Every finding on record at Holiday Hill Inc

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 3 (Resident #6, Resident #49, and Resident #50) of 14 residents reviewed for unnecessary medications. The facility failed to ensure Resident #6's PRN Lorazepam (medicine used to treat the symptoms of anxiety) and PRN Risperidone (medicine used to treat mental health disorders) were discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #49's PRN Lorazepam (medicine used to treat the symptoms of anxiety) were discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #50's PRN Alprazolam (medicine used to treat the symptoms of anxiety), Haloperidol (medication used to treat behaviors), and Hydroxyzine (medicine used to treat the symptoms of anxiety) were discontinued after 14 days or a documented rational for the continued provision of the medication. These failures placed residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.Findings included: Resident # 6 Review of Resident #6's electronic face sheet revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Dementia, and Cerebral Ischemic Attack (brain stroke). Review of Resident #6's Significant Change in Status MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score 03 which indicated severe cognitive impairment. Review of Section N: Medications revealed Resident #6 was receiving anti-anxiety medications and was not receiving antipsychotic medications. Review of Resident #6's electronic physician orders revealed: Lorazepam Oral Concentrate 2 MG/ML give 1 ml by mouth every 2 hours as needed for anxiety/insomnia/SOB, with a start date of 12/05/2025 and no end date and Risperidone Oral Tablet 0.5 MG give 1 tablet by mouth every 8 hours as needed for agitation, with a start date od 11/26/2025 and no end date. Review of Resident #6's physician progress notes from November 2025- January 2026 revealed no documented rationale for the continued provision of lorazepam or risperidone. Review of Resident #6's electronic MAR for December 2025 revealed no doses of Lorazepam or Risperidone had been administered. Review of Resident #6's electronic MAR for January 2025 revealed no doses of Lorazepam or Risperidone had been administered. Observation on 01/06/2026 at 11:29 am, Resident #6 was lying in bed with call light in reach. Resident unable to answer questions. Record review of Drugs.com for Lorazepam accessed on 01/07/2026 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Record review of Drugs.com for Risperidone accessed on 01/07/2026 at https://www.drugs.com/risperidone.html revealed: Risperidone is an antipsychotic medicine that works by changing the effects of chemicals in the brain. Resident # 49 Review of Resident #49's electronic face sheet revealed resident was a [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Alzheimer's Disease, Insomnia, and Depression. Review of Resident #49's Significant Change in Status MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns no BIMS score recorded. Review of Section N: Medications revealed Resident #49 was not receiving anti-anxiety medications and was receiving antipsychotic medications. Review of Resident #49's electronic physician orders revealed: Lorazepam Oral Concentrate 2 MG/ML give 1 ml by mouth every 2 hours as needed for anxiety/insomnia/SOB, with a start date of 12/16/2025 and no end date. Review of Resident #49's physician progress notes from November 2025- January 2026 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #49's electronic MAR for December 2025 revealed 1 dose of Lorazepam had been administered. Review of Resident #49's electronic MAR for January 2025 revealed no doses of Lorazepam had been administered. Observation on 01/07/2026 at 11:41 am, Resident #49 was in the dining room dancing with staff and other residents during activity time. Resident # 50 Review of Resident #50's electronic face sheet revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Dementia and Neurocognitive Disorder. Review of Resident #50's admission MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns no BIMS score recorded. Review of Section N: Medications revealed Resident #50 was receiving anti-anxiety medications, antipsychotic medications, and antidepressant medications. Review of Resident #50's electronic physician orders revealed: Alprazolam Oral Tablet 0.25 MG give 1 tablet by mouth every 8 hours as needed for Behaviors, with a start date of 12/05/2025 and no end date, Alprazolam Oral Tablet 0.5 MG give 1 tablet by mouth every 8 hours as needed for Behaviors, with a start date of 12/05/2025 and no end date, Haloperidol Lactate Injection 5 MG/ML inject 5 mg intramuscularly every 1 hours as needed for increased agitation/anxiety, with a start date of 11/25/2025 and no end date, and Hydroxyzine Oral Tablet 25 MG give 1 tablet by mouth every 4 hours as need for Behaviors, with a start date of 01/06/2025 and no end date. Review of Resident #50's physician progress notes from November 2025- January 2026 revealed no documented rationale for the continued provision of lorazepam, haloperidol, or hydroxyzine. Review of Resident #50's electronic MAR for December 2025 revealed 1 dose of Alprazolam 0.5 MG had been administered and no doses of Haloperidol had been administered. Review of Resident #50's electronic MAR for January 2025 revealed 1 dose of Alprazolam 0.25 MG had been administered and no doses of Haloperidol or Hydroxyzine had been administered. Observation on 01/06/2026 at 2:30 pm, Resident #50 was sitting in his recliner with family at his side. Record review of Drugs.com for Haloperidol accessed on 01/07/2026 at https://www.drugs.com/haloperidol.html revealed: Haloperidol is an antipsychotic medicine used to treat schizophrenia. Review of Drugs.com for Hydroxyzine accessed on 01/07/2026 at https://www.drugs.com/ hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. During an interview on 01/07/2026 at 3:13 PM, the DON stated antianxiety medication, or any psych medications should not have been scheduled as PRN for more than 14 days. She stated that residents that were hospice have prn medications longer than 14 days because the order stated that it was for the duration of hospice services. She stated that the pharmacist told her that as long as the order stated the duration that it was ok for them to be over 14 days. She stated that she was not aware that there had to be a documented rational for the continuation of the medication past 14 days. The DON stated that she was not aware of any physician documentation regarding the rational for the continuation of the medication. She stated the only possible negative outcome would be that a resident could have been overmedicated unnecessarily. Review of document titled, Antipsychotic Medication Use, revised July 2022 revealed in part: Residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review.16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rational for continued use.

Based on observation, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 14 (Resident #4 and Resident #10) residents reviewed for infection control practices. The facility failed to ensure LVN A performed hand hygiene and changed gloves at the appropriate times while providing G-tube dressing change for Resident #4. The facility failed to ensure LVN A performed hand hygiene and changed gloves at the appropriate times while providing G-tube feeding for Resident #4. The facility failed to ensure CNA B performed proper incontinent care and proper use of peri-wipes while providing incontinent care for Resident #10. These failures could place the residents at risk for spread of infection. The findings include: Record review of Resident # 4's electronic face sheet dated 01.08.2026 revealed a [AGE] year-old male admitted 09.27.2019 with diagnoses of: Surgical Aftercare following surgery o the digestive system, Dysphagia (difficulty swallowing), Hemiplegia and Hemiparesis (paralysis) affecting right dominant side, Encounter for Gastrotomy (surgical procedure to insert a tube for long-term feeding, fluids or medication). Record review Resident #4's Annual MDS dated 12.17.2025 revealed BIMS score of 03 meaning severe cognitive deficit. Section K nutritional approaches-tube feeding Record review of Resident #4's Physician orders dated 01.01.2026 revealed Check residual before each feeding, Check peg tube placement before each feeding, flush peg tube with 120 mL of water before feedings, Jevity 1.5 calorie 237 mL QID via PEG tube between meals. PEG tube: change 4x4 dressing to site QD and PRN. Monitor for signs and symptoms of infection. Record review of Resident #4's Care Plan dated 12.17.2025 revealed Resident requires PEG tube feedings of Jevity related to Dysphagia, resisting eating. Is at risk for skin breakdown related to fragile skin/cognitive impairment. Interventions assess skin weekly, turn and reposition every 2 hours. Record review Resident #10's electronic face sheet dated 01.08.2026 revealed an [AGE] year-old female admitted 07.31.2024 with diagnoses of Dementia (significant decline in thinking, memory and other mental skills), Alzheimer's disease (brain disorder) , Hypertension (high blood pressure). Record review of Resident #10's Physician orders dated 01.01.2026 revealed monitor for refusal of care. Record review of Resident #10's quarterly MDS dated 11.07.2025 revealed BIMS score 03 severely impaired cognitive status. Section H Urniary continence-Occasional incontinence, Bowel continence-Occasional incontinence. Record Review of Resident #10's Care plan dated 11.07.2025 revealed ADL functions toileting moderate assist. Bladder incontinence related to confusion and dementia. Interventions: clean peri-area with each incontinence episode. During an observation on 01.07.2026 at 10:00 a.m. LVN A removed G-tube dressing from Resident #4's G-tube site. LVN A did not change gloves or use hand hygiene before placing clean dressing to Resident #4's G-tube site. LVN A did not remove gloves when transporting 60 mL syringe to resident's bathroom to rinse it out and continued to provide Resident #4 with G-tube feeding with same gloves on her hands. During an interview on 01.07.2026 at 10:30 a.m. LVN A stated not using proper hand hygiene and changing gloves when placing a clean dressing on resident and not changing gloves after taking syringe to bathroom, could have caused an infection or spread of an infection. LVN A stated this failure occurred due to her being nervous and focused on completing G-tube and feeding. LVN A stated she had been trained in infection control. During an observation on 01.08.2026 at 09:30 a.m. CNA B used same two incontinent care wipes to clean Resident #10's buttock area. CNA B folded the incontinent care wipe after each wipe. During an interview on 01.08.2026 at 09:44 a.m. CNA B stated she always folded the wipes when providing incontinent care. CNA B stated this could have caused a spread of infection. CNA B stated she had received infection control training. CNA B stated she did not know why this failure occurred. During an interview on 01.08.2026 at 10:00 a.m. the DON stated gloves should have been changed after removing dirty dressing. The DON stated hands should have been washed or hand sanitizer should be used after removing gloves and before putting on clean gloves. The DON stated gloves should have been used when providing G-tube feeding and removed if leaving the bedside for anything. The DON stated this failure occurred due to LVN A being nervous. The DON stated she was unsure why CNA B did not use an incontinent care wipe for each time she wiped the resident. The DON stated she and the ADON were responsible for monitoring staff for infection control practices. The DON stated nursing staff received annual competency checks. Review of facility's policy titled: Standard Precautions dated revised September 2022 revealed:Policy StatementStandard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions and excretions (example sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 1.2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision-making in various clinical situations. Standard precautions include the following practices: Hand hygiene Hand hygiene refers to handwashing with soap (anti-microbial or non-anti-microbial) or use of alcohol-based hand rub, (ABHR) which does not require access to water.Hand hygiene is performed with ABHR or soap and water1.before and after contact with the resident2. before performing an aseptic task3. before moving from work on a soiled body site to a clean body site on the same resident:.5 after removing gloves.Hands are washed with soap and water when visibly soiled with dirt, blood, or body fluids.Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean body-site during resident care.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #23) whose assessments were reviewed, in that: The facility failed to ensure Resident #23's Quarterly MDS assessment was coded correctly related to the administration of insulin. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #23's face sheet, dated 01/07/2026, revealed an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses including: cerebral infarction (death of brain tissues from a blocked artery in the brain), depression, high blood pressure, diabetes mellitus type 2, heartburn, anemia, atrial fibrillation (an irregular heart rhythm), coronary artery disease (disease of the blood vessels surrounding the heart), gout (crystal buildup that causes pain and swelling in the joints), and overactive bladder. Record review of Resident #23's Physician orders and Medication administration records for December 2025 and January 2026 revealed an order for: Ozempic (a once-weekly medicine for adults with type 2 diabetes used to improved blood sugar that belongs to a class of drugs called glucagon-like-peptide-1 receptor agonists (GLP-1 agonists)) (1 MG/DOSE) Subcutaneous Solution Pen-Injector 4 MG/ 3 mL (Semaglutide) Inject 1 mg subcutaneously one time a day every Sat to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). There was no order for insulin or record of insulin administration. Record review of Resident #23's Quarterly MDS, dated [DATE], Section C - Cognitive Patterns, subsection C 0500 BIMS Score Summary revealed Resident #23 had a BIMS score of 03, indicating severe cognitive impairment. The assessment further indicated in Section N - Medications, subsection N0350 Insulin, A. Insulin injections, Resident #23 received one insulin injection during the previous seven days. During an interview on 01/07/2026 at 8:32 AM, LVN A stated she was not aware that Ozempic was not considered an insulin. She stated Resident #23 had been receiving Ozempic for a long time for his Type 2 diabetes. LVN A stated she was not familiar with the MDS process or coding medications on the MDS. During an interview on 01/08/2026 at 10:44 AM, the DON stated the MDS Coordinator was responsible for entering data into the MDS. She stated she was responsible for monitoring the accuracy of the MDS's. The DON explained failure to accurately code a resident's MDS could result in the resident not receiving appropriate care. She stated her expectations were for the MDSs to be coded currently. During an interview on 01/08/2026 at 10:57 AM, the MDS Coordinator stated she was aware that she coded Resident #23's MDS to show he had received insulin due to the order for an injectable antidiabetic medication. She stated she was not aware the medication was not classified as insulin. The MDS Coordinator was unable to state an adverse effect on the resident related to incorrect coding on the MDS. She stated the DON was responsible for monitoring the accuracy of the MDS's. The facility used the RAI manual in lieu of a separate policy on coding MDS. Record review of Minimum Data Set (MDS) Coding fact sheet for Ozempic, accessed on 01/07/2026, revealed, Ozempic is an injectable non-insulin antidiabetic medication . and Do not check the box for insulin administration in the MDS, as Ozempic is not insulin. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.11, October 2024 revealed, N0350: Insulin. 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed.Coding Instructions for N0350Ao Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. Record review of the National Library of Medicine, Medline Plus (https://medlineplus.gov/druginfo/meds/a619057.html) accessed 01/14/2026, revealed Semaglutide is used along with a diet and exercise program to control blood sugar levels in adults with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood). Semaglutide is in a class of medications called incretin mimetics. It works by helping the pancreas to release the right amount of insulin when blood sugar levels are high. Insulin helps move sugar from the blood into other body tissues where it is used for energy. Semaglutide also works by slowing the movement of food through the stomach.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, for 1 of 1 facility, the results of the most recent survey of the facility including any plans of correction without identifying information about complainants or residents reviewed for resident rights. The facility failed to ensure the three preceding years of any surveys, certifications, and complaint investigations with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. This failure could place residents at risk of not reviewing the findings from State surveys and investigations conducted in the facility without asking to review the reports. Findings included: During an observation and record review on 01/07/2026 at 1:38 PM, the most recent State survey results, plan of correction, and report of contact dated 07/14/2022, were in a black 3-ring binder in a wall pocket located by the main entrance door. There was no evidence of State survey results for 2023 or 2024. During an interview on 01/08/2026 at 11:05 AM, the Administrator stated the Human Resources Director was responsible for maintaining current required postings. She stated her expectations were for all postings to be current. The Administrator could not answer why the survey results required were not included in the binder. The Administrator explained the effect on residents may be if a resident wanted to review the results, they would not be able to. The Administrator stated she had the results for the previous 5 years in a file but was not aware of the requirement to make the results publicly available. The Administrator stated the facility did not have a policy specific to required postings.

Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure foods were heated to a temperature of 165 degrees F and held at least 15 seconds when food temperature was below 140 degrees F. 2. The facility failed to ensure temperature logs were completed for all meal services. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an interview on 09/17/2024 at 10:30 a.m., [NAME] B stated she pureed beef taco meat with cold milk in the blender until it reached appropriate texture. She then placed pureed beef taco meat into a pan and into the steam table. During an observation on 09/17/2024 at 10:33 a.m., beef taco puree was in aluminum pan sitting in the steam table. [NAME] B pureed charro bean soup. She added prepared charro bean soup and cold milk to blender. She blended both together until food reached pudding texture. She then placed pureed charro bean soup into oiled aluminum pan and placed pan into the steam table. During an interview on 09/17/2024 at 10:52 a.m., [NAME] B stated she had performed all steps of pureeing beef and beans. She stated she was done with pureed foods. During an interview on 09/17/2024 at 10:53 a.m., [NAME] A stated she would place food in the oven after pureeing to make sure the food temperature reached a temperature of 140 degrees F. During an observation and interview on 09/17/2024 at 10:54 a.m., [NAME] B stated she forgot to place pureed foods in the oven after pureeing them. [NAME] B obtained the temperature of 110 degrees F of pureed beans from the pan sitting on the steam table. [NAME] B obtained the temperature of 95 degrees F of pureed meat from the pan sitting on the steam table. [NAME] B covered both pans with foil and placed pans into oven. During an observation on 09/17/2024 at 11:30 a.m., binders of food temperature logs in the kitchen revealed: March 25, 2024, no logged food temperatures for items served during supper. March 26, 2024, no logged food temperatures for items served during supper. March 27, 2024, no logged food temperatures for items served during supper. March 31, 2024, no logged food temperatures for items served during supper. April 17, 2024, no logged food temperatures for items served during breakfast or lunch. April 18, 2024, no logged food temperatures for items served during breakfast or lunch. May 1, 2024, no logged food temperatures for items served during lunch except Meat 1. May 2, 2024, no logged food temperatures for items served during lunch except Meat 1. June 3, 2024, no logged food temperatures for items served during supper. June 4, 2024, no logged food temperatures for items served during supper. June 18, 2024, no logged food temperatures for items served during lunch. June 19, 2024, no logged food temperatures for items served during lunch and only cereal oats temperature logged for breakfast. June 24, 2024, no logged food temperatures for items served during breakfast or lunch. June 25, 2024, no logged food temperatures for items served during breakfast or lunch. June 26, 2024, no logged food temperatures for items served during breakfast or lunch. July 1, 2024, no logged food temperatures for items served during breakfast or lunch. July 2, 2024, no logged food temperatures for items served during breakfast or lunch. September 16, 2024, no logged food temperatures for items served during supper. September 17, 2024, no logged food temperatures for items served during supper. September 18, 2024, no logged food temperatures for items served during supper. September 19, 2024, no logged food temperatures for items served during supper. September 20, 2024, no logged food temperatures for items served during supper. September 21, 2024, no logged food temperatures for items served during supper. September 22, 2024, no logged food temperatures for items served during supper. September 23, 2024, no logged food temperatures for items served during supper. September 24, 2024, no logged food temperatures for items served during supper. September 25, 2024, no logged food temperatures for items served during supper. September 26, 2024, no logged food temperatures for items served during supper. September 27, 2024, no logged food temperatures for items served during supper. September 28, 2024, no logged food temperatures for items served during supper. During an observation on 09/17/2024 at 11:36 a.m., [NAME] B obtained temperature of 148 degrees F of pureed beans in the pan taken out of the oven. She placed the pan of beans onto the steam table. [NAME] B obtained temperature of 127 degrees F of pureed meat. She placed the pan back into the oven. During an observation on 09/17/2024 at 11:45 a.m., [NAME] A obtained temperature of 151.7 degrees F of pureed meat. She placed the pan of meat onto the steam table. During an interview on 09/17/2024 at 10:42 a.m., the ADMN stated all residents eat out of the kitchen. During an interview on 09/17/2024 at 12:31 p.m., the DM stated she expected for food recipes to be followed. She stated if a recipe stated to bring up food temperature to 165 degrees F, then the kitchen staff should have heated food to 165 degrees F. She did not state any negative effects on the residents. The DM would not comment on if food had been in danger zone or what effect not reheating to 165 degrees F could have on the residents. She stated she monitored that food temperatures were logged, and the recipes were followed. She stated she expected for temperature logs to be filled out with the temperatures for all meals. She stated the kitchen staff may have forgotten to fill in the log and staff turnover may have led to failure of temperature logs to be completed. She stated not filling out temperature logs could lead to infections in residents . During a telephone interview on 09/19/2024 at 8:13 a.m., the Dietitian stated the kitchen staff could add cold milk into the food to be pureed but the food would need to be reheated to 165 F for 15 seconds after it was pureed. She stated if the recipe stated to heat food to 165 F she expected for the kitchen staff to follow the recipe. She stated the guidelines state, the goal was for food to be heated to 165 F for 15 seconds for food safety. After food had been heated to 165 F it could be maintained at 135 F. The Dietitian stated she expected for food temperature logs to be completed with temperatures of the food that was obtained prior to serving. She stated failing to log food temperatures could lead to the DM not knowing temperatures of food for that meal service. She stated the DM monitored the food temperature logs were completed. She did not know why the food temperature logs had not been completed for all meal services or why the Cooks did not heat the food to 165 F during preparing steps . During an interview on 09/19/2024 at 8:29 a.m., the ADMN stated she expected for kitchen staff to heat the food to 165 F if the recipe stated to. She stated not heating food to appropriate temperatures could lead to food not being safe to eat. She stated she expected for the food temperature binder to be filled out every meal. She stated the food temperature log was proof that the temperature of the food had been correct for the safety of serving out to residents. She stated the DM monitored recipes were followed and the temperature of foods were appropriate. The ADMN stated the DM monitored that the food temperature logs were filled out every meal. She stated she did not know why foods were not heated to 165 F for 15 seconds after food temperature dropped below 140 F or why the temperature logs were not completed. Record review of policy titled, Daily Food Temperature Control with no date revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges .Prior to meal service, the cook shall take the temperature of all hot and cold foods .Temperatures are recorded on the Temperature Log form .All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds. Record review of pureed charro bean soup recipe dated June 3, 2024, revealed: Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of >140F for only 4 hours. Record review of pureed soft beef taco recipe dated June 3, 2024, revealed: Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of 140F for only 4 hours. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 09/19/2024), revealed: 3-403.11 Reheating for Hot Holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds. (B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57 C (135 F) when being reheated for hot holding. (D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the food is between 5 C (41 F) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours. (E) Remaining unsliced portions of MEAT roasts that are cooked as specified under 3-401.11(B) may be reheated for hot holding using the oven parameters and minimum time and temperature conditions specified under 3-401.11(B).

