9 residents who were transferred, according to a list provided by the Admissions Coordinator on 7/09/2020 at 2:59 PM. The findings are: 1. Resident #65 had [DIAGNOSES REDACTED]. a. The MDS assessment dated [DATE] documented a Discharge Return Anticipated on 5/29/2020 and an Entry on 6/02/2020. b. On 07/09/2020 at 10:40 AM, the Admissions Coordinator he was asked if the resident and the resident's representative were notified in writing of the transfer and the bed hold and he stated, We do that for the rehab residents but we don't for the long term care residents because they would panic thinking we were not going to hold their bed for them. So, no we are not completely compliant with that. Then he was asked so am I understanding you correctly, you did not send the written notification of the hospitalization transfer and bed hold for Resident #65? He stated, No. We did not. c. On 7/10/2020 at 8:27 AM, a copy of the bed hold notification on transfer policy and procedure was received from the Admissions Coordinator. It documented, .In the event of an emergency transfers of a resident, Hillcrest Home will provide within 24 hours written notice of the facility's bed -hold policies, as stipulated in each state's plan . d. On 7/10/2020 at 8:45 AM, during an interview with the Admissions Coordinator he was asked if the resident's transferred from the list were given written notification of bed-hold and he stated, A copy was sent with them to the hospital but there is no guarantee that it was actually given to the resident and representative, since it is given to the hospital personnel.

Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator and/ or freezer were covered and / or sealed, labeled, and dated in 1 of 1 kitchen and 4 (Terra Vista, Crestview, Ridgemont, and Brookside) of 6 Halls' kitchenettes; dietary staff kept their hair / facial hair covered while working in 2 (Crestview and Terra Vista) of 6 Halls' kitchenettes; Dietary Staff who carried out meal preparation and service washed hands / changed gloves between dirty and clean tasks and / or before handling clean equipment or food items in 2 (Terra Vista and Crestview) of 6 Halls' kitchenettes to prevent potential for food borne illness for residents who received meals from the affected kitchen / kitchenettes. These failed practices had the potential to affect all 95 residents who received meal trays from the kitchen and / or kitchenettes (total census: 95), as documented on a list provided by the Dietary Manager on 2/18/19. The findings are: 1. On 2/18/19 during the initial tour of the kitchen, the following observations were made: a. At 11:54 a.m., four unopened bags of fruit punch and one opened bag of fruit punch in a zip-lock bag were stored in a box on a shelf in the Dry Storage area in the kitchen. One box of 10 lemonade drink bags was also stored on a shelf in the Dry Storage area in the kitchen. The boxes and bags of fruit punch and lemonade were not dated. b. At 11:59 a.m., five cups of Greek yogurt were stored on a shelf in the walk-in refrigerator. Each of the 5 cups of yogurt were dated, Jan (January) 23 2019. On 2/19/19 at 11:00 a.m., the Dietary Manager was shown the Greek yogurts and stated, Oh, these should not be in here. c. At 12:01 p.m., a box that contained 3 packages of strawberries was stored on a shelf in the walk-in refrigerator. Neither the box, nor any of the 3 packages, were dated. d. At 12:05 p.m., two bags of oranges were stored in a plastic bag on the top shelf of the walk-in refrigerator. The bags were not dated. e. At 12:06 p.m., three packages of mushrooms were stored on a shelf in the walk-in refrigerator. The packages were not dated. f. At 12:07 p.m., one box containing approximately 60 lemons was stored on a shelf in the walk-in refrigerator. The box was not dated. g. At 12:08 p.m., one zip-lock bag of shredded carrots was stored on a shelf in the walk-in refrigerator. The bag contained no label and was not dated. h. At 12:12 p.m., one bag of spinach was stored on a shelf in the walk-in refrigerator. The bag contained a label which documented, Use by (MONTH) 15 2019. i. At 12:14 p.m., one bag of mozzarella cheese was stored on a shelf in the walk-in refrigerator. The bag contained a label which documented, Use by (MONTH) 15 (YEAR). 2. On 2/18/19, during an initial tour of the six hall kitchenettes, the following items were identified: At 12:27 p.m. in the Terra Vista Hall kitchenette: a. At 12:27 p.m., a white side-by-side refrigerator / freezer in the front kitchenette area had one container of three sliced lemons stored on a shelf. The container was not dated. b. One zip-lock bag of blueberries was stored on a shelf in the white freezer. The bag contained no label, and was not dated. c. Thirteen bananas were stored on a shelf in the white freezer. The bananas were brown and were not dated. From 12:39 p.m. to 12:51 p.m. in the Crestview Hall kitchenette: a. A zip-lock bag of 7 potatoes was stored on the bottom shelf of the silver reach-in refrigerator. The bag was not dated. b. One bag containing four pastry slices was stored on a shelf in the freezer at the back of the kitchenette. The bag contained no label and was not dated. c. One bag of chopped meat was stored on a shelf in the freezer. The bag contained no label and was not dated. d. One bag of approximately 60 sausage patties was stored on a shelf in the freezer. The bag contained no label and was not dated. From 1:49 p.m. to 1:54 p.m. in the Ridgemont Hall kitchenette: a. One bag containing two sausage patties was stored on a shelf in the refrigerator at the front of the kitchenette. The bag was not dated. b. One 2-pound bag of white cheese was stored on a shelf in the refrigerator. The bag contained no brand label and was not dated. c. Thirty-three vanilla shakes were stored on the top shelf in the door of the white freezer in the back of the kitchenette. The vanilla shakes were not dated. Seven strawberry shakes and eight vanilla shakes were stored on the middle door shelf of the white freezer. The strawberry and vanilla shakes were not dated. d. One bag of frozen cookies was stored on the bottom shelf of the freezer. The bag contained no brand label and was not dated. At 2:04 p.m., the Brookside Hall Kitchenette contained a silver colored side-by-side refrigerator / freezer in the front kitchenette area. One bag containing four slices of bread was stored on a shelf in the freezer. The bag of sliced bread contained no label and was not dated. 3. On 2/18/19 at 4:20 p.m., Certified Nursing Assistant (CNA) #1 was in the Crestview Front Kitchenette and was standing by the steamtable. He had a beard that was approximately one-half inch in length, from the base of both ears, on both sides of his face, with a goatee beard, which was approximately one-half inch wide, under his bottom lip, and a moustache over his top lip. He was not wearing a beard restraint. a. At 4:25 p.m., CNA #1 washed his hands and went to the back of the kitchen. He was still not wearing a beard restraint. He came out of the back of the kitchen with a transparent bowl of ice. He washed his hands in the handwashing sink in the front kitchenette area. He went to the refrigerator in the front kitchenette area and removed a bowl of coleslaw from the refrigerator and placed it in the transparent bowl of ice. CNA #1 went to the back of the kitchen and came out into the front kitchenette area with a rectangular gray colored tray that contained ice and placed the tray of ice on the counter top next to the stove. He was still not wearing a beard restraint. He washed his hands and went to the back of the kitchen and returned to the front of the kitchen with four pitchers of juice. He placed the four pitchers of juice into the large tray of ice. He washed his hands, removed a paper towel, and patted his hands dry. He turned off the faucet with the same paper towel, and used the same paper towel to pat his right wrist dry before disposing of the paper towel. He removed a menu folder from a drawer opposite the steam table and placed it on the counter top behind the steamtable. He removed four tumbler glasses from a cabinet and placed them by the pitchers in the tray of ice. He went to the back of the kitchen and came back to the front of the kitchen with a pitcher of ice. He was still not wearing a beard restraint. He removed a cup from a cabinet and poured coffee into the cup. He walked over to a table where a resident was sitting and gave the cup of coffee to the resident. He came back into the front of the kitchenette with a green colored cup from another resident, filled it with coffee, and took it back to the resident. He went back into the front of the kitchenette and washed his hands. He scooped ice out of the pitcher of ice, placed it in the glasses, and poured juice into the glasses of ice. He placed lids on all four glasses. A resident just outside of the kitchenette area asked for a menu, and CNA #1 gave him a paper menu. He then put straws into the 4 glasses and took them out to two tables in the dining area. He gave one glass to a resident and placed three glasses on a table not occupied by residents. b. On 2/18/19 at 4:32 p.m., CNA #1, who was still not wearing a beard restraint, filled a glass with red juice, filled a cup with coffee, and gave both to a resident on the outside of the kitchen area. He washed his hands and got a paper towel and patted his hands dry. He turned off the faucet with the paper towel, then patted both hands dry again with the same paper towel. He filled a glass with ice from the pitcher of ice, poured tea into the glass, and placed a plastic lid on the glass. He picked up a green colored cup, filled it with coffee, walked into the dining area, and gave the green colored cup to a resident in the dining area. CNA #1 went back into the front of the kitchenette, picked up a glass, and went to the refrigerator in the front of the kitchenette. He opened the door of the refrigerator and removed a carton of milk. He poured milk into the glass, half-filled the glass, and put the glass on the counter top opposite the steam table near the handwashing sink. CNA #1 washed his hands and got a paper towel to pat dry his hands. He turned off the faucet and used the same paper towel to wipe inside the handwashing sink. He disposed of the paper towel and went to the refrigerator in the front of the kitchenette. He removed a carton of milk and poured another glass of milk. He picked up a Sharpie brand black colored pen, wrote on top of the milk carton, and placed it back in the refrigerator. He washed his hands. He checked the temperatures of the food items on the steam table, and then put on gloves. He did not don a beard restraint at any time during these procedures. c. On 2/18/19 at 4:45 p.m., the supper meal service began, and CNA #1 was still not wearing a beard restraint. He removed his gloves, picked up the menu book, and placed it next to the steamtable. He removed scoops from a drawer behind the steamtable, and then put on new gloves. He portioned the supper meal foods onto plates for other staff to distribute to the residents. The last plate was served to the residents at 5:10 p.m. CNA #1 did not wear a beard restraint throughout the supper meal service to the residents. 4. On 2/18/19 at 4:32 p.m., on the Terra Vista Hall, Homemaker #2 served the first plate of food for the supper meal. Homemaker #2 wore gloves and used her hands to open up the hot dog buns, then wore the same gloves to pick up tongs to put a hot dog on the bun, and picked up the mustard bottle with the same gloved hand to put mustard on the hot dog bun. Homemaker #2 used the same gloved hand to pick up tongs to place tater tots on the plate next to the hot dog, picked up the plate, and took the plate to a resident seated at a table in the Terra Vista Hall Dining Room. Homemaker #2 wore the same gloves and reached into a drawer with a gloved hand, picked up a napkin, and gave the napkin to a resident. 5. A facility policy titled, Dietary Employee Personal Hygiene, provided by the Administrator on 2/19/19 at 10:28 a.m., documented, .Hair should always be covered . The Administrator was asked, should staff wear hair and beard restraints in the hall kitchenettes. He stated, Well, some staff just go in there to get a snack or drink for a resident. The Administrator was asked, is there the potential for hair to make contact with food, if staff do not wear a hair restraint or beard restraint in the main kitchen or hall kitchenette areas? The Administrator stated, Well, yes, there is.