45216 Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #1, Resident #32, and Resident #57) reviewed for comprehensive care plans. The facility failed to ensure Resident #1 had a care plan to address an indwelling urinary catheter, a continuous blood glucose monitoring device (a sensor worn by the resident that continuously provides real-time blood sugar, or glucose, levels), and weight loss. The facility failed to ensure Resident #32 had a care plan to address a physician's order for a fall mat. The facility failed to ensure Resident #57 had a care plan to address a physician's order for hospice services. These failures could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Resident #1 Record review of Resident #1's electronic face sheet revealed a [AGE] year-old male, admitted [DATE] with medical diagnoses of pressure wounds on the left buttock and left heel, high blood pressure, chronic migraine headaches, diabetes, and parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors). Record review of Resident #1's Admission MDS dated [DATE] revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 15 on a 0-15 scale, indicating intact cognition . Record review of Resident #1's physician orders dated 09/12/2024 revealed an order for [brand name] device (Continuous Glucose System Receiver ). Record review of Resident #1's weights revealed he weighed 158 pounds on 07/29/2024 and 136 pounds on 09/10/2024 indicating a 13.92% weight loss. Review of Resident #1's care plan revised on 08/02/2024 revealed no evidence addressing weight loss, catheters, or glucose monitoring. During an on observation on 09/19/24 at 9:50 AM, Resident #1 had an indwelling urinary catheter with the collection bag hanging on the right side of the bed draining by gravity . Resident #32 Record review of Resident #32's electronic face sheet revealed an [AGE] year-old male admitted [DATE] with medical diagnoses of dementia, heart disease, enlarged prostate, and high blood pressure. Record review of Resident #32's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 3 on a 0-15 scale, indicating severe cognitive impairment. Record review of Resident #32's physician's order dated 08/10/2024 revealed Fall mat at bedside every day and night shift for falls. Record review of Resident #32's care plan dated initiated and revised 06/19/2024, indicated the resident was at risk for falls. Utilizing a fall mat was not included in the interventions. Focus: [Resident] is at risk for falls d/t Confusion, Gait/balance problems, Incontinence, Poor communication/comprehension, Unaware of safety needs, Vision/hearing problems. Goal: The resident will be free of falls throughout the review date. Target date 08/26/2024. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear WHEN UP mobilizing in w/c. Follow facility fall protocol. Record review of Resident #32's Quarterly MDS dated [DATE] in Section J - Health Conditions, subsection J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment. revealed Resident #32 experienced 2 falls without injury and one fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall related injury that causes the resident to complain of pain). During an observation on 09/17/24 at 10:43 AM, Resident #32 was in his room with a visitor. No fall mat was seen in the room. Resident #57 Record review of Resident #57's electronic face sheet revealed an [AGE] year-old female admitted [DATE] with medical diagnoses of lung cancer, liver cancer, high blood pressure, and chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe). Record review of Resident #57's Admission MDS dated [DATE], Section C - Cognitive Patterns, subsection C0500. BIMS Summary Score revealed a score of 4 on a 0-15 scale indicating severe cognitive impairment. Section O-Special Treatments, Procedures, and Programs, subsection K1 revealed the resident was receiving Hospice care. Record review of Resident #57's physician's order dated 08/05/2024 revealed an order to Admit to [provider] hospice. Record review of Resident #57's Comprehensive Care Plan dated 08/14/2024 revealed hospice care services were not addressed. During an interview on 09/19/24 at 2:10 PM, CNA E stated she only looked at care plans when she had a question about a resident. She stated the nurse would pull the care plan up on the computer and show her the information she needed. CNA E stated the nurses were responsible for making the care plans . During an interview on 09/19/24 at 2:15 PM, LVN D stated the DON was responsible for the care plans. LVN D stated catheters should be included on the care plan. She stated not including catheters on a resident's care plan may cause the resident to not receive the care needed. LVN D stated a continuous blood glucose monitor device also should be included on the care plan. During an interview on 09/19/24 at 2:22 PM, with the DON and the MDS Coordinator, the DON stated the MDS Coordinator was responsible for creating the care plan, but the DON was ultimately responsible. The DON stated catheters should be addressed on the care plan. The DON stated she did not think the effect on the resident would be consequential and stated, we still know it's there and have orders for it. The DON stated hospice services should be addressed on the care plan. She stated care plans were reviewed and updated on admission, annually, and when needed. The DON stated her expectations for completing care plans was for all information on how to best assist the residents was included. The MDS Coordinator stated she was new to do doing care plans. She stated she had years of experience with completing the MDS. Training on how to complete care plans was by learning on the job. During an interview on 09/19/24 at 2:41 PM, LVN D stated the continuous glucose monitoring device used by Resident #1 should be addressed on the care plan. She stated the DON made changes to the care plans when needed. LVN D stated the resident could possibly not receive the care needed if the information was not included on the care plan. During an interview on 09/19/24 at 2:43 PM, the DON stated an indwelling urinary catheter should be addressed on the care plan. The DON stated the continuous glucose monitoring device should be addressed on the care plan. The DON stated weight loss experienced by Resident #1 should be addressed on the care plan. She stated the care plan included interventions to prevent further weight loss. She stated the issues would not have a negative effect on residents because the staff had physician's orders for care and the staff were aware the resident had the monitoring system. The DON stated she did not know why these failures occurred. She explained the MDS coordinator was responsible for the care plans and the DON was responsible for monitoring the review and revision of the care plans. Record review of facility policy dated March 2022, Care Plans, Comprehensive Person-Centered, Item 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . Item 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition.

Based on observations, interviews, and record review, the facility failed to conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 2 of 2 (Residents #4 and #9) residents reviewed for bed rails. The facility did not conduct regular inspections of bed rails, including Residents #4 and #9's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails. The findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, unsteadiness on feet, muscle weakness, reduced mobility, and need for assistance with personal care. Record review of Resident #4's annual MDS assessment dated [DATE] revealed: BIMS score of 03 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #4 needed moderate assistance going from sitting to lying and maximal assistance going from lying to sitting on side of bed; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #4's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t confusion, dementia, impaired balance. Date Initiated: 05/14/2024. Interventions: SIDE RAILS MMAY HAVE 1/2 RAILS UP X 2 AS ENABLER Date Initiated: 05/14/2024. Record review of Resident #4's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/30/2023 with instructions MAY HAVE 1/2 SIDERAILS UP X 2 AS AN ENABLER. Record review of Resident #4's electronic records on 09/19/2024 revealed no evidence of regular inspections of bed rails. During an observation on 09/17/2024 at 3:15 p.m., Resident #4's bed had half rails on both sides of the bed in the up position. During an observation on 09/19/2024 at 9:06 a.m., Resident #4 was lying in bed and had half rails on both sides of the bed in the up position. Resident #9 Record review of Resident #9's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, diabetes, and cerebral infarction (stroke). Record review of Resident #9's quarterly MDS dated [DATE] revealed BIMS score of 11 meaning moderate cognitive impairment; Section GG (Functional Status) revealed Resident #9 was independent with going from sitting to standing position; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #9's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t abnormal gait and impaired mobility. Intervention: SIDE RAILS: MAY HAVE 1/2 SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/28/2023 with instructions MAY HAVE 1/2 SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic records on 09/19/2024 revealed no evidence of regular inspections of bed rails. During an observation and interview on 09/18/2024 at 10:02 a.m., Resident #9 lying in her bed with half rail on the left side of the bed in an up position. Resident #9 stated she used the rail for mobility when she exited the bed. During an observation on 09/19/2024 at 9:06 a.m., Resident #9 was lying in bed and had half rail on the left side of the bed in the up position. During an interview on 09/19/2024 at 8:24 a.m., the MD stated he installed the bed rails to bed frames. He stated he did not perform routine bed rail, mattress, or bed frame assessments for risk of entrapment. He stated he would inspect the bed rail if he had been told rails were loose by housekeeping or the nursing staff. He stated he did not keep a log of those inspections. He stated he did not know who monitored that those inspections had been performed. The MD stated he had not performed inspections because he had not known to routinely inspect bed frames, mattresses, or bed rails . During an interview on 09/19/2024 at 8:31 a.m., the ADMN stated the MD would check bed rails if he had been told by a CNA that something was wrong with bed rails. She stated she did not know who monitored inspections were done but would get the facility policy to review. During a follow up interview on 09/19/2024 at 10:40 a.m., the ADMN stated the facility ensured the inspection of all bed frames, mattresses, and bed rails by the maintenance director who would correct any issues when staff brought issues to his attention. She stated the CNAs knew when a bed rail was not working appropriately and could monitor the equipment was working appropriately. She stated the equipment was inspected and maintained according to manufacturer's recommendations since no regular inspections were listed in Medline's instructions for installing rail. The ADMN stated she did not know if inspections were documented but would look in the maintenance log. She stated no negative effect had occurred to residents. She stated the maintenance director would report that he had repaired a bed rail in some of the morning meetings, but no documentation could be given to show what bed or room he had performed the repair . Review of facility policy titled Bed Safety and Bed Rails dated August 2022 revealed: Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee.

Based on observations, interviews, and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 2 of 2 residents (Resident #4 and Resident #9) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for Resident #4 and Resident #9. These failures could place residents at risk for injury and restricted movement. The findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, unsteadiness on feet, muscle weakness, reduced mobility, and need for assistance with personal care. Record review of Resident #4's annual MDS assessment dated [DATE] revealed: BIMS score of 03 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #4 needed moderate assistance going from sitting to lying and maximal assistance going from lying to sitting on side of the bed; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #4's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t confusion, dementia, impaired balance. Date Initiated: 05/14/2024. Interventions: SIDE RAILS MAY HAVE 1/2 RAILS UP X 2 AS ENABLER Date Initiated: 05/14/2024. Record review of Resident #4's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/30/2023 with instructions MAY HAVE 1/2 SIDERAILS UP X 2 AS AN ENABLER. Record review of Resident #4's electronic records on 09/19/2024 revealed no evidence of an attempt to use alternatives to bed rails or an assessment for the risk of entrapment. During an observation on 09/17/2024 at 3:15 p.m., Resident #4's bed had half rails on both sides of the bed and were in the up position. During an observation on 09/19/2024 at 9:06 a.m., Resident #4 was lying in bed and had half rails on both sides of the bed and were in the up position. Resident #9 Record review of Resident #9's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, diabetes, and cerebral infarction (stroke). Record review of Resident #9's quarterly MDS dated [DATE] revealed BIMS score of 11 meaning moderate cognitive impairment; Section GG (Functional Status) revealed Resident #9 was independent with going from sitting to standing position; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #9's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t abnormal gait and impaired mobility. Intervention: SIDE RAILS: MAY HAVE 1/2 SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/28/2023 with instructions MAY HAVE 1/2 SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic records on 09/19/2024 revealed no evidence of an attempt to use alternatives to bed rails or an assessment for the risk of entrapment. During an observation and interview on 09/18/2024 at 10:02 a.m., Resident #9 was lying in her bed with half rail on left side of the bed in up position. Resident #9 stated she used the rail for mobility when she exited the bed. During an observation on 09/19/2024 at 9:06 a.m., Resident #9 was lying in bed and had half rail on left side of the bed in the up position. During an interview on 09/19/2024 at 8:56 a.m., LVN C stated she did not do risk for entrapment or bed rail assessments. She stated she did not know who performs those assessments . During an interview on 09/19/2024 at 9:00 a.m., the ADON stated she guessed she was who was responsible to perform the risk of entrapment assessments on the residents who had bed rails. She stated both Resident #4 and Resident #9 used bed rails for mobility. She stated no risk of entrapment assessment had been performed. She stated not performing assessment could lead to facility not ensuring safety of residents when using bed rails. During an interview on 09/19/2024 at 9:02 a.m., the DON stated the facility had not performed a risk of entrapment on residents who had bed rails. She stated for safety reasons, assessments should have been performed. The DON stated no negative outcome had occurred from the assessments not being performed . Review of the facility policy titled Bed Safety and Bed Rails dated August 2022 revealed: The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent .Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers; c. lowering the bed; and/or d. use of concave mattresses to reduce rolling off the bed .The resident assessment to determine risk of entrapment includes, but is not limited to: a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medication(s); e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition; j. communication; k. mobility (in and out of bed); and l. risk of falling.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care. The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1 This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings include. Record review of face sheet dated 6/11/24 indicated Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Hemiplegia (weakness caused by brain or spinal cord problems) and Hemiparesis (weakness on one side) following Cerebral Infarction (blood in the brain) affecting left non-dominant side, Cerebellar Stroke Syndrome, unsteadiness on feet, muscle weakness, reduced mobility, depression, Hyperlipidemia (high levels of fat) and disorder of the Autonomic Nervous system. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 1 which indicates severe cognitive impairment. Record review of the physician orders dated 6/10/24 indicated Resident #1, left thigh had an order to cleanse, pat dry, apply Xeroform (non-adherent, occlusive wound dressing) and super absorbent dressing every Tuesday, Thursday, and Saturday until healed. Record review of the TAR dated 6/1/24 through 6/11/24 indicated Resident #1's wound care treatment was being performed on Resident #1's left thigh by the facility. During an observation on 6/11/24 at 2:15pm, Resident #1 was sitting in his wheelchair in the dining room listening to music being played. Resident #1 was wearing shorts and the dressing to his thigh was visible. The dressing was clean and did not look old. The dressing did not have a date or initials. Interview on 6/11/24 at 2:45pm RN B stated she performed wound care on Resident #1 on 6/11/24 at 8:00 AM. RN stated she does wound care Tuesday, Thursday, and Saturday. Surveyor and RN looked at Resident #1's dressing, and the dressing was not dated or initialed. RN stated she did not have a marker at the time of treatment and forgot to go back and date/initial. During an interview on 6/12/24 at 1:20pm, LVN A stated it is important to date and initial wound care bandages because, if different nurses were working the hall, or the nurse was not going to be there the next day, the dressing should be initialed and dated to show wound care has been performed. Interview on 6/12/24 at 2:45pm DON stated her expectations for wound care were do wound care as ordered, follow infection control, let DON know if there is a change or question about the wound and/or wound care, document in the TAR, do a skin report, initial and date on the dressing, and follow policy. Review of facility's (No date) Wound Care policy Steps in the Procedure, Step #13 reflected 'Dress wound, mark wound dressing with initials and date'.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure all food was not kept past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: During an observation on 08/07/2023 between 10:20 AM and 11:00 AM revealed: Refrigerator #1 1. One open container of cottage cheese without an open date, labeled with a use by date of 07/02/2023. 2. Two containers of sour cream labeled with a use by date of 07/28/2023. 3.One opened container of sour cream without an open date, labeled with a use by date of 07/07/2023. 4.One bag with a seal contained celery that had brown spots on celery with and open date of 07/02/2023. Freezer #1 1.An open package of chicken strips not labeled with an item description or an open date. During an interview on 08/09/2023 at 2:25 PM, the DM stated her expectation was that food was labeled when received and again when opened and that items be discarded after 5 days of being opened. The DM stated effect on residents could have been residents had gotten food poisoning. The DM stated staff not paying attention to dates led to failure of items not being discarded. The DM stated the cooks, dietary aides and the DM were responsible to ensure items were thrown out. The DM stated they did not have a policy. During an interview on 08/09/2023 at 5:35 PM, the ADMN stated her expectation was that food items were labeled correctly and were discarded when past the use by date. The ADMN stated receiving food past the 'use by date could have caused residents not to receive flavorful food or could have gotten sick. The ADMN stated staff being confused about not knowing policy was what led to failure. The ADMN stated the DM was responsible for monitoring to ensure food was stored and labeled correctly and not kept past use by date. Review of Food Code 2022 accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 6 of 12 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of sign in sheets for QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023 revealed no evidence that the MD attended QAPI meeting. During an interview on 08/09/2023 at 4:38 PM the ADMN stated the only way to verify that MD attended meetings was his signature on the sign in sheets. The ADMN stated that the MD was a required member of the QAPI team but did not attend the meetings. Record review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action dated March 2023 revealed: Quality deficiencies that are identified with feedback and data and will undergo appropriate corrective action. Corrective actions are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee, is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems and comprehensive level. Record review of document titled Quality Assurance Committee Members , without a date, revealed MD was a member of the committee. Record review of Medical Director Agreement signed 04/17/2012 and renewed on 11/1/2015 revealed: The agreement addresses the medical director's responsibilities for the following: Serving as a member of the organized medical staff, attending its meetings, and helping to ensure adherence to the medical staff bylaws, rules, and regulations. Participating in establishing policies, procedures and guidelines designed to ensure the provision of adequate comprehensive services. Participation in the resident care management system.

Based on observations, interviews and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct identified quality deficiencies for the failing to conduct criminal history/EMR/NAR verifications on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability reviewed in that: The Facility HR failed to correct and monitor a quality deficiency identified on the previous survey, regarding employee criminal history, and EMR/NAR checks had been performed since previous past noncompliance. These findings placed residents at risk of receiving care by someone that was unemployable due to abuse/neglect charges in the past. Findings Include: Record review of the ADMN the personnel file revealed a hire date of 09/08/2014. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DON the personnel file revealed a hire date of 09/13/2021. There was no documentation evidence of an annual EMR/NAR found in the file Record review of the SW the personnel file revealed a hire date of 09/05/2022. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the AD the personnel file revealed a hire date of 08/30/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DM the personnel file revealed a hire date of 11/08/2011. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DE the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of RN-A the personnel file revealed a hire date of 08/15/2011. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the RN-B the personnel file revealed a hire date of 07/13/2022. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of LVN-C the personnel file revealed a hire date of 11/12/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of LVN-D the personnel file revealed a hire date of 04/23/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-E the personnel file revealed a hire date of 03/21/2016. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-F the personnel file revealed a hire date of 12/16/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the CNA-G personnel file revealed a hire date of 07/21/2017. There was no documented evidence of a Criminal History check prior to employment. There also was no annual EMR/NAR check found in the file. Review of the facility's CMS 2567/facility-submitted Plan of Correction dated 07/27/2022 which was submitted in response to the 07/14/2022 SSA recertification survey revealed: Facility failed to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 9 of 13 (DON, AD, DM, LVN-JB, LVN-MM, Cook-A, NA-NC, CNA-AL, RN-WA) employees reviewed for employability. Identification of other residents having the potential to be affected include: All resident that resides in the facility have a potential to be affected. Actions taken/systems put into place to reduce the risk of further occurrences include: Staff reeducated on the requirement from proper background checks in relation to the hiring process, annual checks, and as needed. An interview on 08/15/2023 at 7:10 PM, the ADMN stated previous deficiencies were to be monitored and followed up by the Department Heads and ADMN staff as well as the MD. She stated previous deficiencies of personnel files not being followed up should have been discussed and addressed in the QAPI. She stated they were only discussed in the morning meetings, but remembered them being discussed with HR. The ADMN stated she had not been in the position of ADMN and was not sure how to address previous issues with QAPI and stated she was unaware of these deficiencies previously cited. The ADMN stated it was her responsibility to monitor as well as Department Heads to follow up on previous deficiencies cited. The ADMN stated the negative impact for residents were that it could have interfered with safety and health or their well-being if not addressed in a timely manner. She stated what lead to the failure was, there was no ADMN at that time after the previous survey as well as no leader to oversee or correct those situations. The ADMN's expectations were for those matters of previous citations to be addressed in a timely manner for those issues and not to arise in upcoming surveys. There was no POC policy provided during survey time while in facility prior to exit.