Based on record review and interview, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was completed prior to admission to ensure residents received the needed care and services in the most appropriate setting for 3 (Residents #27, #36 and #84) of 5 (Residents #27, #36, #84, #28, and #34) sampled residents who had a mental illness. The failed practice had a potential to affect 13 residents who had a mental illness, as identified by the list provided by the Assistant Director of Nursing on 2/20/19. The findings are: 1. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. 2. Resident #36 was admitted on [DATE] with [DIAGNOSES REDACTED]. 3. Resident #84 was admitted on [DATE] with [DIAGNOSES REDACTED]. 4. As of 2/20/19 at 2:04 p.m., the clinical records of Residents #27, #36, and #84 contained no documentation to indicate a Level I PASRR evaluation had been completed prior to admission. a. On 2/19/19 at 2:00 p.m. and 2/20/19 at 8:00 a.m. and 9:45 a.m., the Assistant Director of Nursing (ADON) was asked for documentation of the Level I PASRR for Residents #27, #36, and #84. b. On 2/20/19 at 11:16 a.m., the Administrator stated, It must have fallen through the gap. c. As of 2/20/10 at 3:02 p.m., the Director of Nursing (DON) was unable to provide completed PASSR documentation for Residents # 27, #36, and #84.

Based on observation, record review and interview, the facility failed to ensure interventions were developed and implemented to prevent further potential falls and minimize the risk for fall-related injuries for 2 (Residents #90 and #27) of 24 (Residents #27, #90, #2, #10, #15, #23, #28, #33, #34, #35, #36, #42, #47, #50, #62, #68, #74, #77, #78, #84, #91, #248, #249, and #254) sampled residents who were at risk for falls, and 6 (Residents #2, #23, #27, #50, #62, and #90) sampled residents who had falls in the last 4 months. This failed practice had the potential to affect 82 residents who were at risk for falls (total census: 95), and 13 residents who had falls in the last 4 months, as documented on a list provided by the Director of Nursing on 2/20/19. The findings are: Resident #90 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/19 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS); required extensive one person physical assistance with bed mobility, and required extensive two person physical assistance for transfers and toileting, and bathing, had two or more falls since admission with no injury, received a Restorative Nursing Program with active range of motion 7 out of the last 7 days, and had a bed alarm and a chair alarm to monitor movement and alert staff when movement is detected. a. The Plan of Care with a revised date of 2/7/18 documented, .I am at high risk for falls r/t (related to) confusion, gait / balance problems, incontinence, psychoactive drug use, unaware of safety needs, wandering . I have silent alarms in place in wheelchair and in bed (2/7/18) . I use a low bed with mat (7/2/18) . I have a rimmed mattress (7/3/18) Restorative ambulation as ordered (2/1/19) . Restorative nursing program for PROM (passive range of motion) bilateral upper extremities 5 times weekly with quarterly review (4/30/18) . review information on past falls and attempt to determine causes of falls (7/25/18) . I have an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia . I require extensive two person assist (assistance) with gait belt, unless I have side rails / CNA (Certified Nursing Assistant) to grab, then I require only 1 person with gait belt (10/4/18) . b. Incident Reports dated 1/20/19, 12/23/18, 12/7/18, 12/2/18, 11/30/18 and 11/27/18, and 11/21/18 documented the following: 1.) A facility Incident and Accident form dated 11/21/18 at 20:15 (8:15 p.m.) documented, .Location . Resident's Room .Resident found lying on fall mat beside low bed with rimmed mattress . Predisposing Physiological factors . Confused . Predisposing situation factors . Blank Notes .Resident's [MEDICATION NAME] d/c (discontinued) 9/5/18. Since that time, staff reports that resident has been more alert and active. He frequently self-transfers or attempts to self-transfer. Resident already has a low bed, rimmed mattress, soft mat next to bed. Will continue to encourage him to use call button . There was no documentation that any interventions were implemented, other than instructing the cognitively impaired resident to use their call light. 2.) A facility Incident and Accident form dated 11/27/18 at 14:30 (2:30 p.m.) documented, .Location .Living Room . Resident was found in the floor on his hands and knees attempting to cover up another resident with a blanket . Predisposing Physiological Factors . Confused . Predisposing Environmental Factors . Blank . Predisposing Situation Factors . Unsafe Behavior . Notes .Resident's [MEDICATION NAME] d/c (discontinued) 9/5/18. Since that time, staff reports that resident has been more alert and active. Silent alarms in place in wc (wheelchair) and in bed. No late injuries occurred. Will continue to encourage use of call button. Restorative nursing program as ordered . There was no documentation that any interventions were implemented, other than instructing the cognitively impaired resident to use their call light. 3.) A facility Incident and Accident form dated 11/30/18 at 18:29 (6:29 p.m.) documented, .Location .Living Room . Visitor saw resident slide out of his wheelchair and onto the floor . Predisposing Environmental Factors . Crowding . noise . Predisposing Physiological Factors . Confused .Impaired memory . Predisposing Situation Factors . Large groups, unsafe behavior, transferring without assist .Notes . Resident slid out of his wheelchair in the living room while a church group was singing. One of the visitors saw the resident slide out of his chair and onto his bottom. Staff assisted resident back into his wheelchair. Vital signs .BP (blood pressure) 171/88, P (pulse) 77, T (temperature) 99.6, R (respirations) 16 . O2 (Oxygen) 97% on room air . Resident was assessed for injuries, none were found. Administered PRN (as needed) Tylenol . for elevated temp (temperature). Forwarded information to Dr. (Name) .Will ask day shift to inform family about the fall. Will continue to monitor for late injuries . 2/20/19 Note . Staff agreed that we need to pay better attention to resident's needs to help prevent other falls. Temp elevated. Monitor for s/s (signs / symptoms) of URI (Upper Respiratory Infection). Restorative Nursing Program as ordered . There was no documentation to indicate any new interventions were developed or implemented to prevent further potential falls, or to determine a causative factor since the resident had been found on the floor twice in a three day period in the living room area. There was also no documentation that the CNAs were questioned when the resident was last checked on, positioned, or toileted prior to this fall. 4.) A facility Incident and Accident form dated 12/2/18 at 18:22 (6:22 p.m.) documented, .Location .Living Room . Staff found resident sitting in the living room floor with his pants and underwear pulled down. Resident said that he needed to go to the bathroom . Resident assisted back in his wheelchair . Resident assessed for injuries, found skin tear on resident's right thumb. Resident was assisted to the bathroom by staff . Predisposing Environmental Factors .Crowding . Predisposing Physiological Factors . Gait Imbalance .Weakness / fainted . Predisposing Situation Factors .Ambulating without assist .Unsafe behavior . Note: Staff found resident on the floor in the living room with his pants and underwear pulled down . Resident stated that he needed to use the bathroom . Resident assessed for injuries, found skin tear to resident's right thumb. Applied steri-strips to thumb. Staff assisted resident to bathroom. Resident's underwear was dry and resident did not urinate or have a BM (bowel movement) while on the toilet .Will continue to monitor for late injuries . Note 12/3/18 .Resident will be on a chair alarm so that staff is alerted to when he gets up. Staff will try to anticipate resident's needs better. Encouraged staff to wheel resident around in his wheelchair so that he gets to move around . There was no documentation to indicate any new interventions were developed or implemented (the resident already had a chair alarm), or that toileting the resident more frequently was considered since the resident was found sitting in the floor with his pants and underwear pulled down, and the resident stated he needed to go to the bathroom. 5.) A facility Incident and Accident form dated 12/7/18 at 15:45 (3:45 p.m.) documented, .Resident found on the floor on his side in the living room. Resident states he was trying to turn off the thermostat, when questioned resident states he was not hot or cold. Upon further questioning resident states he hit his head 'softly' . Predisposing Physiological Factors .Recent change in Medications / New . Predisposing Situation Factors . Large Groups, unsafe behavior, transferring without assist . Note . Resident pad alarm in place and working, resident last toileted at 1500 (3:00 p.m.) . Initiated hourly checks for next 24 hours to be completed by CNA staff .documenting if resident is restless or not . There was no documentation indicating whether the alarm was functioning at this time. 6.) A facility Incident and Accident form dated 12/23/18 at 20:20 (8:20 p.m.) documented, .Resident found kneeling in front of his recliner in the living room. He was pushing it around . Predisposing Environmental Factors . Furniture . Predisposing Physiological Factors . confused, gait imbalance . Predisposing Situation Factors . Removed alarm . Note: Resident continues to experience frequent falls since [MEDICATION NAME] discontinued. Staff reports that resident is more active. Request order for PT (Physical Therapy) eval (evaluation) and treat (treatment) . 7.) A facility Incident and Accident form dated 1/20/19 at 17:50 (5:50 p.m.) documented, .Location .Living Room . Resident found crawling in the floor . Assessed for injury, none found . Predisposing Physiological Factors . Confused, Impaired Memory . Note . Increase monitoring. Continue with PT (Physical Therapy) as ordered . There was no documentation that an intervention was developed and implemented to prevent further falls. c. On 2/20/19 at 10:33 a.m., Licensed Practical Nurse (LPN) #1, Unit Manager, was asked, do you put new interventions in place when a resident has a fall? She stated, We do, depending on the circumstance. We use the interventions that are already in place. She was asked, do you have new interventions in place for each fall for this resident? She stated, No. d. On 2/20/19 at 11:09 a.m., the Assistant Director of Nursing (ADON) was asked, do you put a new intervention in place when a resident has a fall? She stated, It depends on the situation but, yes after a fall they should have a new intervention. e. On 2/20/19 at 1:25 p.m., the Administrator was asked, should each fall have an intervention? He stated, Yes. f. On 2/20/19 at 1:51 p.m., the Director of Nursing (DON) was asked, should each fall have an intervention to help prevent future falls? She stated, Yes, they should have an intervention to help prevent any other falls. g. On 2/20/19 at 2:03 p.m., Licensed Practical Nurse (LPN) #1), Unit Manager, was asked about the fall on 1/20/19, for which the intervention was documented as Continue with Physical Therapy (PT) as ordered. The LPN was asked, Was that a new intervention? She stated, No, he was in therapy. h. A facility polity titled Accidents and Supervision provided by the Assistant Director of Nursing on 2/20/19 at 1:45 p.m., documented, .using specific interventions to try to reduce a resident's risks from hazards in the environment . Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidenced-based practice .Monitoring and Modification . evaluating the effectiveness of interventions . process of adjusting interventions as needed to make them more effective in addressing hazards and risks . Include .ensuring that interventions are implemented correctly and consistently . evaluating the effectiveness of interventions . modifying or replacing interventions as needed . evaluating the effectiveness of new interventions . 2. Resident #27 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 11/21/18 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; exhibits no behavioral symptoms; does not reject care; does not exhibit wandering behavior; required extensive one person physical assistance with bed mobility, transfer, toilet use and personal hygiene; was always continent of bladder and of bowel; had two or more falls since admission with no injury, had one fall since admission with injury; and used a bed alarm and a chair alarm daily. a. A Care Plan with a revised date of 12/21/18 documented, .I am at a high risk for falls r/t (related to) unaware of safety needs, confusion . Anti-rollback brakes to wheelchair (1/23/17) . Anti-tippers to wheelchair (1/23/17) . Ensure that I am wearing appropriate footwear (my navy slippers with Velcro closure) when ambulating or mobilizing in wc/ (wheelchair) (12/12/15) . I use electronic silent pressure alarms in wheelchair and bed. Ensure the device is in place as needed and functioning properly (12/12/17) . Please make sure my wander watch on my right wrist is in place at all times to ensure my safety. Monitor / document every shift (2/27/18) . PT (Physical Therapy) consult as ordered (8/6/18) . I have an ADL (activities of daily living) self-care performance deficit r/t Dementia . I require extensive one person assistance during toileting (2/27/18) . I require extensive assistance in order to re-position in bed (12/21/18) . Encourage me to use bell to call for assistance (7/13/17) . I require extensive one person assist (assistance) with gait belt with transferring, unless I have something strong to hold on to, then I only require stand by assistance (2/27/18) . The Care Plan documentation indicated there were no revisions to the fall interventions on the resident's Care Plan since 8/6/18. b. Incident and Accident reports dated 12/26/18, 11/26/18, and 11/14/18 documented the following: 1.) A facility Incident and Accident form dated 11/14/18 at 13:40 (1:40 p.m.) documented, .Location .Resident's room . Resident found in bedroom across the hall from his bedroom laying on his side, resident pad alarm was working. Resident states he landed on his buttocks, stating he was going to feed the birds . Resident assessed for injuries, none noted . Resident assisted to sit back in wheelchair . Initiated 30 min (minute) checks for 24 hours . initiated neuro (neurological) check per protocol . Predisposing Environmental Factors . rugs / carpeting . Predisposing Physiological Factors . confused, drowsy, Antipsychotic medication, gait imbalance, impaired memory . recent change in condition, recent illness, recent change in medications / new, sedated . Predisposing Situation Factors . Unsafe behavior, wanderer, transferring without assist (assistance) .Note .2/20/19 . Initiated 30 minute checks for 24 hours. Wander guard bracelet remains in place. Silent alarms remain in place . There was no documentation of any additional interventions that were put in place after the 24-hour period of increased monitoring, to minimize the potential for further falls. 2.) A facility Incident and Accident form dated 11/26/18 at 22:15 (10:15 p.m.) documented, .Location .Resident's Room . Resident found lying in room floor with swelling and laceration to back of head . Assessed for injury, skin tear to R (right) elbow and laceration with swelling around it to back of head noted. Assessed for pain, c/o (complained of) pain to bilateral hips and head noted. Contacted (Name) MD (Medical Doctor), received order to send to ER (emergency room ) for eval (evaluation) and treat (treatment). Resident too confused to allow vitals to be checked . Injuries . Laceration back of head . skin tear . right elbow . Predisposing Situation Factors . alarm off . Note: Resident sent to ER for eval and treat of laceration to back of head. Laceration glued and has since healed. Silent alarms remain in place in w/c (wheelchair) and in bed. Bed placed in low position with soft mat . 3.) A facility Incident and Accident form dated 12/26/18 at 10:45 (10:45 a.m.) documented, .Location .Living Room . Resident fell forward out of wheelchair, large hematoma noted to forehead, large skin tear to left hand, resident c/o (complained of) pain everywhere; including head and neck, crying out and flinging extremities noted . Immediate Action Taken . (Name) APN (Advanced Nurse Practitioner) at facility states to send resident to ER (emergency room ) for evaluation . Resident left on floor, EMT (Emergency Medical Technician) arrived and resident sent to (Hospital Name) ER . Injuries . Hematoma .face . skin tear . left hand (back) . Predisposing Environmental Factors . furniture, crowding, noise, rugs / carpeting . Predisposing Physiological Factors . drowsy, impaired memory, weakness . Note .12/27/18 . Resident sent to ER for eval and treat r/t (related to) fall, hematoma to forehead. Upon return from ER, TAO (Triple Antibiotic Ointment) and [MEDICATION NAME] applied to forehead daily. Resident completed antibiotic therapy for hematoma. Area has since healed. Wander watch remains in place . There was no indication as to whether the silent alarms were in place and functioning at the time of the fall, and no documentation that an intervention was developed and implemented to prevent further falls / injuries.