45732 Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 3 (Resident #18, Resident #41, and Resident #2) of 8 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #18's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 2. The facility failed to ensure Resident #41's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 3. The facility failed to ensure Resident #2's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. These failures place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Resident # 18 Review of Resident #18's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, and Cerebral Infarction (brain stroke). Review of Resident #18's Annual MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score not performed; Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #18's electronic physician orders revealed: Lorazepam Oral tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 06/28/2022 and no end date. Review of Resident #18's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #18's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #41 Review of Resident #41's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, Insomnia, and Dementia. Review of Resident #41's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 10 (moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #41's electronic physician orders revealed: Lorazepam Oral Concentrate 2MG/ML give 1 ml by mouth every 4 hours as needed for Anxiety with a start date of 03/15/2022 and no end date. Review of Resident #41's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #41's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #2 Record review of Resident #2's electronic face sheet revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 99 (indicating resident was unable to complete the interview); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #2's electronic physician orders revealed: Lorazepam Oral Tablet 0.5mg give 1 tablet by mouth every 6 hours as needed for Anxiety with a start date of 06/28/2023 and no end date. Review of Resident #2's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #2's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. During an interview on 08/09/2023 at 3:40 PM, the ADON stated her, and the facility staff were unaware that PRN psychotropic medications could only be ordered for 14 days. She stated the pharmacist had not mentioned anything about this to the facility. During an interview on 08/09/2023 at 5:58 PM, the DON stated she was not aware of the regulation on PRN psychotropic medications. She stated it was her responsibility to be current and up to date on regulations. She stated she had not seen it on the pharmacy consult review. She stated the harm to the resident could be receiving medication not needed or being over medicated. Review of document titled, Consult Pharmacist Report, dated 04/13/2023 revealed: Recommendations and Additional Comments: .3. PRN psychoactive medication orders should indicate how long the order is to be in effect, otherwise they are only good for 14 days. The physician can indicate a longer duration for the order and hospice can indicate that it is good for the duration of hospice services. The duration must be indicated on the order itself for easy reference. Review of facility policy titled, Nursing Services Policy and Procedure Manual for Long-Term Care, revised July 2022 revealed: Behavior, Mood, and Cognition: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 10 days of the second quarter of year 2023. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Review of facility's RN nursing schedule for RN for 01/2023-02/2023, 10 of the 59 days (01/07/2023, 01/08/2023, 01/14/2023, 0115/2023, 01/21/2023, 01/22/2023, 02/04/2023, 02/05/2023, 02/18/2023, and 02/19/2023) reflected there was no RN coverage. An interview on 08/09/23 at 6:26 PM the Admn stated it was the DON who was responsible and monitored the RN coverage. She stated when someone calls in, the DON would usually come in and if not, the on-call RN should had been called. The ADMN stated the negative impact for residents was there could possibly be a crisis with a resident requiring the care of an RN, which could have possibly led to an increased risk of possible illness or worse. She stated the failure occurred when the facility tragically lost an RN and at that time, they were searching for another RN leaving them down two RN's. The ADMN stated she was not sure why the DON did not come into the facility to cover for those days previously missed. The ADMN expectations were to have the required RN coverage, following the facility policy and procedures. An interview on 08/09/2023 at 6:40 PM, the DON stated they should follow the protocols, having an RN on a rotation. She stated the protocols were to have an RN or DON. She stated they were down two RN's during that time. The DON stated it would have been herself who was responsible in this being monitored. She stated she felt there were no negative impact as she was confident and trusts in her staff being LVN's. The DON stated her expectations from now on were for the facility to have the proper RN coverage. Record review of facility policy titled, Staffing, Sufficient and Competent Nursing dated 2001, revised August 2022, revealed the following: Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in according with resident care plans and the facility assessment. Policy Interpretation and Implementation: Sufficient Staff . .3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RN's may be scheduled more than eight hours depending on the acuity needs of the resident.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability. Facility staff did not have criminal history check and/or an EMR/NAR check prior to offering employment to the facility and/or annually for employees. These findings placed residents at risk of receiving care by someone that was unemployable. The findings included: Record review of the ADMN the personnel file revealed a hire date of 09/08/2014. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DON the personnel file revealed a hire date of 09/13/2021. There was no documentation evidence of an annual EMR/NAR found in the file Record review of the SW the personnel file revealed a hire date of 09/05/2022. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the AD the personnel file revealed a hire date of 08/30/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DM the personnel file revealed a hire date of 11/08/2011. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DE the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of RN-A the personnel file revealed a hire date of 08/15/2011. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the RN-B the personnel file revealed a hire date of 07/13/2022. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of LVN-C the personnel file revealed a hire date of 11/12/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of LVN-D the personnel file revealed a hire date of 04/23/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-E the personnel file revealed a hire date of 03/21/2016. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-F the personnel file revealed a hire date of 12/16/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the CNA-G personnel file revealed a hire date of 07/21/2017. There was no documented evidence of a Criminal History check prior to employment. There also was no annual EMR/NAR check found in the file. An interview on 08/09/23 at 6:37 PM the ADMN stated the facility had not had a steady HR in the past year. The HR the facility had previously had not kept up with the EMR's or criminal background checks of employee staff. She stated the responsibility of this should have been HR, but being they had no one at that time, the responsibility fell on her as ADMN. She stated the negative impact to residents was, there was not one, as she felt the EMR's, and background checks were somewhere in the facility with management not able to find them. She stated the failure was not having a steady HR and not having a corporate lifeline to guide the upper management on what was needed to run the facility correctly. The ADMN stated her expectations were for the EMR's and background checks to be completed on every facility staff member and expecting the new HR coming in to be trained to her full extent following policies and guidelines. Review of facility policy Background Screening Investigations dated 2001 and revised 2019 revealed: Policy Statement Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants four positions with direct access to residents (direct access employees). Policy Interpretation and Implementation 1. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long-term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with the patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction check (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. 3. 3. For any individual applying for a position, the state EMR search is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or have the property have been entered into the applicants file. Review of the New Hire Application for Employment revealed: the included document DPS Computerized Criminal History (CCH) Verification with the revised date of 09/2015.

Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 lunch meal reviewed. The facility failed to follow the recipe when preparing the puree bread. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings included: During an observation on 08/07/2023 at 10:45 AM, Cook did not follow the recipe while she pureed sliced bread . Cook placed sliced bread into processor and added milk and pancake syrup to the processor. During an interview on 08/09/2023 at 2:25 PM, the DM stated her expectation was cooks follow the recipes. The DM stated staff have always added the pancake to the puree bread. The DM stated residents' diets could have been affected by adding the syrup because it was not calculated in their calorie count. The DM stated what led to failure was that cooks did what they always did and did not follow the menu. During an interview on 08/09/2023 at 5:35 PM, the ADMN stated her expectation was the cooks should have followed the recipe for puree. The ADMN stated the DM was responsible for ensuring cooks followed recipes. The ADMN stated effect on residents could have been residents' calorie intake could have been altered. The ADMN stated cooks not reading and following recipes led to failure. Record review of facility recipe titled roll, revealed May add liquid to reach desired consistency. Ex[example] reserved liquid/juice, milk. Record review of facility policy titled, Food and Nutrition Services dated October 2017 revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 10 staff (LVNG, LVNH, ADON, DON, CNAA, GBI, GBL, HKF, LVNM, CNAC) reviewed for infection control. The facility failed to ensure LVNG, LVNH, ADON, DON, CNAA, GBI, GBL, HKF, LVNM, CNAC wore proper PPE according to manufacturer's specifications during a Covid outbreak. These failures could affect residents that reside in the facility and placed them at risk of infection. Findings included: During an observation and interview on 08/23/2022 at 10:26 AM, LVNG was observed wearing a KN95 mask at the nurse's station. LVNG stated the COVID positive residents were on the hot unit and the COVID negative residents were on the cold unit. LVNG stated she was the charge nurse for the hot unit and the cold unit because the facility did not have another nurse to be dedicated to the hot unit only. She stated she did the resident assessments and administers medications to residents on both the Covid hot unit and non-Covid cold unit. LVNG stated the hot unit was staffed with one CNA and one TNA. She also stated she wore a KN95 mask in the hot unit and did not change it after leaving the hot unit. LVNG stated that wearing a KN95 mask was sufficient because she had COVID at the beginning of the month and she was immune to spreading COVID to residents or getting COVID again. LVNG stated she was wearing proper PPE that the facility provided to her. During an observation and interview 08/23/2022 at 4:25 PM, LVNH wore a KN95 mask on the cold unit at the nurse's station. LVNH stated if she was called to assist on the hot unit she already had her KN95 mask on. LVNH then stated she was following proper PPE/CDC guidelines and she would not spread Covid as she had a good seal with a KN95 mask because her glasses did not fog up. During an interview 08/23/2022 at 4:49 PM, the ADON stated LVNG had been trained on proper PPE when entering and exiting the hot unit. The ADON stated her expectation was for all staff to wear full proper PPE to include an N95 mask with COVID positive residents and residents with unknown COVID status. The ADON stated she also expected that when staff exited the hot unit, the staff were to doff all of the PPE, including the N95 mask, perform hand hygiene, and apply a new mask. The ADON also stated staff could spread COVID to other staff and residents if failing to change masks. She stated the failure was due to staff being lazy and not following facility trainings on proper PPE. During an interview 08/23/2022 at 6:00 PM, the DON stated failing to wear an N95 mask on the hot unit could spread COVID to other staff and residents. The DON stated that even though a staff had COVID previously, that staff member may have had a different variant and still required to wear an N95 on the hot unit. She stated expectations were for all staff to always wear proper PPE, follow the proper guidelines unless eating or drinking, and follow the training. During an interview 08/24/2022 at 11:11 AM, Resident #1's Representative stated Resident #1 was admitted to the facility on [DATE] but then contracted COVID on 08/21/2022 which required hospitalization on [DATE]. Resident #1's Representative stated she requested Resident #1 to be taken to the hospital on 08/23/2022. She stated Resident #1 will not return to the facility because she felt the staff had not taken proper precautions when caring for Resident #1. During an observation on 08/24/2022 at 12:31 PM, outside of the hot unit was a red trashcan overflowing with doffed PPE. COVID negative residents were observed to walk by within 6 feet of the overflowing PPE. During an interview on 08/25/2022 at 9:25 AM, the ADON stated the facility had three (3) more COVID positive residents. She stated the COVID was spreading because on 08/17/2022, CNAA began to present with COVID symptoms, but COVID point of care test was negative and CNAA was assigned and worked the cold unit on 08/17/2022. The ADON stated on 08/18/2022 CNAA continued to present symptoms, but COVID point of care test continued to be negative and CNAA was assigned and worked the cold unit on 08/18/2022. The ADON stated on 08/22/2022 CNAA was tested again and tested positive, so CNAA was assigned to work the hot unit with COVID positive residents. During an interview on 08/25/2022 at 9:36 AM, GB-I stated the facility's COVID numbers were increasing and that she was not worried about contracting COVID because she had COVID before and was most likely immune. Another Board Member of the Governing Body, GB-L, stated she has been vaccinated and was not worried about contracting COVID. During an observation and interview on 08/25/2022 at 11:41 AM, HKF was wearing a KN95 mask below the nose in the hallway near the resident dining room. She stated she was wearing a ventilated mask and did not know the name. HKF stated it was her first day at the facility and has not been fit tested for an N-95 mask. She also stated she had no training on PPE, how to wear her mask, and expectations if going to the hot unit. During an observation and interview 08/25/2022 at 1:20 PM, the Hospice nurse was wearing an N95 with both straps pulled down around the neck when exiting the hot unit into cold unit. She stated she saw Resident #4 on the hot unit. She also stated she wore a surgical mask over her N95 when on the hot unit. Hospice nurse stated when exiting the hot unit she only doffs her surgical mask and does not change out her N95. She stated failing to don and doff PPE correctly can spread the COVID virus to the residents. During an interview 08/25/2022 at 1:43 PM, LVNM and CNAC both stated that COVID was increasing at a rapid pace in the facility. CNAC stated the spread of COVID in the facility was due to staff not wearing proper PPE with suspected COVID positive residents. During an interview 08/26/2022 at 11:40 AM, the ADON stated Residents #12 and #13 had presented with signs and symptoms of COVID but tested negative with the facility COVID point of care test. The ADON stated that she contacted the facility PA to perform PCR COVID tests on the residents. During an observation and interview on 08/26/2022 at 2:00 PM, Resident #14 was sitting in her recliner asking CNAB where her roommate, Resident #13, was taken. CNAB was wearing a KN95 mask and stated, Resident #13 was transferred to the Covid hot unit because her PCR COVID test returned positive. CNAB stated the residents who were exposed or unknown COVID status were not quarantined from other residents nor increase in transmission-based precautions. CNAB also stated she only wore a KN95 mask with residents who were exposed or had unknown COVID status since the outbreak began. She stated she had not been trained to don full PPE for residents who were exposed or had unknown COVID status. CNAB also stated it was not mandatory to wear a N95 mask. During an interview on 08/26/2022 at 3:10 PM, the ADON stated the facility policy was to move COVID exposed residents; however, with the closing of B hall due to construction, the facility did not have enough rooms to separate residents who were COVID exposed, residents with unknown COVID status, or residents with negative COVID status. The ADON stated the facility had no way to keep residents with unknown COVID status to stay in their rooms. She stated the facility staff could choose their preference to wear KN95 masks or N95 masks. She stated the whole facility at this point should be considered warm with all staff donning full PPE with N95 masks. The ADON stated the facility had sufficient PPE supply stock. The ADON stated the expectations were for the COVID numbers to decrease, all staff to be aware and cautious to take the proper precautions to prevent the spread of COVID. The ADON stated the failure was the staff members were not implementing their training and being lazy which led to the impact of COVID spread to other staff and residents. Record review of facility All Staff In-Service Wearing a mask at all times in facility, and wearing correctly, and CDC guidelines dated 07/22/2021 revealed: N-95 respirators or respirators that offer a higher level of protection should be used instead of a facemask Disposable respirators and facemask should be removed and discarded after exiting the patient's room or care area and closing the door Record review of facility Infection control In-Service dated 07/22/2021 revealed: 3. Staff Screening: If any fever or respiratory symptoms arise during shift, they will be sent home to self-isolate. Record review of outline for training titled, Infection control, Donning and Doffing Infection Control (Mask, PPE) All Staff Inservice dated 07/22/2021 revealed: Staff Screening: If any fever or respiratory symptoms arise during shift, they will be sent home to self-isolate Review of facility in-service tracking of in-service titled Wearing a mask at all times in facility, and wearing correctly, and CDC guidelines dated 07/22/2021 revealed: LVNG completed in-service training on 07/22/2021 LVNH completed in-service training on 07/23/2021 ADON completed in service training on 07/23/2021 DON completed in-service training on 07/26/2021 CNAA completed in-service training on 07/23/2021 GBI had no evidence of in-service training GBL had no evidence of in-service training HKF had no evidence of in-service training LVNM completed in-service training on 08/03/2021 CNAC had no evidence of in-service training. Record review on 08/26/2022 of the N95 Respirator manufacturer instructions revealed: The respirators is approved only in the following configuration . Caution and Limitations: Failure to properly use and maintain this product could result in injury or death . Never substitute, modify, add, or omit parts . Fitting instructions: Pull the top headband to top back of head. Pull the bottom headband overhead and place around neck below ears. Review of facility's COVID Response Plan dated 06/27/2022 revealed: A well fitted KN95 respirator can be used by the healthcare personnel providing care for residents who are COVID-19 negative. KN95 respirators may also be used in non-resident areas, i.e., while in all areas of the facility outside the Isolation (COVID-19 positive) zone and Quarantine (Unknown COVID-19) zone Full PPE is required (NIOSH-approved N-95 or equivalent or higher-level respirator, gown, gloves, and eye protection) for healthcare personnel working inside the Isolation (COVID-19 positive) zone and Quarantine (Unknown COVID-19) zone CDC guidance. KN95 respirators should not be used as a part of the PPE while working in Isolation or Quarantine zones.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on [DATE] between 10:15 AM and 11:00 AM revealed: Dry Storage 1. One 28 oz can of diced tomatoes that was dented. 2. One 10.5 oz can of chicken broth that was dented. 3. One can 104 oz can of apple slices that was dented. 4. Two 115 oz cans of ketchup that were dented. 5. One open 50 lb bag of flour that was not sealed and exposed to air. Fridge #1 1. One opened 5lb container of cottage cheese with a use by date of [DATE]. 2. One opened 5lb container of cottage cheese with a use by date of [DATE]. 3. Two unopened bags of coleslaw with a use by date of [DATE]. 4. One unopened bag of lettuce with a use by [DATE]. 5. One open bag of lettuce with a use by date of [DATE]. 6. One open bag of carrots with a use by date of [DATE]. 7. One unopened bag of carrots with a use by date of [DATE]. Fridge #2 1. One 10 lb tube of defrosted hamburger meat not in original container was not labeled with a date or item written on the tube. The hamburger meat was in a container labeled ground meat with a date of [DATE]. 2. Five single serving tubs containing ranch dressing that were not labeled with item or an open date. 3. One container (previously purposed for cottage cheese) containing apple crisp that was not sealed. 4. One cool whip container containing chocolate pudding not in original packaging. During an interview on [DATE] between 10:15 AM and 11:00 AM with the DM, she stated that she was the DM and started in [DATE]. The DM stated the dented cans should not have been in the storeroom, that they are taken to a separate room down the hall. The DM stated dented cans should not be used, they need to be thrown out or sent back to supply company. The DM stated the hamburger meat should be defrosted in the fridge and used within 24 hours or thrown out. The DM did not know why the hamburger meat was not dated or how long it had been in the fridge to defrost. The DM stated that everyone was responsible for dating and throwing out expired items. The DM stated it was her responsibility to go behind kitchen staff to ensure they were doing what needed to be done. The DM stated leftovers should have been thrown out after 3 days. The DM stated that leftovers should have been stored in clear plastic containers not reusing cool whip or cottage cheese containers. The DM stated she had told staff not to reuse cool whip or cottage cheese containers to store leftovers. The DM stated the cool whip and cottage cheese containers to do not seal properly and containers not sealing properly could cause food to spoil, loose flavor, take on flavors from the fridge, and could develop bacteria. The DM stated these failures could lead to residents becoming sick with food poisoning from salmonella or other bacteria. DM stated what lead to the failures in kitchen was that she was new and is trying to get everything in order. During interview on [DATE] at 2:21 PM with the DON, she stated her expectation in the kitchen was food needs to be labeled with date opened and item description. The DON stated food should be thrown out when the expiration date is met. The DON stated leftovers should be stored in appropriate containers, not in reused cool whip or cottage cheese containers because the reused containers do not seal properly. The DON stated hamburger meat should have been used or discarded within 24 hours, after setting out for defrosting. The DON stated the failures in the kitchen could affect residents by residents becoming sick from food born illness. The DON stated what led to failures in kitchen was staff refusing to follow the policy and the DM not going back and checking. DON stated the DM was responsible for the kitchen. During interview on [DATE] at 3:38 PM with the DM, she stated staff were trained when hired on proper storage and labeling and thinks there was a check off list but does not know where to find the check off list. The DM also stated they have had some in-services but does not know where previous DM stored them. During interview on [DATE] at 3:39 PM with HR, she stated she has not seen any type of check off list or trainings on food handling, storage, or labeling. Record review of CMS Form 672 dated [DATE] revealed all residents ate from the kitchen. Record review of the policy titled, Refrigerators and Freezers, dated [DATE] revealed: All food should be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 'Use by' date will be completed with expiration dates on all prepared food and refrigerators. Expiration dates on unopened food will be observed and 'used by' dates indicated once food is opened. Supervisors will be responsible for ensuring food items and pantry, refrigerators, and freezers are not expired or past perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Record review of policy titled, Food Receiving and Storage, dated [DATE] revealed: Dry foods that are stored in bins will be removed from original packaging, labeled and dated (used by date). Such foods will be rotated using a 'first in- first out' system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date).