Based on observation, record review, and interview, the facility failed to ensure a nurse providing wound care avoided allowing her hair to come in contact with a resident's open wounds, to prevent potential wound infection for 1 (Resident #248) of 6 (Residents #248, #33, #62, #67, #77, and #250) sampled residents who had physician orders for wound care. This failed practice had the potential to affect 10 residents who had physician's orders for wound care, according to a list provided by Registered Nurse (RN) #1 on 2/20/19 at 1:47 p.m. The findings are: Resident #248 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set was pending at the time of the survey. a. The Baseline Care Plan dated 2/10/19 documented the resident required physical assistance of 1 person for bed mobility and bathing and required physical assistance of 2 persons for transfers. b. A Physician's Order dated 2/15/19 documented a Wound Clinic referral for the resident, due to poor circulation to the resident's left lower extremity. c. A Physician's Order dated 2/19/19 documented, .Cleanse vascular wounds with antibacterial soap and water, let air dry and apply [MEDICATION NAME] to all wounds to the left foot two times daily for wounds . Place cotton sock over and keep dry . d. On 2/20/19 at 11:04 a.m., Registered Nurse (RN) #1 was providing wound care to the toes on the resident's left foot. All of the toes had necrotic areas on the bottom, and the great toe had a necrotic area on the medial side. There was white, drying skin at the edges of the toes and between the toes. The 4th toe had an opened area on the top, with skin missing approximately 1.5 centimeters (cm) to 2 cm from the top of the toe. There was no odor or discharge observed. RN #1 removed the resident's nonskid sock and cleansed all of the resident's toes with soap and water and 4 by 4 gauze. RN #1's hair was long and hanging down just below her chest level. As RN #1 was bending over the resident washing his toes, her long hair touched the resident's open wounds on the 3rd, 4th, and 5th toes. The RN cleansed and dried the resident's toes, and applied [MEDICATION NAME] to the wounds with cotton tipped swabs. The RN's hair again touched the resident's open wounds on the 4th and 5th toe on the left foot when she leaned over to apply the [MEDICATION NAME] swab to the resident's wounds. e. On 2/20/19 at 11:24 a.m., RN #1 was asked if she had noticed her hair touching the wounds on the resident's foot during care, and if she thought that was a problem. She stated, It is infection control. I should have pulled my hair back. f. On 2/20/19 at 1:56 p.m., the Director of Nursing (DON) was asked what her expectation was for nurses with long hair providing wound care and stated, The hair never should have touched the wound. She should have pulled it back to prevent this. It is an infection control issue.

Based on observation, record review, and interview, the facility failed to ensure a seat belt was securely applied per manufacturer's instructions to prevent potential resident injury during transport via wheelchair in the facility van, which resulted in a resident falling to the floor when the van was in motion; failed to ensure transport staff called for assistance to get the resident off of the van floor prior to continuing the transport; failed to ensure the incident was investigated to determine whether the resident's fall to the floor was caused by a staff failure or equipment failure and to facilitate the ability to determine if further training and increased supervision was needed; and, failed to ensure training of transportation staff included hands-on demonstrations and a successful return demonstration to verify that staff were competent to carry out transportation duties for 1 (Resident #9) of 14 (Residents #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, and #17) case mix residents who utilized a wheelchair for mobility and used the facility van for transportation. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #9, and had the potential to cause more than minimal harm to 59 residents who were transported in the facility van while in a wheelchair, as documented on a list provided by the Assistant Director on 1/27/17 at 8:39 a.m. The facility was informed of the Immediate Jeopardy condition on 2/3/17 at 10:10 a.m. The findings are: Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 11/22/16 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status, required extensive physical assistance of 2 plus persons for bed mobility and transfers, had shortness of breath upon exertion, required oxygen therapy, and used a wheelchair for mobility. a. A Nurse's Note dated 11/11/16 at 9:00 a.m., documented, .Resident refusing to get up for breakfast. O2 (oxygen) sat (saturation) 83-87% on 2 liters via NC (nasal cannula). Temp (temperature) 97.6. BP (blood pressure) 146/63. HR (heart rate) 92. RR (respiratory rate) 28. Wheezing present in bilateral lungs anteriorly and posteriorly. Resident's skin cool, clammy to touch. Blood sugar 283 . b. A Nurse's Note dated 11/11/16 at 10:11 a.m. documented, .Forwarded assessment information to APN (Advanced Practice Nurse). Received telephone orders to send resident to ER (emergency room ). Notified resident's family and they agree with treatment plan . c. An Incident Report dated 11/11/16 documented, .Resident was transported to (Hospital) ER this morning. During transport, staff member states that resident began sliding out of wheelchair. Staff member (Transport Employee #1) believed that resident would make it to the hospital without falling out of chair, but resident slid out of chair onto transport vehicle floor. Transport staff states that (Hospital) RN (Registered Nurse) and CNA (Certified Nursing Assistant) assisted resident off of transport vehicle floor onto hospital bed . No injuries observed . Alert . d. A Nurse's Note dated 11/11/16 at 5:07 p.m. documented, Resident was transported to (Hospital) ER this morning. During transport, staff member states that resident began sliding out of wheelchair. Staff member believed that resident 'would make it to' the hospital without falling out of the chair, but resident slid out of chair onto transport vehicle floor. Resident's foot pedals attached to wheelchair and wheelchair pad in place. Transport staff states that (Hospital) RN (Registered Nurse) and CNA assisted resident off of transport vehicle floor onto hospital bed. ER nurse . stated ER staff helped assist resident off the floor (of the van) and no injuries were noted when body audit was completed. Resident denies pain . e. On 1/26/17 at 7:19 a.m., Licensed Practical Nurse (LPN) #1 stated, I did a verbal in-service with my staff on if a resident is too weak, then Emergency Medical Services (EMS) should be called to transport the resident. I did not have anyone sign anything. f. On 1/26/17 at 7:48 a.m., the Assistant Director was asked what training Transport Employee #1 had received. She stated, We have a training checklist and did a pre and post-training with (Transport Employee #1). g. On 1/26/17 at 7:59 a.m., the Transport Coordinator was asked what training Transport Employee #1 had received. The Transport coordinator stated, (Transport Employee #1) was the back-up driver that day and she had a friend with her. Instead of stopping when the resident started sliding, she kept going. I just went over the in-service paper with her. I didn't physically go out to the van, but probably should have. h. On 1/26/17 at 8:12 a.m., the Transport Coordinator provided the following in-service records: 1.) An in-service record dated 7/8/16 documented, In-service Training and Checklist for Transport Van . (signatures of Transport Employees #1 and #2) . There was no section on the In-service Training and Checklist for Transport Van form to indicate steps on actions to take if a resident were to have an accident during transportation. 2.) An in-service record dated 11/14/16 (3 days after the incident) documented, In-service and Training for (Facility Name) Transport Van . Retrained 11/14/16 . (signed by Transport Employee #1) . 8. If Resident moves during transport, or is at risk of falling, driver must stop immediately and secure resident. Driver may need to call for assistance if needed . i. On 1/26/17 at 10:08 a.m., Transport Employee #1 was asked, What happened during the transport of (Resident #9) on 11/11/16? Transport Employee #1 stated, I was back-up transport that day. The nurse asked if I would take the resident to the ER (emergency room ). She (the resident) was in her wheelchair with a cushion and foot pedals. I put her in the van and strapped it (the wheelchair) down. I could tell she (the resident) was weak. (CNA #1) helped me reposition her in the wheelchair to transport her. Then, I buckled her in with the seatbelt. As I was driving, there are hills, and I could tell in the rear-view mirror that she was sliding down. I didn't have anywhere to pull over. I kept going and then pulled over. My friend (non-staff member) was in the van with me. We stopped and tried to get her off the floor, but we were unable to. We were about a mile from the hospital. The resident was left sitting on the floor of the van with her bottom on the floor and her knees bent to her chest. When we got to the ER, I asked the ER staff to help. It took 3 staff to assist, because she was so weak and was dead weight. I should have called someone when it happened. Transport Employee #1 was asked, Who did you report this incident to? Transport Employee #1 stated, When I got back to the nursing home, I told the nurse about what happened. She told me I had to fill out an Incident Report, and I gave it back to another nurse. She was asked, Were you in-serviced after the incident? She stated, They went over stuff with me. (Director of Nursing and the Transport Coordinator) came to me and had me sign a paper. They didn't go with me to the van to do the in-service. They just went over changes in the in-service. She was asked, How were you trained to transport residents? She stated, I rode with the main transport lady, (Transport Employee #2), for 2 days. The first day I watched, and the second day she had me do everything. She is the one who in-serviced and trained me. She was asked, How often do you transport residents? She stated, I'm back-up transport on Wednesdays, and as needed. I average a couple of days a week. j. On 1/26/17 at 11:20 a.m., Transport Employee #1 demonstrated how she secured the resident in the facility van. The Surveyor sat in the wheelchair with a pad and no foot pedals, and was wheeled into the van. The back of the wheelchair was secured to the van. The seatbelt was placed over the surveyor and buckled. The front of the wheelchair was secured to the van. The Surveyor attempted to slide out of the wheelchair. The Surveyor was able to slide down, with the pad still in place, until the seatbelt was under the Surveyor's armpits. When the Surveyor's arms were elevated, the Surveyor slid further down, with the seatbelt stopping at the Surveyor's neck. Transport Employee #1 stated she could not remember where the seatbelt was located after the resident slid out of the wheelchair and was sitting on the floor of the van. k. The manufacturer's instructions for the van's restraint system, titled, Driver/Operator Instruction Guide . The Q'Straint (and) M-Series, provided by the Administrator on 1/26/17 at 11:40 a.m., documented, .Auxiliary wheelchair equipment should be secured to the wheelchair or removed from the wheelchair and secured in the vehicle during transportation . Whenever possible, items attached to the wheelchair in front of the occupant should be removed and secured separately during transportation .Lap / Shoulder Belts .Belt should bear upon the bony structure of the body and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger's hip. Adjust the belts as firmly as possible consistent with user comfort. Ensure that the belt is not twisted .Postural Belt .Place postural belt around person, below the arms .Buckle up around the wheelchair .Make sure the padding is located at the chest height .Adjust belt if necessary .Restraints should not be held away from body by wheelchair components .List of items for each passenger and chair location: 4 wheelchair belts .1 lap and shoulder belt . l. On 1/26/17 at 11:40 a.m., the Assistant Director stated that the facility did not have a policy on training staff how to transport residents in the facility vehicle. They only had a document titled, In-service Training and Checklist for Transport Van. Refer to paragraph h.1 above. m. On 2/2/17 at 2:09 p.m., Transport Employee #2 (the routine van driver) was asked about the incident involving Resident #9 on 11/11/16. She stated, I was on maternity leave when this happened, so I don't know a whole lot. She was asked if she was the person who trained other employees on transport procedures. She stated, Yes. She was asked what the training involved. She stated, We have an in-service sheet that we go over, and then they ride with me for about a week. Shadow me. She was asked if the van used the Q'Straint System. She stated, Yes. All three of our vans use that system. She was asked how she was trained on the system. She stated, When I was trained, it was hands on. Q'Straint has a video on their website. I watched it and it's going to become part of our training because I have two new people coming on. The video has not been used in training yet. She was asked what was normal practice if a transport was scheduled and the resident was noticeably weak. She stated, If someone cannot physically sit up in the chair, I ask them to use an ambulance for transport. We have put a second staff person in the van before, but from what I've heard, the resident was okay when they left, but changed during transport. n. On 2/2/17 at 3:41 p.m., the DON was asked if there was any more documentation to go along with the Incident Report for 11/11/16, to show that the facility investigated to try to determine what caused the resident to slide out of the wheelchair during transport. She stated, I