Based on interviews and record reviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for administration. There was no active licensed administrator in the facility from [DATE] to [DATE]. The facility did not report the 3 new active positive cases of Covid 19 that began on [DATE]. The facility had not been doing criminal history, EMR/NAR checks prior to employment and/or annually for 9 of 13 staff reviewed. The facility was not ensuring employees had dementia training for employees that included staff for the certified Alzheimer's unit of the facility for 3 of 13 staff reviewed. These findings placed all residents at risk of not achieving their highest practicable physical, mental, psychosocial well-being. Findings included: During an interview with DON and ADON on [DATE] at 10:00AM, DON said the facility did not have an ADM at the moment for the facility. ADON said ADM-A left in mid-April of 2022 or May of 2022 and the facility had a consultant in the building as acting ADM-B, but he had a Louisiana license, and he could not get it transferred to Texas, so he left in mid -[DATE]. DON said she was the acting ADM as well as the DON for the facility at that time. DON said she did not have an active ADM license. ADON said the ADM was who usually reported Covid-19 cases to HHSC and did a spreadsheet that tracked the positive Covid-19 cases to the HHSC program manager of the facility. ADON said she had looked online and did not find that Covid-19 was a reportable illness. During an interview with HR on [DATE] at 2:30PM, she said the former HR person had removed a lot of the computerized training, and HR did not realize the staff was not completing the orientation or annual training prior to the review of personnel files. HR said she was working on getting the computerized training added back for the staff to be able to complete all required trainings. She said that while she was getting requested personnel records ready for surveyor review, she was not able to find that some of the employees had a criminal history check and/or an EMR/NAR run prior to their employment or annually. She said she had been working as HR for a short time and those employees were hired prior to her assuming the responsibilities of HR. During an interview with HR on [DATE] at 9:30AM, she said the facility was not in compliance with employee background checks or trainings prior to [DATE]. During an interview with DON and ADON on [DATE] at 3:11PM, DON said she was the acting ADM, DON, and abuse coordinator for the facility. DON said the former HR person was not doing criminal history checks and/or EMR/NAR checks prior to new staff employment and the DON did not realize they were not being completed. DON said the former HR person was not sure about which staff needed what trainings, so she removed a lot of the trainings from the facility's computerized training system and DON did not realize they were not being completed by new staff on orientation or annually. DON said the facility had an active licensed certified Alzheimer's unit in the facility. ADON said the HR department sent out a weekly delinquent training schedule for the staff of each department to each of the department managers that they followed, but if it was not in the system then it would not show that it was delinquent anyway. DON said she felt that the reason for the failure of the trainings and background checks were in part, because of the changing of the former to the new HR personnel and the new HR personnel not being properly trained. DON said that some of the failures with the reporting of Covid 19 were due to no actual ADM at that time and the DON and ADON not knowing that it was reportable. DON said the facility did not notify HHS about either administrator leaving and the facility not having an administrator. Record review of ADM hire dates on [DATE] were as follows: ADM-A with an active NFA license with expiration date of [DATE] with last renewal of [DATE]. Hired [DATE] and a termination date of [DATE]. ADM-B with an expired NFA license as of [DATE] with a hire date of [DATE] and a termination date of [DATE]. Record review of Administrator Job Description dated February 2017 revealed: Plans, organizes and directs the operations of the center home. Takes all reasonable steps to assure that quality long term care services are provided through the center home. Coordinates long term care activities with outside agencies and offices . Licensure, Registry or Certification: Current licensure by the Texas Board of Licensure for Nursing Home Administrator . Adopts and enforces rules and regulations relative to the level of health care and safety of the residents, and others, and for the protection of their personal property and civil rights ensures that a person in authority is designated if the facility does not have an administrator and ensures that the designated person notifies the Texas Department of Human Resources. Assures that in the absence of an administrator another employee of the facility is authorized, in writing, to act on the administrator's behalf. Record review of facility policy labeled Covid-19 Novel Coronavirus dated [DATE] revealed: Positive Staff . Immediate Action (,d+[DATE] hours) . Complete Self Report to HHSC . within 2 hours . If a resident receives a positive test result . Self-Report to state within 2 hours via TULIP. Record review of TULIP intake 8 accessed on [DATE] at https://txhhs.lightning.force.com/lightning/r/RS_Case__c/a2e8y 02QTTAA2/view revealed: Date Received: [DATE] 4:03 PM . Facility First Learned of Incident [DATE] 3:00 PM . Date and Time of the Incident [DATE] 3:00 PM . NOTE [DATE]: THE FACILITY IS ON THE [DATE] RECOVERED COVID-19 SPREADSHEET. NO OTHER COVID-19 INCIDENTS FOUND IN TULIP WITHIN THE PAST 14 DAYS . Narrative of the incident: This employee began to feel ill during work, congestion, and fatigue. We at the facility tested this employee and he showed positive for COVID 19. Actions and notifications: Employee was removed from facility and placed on 10-day quarantine, He is fully vaccinated Record review of Personnel Files on [DATE] revealed: DON with a hire date of [DATE]. Last criminal history was run [DATE] with HR unable to determine when previous criminal history was run, and last EMR/NAR date was [DATE]. DM with a hire date of [DATE] with a last EMR/NAR date of [DATE] with HR unable to determine when previous EMR/NAR had been run. Cook-A with a hire date of [DATE] with a criminal history and EMR/NAR date of [DATE]. AD with a hire date of [DATE] with a last EMR/NAR date of [DATE] with HR unable to determine when previous EMR/NAR had been run. LVN-JB with a hire date of [DATE] with no previous criminal history run date and EMR/NAR date of [DATE], HR unable to determine last annual criminal history/EMR/NAR run date. LVN-MM with a hire date of [DATE] with an EMR/NAR date of [DATE], HR unable to determine previous EMR/NAR run date, no dementia training. RN-WA with a hire date of [DATE] with no previous criminal history/EMR/NAR run date, HR unable to determine previous criminal history/EMR/NAR run date. NA-NC with a hire date of [DATE] with criminal history/EMR/NAR run date of [DATE], HR unable to determine previous criminal history/EMR/NAR run date, no dementia training. CNA-AL with a hire date of [DATE] with criminal history/EMR/NAR run date of [DATE], HR unable to determine previous criminal history/EMR/NAR run date. CNA-SJ with a hire date of [DATE] with no dementia training. Record review of facility Resident Abuse Policy revised [DATE] revealed: Our policy is based on the [DATE]rd in 2006 provider letter number O,d+[DATE] regarding guidelines for reporting abuse and the [NAME] abuse prevention program manual published in 2000. In order to prevent and reduce potential for abuse, every new employee's background and criminal history is investigated before they are hired. The human resource manager, or their designee, will conduct a search through the DPS criminal background history and a check is run through the sex offender registry to see if they have any records. Certain offenses will prevent them from being hired. Also, the employee misconduct registry and nurse aide registry is searched for recorded violations before they are allowed to have any contact with our residents. Record review of Employee Handbook undated revealed: Background checks will be performed prior to employment and annually by Human Resources Coordinator. Record review of Employee Handbook undated revealed: Education and Training. All employees are required to fulfill regulatory training requirements per Long Term Care/Skilled Nursing Facility license mandates per Texas Department of Health and Human Services Commission .All employees . will have monthly and/or annual training assigned . It is requirement of successful employment . Human Resources assigns and tracks completion of all online training . In-service training is provided as needed, in an effort to improve and maintain knowledge of ever-changing health care and Long-Term requirements.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 9 of 13 (DON, AD, DM, LVN-JB, LVN-MM, Cook-A, NA-NC, CNA-AL, RN-WA) employees reviewed for employability. HR staff did not have run criminal history check and/or an EMR/NAR check prior to offering employment to the facility and or annually for long term employees. These findings placed residents at risk of receiving care by someone that was unemployable due to abuse/neglect charges in the past. Findings included: During an interview with HR on 7/13/22 at 2:30PM, she said that while she was getting requested personnel records ready for surveyor review, she was not able to find that some of the employees had a criminal history check and/or an EMR/NAR run prior to their employment or annually. She said she had been working as HR for a short time and those employees were hired prior to her assuming the responsibilities of HR. During an interview with HR on 7/14/22 at 9:30AM, she said that the facility was not in compliance with the criminal history/EMR/NAR checks prior to 7/12/22. During an interview with DON on 7/14/22 at 3:30PM, she said that she did not realize that employees did not have their criminal history/EMR/NAR ran prior to employment or annually until HR was reviewing the personnel files requested for survey. She felt that the failure occurred because the former HR was not running the checks and she did not properly train the new HR. Record review of Personnel Files on 7/13/22 revealed: DON with a hire date of 9/18/14. Last criminal history was run 7/13/22 with HR unable to determine when previous criminal history was run, and last EMR/NAR date was 5/25/21. DM with a hire date of 11/8/11 with a last EMR/NAR date of 7/13/22 with HR unable to determine when previous EMR/NAR had been run. Cook-A with a hire date of 1/11/22 with a criminal history and EMR/NAR date of 1/13/22. AD with a hire date of 1/17/13 with a last EMR/NAR date of 7/13/22 with HR unable to determine when previous EMR/NAR had been run. LVN-JB with a hire date of 1/25/16 with no previous criminal history run date and EMR/NAR date of 7/13/22, HR unable to determine last annual criminal history/EMR/NAR run date. LVN-MM with a hire date of 5/2/22 with an EMR/NAR date of 7/13/22, HR unable to determine previous EMR/NAR run date. RN-WA with a hire date of 3/20/18 with no previous criminal history/EMR/NAR run date, HR unable to determine previous criminal history/EMR/NAR run date. NA-NC with a hire date of 8/13/21 with criminal history/EMR/NAR run date of 7/13/22, HR unable to determine previous criminal history/EMR/NAR run date. CNA-AL with a hire date of 3/28/22 with criminal history/EMR/NAR run date of 7/13/22, HR unable to determine previous criminal history/EMR/NAR run date. Record review of facility Resident Abuse Policy revised March 2017 revealed: Our policy is based on the October 3rd in 2006 provider letter number O6-32 regarding guidelines for reporting abuse and the [NAME] abuse prevention program manual published in 2000. In order to prevent and reduce potential for abuse, every new employee's background and criminal history is investigated before they are hired. The human resource manager, or their designee, will conduct a search through the DPS criminal background history and a check is run through the sex offender registry to see if they have any records. Certain offenses will prevent them from being hired. Also, the employee misconduct registry and nurse aide registry is searched for recorded violations before they are allowed to have any contact with our residents. Record review of Employee Handbook undated revealed: Background checks will be performed prior to employment and annually by Human Resources Coordinator.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for one of eight residents (Resident #6) reviewed for accidents and hazards. The facility failed to properly secure Resident #6's seatbelt in the facility van during transport resulting in the resident sliding out of her wheelchair and onto the floor resulting in an acute fracture of the neck of the fifth metatarsal. The facility's deficient practice resulted in harm to Resident #6 and could place any of the 67 (in a chair all or most of the time) residents residing in the facility requiring the facility van for transportation by increasing their risk for injury and causing a physical decline in their health. The findings included: Review of Resident #6's clinical record physician's orders [REDACTED]. Record review of the Provider Investigation Report dated 06/016/16 revealed on 06/09/16 at 9:30 a.m. the facility failed to put Resident #6's seat belt on while transporting her in the facility van. Resident #6 fell out of her wheelchair sustaining a fracture to her right fifth metatarsal. The metatarsal bones are the long bones in your foot that connect your ankle to your toes. They also help you balance when you stand and walk. A sudden blow or severe twist of your foot, or overuse, can cause a break, or acute (sudden) fracture, in one of the bones. (<http://emedicine.medscape.com/article/ 2-overview>) Record review of Resident #6's MDS dated [DATE] revealed she was alert and oriented. Resident #6 had a BIMS (Brief Interview of Mental Status) score of 15 out of 15 which indicates that she was cognitively intact. She makes herself understood and could understand others. She required limited assistance for transfers, dressing, toileting, personal hygiene, and bathing. She required set up and supervision for bed mobility, eating and ambulation on the unit. She was occasionally incontinent of bowel and bladder. Record review of Resident #6's Care Plan dated 6/09/16 revealed, Resident fell , Resident to be belted at all times during transportation . Record review of Resident #6's Care Plan dated 6/13/16 revealed fracture second through fifth metatarsals. Difficulty with mobility; transfers. Approaches included physical therapy to evaluate and treat. Record review of Resident #6's Care Plan dated 6/15/16 revealed Resident is at risk for falls as evidenced by; cognitive impairment due to [DIAGNOSES REDACTED]. Record review of Resident's #6 Care Plan dated 6/16/16 revealed; refusing to wear boot, right foot toes fractured. Approaches include; pt. refuses to wear boot; stop wearing boot, continue compression and evaluating right foot; x-ray right foot in two weeks. Review of a Radiology Report dated 6/9/16 at 10:29 am revealed an acute fracture of the neck of the fifth metatarsal. Age-indeterminate fractures of the necks of the second through fourth metartaslas. Recommend continued follow-up. Moderate degenerative changes in the foot. In an interview/observation on 07/05/2016 at 4:15 p.m., Resident #6 was alert and oriented and answered questions appropriately. She said that while they were in route to the hospital a dog darted out in front of the van and the driver had to press on his brakes to keep from hitting the dog and she just slid out of her wheelchair. She said that the Van Driver did not put her seatbelt on her that day (06/09/16). She said she did not feel pain in her foot right away but by the time she got to the hospital she was having some pain. She said they x-rayed her foot and found that it was broken. She said the doctor wanted her to wear a boot on that foot so the fracture would heal faster. She said that she does not like the boot and she is not going to wear it. Resident was observed not wearing the boot at the time of the interview. In an interview on 07/06/16 at 10:05 a.m., Transporter A said that he failed to put the seatbelt on Resident #6 on 6/9/2016 when he was taking her to the hospital to have her shoulder x-rayed. He said that he did realize her seat belt was not on but they were already rolling down the road and he didn't stop. He said they were going just a short distance. He said he was about a half mile down the road, only had about a mile to go. He said that he was traveling about 30 to 40 miles per hour. He said that a dog ran out in front of the van and he braked to keep from hitting the dog and when he braked Resident #6 slid out of the wheelchair. He said that he always buckles the resident's seatbelt but on this particular day he was laughing and joking around with the resident, just enjoying the day, and he said it just got by me. He said that he did have his seat belt on and the CNA that was accompanying them also had her seat belt on. He said they used to have a check off list but they have not used it for a long time. He said that when Resident #6 slid out of the wheelchair he pulled over to the side of the road and a passerby stopped and helped him get Resident #6 back in the wheelchair. He said that he made sure her seat belt was secure before he continued down the road. He said that Resident #6 did not complain of pain right away. He said that after they got to the local hospital is when she complained of pain. He said that the hospital x-rayed her foot while she was getting her shoulder looked at. In an interview with Human Resource Manager on 7/6/16 at 11:15 a.m. she said that Transporter A called her on 6/9/2016 at 11:39 a.m. to notify her of the incident involving Resident #6. She said that Transporter A told her that he had to brake to dodge a dog coming onto the road and when he did Resident #6 slid out of her wheelchair onto the van floor. She said that she asked Transporter A if Resident #6 was properly secured with the safety belts during transport. She said that Transporter A replied unfortunately not. At 11:50 a.m. the HR Manager notified the facility Administrator of the incident. At that time the decision was made to suspend Transporter A and CNA A, for not ensuring that the Resident #6 was properly secured in the vehicle during a transport and he would remain suspended pending investigation. At approximately 12:00 p.m. the HR Manager said that she notified LVN D that Resident #6 was involved in an incident and that she had slid out of her wheelchair enroute to the local hospital and for her to follow up with a complete assessment once Resident #6 returned to the facilty. She said because they were already so close to the hospital to continue on to the hospital and inform them of they incident when they arrived. She said that the hospital did an x-ray of Resident #6's right foot when she stared complaining of pain. She said at first the Family Nurse Practitioner (FNP) stated it was arthritis but the radiology report showed there was an acute fracture of the neck of the fifth metatarsal of the right foot. There was age-indeterminate fractures of the necks of the second through the fourth metatarsals. No other injuries were noted. She said that she implemented the checkoff list on that same day of the incident 6/9/16 to Transporter A and CNA A. She said that the checklist was to be completed prior to any departure. In an interview on 7/19/16 at 1:00 p.m., Transporter A demonstrated while describing how to load and secure residents in their wheelchairs into the facility van. He demonstrated and described that when residents are in wheelchairs he would position the wheelchair in the designated area, facing forward. He then demonstrated and described how he used the four straps to secure the wheelchair, two in the front and two in the back. After locking the wheels of the wheelchair, to the van, he demonstrated and described how to use the seatbelt to secure the resident and wheelchair. He said that everybody should wear their seat belt in the van. Transporter A then stated that his demonstration was finished, the resident was secure in the wheelchair and the wheelchair was secured in the van. When this surveyor asked Transporter A about the checklist that had been implemented on 6/09/16 Transporter A stated I will complete the checklist after I get to the doctor's office or wherever I am going. The Human Resource Manager was the resident during the demonstration; she said to Transporter A The checklist is to make sure that all the safety measures are in place before you leave the facility, that's the reason to have a checklist. If you wait until you get there what will prevent the same thing from happening again that happened with Resident #6 . In an interview on 7/6/2016 at 10:40 a.m. with CNA A, who accompanied Transporter A and Resident #6 at the time the incident occurred. She said that she should have checked to see that Resident #6's seat belt was secured. She said that they were all talking and laughing and it was just overlooked. She said that she should have paid more attention. She said I share in the responsibility because I didn't check. She said that the Human Resource Manager in-serviced her and Transported A when they returned back to the facility on a checklist that was to be implemenmented that day 6/9/16 and to be completed before every departure. She said that she was suspended for three days. In an interview on 07/20/16 at 9:35 a.m. with the Human Resource Manager she said that Transporter A had been properly trained and had passed a Driver Safety Test when he was hired 10/21/2010 . She said that any employee that was on the insurance had to go through the check off list which includes, using the lift, proper utilization of the restraints for the wheel chairs, wheelchair brakes, lap/shoulder belts, and appropriate speed. She said that she was very disappointed during the demonstration on 07/19/16 with Transporter A. She said the intent was not to monitor that the paperwork was complete but to actually use the checklist to ensure the resident and the wheelchair was secured properly before every departure from the facility. In an interview on 07/20/16 at 10:15 a.m., the Administrator stated that he felt Transporter A was neglectful in failing to place a seatbelt on Resident #6 prior to leaving the facility on 6/9/2016. Record review of the job description of the facility Transportation Aide dated 01-11-06 and signed by Transporter A 10/21/2010 revealed the following; Essential duties and responsibilities; A . 3. Assures residents are properly seated or secured in the van prior to proceeding 4. Drives at a safe appropriate speed and avoids sudden stops or swerves as much as possible B. Performs other support duties for the department as required. 1. Assists in maintaining a clean safe environment for residents . Other significant requirements; .D. Follows safety guidelines and policies for the center. CMS Form 672 dated 6/07/16 documented a facility census of 89, with 67 residents residing in the facility that require a wheelchair all or most of the time.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents (Residents #1) reviewed for accidents. a) Resident ID#1, who had hand tremors, was given a full cup of coffee by a staff member and the resident spilled the coffee on herself. The resident was assessed but not immediately taken for a change of clothes. The resident sustained [REDACTED]. b) The facility failed to implement interventions or inservice staff that coffee temperatures were high, and staff continued to serve residents excessively hot coffee. Residents also continued to self-serve hot coffee from the coffee container in the dining room. On 1/4/14, twenty-four hours after the burn incident, the coffee temperature was 175 degrees Fahrenheit. An Immediate Jeopardy (IJ) was identified on 1/4/14. While the IJ was removed on 1/6/14, the facility remained out of compliance at a level of Actual Harm that is isolated. This failure could place 73 residents that are coffee drinkers at risk for burn injuries. The findings included: Resident ID #1's face sheet dated 12/30/13 revealed the resident was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident ID #1's Quarterly MDS dated [DATE] revealed the resident's functional status was unsteady with moving from seating to standing, unsteady on walking and turning around. The MDS indicated the resident needed staff supervision for eating. The Weekly Nursing Summary Dated 12/24/13 revealed the Resident ID #1 needed extensive assistance with bed mobility, transferring, dressing, bathing, and toilet use (always incontinent). The summary documented she needed supervision for eating. Review of Nurses' Notes dated 1/3/14 at 8:15 AM revealed a CNA informed a nurse that Resident ID #1 had spilled hot coffee on her pants. The nurse documented she assessed Resident ID #1 and the resident had no pink or red area to the right thigh. Nurses notes documented that the resident stated to the nurse that the area was burning. The MD and MDS nurse (resident's granddaughter) were notified at that time and the MD stated he would see the resident on rounds today. Nurses' notes dated 1/3/14 at 8;15 AM also documented "teaching given to dining room aide on importance of not filling coffee cup to rim d/t (due to) increased shaking of resident's hands. Able to voice needs to staff. WCTM (will continue to monitor)." Review of the MD orders dated 1/3/14 at 9:00 AM revealed the resident was ordered Silvadene Cream 1% (cream used to treat 2nd and 3rd degree burns) twice a day to right thigh due to coffee burn. Further review of Nurses' Notes on 1/3/14 at 6:50 PM revealed the resident had an intact blister to the right thigh and slight redness to the surrounding tissue. "When the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn. ? Blisters develop ? Skin takes on an intensely reddened, splotchy appearance ? There is severe pain and swelling." (<http://www.mayoclinic.org/first-aid/first-aid-burns/basics/ART- 649> accessed 1/10/14) Observation on initial rounds on 1/4/14 at 8:05 AM revealed Resident ID #1 sitting up in her bed with her breakfast tray in front of her. Nurse Aide #4 was helping her at the time and removed a plastic lid from a full cup of coffee and handed it to the resident to drink. Observation of the coffee container in the dining room on 1/4/14 at 8:40 AM after the surveyor made initial rounds, revealed the coffee was at 175 degrees Fahrenheit. The container was available for residents to self serve themselves coffee with no supervision. One unidentified resident was just filling up his coffee prior to the surveyor measuring the coffee temperature. According to the American Burn Association, Scald Injury Prevention, Educator ' s Guide, accessed on 1/8/14); (<http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf> ? Water at 155 degrees Fahrenheit can cause a third degree burn to occur in 1 second. ? Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults Interview with ADON (staff ID #3) on 1/4/14 at 8:40 AM revealed she thought the temperature was too hot for the residents to drink. Staff ID #3 stated the the dietician had talked the the Dietary Manager yesterday (after the burn incident) and told her she needed to turn the coffee pot down. Staff ID #3 stated she thought that had been done and was unaware that the Dietary Manager had not turned it down. Interview (on the phone) with the Dietary Manager on 1/4/14 at 8:50 AM revealed that the Dietician did tell her yesterday to turn the coffee down 10 degrees and it had measured at that time 155 degrees Fahrenheit. The Dietary Manager stated she called the coffee company to have someone come out to turn the coffee machine down, because she was not able to. The coffee company did not come out and the Dietary Manager did not let anyone know when she left at 5 PM the day of the incident that no one arrived to turn the coffee machine down. Interview with Nurse Aide #8 on 1/4/14 at 9:10 AM revealed she was the nurse aide that wheeled Resident ID #1 out of the dining room once the resident had spilled coffee on herself. She stated she took the resident to LVN #6 and they looked at her right thigh area and she did not have any redness at that time. Nurse Aide #8 stated that she was told by the LVN to go change her and Nurse Aide #8 stated she tried to find the nurse aide that was on the resident's hall so could have her change her but the nurse aide was busy that Nurse Aide #8 wheeled the resident without changing her back to the dining room with wet pants. Nurse Aide #8 stated after the incident she was told by LVN#6 to only give the resident a 1/2 cup of coffee due to her shaky hands. Interview with LVN #6 on 1/5/14 at 9:10 AM revealed she was the nurse that assessed the resident after the coffee spill. She stated on assessment the area was not red and she had told the nurse aide to go and change her pants due to being wet from the coffee. Interview (in person) with the Dietary Manager on 1/4/14 at 10:06 am in the dining room revealed she going to move the pot of coffee out of the dining room and cool it down to 149 degrees before serving the residents. The Dietary Manager did remove the pot of coffee at that time. On 1/4/14 at 11:05 AM an IJ situation was identified and the Administrator was informed. Interview with the administrator on 1/4/14 at 11:05 AM revealed she was under the impression that the coffee temperature had been turned down by the Dietary Manager on 1/3/14 after she and the dietician had spoken to her about the incident. The administrator stated the Dietary Manager never let anyone know that the coffee had not been turned down before she went home. The administrator stated she was going to talk with the Dietary Manager and the two ADON's and come up with a plan to prevent the coffee from being too hot for the residents. Interview with the Dietary Manager on 1/4/14 at 12:30 PM revealed that the plan was to always cool the coffee down to 140 degrees Fahrenheit before serving and to record it on a log that hung by the coffee machine. Record Review revealed on 1/4/14 a Farmer Brother's Coffee Invoice was signed by a representative that came out and turned the coffee machine temperature to 140 degrees Fahrenheit. Observation on 1/5/14 at 7:20 AM revealed the coffee temperature was 140 degrees, the coffee was served to six residents out in the dining room prior to the breakfast pass. Observation on 1/5/14 at 7:45 AM revealed a second pot of coffee had been brewed and it was sitting on the counter waiting to be cooled down. It measured 136 degrees at that time. Interview with the Staffing Coordinator on 1/6/14 at 9:10 AM revealed the facility did not have a hot beverage policy but that she had written one up yesterday and then she proceeded to hand the surveyor a policy dated 1/4/14. Observation on 1/4/14 at 10:01 AM revealed Resident ID #1's right thigh had a second degree burn that staff measured 6 centimeters by 7 centimeters. The blister was no longer intact and the top layer had peeled back with an open wound Observation of Resident ID #1's burn to the right thigh on 1/6/14 at 1:05 PM revealed the wound had a greenish white coating covering the wound with redness around the wound bed. The resident stated she was having pain to the wound at that time. The facility's Plan of Removal of Immediate Jeopardy was accepted on 1/6/14 at 12:45 PM and included: 1) Coffee was removed from resident's reach in the dining room at 10:12 AM on January 4,2014. On January 4, Farmers Brothers, contracted coffee provider adjusted the temperature on the coffee makers in Holiday Hill and unplugged and turned off the water to the Allen Center coffee maker until a solution can be found to bring the temp. down to 140 degrees. Until then, coffee will be transported from Holiday Hill to the Allen Center. 2) Facility Management (administrator, assistant directors of nursing, food service supervisor, and dietary consultant) have agreed that coffee will be served at 140 degrees beginning with the noon meal on 1/4/14. 3) Temperatures will be checked by dietary personnel each time coffee is brewed and before it is taken to the dining room to be accessible to residents; dates,times, and temperatures of the coffee will be recorded on coffee temperature log. Every dietary employee will be responsible for logging in the coffee temperature information on the log, and food service supervisor will be responsible for monitoring the logs to ensure that no coffee is delivered to the dining room or to residents without first being temped (temp. no greater than 140 degrees) and recorded on the logs. 4) Resident ID #1 is offered a half-cup of coffee with her meals, whether she consumes her meals in her room or in the dining room. This resident may have as many refills as she desires which will also be filled only at half-cups levels. 5) treatment of [REDACTED]. Pain management was achieved as follows: one Tramadol 50 milligrams was administrated on January 3 at 5:15 PM for mild general discomfort, one Hydrocodone 7.5/325 milligrams was administered at 6 PM on January 3, two tablets Hydrocodone 7.5/325 milligrams at 10 PM on January 3. Pain meds given on January 4 include two tablets Hydrocodone 7.5/325 milligrams which was given at 1:25 PM due to complaint of back pain and an additional two tablets of Hydrocodone 7.5/325 milligrams at 6:25 PM due to complaint of back pain. No additional pain medication was administered after 6:25 PM dose on January 4. All facility employees have been inserviced on these new procedures. On 1/6/14 at 12:45 PM the surveyor verified that staff been inserviced and Resident ID #1 had been served a half cup of coffee with her noon meal. The coffee temperature in the dining room was 132 degrees in the dining room at that time. When the IJ was removed on 1/6/14, the facility remained out of compliance at a Scope and Severity Level of Isolated Actual Harm because the facility had yet monitored their plan for effectiveness. Interview with the administrator on 1/6/14 at 9:10 AM revealed the facility had 73 coffee drinkers.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality of care for one of 18 residents (Resident #1) reviewed for quality of care. The facility failed to: a. perform a complete head to toe skin assessment on Resident #1 for four days following his hospitalization and readmission resulting in a delay in identification and treatment of [REDACTED]. b. clarify Resident #1 ' s Physician ' s Orders regarding the leg immobilizer in place upon readmission c. follow their own policy for skin assessments and immobilizers related to Resident #1 This failure affected one resident with a leg immobilizer in place resulting in a delay of identification and treatment of [REDACTED]. Findings included: During initial tour on 02/12/13 at 10:25 a.m. LVN B identified Resident #1 as bedfast and non-ambulatory after a tibia fracture in August 2012. She stated he had stage II pressure ulcers on his buttocks and coccyx area. LVN B said Resident #1 had a history of [REDACTED]. Record review of Resident #1 ' s Face Sheet dated 01/10/13 revealed he was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1 ' s " Status Upon Admission Data Collection " dated 09/28/12 revealed he was admitted to the facility with [DIAGNOSES REDACTED]. In " skin condition " Resident #1 was assessed to have redness to the buttocks bilaterally. There was no documentation of any skin breakdown on his right leg. In " functional status " Resident #1 was assessed to require total assistance for transfers, non-weight bearing, on bedrest with a knee immobilizer (medical splint applied to the leg to prevent movement extending from the upper thigh to the ankle) in place. Resident #1 was assessed to be dependent for all aspects of personal grooming and toileting. Record review of Resident #1 ' s admission orders [REDACTED]. There was no Physician ' s Order related to a knee immobilizer. Record review of Resident #1 ' s Nurse ' s Notes revealed the following: 09/28/12 at 4:30 p.m.: " ...general skin condition reddened and dry. Total assist. Reddened buttocks ...oriented only to person ...c/o (complained of) pain to tibial area [MEDICAL CONDITION] 2+ to right lower extremity, Received orders ...start PT (physical therapy) in one week. Non-weight bearing ... " The areas for Pressure Sores and Braces/Casts/Splints were left unchecked. 09/29/12 at 9:20 a.m.: " ...Res(ident) c/o not feeling well. Labored breathing. Use of accessory muscles. Pale. This nurse called and notified physician. Orders to send to ER (emergency room ) ...B/P (blood pressure) at 159/117 ... " The areas for Pressure Sores and Braces/Casts/Splints were left unchecked. at 5:30 p.m.: " ...refused v/s (vital signs) ...resident refused q (every) meal today. Voiced that he wanted for us to let him go and he was tired ... " There areas for Pressure Sores and Braces/Casts/Splints were left unchecked. 10/01/12 at 1:05 p.m.: " ...res(ident) in bed ...resp(irations) slightly labored ...res(ident) complained of pain, but unable to verbalize amount, non-verbal indicators noted. Res(ident) received prn (as needed) pain medication as ordered ... " Resident #1 ' s temperature was documented 99.4 on the day shift. The areas for Pressure Sores and Braces/Casts/Splints were left unchecked. 10/02/12 at 4:30 p.m.: " ...Resident changed from full code to DNR (do not resuscitate) per family request ... " Resident #1 ' s temperature was documented 100.1 on the day shift. The areas for Pressure Sores and Braces/Casts/Splints were left unchecked. (no time documented): " ...incomplete skin assessment of 09/28/12 did not reveal pressure sores to right posterior thigh and right ankle. These wounds discovered today under right ... soft brace with metal stays ...thigh 3.5cm (centimeters) x 2.5 cm, dark angry red, eschar around distal edges. Ankle 4.5 x 3 cm, dark dry angry redness with spots of black eschar. No depth measurements until possible cast removal 10/03/12. Right heel reddened ...physician notified, no new orders, physician to see resident 10/03/12 at facility at approximately 1:00 p.m. Resident cries out in pain upon repositioning. Pain to right fracture(d) leg and wounds ... " 10/03/12 at 2:30 p.m.: " ...Dr (named) here received new order to d/c (discontinue) brace to right leg. Stage III pressure area to right thigh measures 4 cm x 1.5 cm x 0.3 cm with wound bed necrotic with edges with white sloughing with 7 cm x 4 cm reddened area around - warm to touch. Stage III to right heel 3.5 cm x 2 cm x 0.5 cm with wound bed necrotic with edges with brown sloughing. Stage II to right ankle 1 cm x 1.5 cm x 0.1 wound bed necrotic in color edges macerated with 2.5 x 2.5 reddened around. No tunneling noted with scant amount bloody drainage to areas x (times) 3 ... " In an interview on 02/14/13 at 12:20 p.m. the DON stated Resident #1 was readmitted to the facility on Friday, 09/28/12 at 4:30 p.m. She said Resident #1 arrived to the facility with a knee immobilizer in place. The DON stated that although there was no physician ' s order regarding the knee immobilizer it was implied it was not to be removed. The DON confirmed Resident #1 did not receive a full skin assessment upon his readmission on 09/28/12 per facility policy. The DON said it was her responsibility to perform skin assessment on Resident #1. She stated Resident #1 arrived to the facility late on a " Friday " and she had already left for the weekend. Record review of the Texas Board of Nursing Rules and Regulations accessed on 02/22/13 at: <http://www.bon.texas.gov/nursinglaw/pdfs/bon-rr.pdf> revealed the following: ?217.11. Standards of Nursing Practice The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse ' s license even if no actual patient injury resulted. (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client Record review of the facility policy " Resident Full Skin Assessment " dated February 2013 revealed " ...upon admission ...the nursing staff will perform head to toe skin assessments ... " Record review of the facility policy " Nursing Care for Immobilizers, Casts, Braces, and Splints " dated February 2013 revealed " ...When a resident receives an immobilizer, the SN (skilled nurse) assessment is to include a head to toe full skin assessment identifying the type of immobilizer ...the physician ' s orders for care of the cast and the effected limb should be present. If no orders are including regarding the care, removal and replacement of the cast/brace/splint, the staff must notify the physician as soon as possible and request orders for the care of the resident ' s cast/brace/splinted area ...It is essential that these orders are received immediately as the resident cannot receive appropriate nursing care until they are in place ...Inspect the skin condition under and around immobilizer and assess daily for any changes ... " In an interview on 02/15/13 at 12:30 p.m. the DON stated Resident #1 was the only resident that was admitted with a knee immobilizer in place.

Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 7 of 23 residents reviewed for accidents (Residents #2, 15, 12, 21, 22, 24, and 25) as evidenced by: a) failure to provide for Resident #2's safety during transfers using a mechanical lift. Staff tilted Resident #2's wheelchair onto the back 2 wheels while the resident's weight was being lowered down into the chair creating a fall risk which could result in injury. b) failure to ensure staff were using assistive devices in a safe manner by following manufacturer's instruction to always have the base legs of lift in the open and in the locked position before moving a resident during a transfer. Staff used a mechanical lift in an unsafe manner multiple times by not following the manufacturer's recommendations for safe use when transferring Residents #2, #15, and #25. Failures (a) and (b) resulted in an Immediate Jeopardy which was identified on 11/18/10. While the Immediate Jeopardy was removed 11/20/10, the facility remained out of compliance at a level of no actual harm with the potential for more than minimum harm at a pattern c) failure to ensure staff were following safe practices when Residents #2 and 24 were transferred to a wheelchair without locking the wheels of the chair. d) failure to use a gait belt in a safe manner while transferring Resident #12 when the belt was secured too loosely to support the resident's weight. Staff failed to use a gait belt when transferring Resident #22. Instead staff pulled the resident up with their hands positioned under the resident's armpits. Resident #22 had a hemodialysis port on her upper right arm near the armpit. e) failure to follow resident #21's care plan during transfer. The resident was assessed as a 2-person transfer. Resident fell while being transferred by one staff, resulting in facial bruising. f) failure to store hazardous substances in a manner to prevent access by 9 confused residents identified by the facility who wandered. These failures could result in accidents and injuries to any of the 48 residents identified by the facility as needing assistance with transfers. Findings include Resident #2: Review of Resident #2's Admission Face Sheet revealed Resident #2 was admitted to the facility on [DATE] at 1:50 p.m. The resident was a [AGE] year old female at the time of the survey. Review of Resident #2's History and Physical dated 1/28/10 revealed Resident #2 had a past medical history of [REDACTED]. Resident #2's past surgical history included; left below the knee amputation due to diabetes. Review of Resident #2's Fall Risk Assessment, dated 10/25/10, revealed that the resident's score was 13. The Fall Risk Assessment Total parameters indicated a total score of 10 or greater should be considered at high risk for potential falls. Review of Resident #2's Mini-Mental State Examination dated 10/25/10, revealed Resident #2 had a total score of 15 out of a maximum score of 30, indicating severity of cognitive impairment as moderate. Review of Resident #2's Behavioral Symptoms Checklist dated 10/25/10, revealed Resident #2 had no behaviors for all categories assessed with [REDACTED]. Review of Resident #2's consolidated physician's orders [REDACTED]. Review of Resident #2's annual Minimum (MDS) data set [DATE], revealed the resident had short and long term memory problems. She was able to make her self understood and usually able to understand others. Resident #2 required total assistance from 2(+) staff for bed mobility, transfers, dressing, and toilet use, and required assistance from 1 staff for personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 2 (Not steady, only able to stabilize with human assistance) for moving from seated to standing position, moving on and off the toilet, and surface to surface transfer. Resident #2 had impairment on both sides in both upper and lower extremities. Resident #2 was incontinent of bowel and bladder. Resident #2 was assessed to be 66 inches tall and weighed 348 lbs. Review of Resident #2's most recent Care Plan dated 10/19/10 (with no documented update) revealed the facility had identified Resident #2 as having; Problem Behaviors. The goal and target date were listed as: Resident #2 will not have any adverse reactions related to eating problems times 90 days. Approaches included: ( a hand written addendum under approaches stated, Calls CNA's names if they don't take her to smoke use lift the way she says whether it is right or wrong.)Redirect resident when asking for food, encourage low calorie snacks, inform resident of possible problems related to health, encourage resident not to use bad language . An observation on 11/16/10 at 11:00 a.m. revealed CNAs 'B' and 'C' performed a transfer of Resident #2 from her bed to her wheelchair. Resident #2 was lifted with a mechanical lift. The lift was wheeled out from under Resident #2's bed with the lift legs in the closed position. CNA 'B' operated the mechanical lift and opened the legs of the lift to the wide open position while CNA 'C' stabilized Resident #2 and put the wheelchair in place (without locking the wheels of the wheelchair). As the CNAs were lowering Resident #2 over the wheelchair with the lift, Resident #2 stated, "Tip the chair". CNA 'C' stated, "We have to tip the wheelchair back so she can get into it better." CNAs 'B' and 'C' were asked if "tipping " the wheelchair back was normal practice. CNA 'B' said, "We are going to be in trouble for this aren't we?" CNA 'C' tipped the wheelchair back onto the back two wheels (the wheels continued to be unlocked). CNA 'B' lowered Resident #2 into the tipped and unlocked wheelchair while CNA 'C' lowered the wheelchair back onto four wheels. During the process of lowering Resident #2 into her wheelchair, CNA 'B' stated, "The lift is still going down and I'm not pressing the button anymore." The swivel bar on the mechanical lift was observed to continue to move downward after CNA 'B' had released the control button. CNA 'C ' stated, "I will take the lift for maintenance to look at." Note: ** The swivel bar as indicated by the manufacture's manual for the Reliant/450 is the bar that the sling is attached to in order to facilitate lift/transfer. *** In an observation on 11/16/10 at 11:15 a.m., CNA 'C' was observed pushing the mechanical lift down the hallway towards the maintenance room. In an interview on 11/16/10 at 11:30 a.m. CNA 'C' said she had to pull "really hard" several times to lift Resident #2's wheelchair back onto all four wheels after the resident had been lowered into the chair while the chair was tipped back onto the 2 back wheels. CNA 'C' was asked if she had alerted the charge nurse about issues related to "tipping" the wheelchair back for Resident #2. She stated the nurses were aware of the CNAs having to "tip" the wheelchair back for Resident #2. She stated Resident #2 wanted the wheelchair "tipped"back, and the CNAs did it that way to keep Resident #2 from having behaviors. A review of the Invacare Reliant 450 (mechanical lift) Operator's Manual revealed the following: Under --Section 1- General Guidelines: "The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Moving a person suspended in a sling over ANY distance is not recommended. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted." - Using the Sling: "If patient is in a wheelchair, secure the wheel locks in place to prevent the wheelchair from moving forward or backward." - Lifting the Patient: "When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE lifting the patient. - Transferring the Patient: "Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. Under Section 4- General Guidelines: Preparing the Lift for Use: "With the legs of the base open and locked, use the steering handle to push the patient lift into position." - Transferring to a Wheelchair: "Ensure the legs of the lift (with patient) are in open position. Move the wheelchair into position. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. Position the patient over the seat with their back against the back of the chair. Begin to lower the patient. With one assistant behind the chair and the other operating the patient lift the assistant behind the chair will pull the grab handle to seat the patient well back in the chair. This will maintain a good center of balance and prevent the chair from tipping forward." A bold print WARNING under this section states, "The wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport." In an interview on 11/16/10 at 11:40 a.m. the ADON revealed she was not aware of the CNAs "tipping" Resident #2's wheelchair back while transferring her by use of the mechanical lift. She stated, "The CNAs should not ever tilt the wheelchair back with a resident in it." In an interview on 11/16/10 at 11:45 a.m. with LVN 'C' revealed, she was not aware of the CNAs "tipping" the wheelchair back during transfer of Resident #2 with the mechanical lift. She stated, "No, I was not aware of the CNAs tipping the wheelchair back. That could be very dangerous." In an interview on 11/16/10 at 12:00 p.m. LVN 'D' revealed, she was aware the CNAs were "tipping" the wheelchair back during transfers of Resident #2 using the mechanical lift. She said Resident #2 had behaviors and if the CNAs did not do as she requested, Resident #2 screamed and cursed at them. In an interview on 11/16/10 at 12:00 p.m. the DON revealed she was not aware of the CNAs "tipping" the wheelchair back while transferring Resident #2 with the mechanical lift. She stated Resident #2 had behaviors and she yelled and cursed at the CNAs if she didn't get her way. In an interview on 11/16/10 at 12:10 p.m. CNA 'B' revealed she was not comfortable with "tipping" the wheelchair back during transfers with the mechanical lift, but she would tip the wheelchair back so Resident #2 didn't have any behaviors. In an interview on 11/16/10 at 12:15 p.m. the DON revealed she had just spoken to Resident #2 regarding her requests to have the CNA's tip the wheelchair back while transferring her with the mechanical lift. She said she had informed Resident #2 about the safety issues regarding tipping the wheelchair back and instructed her not to ask the CNAs to perform unsafe acts while they were assisting her. An observation on 11/16/10 at 3:30 p.m. revealed CNA 'F', CNA 'E' and CMA 'B' transferring Resident #2 with the mechanical lift. Resident #2 was transferred from the bed to her wheelchair using the mechanical lift. Resident #2 did not request for the CNAs to "tip the chair". Wheels on the wheelchair were observed to be in a locked position. The straps on the back of the sling were utilized to pull Resident #2 back into the chair, where Resident #2 stated she was comfortable. A review of the facility's undated Policy and Procedure for Lifting and Transferring Residents received 11/16/10 revealed: --Facility standard: Residents are lifted and transferred safely in all instances. --Policy: All nurses, and nursing assistants are responsible for using good body mechanics, knowing proper procedures, and properly operating assistive devices. Approved techniques for lifting, transfer, and body mechanics are discussed and demonstrated during each orientation program for nursing personnel. --General: Assess resident to determine physical limitations, tubing or equipment that must be moved, and the ability of the resident to follow directions. Prepare for moving the resident by providing privacy, suitable clothing, chair or wheelchair, enough space to move the resident safely. Lock wheels on bed and wheelchair. The designated method of lifting and transferring of the resident is indicated in the Resident Care Plan. A review of Facility Inservice Sign In Sheet, dated 11/16/10 revealed, "It is never ok to tilt a resident's wheelchair during a transfer. This is a safety risk. Should a problem arise with any resident that may want the wheelchair tilted for transfer, please notify the nurse in charge prior to transfer. Safety, Safety, Safety, Safety, Safety." The Inservice Sign In Sheet revealed 25 staff signatures. In an interview on 11/17/10 at 11:00 a.m. LVN 'E' was not aware of the Facility Inservice on 11/16/10 regarding the CNAs tipping the wheelchair back while transferring Resident #2. She stated, "I didn't work yesterday." In an interview on 11/17/10 at 11:00 a.m. LVN 'F' revealed she was not aware of the Facility Inservice on 11/16/10 regarding the CNAs tipping the