don't think so. If it had happened in the facility, there would be like a 'Fall Scene' done. She was asked if an investigation had been completed for this incident and stated, Not on my part. The ADON and I were in Florida at a conference when that happened and didn't return until the following Monday. I know (Transport Coordinator) did the re-training. He's the Unit Leader. o. On 2/2/17 at 4:19 p.m., CNA #1 was asked if he was the CNA who assisted Transport Employee #1 with putting Resident #9 on the van on 11/11/16. He stated, Yes, I know I was there, but I don't remember specifically who did what. I think I remember coming back in to get footrests for the wheelchair, but I'm a little rusty on how everything else took place. CNA #1 was asked if he was one of the transport aides. He stated, Occasionally. He was asked if he had been trained on proper transport technique. He stated, Yes. He was asked who trained him. He stated, Well it's been a while. The previous transport person, and then (Assistant Director) showed me some stuff . the basics of it. He was asked when he was trained. He stated, Probably 4 years ago. There was a day I worked side-by-side with the previous transport lady, maybe a year ago. He was asked if he remembered Resident #9 being weak prior to transport that day. He stated, She was really weak, but in hindsight, of course, they would have called EMS (Emergency Medical Service). I think I helped (Transport Employee #1) reposition her just prior to transport because she had slid down. p. On 2/2/17 at 4:45 p.m., the Assistant Director provided a list of van drivers and documentation of their transport training. The documentation indicated there were 13 people who were considered transport drivers; however, there was documentation of training for only 8 of them. The documentation for 3 of those 8 had no date to indicate when the training occurred. q. On 2/2/17 at 4:48 p.m., the Transport Coordinator was asked about the incident on 11/11/16 involving Resident #9. He stated, I heard about the incident on Monday (11/14/16) when I came back to work. (Transport Employee #1) told me what happened, and I asked her some questions. From what I gathered, she was seat-belted in correctly. I did not physically take her out to the van and have her show me how everything was done. He was asked why. He stated, Because, it sounded like the resident got pretty sick and wasn't able to hold herself up, and that's how she slid out. The thing I didn't like is that they drove on to the hospital which was five blocks away. I stressed on the re-training to be sure and stop and call for assist. He was asked if he took Transport Employee #1 out to the van and had her demonstrate how to properly secure a resident during the re-training. He stated, No. We talked about what to do. From the story she told me, I assumed the resident was properly secured. There are some steep hills here and people can slide. He was asked if transport re-training is done here on a regular basis, such as annually. He stated, To my knowledge, no. r. On 2/3/17 at 8:05 a.m., a representative with the Q'Straint Company was contacted and asked if a person would be able to slide out of a wheelchair if they were properly secured with a shoulder strap and lap seatbelt. She stated, No. They shouldn't be able to slide out, even on a hill. There's no way they should be able to slide underneath the belt, if it's done properly. She was asked what if a patient becomes limp during transport. She stated, The shoulder belt should hold them in, even if they become limp. s. On 2/3/17 at 8:27 a.m., Transport Employee #1 was asked about the incident involving Resident #9, and if she was the employee who secured the resident in the van. She stated, She was buckled in the van when I got out there. (CNA #1) put her in the van. She was asked if she checked to make sure the resident was properly secured before leaving the facility. She stated, I don't remember checking any of the other straps, but I do remember checking to see if her seatbelt was on. She was asked if the resident had a change of condition during transport. She stated, She was getting weak before I left, because I remember she was sliding back in the wheelchair, and I had the CNA help reposition her, but she continued to slide during transport. She was asked if she thought an ambulance should have been used for the transport. She stated, I do think that would have been the better option. I did talk to the nurse, but she said the resident seemed to be okay when she was put in the wheelchair, but I know when I got her to the van, she seemed to be weak. During the ride to the hospital, she started sliding, but I didn't have a place to pull over. She was asked if (Transport Coordinator) took her out to the van during re-training so she could show her how to properly secure someone. She stated, No, we didn't go out to the van. She was asked if anyone had been randomly observing her secure residents in the van to ensure she was doing it correctly. She stated, No. She was asked to explain how she secured the surveyor in the van on 1/26/17. She stated, I secured her and she tried to slide out, but couldn't get all the way to the floor. She was able to slide out to where the lap belt was to her neck. t. The Immediate Jeopardy was removed, and the scope and severity reduced to E on 2/3/17 at 12:20 p.m., when the facility implemented the following Plan of Removal: .From 6:30 p.m. to 7:30 p.m. on 2/2/17, the Director or his designee in-serviced all the transport drivers using the Q'Straint video and hands-on training that included a return demonstration. Any transport drivers who were not trained on this date because they were not available at the facility will not transport any resident until they have completed the training. All new transport drivers will be trained by the Director or his designee, prior to transporting any residents, using the Q'Straint video and hands-on-training that includes a return demonstration. All transport drivers will be in-serviced annually using the Q'Straint video and hands-on-training that includes a return demonstration. On 2/3/17 the facility will initiate a log to be kept in the transport van, where the driver will document that the chair was safely secured to the van and that the resident was safely secured with the seat belt low and snug, as well as with the shoulder restraint. The log will also ask the driver to document that the resident appears alert and stable, and any concerns related to safety. If there are any such concerns, the log will remind the driver to immediately bring them to the attention of the Director or his designee, who will also monitor the log weekly. The Director, or his designee, will monitor a transport driver securing a resident in the transport van three times each week for four weeks to ensure that the failed practice does not recur (reoccur), and to ensure the safety of residents being transported. Any identified concerns will be addressed immediately, and the monitoring will be extended as needed.