wheelchair back while transferring Resident #2. She stated, "I didn't work yesterday either." In an interview on 11/17/10 at 1:30 p.m. with the ADON, documentation was requested regarding the number of residents that required use of the mechanical lift for transfers. Documentation was received revealing that 16 residents were transferred using a mechanical lift. A review of the facility's Lift Maintenance Log dated 11/18/10 revealed, each lift device shall be checked by the maintenance department for proper working condition each week. The devices shall be numbered and logged as to when they are checked and are in good condition. Any lift not operable shall be red tagged and put up for repair. Invacare Reliant 450 was shown to be "out of order". Resident #15: The findings included: Review of Resident #15's Admission Face sheet revealed this male Resident was admitted to the facility on [DATE] with re-admission on 10/16/2007. The resident was [AGE] years old. Review of Resident #15's History and Physical dated 2/17/10 revealed Resident #15 had a past medical history of [REDACTED]. Review of Resident #15's annual Minimum (MDS) data set [DATE], revealed Resident #15 had short and long term memory problems. He was rarely/never able to make himself understood and rarely/never able to understand others. Resident #15 was assessed to be severely cognitively impaired. Resident #15 required total assistance from 2(+) staff for bed mobility, transfers, dressing, toilet use, and required assistance from 1 staff for locomotion on and off unit, personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 8 (Activity did not occur) for moving from seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #15 had impairment in both upper and lower extremities. Resident #15 was incontinent of bowel and bladder. The resident was assessed to be 70 inches tall and weighed 182 lbs. Review of Resident #15's consolidated physician's orders [REDACTED]. In an observation on 11/15/10 at 4:05 p.m. revealed CNA 'F' and CNA 'E' transferring Resident #15 from his bed to his wheelchair. Resident #15 was rolled onto his right side to roll the lift sling underneath him and then onto his left side to pull it behind him. Resident #15's sling was attached to the mechanical lift. The mechanical lift legs were in opened and locked position while lifting Resident #15. While CNA 'E' began pulling the lift out from under the bed with Resident #15 in the sling, the CNA closed the legs and then reopened them when trying to make accommodations for the resident's wheelchair. Handles on the back of the sling were utilized by CNA 'F' to bring Resident #15 close to the back of his wheelchair. Resident #15 was seated in his wheelchair and a lap-buddy was put in place. In an interview on 11/18/10 at 2:20 p.m. the Administrator and DON were informed an immediate jeopardy had been identified concerning accident hazards. The Administrator and DON were asked to submit a plan to remove. In an observation on 11/18/10 at 3:20 p.m. CNA 'E' and CNA 'I' transferred Resident #15 from his bed to his wheelchair. CNAs 'E' and 'I' adjusted the sling underneath Resident #15 and secured it to the lift. CNA 'E 'operated the mechanical lift while CNA 'I' stabilized the resident. The lift legs were in the closed position for the majority of the transfer until they were placed in the open and locked position while positioning the wheelchair. CNA 'I' did not lock the wheels on the wheelchair at any point during the transfer process. In an observation on 11/19/10 at 3:10 p.m. CNA 'P' and CNA 'Q' transferred Resident #15 from his bed to his wheelchair while LVN 'H' monitored the transfer. Resident #15 was lifted with the mechanical lift operated by CNA 'Q'. The legs of the lift were in wide open and locked position while positioned underneath the bed; however, CNA 'Q' moved the lift out from under the bed with the lift legs closed. CNA 'Q' transported Resident #15 approximately 4 feet to his wheelchair while CNA 'P' stabilized Resident #15's feet. Resident #15 was lowered into his unlocked wheelchair. This observation was made after staff were inserviced on 11/19/10. In an interview on 11/19/10 at 3:15 p.m. LVN 'H' revealed that she had not seen anything wrong with the transfer of Resident #15 at 3:10 p.m. In an interview on 11/19/10 at 4:45 p.m. the DON was asked to demonstrate how to properly use the mechanical lift. The DON took a lift into the break room and said she would pretend that a small table in the room was a bed. While observing the demonstration, it was observed that the legs of the lift were in the closed position while underneath the table. When the lift was pulled from underneath the table she opened the legs up and locked them. The DON was shown the manufactures specifications on use of a mechanical lift, specifically the section stating, "the legs of the lift should be in open and locked position at all times while lifting a resident". In an observation on 11/19/10 at 5:00 p.m. the DON inserviced the ADON, LVN 'H', LVN 'I', CNA 'P' , CNA 'Q', CNA 'I', and CNA 'E' on safe use of the mechanical lift. The DON explained to staff, "At anytime when a resident is in the sling being lifted, the legs of the lift must be in open and locked position to create a wide base and better balance of the lift to ensure the resident is safe." Resident #25: Review of Resident #25's medical record face sheet revealed this [AGE] year old female resident was admitted to the facility on [DATE]. Review of Resident #25's quarterly MDS dated [DATE] revealed the resident was severely impaired in daily decision-making skills and had short-term and long-term memory problems. the resident was totally dependent on 2 or more staff for transfers and totally dependent on one staff for personal hygiene. The resident was incontinent of bowel and bladder and was not ambulatory. The resident's [DIAGNOSES REDACTED]. In an observation on 11/18/10 @ 5:10 p.m. CNA 'E' and CNA 'Q' used the mechanical lift to transfer Resident #25 from her bed to a wheelchair. After both CNAs placed the sling under the resident and attached the sling to the mechanical lift, CNA 'Q' went to the end of the bed and held the wheel chair while CNA 'E' lifted the resident up, swung the resident out over the floor and rolled the lift to the end of the bed where the wheelchair was positioned. The base of the lift remained closed during the entire procedure until just before the lift approached the wheelchair. Just prior to the lift reaching the wheelchair CNA 'E' opened the base of the lift so the resident, who was suspended in the sling, could be maneuvered over the chair and lowered into it. In another observation on 11/19/10 @ 4:35 p.m. CNA 'E' and CNA 'Q' used the mechanical lift to transfer Resident #25 from her bed to a wheelchair. Once the sling was positioned under the resident and attached the to the mechanical lift, CNA 'E' lifted the resident off the bed and pulled the lift out over the floor, with the resident suspended in the sling. The base of the lift was in the closed position. The CNA turned the lift 90 degrees as CNA 'Q' brought the wheelchair to the side of the bed and placed it underneath the resident. CNA 'E' did not open the base of the mechanical lift until just prior to maneuvering the resident over the chair. In an interview on 11/19/10 @ 4:45 p.m. CNA 'E' said the proper procedure for transferring residents with a lift was as follows: When the lift was placed under the bed in preparation for lifting the resident, the base of the lift was closed and the lift wheels were locked. After lifting the resident off the bed the wheels were unlocked and the lift, with the resident suspended, was pulled away from the bed. The wheel chair was brought to the lift and the base of the lift was opened when the wheelchair was placed under the resident. CNA 'E' said the purpose for spreading the base of the lift was to provide stability as the resident was being lowered into the chair. Facility Plan of Removal: On 11/20/10 at 10:00 a.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Program Manager. According to the Plan of Removal the facility immediately (11/16/10) in-serviced all nursing staff per a paper memo on not tipping the wheelchair when using the Hoyer lifts. The facility identified 17 residents who required the use of a lift during transfers. Staff were provided a hands on in-servicing on how to use the Hoyer lift starting on 11/18/10 with return demonstrations required by staff. A re -in-service training per manufactures' s instruction on the Hoyer lift was started on 11/19/10 with nursing staff and was to be completed on all staff by 11/22/10. Any nursing staff that was not working during this time period would not be allowed to use the lifts until they were trained and a return competency demonstration was completed, verified and documented. All licensed staff will be in-serviced regarding the requirement of them to make visual observations of staff of all lift transfers with verification of competency of staff with documentation required. Proper transfers will be required. If improper transfers are witnessed by licensed staff, then the staff doing the transfer will be stopped immediately and re-training will occur at that time. All Staff must complete proper transfer before verification can be confirmed by licensed staff. Completion date of 11/20/10 and ongoing for the next 5 days. All lift devices will be checked weekly by maintenance to assure proper working order. All maintenance will be documented on a maintenance log. The lift that was used in the transfer of Resident # 2 on 11/16/10 was taken out of service until it could be repaired. The Administrator and the Director of Nurses will review and monitor the process throughout the day by making daily rounds and reviewing verification documentation provided by licensed staff on all shifts. This process will be reviewed by the Quality Assurance Committed weekly. Anti-tipping device was applied to the wheelchair of Resident # 2 on 11/18/10. All other resident ' s who use wheelchairs in the facility will have anti-tipping devices installed on their wheelchairs by 11/30/10. Plan of Removal Verification: Facility Nurses and CNA ' s were interviewed on 11/20/10 from 10:00 a.m. to 5:00 p.m. concerning the training they had received on the use of the Hoyer lift and sit to stand lift during transfers per the manufacture ' s instructions. All staff interviewed confirmed they had received the in-service training as specified and had completed a return demonstration of competency as described in the Plan of Removal. On 11/20/10 verification of staff training per the Facility Plan of Removal and manufacture's instructions was made by multiple observations of staff using the Hoyer and sit to stand lift correctly during transfers of multiple residents. Licensed staff verified they were to observe staff during every transfer with the Hoyer and sit to stand lifts on their shifts. On 11/20/10 review of monitoring sheets used by licensed staff to document competency of staff were reviewed. This review as well as interviews with nursing staff verified licensed staff were observing and documenting competency of staff during return demonstrations of all transfers using the lifts per the manufacture's instructions and per the facilities Plan of Removal. Observation of Resident # 2 on several occasions on 11/19/10 and 11/20/10 verified the facility had placed anti-tip devices on her wheelchair to prevent tipping as per the facility Plan of Removal. The facility also stated in their Plan of Removal all wheelchairs will be fitted with anti-tipping devices to prevent any other resident from being tipped backwards either accidentally or intentionally during transfers. These devices were ordered by the facility and will be placed on wheelchairs as they are delivered to the facility. This action will be completed by 11/30/10. According to the facility ' s Plan of Removal all lift devices will be checked weekly by maintenance personnel for proper working condition and logged on a monitoring log, any lift not working correctly will be removed from use until it is repaired. This correction was verified by observation of all lifts and interview with the maintenance director, as well as review of the maintenance log for all lifts on 11/20/10. During an interview with the Administrator on 11/20/10 at 10:00 p.m. he said no staff will be allowed to use any of the facility lifts until they have been trained and demonstrated competency. He said all of the facility interventions will be added to the facility ' s Quality Assurance and will become part of the ongoing safety meetings. The Immediate Jeopardy was lowered to potential for more than minimal harm at a pattern prior to the exit at 10:15 p.m. on 11/20/10. NON IMMEDIATE JEOPARDY FINDINGS Resident #21: Review of Resident #21's medical record face sheet revealed this male resident was admitted to the facility on [DATE]. He was [AGE] years old at the time of this survey. Review of Resident #21's consolidated physician orders [REDACTED]. Review of Resident #21's admission MDS dated [DATE] revealed the resident was able to understand others and able to make himself understood. The resident had some short-term memory problems. The resident had no indicators of inattention, disorganized thinking, or altered awareness. For transfers the resident was totally dependent and required physical assistance from 2 staff. Review of Resident #21's care plan dated 10/8/10 revealed the problems of the resident's inability to perform activities of daily living and bathing. The care plan documented the resident required 2 staff for transfers. Review of Resident #21's nursing notes dated 10/21/10 at 6:30 p.m. revealed a CNA was helping the resident off the commode when he fell and hit his face. The nurse documented the resident's fall resulted in bruising of the left cheek and right side of his nose. On 10/23/10 at 3:15 p.m. the nurse documented the resident's facial bruising was still present at that time. Review of a facility Investigation Report dated 10/21/10 at 6:30 p.m. revealed Resident #21 fell face first to the floor during a transfer in the bathroom. According to this report, a single CNA was assisting the resident to transfer at the time of the fall. In an interview on 11/19/10 at 2:55 p.m. Resident #21 said sometimes when he got up he could not maintain his balance, and that was one of the reasons he lived in a nursing home. He said that was what happened when he fell in the bathroom (on 10/21/10). He said at that time there was only 1 CNA helping him to transfer. In an interview on 11/20/10 at 5:37 p.m. CNA 'N' said he had worked in the facility about 2 1/2 months on the hall where Resident #21 resided. CNA 'N' said at the time Resident #21 fell in the bathroom (on 10/21/10) the resident wanted to get off the toilet because he was feeling weak. The CNA said he knew at that time the resident required 2 staff for transfers, but he was not able to get another staff to help him because the other staff members were busy in other resident rooms. CNA 'N' said he tried to help the resident transfer by himself but was unable to keep the resident from falling. Resident #22: Review of Resident #22's Face Sheet dated 11/15/10 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of the survey. Review of Resident #22's Care Plan dated 11/06/08 revealed the resident received hemodialysis three times a week. The resident had a port (graft) to her right upper arm (a graft becomes an artificial vein that can be used repeatedly for needle placement and blood access during hemodialysis). The goal was for the resident not to have complications due to her dialysis port (graft) over the next 90 days. The approaches included to not lift the resident by her right arm. The resident was on coumadin, a blood thinner, related to the dialysis port (graft) on her right upper arm. The approaches included using a padded sling for the lift during transfers (to decrease the risk of bruising). The resident required assist x 2 for transfers and assist x 3 with ambulation. The approaches included to transfer the resident per one staff assist (the resident required 2 staff to transfer), ambulate resident per staff assist x 3 with a walker, staff may use a mechanical lift and use a padded sling for the lift. There were no updates to the care plan. Review of Resident #22's annual MDS dated [DATE] revealed the resident had short-term and long-term memory problems but was able to recall the location of her own room and that she was in a nursing home. The resident was moderately impaired for decision making. The resident had mood indicators which included feeling tired or having little energy and being short-tempered, easily annoyed. The resident rejected care 1 to 3 days a week. The resident was totally dependent and required the assistance of two staff persons for bed mobility and transfers. The resident required extensive assistance of one staff person for dressing, personal hygiene and bathing. The resident was dependent of one staff person for toilet use. The resident was not steady, only able to stabilize with human assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfer (transfer between the bed and chair or wheelchair). The resident had functional limitation in range of motion on both sides of her upper and lower extremities. The resident was always incontinent of bowel and bladder. Review of Resident #22's Incident/Accident Reports revealed: --on 7/11/10 at 10:00 a.m. two un-named CNA's were transferring the resident to the toilet and the resident bumped her l

Based on observations, interviews, and record reviews the facility failed to ensure that it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical well-being of 3 of 23 residents reviewed for accidents (Residents #2, 15, and 25) as evidenced by: The Director of Nursing Services failed to: a) effectively train staff in the safe use of the mechanical lift after learning staff were tilting Resident #2's wheelchair back onto the back 2 wheels while the resident's weight was being lowered down into the chair creating a fall risk which could result in injury. After training on 11/16/10, staff did not continue to tilt the resident's wheelchair during transfers, however continued to use the mechanical lift in an unsafe manner by not opening the base (legs) of the lift to provide stability and by moving Resident #25 while suspended in the lift sling over distances greater than recommended by the manufacturer's guidelines. b) supervise and monitor nursing staff for competency to assure they understood how to use assistive devices (mechanical lift) in a safe manner after a second inservice was conducted on 11/18/10 at 4:15 p.m. Staff continued to use the mechanical lift in an unsafe manner by not following the manufacturer's recommendations for safe use when transferring Residents #2, #15, and #25. The unsafe practices continued until facility staff were made aware of the manufacture's instructions. These failures resulted in an Immediate Jeopardy which was identified on 11/18/10 at 2:20 p.m.. While the Immediate Jeopardy was removed on 11/20/10, the facility remained out of compliance at a level of no actual harm with the potential for more than minimum harm at a pattern. These failures could result in accidents and injuries to any of the 48 residents identified by the facility as needing assistance with transfers. Findings include: Resident #2: Review of Resident #2's Admission Face Sheet revealed Resident #2 was admitted to the facility on [DATE] at 1:50 p.m. The resident was a [AGE] year old female at the time of the survey. Review of Resident #2's consolidated physician's orders [REDACTED]. Review of Resident #2's History and Physical dated 1/28/10 revealed Resident #2 had a past medical history of [REDACTED]. Resident #2's past surgical history included; left [MEDICAL CONDITION] due to diabetes. Review of Resident #2's annual Minimum (MDS) data set [DATE], revealed the resident had short and long term memory problems. She was able to make her self understood and usually able to understand others. Resident #2 required total assistance from 2(+) staff for bed mobility, transfers, dressing, and toilet use, and required assistance from 1 staff for personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 2 (Not steady, only able to stabilize with human assistance) for moving from seated to standing position, moving on and off the toilet, and surface to surface transfer. Resident #2 had impairment on both sides in both upper and lower extremities. Resident #2 was incontinent of bowel and bladder. Resident #2 was assessed to be 66 inches tall and weighed 348 lbs. Review of Resident #2's Fall Risk Assessment, dated 10/25/10, revealed that the resident's score was 13. The Fall Risk Assessment Total parameters indicated a total score of 10 or greater should be considered at high risk for potential falls. Review of Resident #2's Mini-Mental State Examination dated 10/25/10, revealed Resident #2 had a total score of 15 out of a maximum score of 30, indicating severity of cognitive impairment as moderate. Review of Resident #2's Behavioral Symptoms Checklist dated 10/25/10, revealed Resident #2 had no behaviors for all categories assessed with [REDACTED]. An observation on 11/16/10 at 11:00 a.m. revealed CNAs 'B' and 'C' performed a transfer of Resident #2 from her bed to her wheelchair. Resident #2 was lifted with a mechanical lift. The lift was wheeled out from under Resident #2's bed with the lift legs in the closed position. CNA 'B' operated the mechanical lift and opened the legs of the lift to the wide open position while CNA 'C' stabilized Resident #2 and put the wheelchair in place (without locking the wheels of the wheelchair). As the CNAs were lowering Resident #2 over the wheelchair with the lift, Resident #2 stated, "Tip the chair". CNA 'C' stated, "We have to tip the wheelchair back so she can get into it better." CNAs 'B' and 'C' were asked if "tipping " the wheelchair back was normal practice. CNA 'B' said, "We are going to be in trouble for this aren't we?" CNA 'C' tipped the wheelchair back onto the back two wheels (the wheels continued to be unlocked). CNA 'B' lowered Resident #2 into the tipped and unlocked wheelchair while CNA 'C' lowered the wheelchair back onto four wheels. During the process of lowering Resident #2 into her wheelchair, CNA 'B' stated, "The lift is still going down and I'm not pressing the button anymore." The swivel bar on the mechanical lift was observed to continue to move downward after CNA 'B' had released the control button. CNA 'C ' stated, "I will take the lift for maintenance to look at." Note: ** The swivel bar as indicated by the manufacture's manual for the Reliant/450 is the bar that the sling is attached to in order to facilitate lift/transfer. *** In an observation on 11/16/10 at 11:15 a.m., CNA 'C' was observed pushing the mechanical lift down the hallway towards the maintenance room. In an interview on 11/16/10 at 11:30 a.m. CNA 'C' said she had to pull "really hard" several times to lift Resident #2's wheelchair back onto all four wheels after the resident had been lowered into the chair while the chair was tipped back onto the 2 back wheels. CNA 'C' was asked if she had alerted the charge nurse about issues related to "tipping" the wheelchair back for Resident #2. She stated the nurses were aware of the CNAs having to "tip" the wheelchair back for Resident #2. She stated Resident #2 wanted the wheelchair "tipped"back, and the CNAs did it that way to keep Resident #2 from having behaviors. A review of the Invacare Reliant 450 (mechanical lift) Operator's Manual revealed the following: --Section 1- General Guidelines: "The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Moving a person suspended in a sling over ANY distance is not recommended. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted." --Section 1- Using the Sling: "If patient is in a wheelchair, secure the wheel locks in place to prevent the wheelchair from moving forward or backward." --Section 1- Lifting the Patient: "When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE lifting the patient. --Section 1- Transferring the Patient: "Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. --"Section 4- Preparing the Lift for Use: "With the legs of the base open and locked, use the steering handle to push the patient lift into position." --Section 4- Transferring to a Wheelchair: "Ensure the legs of the lift (with patient) are in open position. Move the wheelchair into position. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. Position the patient over the seat with their back against the back of the chair. Begin to lower the patient. With one assistant behind the chair and the other operating the patient lift the assistant behind the chair will pull the grab handle to seat the patient well back in the chair. This will maintain a good center of balance and prevent the chair from tipping forward." A bold print WARNING under this section states, "The wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport." In an interview on 11/16/10 at 11:40 a.m. the ADON revealed she was not aware of the CNAs "tipping" Resident #2's wheelchair back while transferring her by use of the mechanical lift. She stated, "The CNAs should not ever tilt the wheelchair back with a resident in it." In an interview on 11/16/10 at 11:45 a.m. with LVN 'C' revealed, she was not aware of the CNAs "tipping" the wheelchair back during transfer of Resident #2 with the mechanical lift. She stated, "No, I was not aware of the CNAs tipping the wheelchair back. That could be very dangerous." In an interview on 11/16/10 at 12:00 p.m. LVN 'D' revealed, she was aware the CNAs were "tipping" the wheelchair back during transfers of Resident #2 using the mechanical lift. She said Resident #2 had behaviors and if the CNAs did not do as she requested, Resident #2 screamed and cursed at them. In an interview on 11/16/10 at 12:00 p.m. the DON revealed she was not aware of the CNAs "tipping" the wheelchair back while transferring Resident #2 with the mechanical lift. She stated Resident #2 had behaviors and she yelled and cursed at the CNAs if she didn't get her way. In an interview on 11/16/10 at 12:10 p.m. CNA 'B' revealed she was not comfortable with "tipping" the wheelchair back during transfers with the mechanical lift, but she would tip the wheelchair back so Resident #2 didn't have any behaviors. In an interview on 11/16/10 at 12:15 p.m. the DON revealed she had just spoken to Resident #2 regarding her requests to have the CNA's tip the wheelchair back while transferring her with the mechanical lift. She said she had informed Resident #2 about the safety issues regarding tipping the wheelchair back and instructed her not to ask the CNAs to perform unsafe acts while they were assisting her. An observation on 11/16/10 at 3:30 p.m. revealed CNA 'F', CNA 'E' and CMA 'B' transferring Resident #2 with the mechanical lift. Resident #2 was transferred from the bed to her wheelchair using the mechanical lift. Resident #2 did not request for the CNAs to "tip the chair". Wheels on the wheelchair were observed to be in a locked position. The straps on the back of the sling were utilized to pull Resident #2 back into the chair, where Resident #2 stated she was comfortable. A review of the facility's undated Policy and Procedure for Lifting and Transferring Residents received 11/16/10 revealed: --Facility standard: Residents are lifted and transferred safely in all instances. --Policy: All nurses, and nursing assistants are responsible for using good body mechanics, knowing proper procedures, and properly operating assistive devices. Approved techniques for lifting, transfer, and body mechanics are discussed and demonstrated during each orientation program for nursing personnel. --General: Assess resident to determine physical limitations, tubing or equipment that must be moved, and the ability of the resident to follow directions. Prepare for moving the resident by providing privacy, suitable clothing, chair or wheelchair, enough space to move the resident safely. Lock wheels on bed and wheelchair. The designated method of lifting and transferring of the resident is indicated in the Resident Care Plan. A review of Facility Inservice Sign In Sheet, dated 11/16/10 revealed, "It is never OK to tilt a resident's wheelchair during a transfer. This is a safety risk. Should a problem arise with any resident that may want the wheelchair tilted for transfer, please notify the nurse in charge prior to transfer. Safety, Safety, Safety, Safety, Safety." The Inservice Sign In Sheet revealed 25 staff signatures. Note: This was not a hands-on inservice and no return demonstrations was completed to ensure staff competency was conducted. The inservice consisted of the above captioned statement on a sign-in sheet. In an interview on 11/17/10 at 11:00 a.m. LVN 'E' was not aware of the Facility Inservice on 11/16/10 regarding the CNAs tipping the wheelchair back while transferring Resident #2. She stated, "I didn't work yesterday." In an interview on 11/17/10 at 11:00 a.m. LVN 'F' revealed she was not aware of the Facility Inservice on 11/16/10 regarding the CNAs tipping the wheelchair back while transferring Resident #2. She stated, "I didn't work yesterday either." In an interview on 11/17/10 at 1:30 p.m. with the ADON, documentation was requested regarding the number of residents that required use of the mechanical lift for transfers. Documentation was received revealing that 16 residents were transferred using a mechanical lift. A review of the facility's Lift Maintenance Log dated 11/18/10 revealed, each lift device shall be checked by the maintenance department for proper working condition each week. The devices shall be numbered and logged as to when they are checked and are in good condition. Any lift not operable shall be red tagged and put up for repair. Invacare Reliant 450 was shown to be "out of order". Resident #15: Review of Resident #15's Admission Face sheet revealed this male Resident was admitted to the facility on [DATE] with re-admission on 10/16/2007. The resident was [AGE] years old. Review of Resident #15's consolidated physician's orders [REDACTED]. Review of Resident #15's History and Physical dated 2/17/10 revealed Resident #15 had a past medical history of [REDACTED]. Review of Resident #15's annual Minimum (MDS) data set [DATE], revealed Resident #15 had short and long term memory problems. He was rarely/never able to make himself understood and rarely/never able to understand others. Resident #15 was assessed to be severely cognitively impaired. Resident #15 required total assistance from 2(+) staff for bed mobility, transfers, dressing, toilet use, and required assistance from 1 staff for locomotion on and off unit, personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 8 (Activity did not occur) for moving from seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #15 had impairment in both upper and lower extremities. Resident #15 was incontinent of bowel and bladder. The resident was assessed to be 70 inches tall and weighed 182 lbs. In an observation on 11/15/10 at 4:05 p.m. revealed CNA 'F' and CNA 'E' transferring Resident #15 from his bed to his wheelchair. Resident #15 was rolled onto his right side to roll the lift sling underneath him and then onto his left side to pull it behind him. Resident #15's sling was attached to the mechanical lift. The mechanical lift legs were in opened and locked position while lifting Resident #15. While CNA 'E' began pulling the lift out from under the bed with Resident #15 in the sling, the CNA then closed the legs and then reopened them when trying to make accommodations for the resident's wheelchair. Handles on the back of the sling were utilized by CNA 'F' to bring Resident #15 close to the back of his wheelchair. Resident #15 was seated in his wheelchair and a lap-buddy was put in place. A review of the Invacare Reliant 450 (mechanical lift) Operator's Manual revealed the following: --"The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Moving a person suspended in a sling over ANY distance is not recommended. --"When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE lifting the patient. --"Ensure the legs of the lift (with patient) are in open position. Move the wheelchair into position. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. Position the patient over the seat with their back against the back of the chair. Begin to lower the patient. With one assistant behind the chair and the other operating the patient lift the assistant behind the chair will pull the grab handle to seat the patient well back in the chair. This will maintain a good center of balance and prevent the chair from tipping forward." In an interview on 11/18/10 at 2:20 p.m. the Administrator and DON were informed an immediate jeopardy had been identified concerning accident hazards. The Administrator and DON were asked to submit a plan to remove the serious and immediate threat. In an observation on 11/18/10 at 3:20 p.m. CNA 'E' and CNA 'I' transferred Resident #15 from his bed to his wheelchair. CNAs 'E' and 'I' adjusted the sling underneath Resident #15 and secured it to the lift. CNA 'E 'operated the mechanical lift while CNA 'I' stabilized the resident. The lift legs were in the closed position for the majority of the transfer until they were placed in the open and locked position while positioning the wheelchair. CNA 'I' did not lock the wheels on the wheelchair at any point during the transfer process. An observation on 11/18/10 at 4:15 p.m. multiple staff were observed attending an inservice in the physical therapy room. Observation revealed staff working with the mechanical lift. In an interview on 11/19/10 at 1:25 p.m. the DON said hands on training was provided for staff in the physical therapy room. According to the DON, 2 staff who were "good at using the lift" demonstrated use of the mechanical lift. The DON said the staff who demonstrated use of the mechanical lift on 11/18/10 were CMA 'C' and CNA 'T'. In an observation on 11/19/10 at 3:10 p.m. CNA 'P' and CNA 'Q' transferred Resident #15 from his bed to his wheelchair while LVN 'H' monitored the transfer. Resident #15 was lifted with the mechanical lift operated by CNA 'Q'. The legs of the lift were in wide open and locked position while positioned underneath the bed; however, CNA 'Q' moved the lift out from under the bed with the lift legs closed. CNA 'Q' transported Resident #15 approximately 4 feet to his wheelchair while CNA 'P' stabilized Resident #15's feet. Resident #15 was lowered into his unlocked wheelchair. This observation was made after staff were inserviced on 11/19/10. In an interview on 11/19/10 at 3:15 p.m. LVN 'H' revealed that she had not seen anything wrong with the transfer of Resident #15 at 3:10 p.m. In an interview on 11/19/10 at 4:45 p.m. the DON was asked to demonstrate how to properly use the mechanical lift. The DON took a lift into the break room and said she would pretend that a small table in the room was a bed. While observing the demonstration, it was observed that the legs of the lift were in the closed position while underneath the table. When the lift was pulled from underneath the table she opened the legs up and locked them. The DON was shown the manufactures specifications on use of a mechanical lift, specifically the section stating, "the legs of the lift should be in open and locked position at all times while lifting a resident". In an observation on 11/19/10 at 5:00 p.m. the DON inserviced the ADON, LVN 'H', LVN 'I', CNA 'P' , CNA 'Q', CNA 'I', and CNA 'E' on safe use of the mechanical lift. The DON explained to staff, "At anytime when a resident is in the sling being lifted, the legs of the lift must be in open and locked position to create a wide base and better balance of the lift to ensure the resident is safe." Resident #25: Review of Resident #25's medical record face sheet revealed this [AGE] year old female resident was admitted to the facility on [DATE]. Review of Resident #25's quarterly MDS dated [DATE] revealed the resident was severely impaired in daily decision-making skills and had short-term and long-term memory problems. the resident was totally dependent on 2 or more staff for transfers and totally dependent on one staff for personal hygiene. The resident was incontinent of bowel and bladder and was not ambulatory. The resident's [DIAGNOSES REDACTED]. In an observation on 11/18/10 @ 5:10 p.m. CNA 'E' and CNA 'Q' used the mechanical lift to transfer Resident #25 from her bed to a wheelchair. After both CNAs placed the sling under the resident and attached the sling to the mechanical lift, CNA 'Q' went to the end of the bed and held the wheel chair while CNA 'E' lifted the resident up, swung the resident out over the floor and rolled the lift to the end of the bed where the wheelchair was positioned. The base of the lift remained closed during the entire procedure until just before the lift approached the wheelchair. Just prior to the lift reaching the wheelchair CNA 'E' opened the base of the lift so the resident, who was suspended in the sling, could be maneuvered over the chair and lowered into it. This observation occurred after a facility inservice training on the mechanical lift on 11/18/10 at 4:15 p.m. In another observation on 11/19/10 @ 4:30 p.m. CNA 'E' and CNA 'Q' used the mechanical lift to transfer Resident #25 from her bed to a wheelchair. Once the sling was positioned under the resident and attached the to the mechanical lift, CNA 'E' lifted the resident off the bed and pulled the lift out over the floor, with the resident suspended in the sling. The base of the lift was in the closed position. The CNA turned the lift 90 degrees as CNA 'Q' brought the wheelchair to the side of the bed and placed it underneath the resident. CNA 'E' did not open the base of the mechanical lift until just prior to maneuvering the resident over the chair. In an interview on 11/19/10 @ 4:40 p.m. CNA 'E' said the proper procedure for transferring residents with a lift was as follows: When the lift was placed under the bed in preparation for lifting the resident, the base of the lift was closed and the lift wheels were locked. After lifting the resident off the bed the wheels were unlocked and the lift, with the resident suspended, was pulled away from the bed. The wheel chair was brought to the lift and the base of the lift was opened when the wheelchair was placed under the resident. CNA 'E' said the purpose for spreading the base of the lift was to provide stability as the resident was being lowered into the chair. In an interview on 11/18/10 at 2:20 p.m. the Administrator and DON were informed an immediate jeopardy had been identified concerning accident hazzards. The Administrator and DON were asked to submit a plan to remove the serious and immediate threat. Facility Plan of Removal: On 11/20/10 at 10:00 a.m. an acceptable Plan of Removal of the Immediate Jeopardy (IJ) was submitted to the Program Manager. According to the Plan of Removal the facility immediately (11/16/10) in-serviced all nursing staff per a paper memo on not tipping the wheelchair when using the Hoyer lifts. Staff were provided a hands on in-servicing on how to use the Hoyer lift starting on 11/18/10 with return demonstrations required by staff. A re -in-service training per manufacturer's instruction on the Hoyer lift was started on 11/19/10 with nursing staff and was to be completed on all staff by 11/22/10. Any nursing staff that was not working during this time period would not be allowed to use the lifts until they were trained and a return competency demonstration was completed, verified and documented. All licensed staff will be in-serviced regarding the requirement of them to make visual observations of staff of all lift transfers with verification of competency of staff with documentation required. Proper transfers will be required. If improper transfers are witnessed by licensed staff, then the staff doing the transfer will be stopped immediately and re-training will occur at that time. All Staff must complete proper transfer before verification can be confirmed by licensed staff (completion date of 11/20/10 and on going for the next 5 days). All lift devices will be checked weekly by maintenance to assure proper working order. All maintenance will be documented on a maintenance log. The lift that was used in the transfer of Resident # 2 on 11/16/10 was taken out of service until it could be repaired. The Administrator and the Director of Nurses will review and monitor the process throughout the day by making daily rounds and reviewing verification documentation provided by licensed staff on all shifts. This process will be reviewed by the Quality Assurance Committed weekly. Anti-tipping device was applied to the wheelchair of Resident # 2 on 11/18/10. All other resident ' s who use wheelchairs in the facility will have anti-tipping devices installed on their wheelchairs by 11/30/10. Plan of Removal Verification: Facility Nurses and CNA ' s were interviewed on 11/20/10 from 10:00 a.m. to 5:00 p.m. concerning the training they had received on the use of the Hoyer lift and sit to stand lift during transfers per the manufacturer ' s instructions. All staff interviewed confirmed they had received the in-service training as specified and had completed a return demonstration of competency as described in the Plan of Removal. On 11/20/10 verification of staff training per the Facility Plan of Removal and manufacturer ' s instructions was made by multiple observations of staff using the Hoyer and sit to stand lift correctly during transfers of multiple residents. Licensed staff verified they were to observe staff during every transfer with the Hoyer and sit to stand lifts on their shifts. On 11/20/10 review of monitoring sheets used by licensed staff to document competency of staff were reviewed. This review as well as interviews with nursing staff verified licensed staff were observing and documenting competency of staff during return demonstrations of all transfers using the lifts per the manufacturer ' s instructions and per the facilities Plan of Removal. Observation of Resident # 2 on several occasions on 11/19/10 and 11/20/10 verified the facility had placed anti-tip devices on her wheelchair to prevent tipping as per the facility Plan of Removal. The facility also stated in their Plan of Removal all wheelchairs will be fitted with anti-tipping devices to prevent any other resident from being tipped backwards either accidentally or intentionally during transfers. These devices were ordered by the facility and will be placed on wheelchairs as they are delivered to the facility. This action will be completed by 11/30/10. According to the facility ' s Plan of Removal all lift devices will be checked weekly by maintenance personnel for proper working condition and logged on a monitoring log, any lift not working correctly will be removed from use until it is repaired. This correction was verified by observation of all lifts and interview with the maintenance director, as well as review of the maintenance log for all lifts on 11/20/10. During an interview with the Administrator on 11/20/10 at 10:00 p.m. he said no staff will be allowed to use any of the facility lifts until they have been trained and demonstrated competency. He said all of the facility interventions will be added to the facility ' s Quality Assurance and will become part of the ongoing safety meetings. The Immediate Jeopardy was lowered to potential for more than minimal harm at a pattern prior to the exit at 10:15 p.m. on 11/20/10.

Based on observation, interview, and record review the facility failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for resident needs. This failure affected 12 residents (Residents #1, #2, #12, #13, #15, #22, #24, #25, and #37) of 24 residents reviewed for care provided by nurse aides. The facility staff failed to: 1. place the abductor pillow in place according to physician order [REDACTED]. 2. provide proper techniques to ensure Resident #2's safety during transfers using a mechanical lift. 3. provide Resident #6 proper urinary catheter care. 4. correctly place the gaitbelt on Resident #12 during a transfer from a wheelchair to a bed. 5. report to the charge nurse new skin breakdown that was observed when providing Resident #13 incontinent care. 6. follow the facility's policy which required staff to lock wheelchair wheels when transferring Resident #15. 7. follow mechanical lift manufactures instructions by failing to have the mechnical lift legs opened and locked during transfer of Resident #15. 8. transfer Resident #21 in a safe manner. 9. use a gait belt when transferring Resident #22 from a wheelchair to the toilet. 10. follow the facility's policy and procedures for transferring residents by not locking the wheelchair during the transfer of Resident #24. 11. open the legs of the mechanical lift to ensure a safe transfer when transferring Resident #25. 12. change gloves after handling a brief that was wet with urine when providing incontinent care for Resident #37. 13. ensure 6 CNAs (CNA A, B, C, E, I, P, and Q) washed their hands following resident contact during incontinent care for Residents #6, #13, and #15. These failures resulted in an Immediate Jeopardy which was identified on 11/18/10. While the Immediate Jeopardy was removed on 11/20/10, the facility remained out of compliance at a level of no actual harm with the potential for more than minimum harm at a pattern. These failures could result in accidents and injuries to any of the 48 residents identified by the facility as needing assistance with transfers. These failures created the risk of injury for Residents #1, #2, #12, #15, #21, #22, #24, and #25, the risk of infection for Residents #6 amd #27, and skin breakdown for Resident #13. All 45 residents who were occationally or frequently incontinent, all 4 residents with urinary catheters, and all 48 residents who required assistance with transfers could have been affected. Evidence includes: Resident #2: Review of Resident #2's Admission Face Sheet revealed Resident #2 was admitted to the facility on [DATE] at 1:50 p.m. The resident was a [AGE] year old female at the time of the survey. Review of Resident #2's consolidated physician's orders [REDACTED]. Review of Resident #2's History and Physical dated 1/28/10 revealed Resident #2 had a past medical history of [REDACTED]. Resident #2's past surgical history included; left [MEDICAL CONDITION] due to diabetes. Review of Resident #2's annual Minimum (MDS) data set [DATE], revealed the resident had short and long term memory problems. She was able to make her self understood and usually able to understand others. Resident #2 required total assistance from 2(+) staff for bed mobility, transfers, dressing, and toilet use, and required assistance from 1 staff for personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 2 (Not steady, only able to stabilize with human assistance) for moving from seated to standing position, moving on and off the toilet, and surface to surface transfer. Resident #2 had impairment on both sides in both upper and lower extremities. Resident #2 was incontinent of bowel and bladder. Resident #2 was assessed to be 66 inches tall and weighed 348 lbs. Review of Resident #2's Fall Risk Assessment, dated 10/25/10, revealed that the resident's score was 13. The Fall Risk Assessment Total parameters indicated a total score of 10 or greater should be considered at high risk for potential falls. Review of Resident #2's Mini-Mental State Examination dated 10/25/10, revealed Resident #2 had a total score of 15 out of a maximum score of 30, indicating severity of cognitive impairment as moderate. Review of Resident #2's Behavioral Symptoms Checklist dated 10/25/10, revealed Resident #2 had no behaviors for all categories assessed with [REDACTED]. An observation on 11/16/10 at 11:00 a.m. revealed CNAs 'B' and 'C' performed a transfer of Resident #2 from her bed to her wheelchair. Resident #2 was lifted with a mechanical lift. The lift was wheeled out from under Resident #2's bed with the lift legs in the closed position. CNA 'B' operated the mechanical lift and opened the legs of the lift to the wide open position while CNA 'C' stabilized Resident #2 and put the wheelchair in place (without locking the wheels of the wheelchair). As the CNAs were lowering Resident #2 over the wheelchair with the lift, Resident #2 stated, "Tip the chair". CNA 'C' stated, "We have to tip the wheelchair back so she can get into it better." CNAs 'B' and 'C' were asked if "tipping " the wheelchair back was normal practice. CNA 'B' said, "We are going to be in trouble for this aren't we?" CNA 'C' tipped the wheelchair back onto the back two wheels (the wheels continued to be unlocked). CNA 'B' lowered Resident #2 into the tipped and unlocked wheelchair while CNA 'C' lowered the wheelchair back onto four wheels. During the process of lowering Resident #2 into her wheelchair, CNA 'B' stated, "The lift is still going down and I'm not pressing the button anymore." The swivel bar on the mechanical lift was observed to continue to move downward after CNA 'B' had released the control button. CNA 'C ' stated, "I will take the lift for maintenance to look at." Note: ** The swivel bar as indicated by the manufacture's manual for the Reliant/450 is the bar that the sling is attached to in order to facilitate lift/transfer. *** In an observation on 11/16/10 at 11:15 a.m., CNA 'C' was observed pushing the mechanical lift down the hallway towards the maintenance room. In an interview on 11/16/10 at 11:30 a.m. CNA 'C' said she had to pull "really hard" several times to lift Resident #2's wheelchair back onto all four wheels after the resident had been lowered into the chair while the chair was tipped back onto the 2 back wheels. CNA 'C' was asked if she had alerted the charge nurse about issues related to "tipping" the wheelchair back for Resident #2. She stated the nurses were aware of the CNAs having to "tip" the wheelchair back for Resident #2. She stated Resident #2 wanted the wheelchair "tipped"back, and the CNAs did it that way to keep Resident #2 from having behaviors. A review of the Invacare Reliant 450 (mechanical lift) Operator's Manual revealed the following: --Section 1- General Guidelines: "The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Moving a person suspended in a sling over ANY distance is not recommended. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted." --Section 1- Using the Sling: "If patient is in a wheelchair, secure the wheel locks in place to prevent the wheelchair from moving forward or backward." --Section 1- Lifting the Patient: "When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE lifting the patient. --Section 1- Transferring the Patient: "Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport. --"Section 4- Preparing the Lift for Use: "With the legs of the base open and locked, use the steering handle to push the patient lift into position." --Section 4- Transferring to a Wheelchair: "Ensure the legs of the lift (with patient) are in open position. Move the wheelchair into position. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. Position the patient over the seat with their back against the back of the chair. Begin to lower the patient. With one assistant behind the chair and the other operating the patient lift the assistant behind the chair will pull the grab handle to seat the patient well back in the chair. This will maintain a good center of balance and prevent the chair from tipping forward." A bold print WARNING under this section states, "The wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport." In an interview on 11/16/10 at 11:40 a.m. the ADON revealed she was not aware of the CNAs "tipping" Resident #2's wheelchair back while transferring her by use of the mechanical lift. She stated, "The CNAs should not ever tilt the wheelchair back with a resident in it." In an interview on 11/16/10 at 11:45 a.m. with LVN 'C' revealed, she was not aware of the CNAs "tipping" the wheelchair back during transfer of Resident #2 with the mechanical lift. She stated, "No, I was not aware of the CNAs tipping the wheelchair back. That could be very dangerous." In an interview on 11/16/10 at 12:00 p.m. LVN 'D' revealed, she was aware the CNAs were "tipping" the wheelchair back during transfers of Resident #2 using the mechanical lift. She said Resident #2 had behaviors and if the CNAs did not do as she requested, Resident #2 screamed and cursed at them. In an interview on 11/16/10 at 12:00 p.m. the DON revealed she was not aware of the CNAs "tipping" the wheelchair back while transferring Resident #2 with the mechanical lift. She stated Resident #2 had behaviors and she yelled and cursed at the CNAs if she didn't get her way. In an interview on 11/16/10 at 12:10 p.m. CNA 'B' revealed she was not comfortable with "tipping" the wheelchair back during transfers with the mechanical lift, but she would tip the wheelchair back so Resident #2 didn't have any behaviors. In an interview on 11/16/10 at 12:15 p.m. the DON revealed she had just spoken to Resident #2 regarding her requests to have the CNA's tip the wheelchair back while transferring her with the mechanical lift. She said she had informed Resident #2 about the safety issues regarding tipping the wheelchair back and instructed her not to ask the CNAs to perform unsafe acts while they were assisting her. An observation on 11/16/10 at 3:30 p.m. revealed CNA 'F', CNA 'E' and CMA 'B' transferring Resident #2 with the mechanical lift. Resident #2 was transferred from the bed to her wheelchair using the mechanical lift. Resident #2 did not request for the CNAs to "tip the chair". Wheels on the wheelchair were observed to be in a locked position. The straps on the back of the sling were utilized to pull Resident #2 back into the chair, where Resident #2 stated she was comfortable. A review of the facility's undated Policy and Procedure for Lifting and Transferring Residents received 11/16/10 revealed: --Facility standard: Residents are lifted and transferred safely in all instances. --Policy: All nurses, and nursing assistants are responsible for using good body mechanics, knowing proper procedures, and properly operating assistive devices. Approved techniques for lifting, transfer, and body mechanics are discussed and demonstrated during each orientation program for nursing personnel. --General: Assess resident to determine physical limitations, tubing or equipment that must be moved, and the ability of the resident to follow directions. Prepare for moving the resident by providing privacy, suitable clothing, chair or wheelchair, enough space to move the resident safely. Lock wheels on bed and wheelchair. The designated method of lifting and transferring of the resident is indicated in the Resident Care Plan. A review of Facility Inservice Sign In Sheet, dated 11/16/10 revealed, "It is never ok to tilt a resident's wheelchair during a transfer. This is a safety risk. Should a problem arise with any resident that may want the wheelchair tilted for transfer, please notify the nurse in charge prior to transfer. Safety, Safety, Safety, Safety, Safety." The Inservice Sign In Sheet revealed 25 staff signatures. In an interview on 11/17/10 at 11:00 a.m. LVN 'E' was not aware of the Facility Inservice on 11/16/10 regarding the CNAs tipping the wheelchair back while transferring Resident #2. She stated, "I didn't work yesterday." In an interview on 11/17/10 at 11:00 a.m. LVN 'F' revealed she was not aware of the Facility Inservice on 11/16/10 regarding the CNAs tipping the wheelchair back while transferring Resident #2. She stated, "I didn't work yesterday either." In an interview on 11/17/10 at 1:30 p.m. with the ADON, documentation was requested regarding the number of residents that required use of the mechanical lift for transfers. Documentation was received revealing that 17 residents were transferred using a mechanical lift. A review of the facility's Lift Maintenance Log dated 11/18/10 revealed, each lift device shall be checked by the maintenance department for proper working condition each week. The devices shall be numbered and logged as to when they are checked and are in good condition. Any lift not operable shall be red tagged and put up for repair. Invacare Reliant 450 was shown to be "out of order". Resident #6: Review of Resident #6 ' s Admission Face Sheet revealed that Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] at 1:10 p.m. and was [AGE] years old at the time of this survey. Review of Resident #6 ' s History and Physical Report dated 11/18/10 revealed had [DIAGNOSES REDACTED]. Review of Resident #6 ' s consolidated Physician orders [REDACTED]. Encourage Fluids, Monitor Intake every shift, Monitor Output every shift, Change Catheter every month, Perform Catheter care every shift. Additional [DIAGNOSES REDACTED]. Review of Resident #6 ' s quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had short and long term memory problems. She was able to understand and had the ability to understand others. Resident #6 was assessed to be moderately cognitively impaired. Resident #6 required total assistance from 1 staff for locomotion on and off the unit. She required extensive assistance from 1 staff for walking in room, and walking in the corridor, and bathing. She required limited assistance from 1 staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Resident #6 was assessed to be incontinent of bowel and continent of bladder. Review of Resident #6 ' s Care Plan updated on 8/27/10 revealed the facility had identified Resident #6 required an indwelling catheter due to [MEDICAL CONDITION] and included Resident #6 being incontinent of bowel, requiring extensive assistance by 1 staff. The Care Plan goal was for Resident #6 to be kept clean and odor free for the next 90 days and Bladder elimination will be maintained safely through Foley catheter while keeping the peri are dry from urine. The Care Plan approaches included: Assist resident times two after every incontinent episode, Catheters care every shift, Change catheter every month, Encourage fluids, Monitor intake and output, Zinc Oxide to peri area when needed. A review of Resident #6 ' s Discharge Summary from Coleman County Medical Center revealed, Resident #6 had been admitted on [DATE] with [DIAGNOSES REDACTED]. She was noted to have a urinary tract infection and was started on [MEDICATION NAME] 250mg via intravenous line. Resident #6 ' s initial laboratory findings included a white cell count of was too numerous to count indicating a urinary tract infection. In an observation on 11/16/10 at 2:00 p.m. revealed CNA ' C ' and CNA ' B ' performing catheter care for Resident #6. During care for Resident #6 ' s catheter, CNA ' C ' was observed to use a wipe to clean Resident #6 ' s vaginal area then wipe the catheter tubing, CNA ' B ' was observed to hold the urine filled catheter bag approximately 4 feet above Resident #6 while she was laying on the bed. Urine was observed flowing back through the tubing towards Resident #6 ' s body. After catheter care was completed and CNA ' s removed their gloves, neither CNA washed their hands before leaving the room. A review of National Guideline Clearinghouse for Preventing Catheter-Associated Urinary Tract Infections dated 3/30/09 revealed guideline objectives and practical recommendations for implementing and prioritizing catheter associated urinary tract infection prevention. In the section titled: Appropriate Management of Indwelling Catheters, guidelines were revealed stating, " Keep the collecting bag below the level of the bladder at all times. " Resident #12: Review of Resident #12's medical record face sheet revealed this female resident was admitted to the facility on [DATE]. She was [AGE] years old at the time of this survey. Review of Resident #12's quarterly MDS dated [DATE] revealed the resident was severely impaired in daily decision-making ability and had short-term and long-term memory loss. The resident resisted care 1 to 3 days a week and was non-ambulatory. The resident required extensive assistance from 2 or more staff for transfers, dressing, and personal hygiene and was incontinent of bowel and bladder. In an observation on 11/17/10 at 4:55 p.m. CNA 'E' and CNA 'G' transferred Resident #12 from her wheelchair to her bed using a gait belt. CNA 'G' placed the gait belt around the resident's waist and bucked it. Prior to the transfer CNA 'G' said she always left the gait belt loose enough on the resident to insert her hand into the belt. When the CNAs stood the resident up the gait belt, which was buckled around the resident, rose up under the resident's arms and did not support the resident's weight. The CNAs completed the transfer and assisted the resident into a sitting position on the bed. Resident #13: Review of Resident # 13 MDS 2.0 quarterly report dated 08/16/10 revealed an [AGE] year old male at the time of the survey that was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13 was totally dependent for ADL ' S, and had functional limitation in range of motion to one side. The resident was incontinent of bowel and bladder. Observation on 11/17/2010 at 9:40 a.m. with CNA 'A' and CNA 'C' during incontinent care of Resident # 13 revealed a pinkish, reddish area to the resident's coccyx approximately 1 centimeters width by 4 centimeters length and 2 areas that appeared to be open areas . Both open areas appeared to be approximately ? centimeter by ? centimeter in circumference during visual observation. Observation on 11/17/10 at 9:40 a.m. during Resident #13's (on Hall D) incontinent care, revealed CNA 'A' and CNA 'C' did not washed their hands prior to beginning incontinent care. Feces were observed on Resident #13's buttocks after incontinent care was complete. In an interview on 11/17/2010 at 9:40 a.m. with CNA ' A ' and CNA ' C ' both stated they were taught to report any significant changes regarding the resident to the Charge Nurse. In an interview on 11/17/10 at 1:45 p.m. CNA 'C' stated she reports any significant changes in residents' condition to the charge nurse at the end of the shift verbally. The CNA said the charge nurse that day for hall D was LVN 'F'. In an interview on 11/17/10 at 2:20 p.m. LVN 'F' was asked if any changes had been reported to her by the CNA ' s regarding any residents on hall D. She stated no. (Note the shift was 6:00 a.m. to 2:00 p.m.) In an interview on 11/17/10 with CNA 'C' at 2:25 p.m. she said she had nothing to report before leaving for the day regarding any changes in Resident's on Hall D. She stated no. Observation on 11/19/10 at 10:00 a.m. during Resident #13's incontinent care CNA 'B' and CMA 'A' revealed feces left on Resident #13's buttocks after incontinent care was complete. Review of care plans initiated on 02/08/2008, and updated on 11/18/2010 for Resident #13 revealed: Monitor and report any skin breakdown, or redness to MD, Resident will be kept clean and dry following each incontinent episode per staff. Resident #15: Review of Resident #15's Admission Face sheet revealed this male Resident was admitted to the facility on [DATE] with re-admission on 10/16/2007. The resident was [AGE] years old. Review of Resident #15's consolidated physician's orders [REDACTED]. Review of Resident #15's History and Physical dated 2/17/10 revealed Resident #15 had a past medical history of [REDACTED]. Review of Resident #15's annual Minimum (MDS) data set [DATE], revealed Resident #15 had short and long term memory problems. He was rarely/never able to make himself understood and rarely/never able to understand others. Resident #15 was assessed to be severely cognitively impaired. Resident #15 required total assistance from 2(+) staff for bed mobility, transfers, dressing, toilet use, and required assistance from 1 staff for locomotion on and off unit, personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 8 (Activity did not occur) for moving from seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #15 had impairment in both upper and lower extremities. Resident #15 was incontinent of bowel and bladder. The resident was assessed to be 70 inches tall and weighed 182 lbs. In an observation on 11/15/10 at 4:05 p.m. revealed CNA 'F' and CNA 'E' transferring Resident #15 from his bed to his wheelchair. Resident #15 was rolled onto his right side to roll the lift sling underneath him and then onto his left side to pull it behind him. Resident #15's sling was attached to the mechanical lift. The mechanical lift legs were in opened and locked position while lifting Resident #15. While CNA 'E' began pulling the lift out from under the bed with Resident #15 in the sling, the CNA closed the legs and then reopened them when trying to make accommodations for the resident's wheelchair. Handles on the back of the sling were utilized by CNA 'F' to bring Resident #15 close to the back of his wheelchair. Resident #15 was seated in his wheelchair and a lap-buddy was put in place. In an observation on 11/17/10 at 9:45 a.m. CNA ' C ' and CNA ' A ' were observed performing incontinent care for Resident #15. Both CNA ' s washed their hands and applied gloves. CNA ' A ' sat two trash bags on Resident #15 ' s bed, one for trash and one with wet wipes ( no peri-wash was used). Resident #15 had feces and was not cleaned with soap and water as indicated in his care plan. While observing care of Resident #15 it was observed that Resident #15 had reddened excoriated areas to his left and right buttocks, crusted yellow creamy substance was observed to folds of groin area and around his scrotum. Resident #15 had a small open area to the back of the right side of his scrotum. CNA ' C ' was asked how often protective cream was applied to Resident #15 and she stated, " Usually the last round per shift. " Resident #15 was dressed in a brief and pants and transferred to his wheelchair. CNA ' C ' was observed to wash her hands before leaving the room. CNA ' A ' did not wash her hands before leaving the room. In an interview on 11/18/10 at 2:20 p.m. the Administrator and DON were informed an immediate jeopardy had been identified concerning accident hazzards. The Administrator and DON were asked to submit a plan to remove the serious and immediate threat. In an observation on 11/18/10 at 3:20 p.m. CNA ' I ' and CNA ' E ' were observed performing incontinent care for Resident #15. Resident #15 had feces and was not cleaned with soap and water as indicated in his care plan. CNA ' I ' used wet wipes to perform incontinent care for Resident #15 wiping from dirty areas to clean areas. Resident #15 ' s left groin area was cleaned from front to back and then CNA ' I ' wiped Resident #15 ' s right groin area without changing the wipe. Resident #15 continued to have reddened excoriated areas to both side of his buttocks and an open area on the back right side of his scrotum and no cream or ointments were used. CNA ' I ' and CNA ' E ' were observed to change their gloves multiple times during incontinent care of Resident #15, however neither CNA was observed to have washed their hands prior beginning incontinent care. CNA 'E' and CNA 'I' transferred Resident #15 from his bed to his wheelchair. CNAs 'E' and 'I' adjusted the sling underneath Resident #15 and secured it to the lift. CNA 'E 'operated the mechanical lift while CNA 'I' stabilized the resident. The lift legs were in the closed position for the majority of the transfer until they were placed in the open and locked position while positioning the wheelchair. CNA 'I' did not lock the wheels on the wheelchair at any point during the transfer process. Neither CNA 'E' or 'I' washed their hands before leaving the residents room. In an observation on 11/19/10 at 3:10 p.m. revealed CNA ' P ' and CNA ' Q ' performing incontinent care for Resident #15 while LVN ' H ' monitored. Both CNA ' P ' and CNA ' Q ' put on gloves. Resident #15 was rolled to his left side while CNA ' Q ' performed incontinent care stating, " You better grit your teeth, this is going to be cold. I over did it with the peri-wash " CNA ' Q ' cleaned feces from Resident #15 ' s buttocks by folding the wipes over and wiping a second and third time before discarding the wipe. Resident #15 was then rolled to his right side and CNA ' P ' looked at Resident #15 ' s buttocks and stated he was clean, never attempting to wipe the area. CNA ' P ' and CNA ' Q ' did not perform any incontinence care to Resident #15 ' s genital area or groin. CNA ' P ' and CNA ' Q ' took off their gloves and placed them in the trash bag. With ungloved hands, CNA ' Q ' gathered the trash bags and left the room without washing her hands, she then returned to the room (without washing her hands on re-entry) and began further care for resident #15. CNA ' P ' and CNA ' Q ' put on gloves and placed a brief on Resident #15. CNA 'P' and CNA 'Q' transferred Resident #15 from his bed to his wheelchair while LVN 'H' monitored the transfer. Resident #15 was lifted with the mechanical lift operated by CNA 'Q'. The legs of the lift were in wide open and locked position while positioned underneath the bed; however, CNA 'Q' moved the lift out from under the bed with the lift legs closed. CNA 'Q' transported Resident #15 approximately 4 feet to his wheelchair while CNA 'P' stabilized Resident #15's feet. Resident #15 was lowered into his unlocked wheelchair. This observation was made after staff were inserviced on 11/19/10. Resident #15 was transported out of the room via wheelchair. CNA ' P ' and CNA ' Q ' were not observed to wash their hands before leaving Resident #15 ' s room. In an interview on 11/19/10 at 3:15 p.m. with LVN ' H ' regarding her monitoring the incontinent care of Resident #15 revealed, LVN ' H ' was asked if she had seen any problems with the incontinence care provided by CNA ' P ' and CNA ' Q ' for Resident #15. She stated she taught the CNA ' s if a resident was soiled to wipe the resident once and then throw the wipe away so they are not " contaminating clean areas " . She also stated she had not witnessed CNA ' P ' perform any incontinent care for her side. She was asked why she had not stopped the CNA ' s to inform them they had failed to provide proper incontinent care. She stated, " Because ya ' ll are here and I didn' t know if you wanted me to stop them. " LVN 'H' revealed that she had not seen anything wrong with the transfer of Resident #15 at 3:10 p.m. Resident #21 Review of Resident #21's medical record face sheet revealed this male resident was admitted to the facility on [DATE]. He was [AGE] years old at the time of this survey. Review of Resident #21's consolidated physician orders [REDACTED]. Review of Resident #21's admission MDS dated [DATE] revealed the resident was able to understand others and able to make himself understood. The resident had some short-term memory problems. The resident had no indicators of inattention, disorganized thinking, or altered awareness. For transfers the resident was totally dependent and required physical assistance from 2 staff. Review of Resident #21's care plan dated 10/8/10 revealed the problems of the resident's inability to perform activities of daily living and bathing. The care plan documented the resident required 2 staff for transfers. Review of Resident #21's nursing notes dated 10/21/10 at 6:30 p.m. revealed a CNA was helping the resident off the commode when he fell and hit his face. The nurse documented the resident's fall resulted in bruising of the left cheek and right side of his nose. On 10/23/10 at 3:15 p.m. the nurse documented the resident's facial bruising was still present at that time. Review of a facility Investigation Report dated 10/21/10 at 6:30 p.m. revealed Resident #21 fell face first to the floor during a transfer in the bathroom. According to this report, a single CNA was assisting the resident to transfer at the time of the fall. In an interview on 11/19/10 at 2:55 p.m. Resident #21 said sometimes when he got up he could not maintain his balance, and that was one of the reasons he lived in a nursing home. He said that was what happened when he fell in the bathroom (on 10/21/10). He said at that time there was only 1 CNA helping him to transfer. In an interview on 11/20/10 at 5:37 p.m. CNA 'N' said he had worked in the facility about 2 1/2 months on the hall where Resident #21 resided. CNA 'N' said at the time Resident #21 fell in the bathroom (on 10/21/10) the resident wanted to get off the toilet because he was feeling weak. The CNA said he knew at that time the resident required 2 staff for transfers, but he was not able to get another staff to help him because the other staff members were busy in other resident rooms. CNA 'N' said he tried to help the resident transfer by himself but was unable to keep the resident from falling. In an interview on 11/20/10 at 6:10 p.m. the DON said the facility did not report to the state agency the incident of 10/21/10 when Resident #21 fell in his bathroom and sustained facial bruising. Review of the facility's undated written policy entitled Holiday Hill Policy on Reportable Incidents revealed the policy included the Texas Department of Aging and Disability Services Provider Letter #06-43 (dated 1/3/07). According to this Provider Letter, the facility was required to report to the state agency incidents of possible

Based on observation, interview and record review the facility failed to ensure that 2 of 10 sampled residents (ID #13, and #15) reviewed for pressure ulcers did not develop pressure sores, and received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to: a) prevent the development of (2) Stage II avoidable pressure sores on Residents #13, and a Stage II pressure sore on Resident #15 by failing to provide pressure relieving devices for the residents' chair and or bed. b) recognize and begin treatment of [REDACTED]. The facility's failure to provide necessary services to prevent pressure sores resulted in Resident #13 developing two Stage II avoidable pressures sores. There were 57 residents identified by the facility who were at risk for pressure sores and receiving preventative skin care. These failures placed these residents at risk for the development of pressure ulcers, delay in treatment resulting in worsening of the resident's skin with breakdown, and a decline in health. Findings include: Resident #13: Review of Resident #13's quarterly MDS Version 2.0 dated 08/16/10 revealed the resident was an [AGE] year old male at the time of the survey and was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13 was totally dependent for ADL's, and had functional limitation in range of motion to one side. The resident was incontinent of bowel and bladder. According to the MDS, the resident had no ulcers and was assessed for pressure relieving devices on the chair and bed and was on a turning/repositioning program. Observation on 11/17/2010 at 9:40 a.m. with CNA 'A' and CNA 'C' during incontinent care revealed a pinkish, reddish excoriated area to the resident's buttocks bi-laterally approximately 1-2 centimeters width by 5-6 centimeters length with 2 open areas. Both opened areas were approximately ? centimeter by ? centimeter in circumference during visual observation. There was no pressure relieving device on Resident ' s #13 bed. Observation on 11/17/10 at 9:40 a.m. during Resident #13's (on hall D) incontinent care, revealed CNA 'A' and CNA 'C' did not wash their hands prior to beginning incontinent care. Feces were observed to remain on Resident #13's buttocks after incontinent care was complete. In an interview on 11/17/2010 at 9:40 a.m. with CNA ' A ' and CNA ' C ' both stated they were taught to report any significant changes such as skin breakdown regarding the resident to the Charge Nurse. In an interview with CNA'I' and CNA'F' and while observing incontinent care on Resident #13 on 11/18/2010 at 4:30 p.m., revealed Residents # 13 buttocks had the same excoriated area and 2 open areas as visually seen on 11/17/2010. CNA'I' and CNA'F' were asked if there were any new orders communicated to them regarding Resident #13's care from the CNA's on the previous shift or from the nurse. Both stated no. Review of Resident # 13 Nurses Notes for the months of September, October, November 2010, and weekly summaries dated: 11/04/2010 and 11/11/2010 revealed no skin problems identified or documented. Review of Physicians Orders for November 2010 for Resident #13 revealed an order for [REDACTED]. During an interview and observation of Resident's # 13 buttocks the DON and LVN'F' on 11/19/2010 at 10:00 a.m. she they confirmed while looking at Resident ' s weekly summary dated 11/18/2010 that under skin condition there were no skin problems identified or documented. Review of Physician orders [REDACTED].#13's sacral, coccyx or buttocks. Review of Resident #13's Physicians orders revealed an order written [REDACTED]. Staff was to apply [MEDICATION NAME] to buttock every shift for 7 days and then re-evaluate the skin. Resident #15 Review of Resident #15's Admission Face sheet revealed the male resident was admitted to the facility on [DATE] with readmission on 10/16/2007 at 2:45 p.m. and was [AGE] years old at the time of the survey. Review of Resident #15's History and Physical dated 2/17/10 revealed Resident #15 had a past medical history of [REDACTED]. Review of Resident #15's annual Minimum (MDS) data set [DATE], revealed Resident #15 had short and long term memory problems. He was rarely/never able to make himself understood and rarely/never able to understand others. Resident #15 was assessed to be severely cognitively impaired. Resident #15 required total assistance from 2(+) staff for bed mobility, transfers, dressing, toilet use, and required assistance from 1 staff for locomotion on and off unit, personal hygiene and bathing. Review of the section regarding balance during transfer and walking was indicated as a 8 (Activity did not occur) for moving from seated to standing position, moving on and off toilet, and surface to surface transfer. Resident #15 had impairment on both sides in both upper and lower extremities. Resident #15 was incontinent of bowel and bladder. Review of the section regarding Skin Conditions revealed; Resident #15 was identified as "at risk for developing pressure ulcers", subcategory Skin and Ulcer Treatments revealed; pressure relieving devices for chair, pressure relieving devices for bed, turning and repositioning, and applications of ointments/medications other than to feet. Resident #15 was assessed to be 70 inches tall and weighed 182 lbs. Review of Resident #15's Braden Scale- for Predicting Pressure Sore Risk dated 10/06/10 revealed Resident #15 had a total score of 14 indicating he was at "moderate risk" for developing pressure sores. Review of Resident #15's consolidated physician's orders [REDACTED]. Further review revealed physicians orders: Keep area in between buttocks clean and dry and monitor for worsening, Perform head to toe skin check. Assess all areas of skin every Saturday. Apply [MEDICATION NAME] powder or ointment when needed to groin and buttocks. Resident #15 had no orders for pressure relieving devices Review of Resident #15's Braden Scale- for Predicting Pressure Sore Risk dated 10/06/10 revealed Resident #15 had a total score of 14 indicating he was at "moderate risk" for developing pressure sores. Review of Resident #15's consolidated physician's orders [REDACTED]. Further review revealed physicians orders: Keep area in between buttocks clean and dry and monitor for worsening, Perform head to toe skin check. Assess all areas of skin every Saturday. Apply [MEDICATION NAME] powder or ointment when needed to groin and buttocks. Resident #15 had no orders for pressure relieving devices Review of Resident #15's Care Plan updated on 10/07/10 revealed Resident #15 was at risk for pressure ulcers due to right sided [MEDICAL CONDITION]. The goal and target date revealed the residents skin will remain intact and will show no signs or symptoms of breakdown for the next 90 days. Approaches were listed as incontinent care every episode, weekly skin assessments by LVN on Saturday's, weekly skin report to be given to DON, Turn resident every 2 hours and when needed by 2 staff, offer pressure reducing mattress for bed , offer pillows to decrease pressure while in bed and in wheelchair, cleanse perineal area with soap and water following each bowel movement, apply [MEDICATION NAME] lotion twice daily per physicians orders, apply [MEDICATION NAME] powder or cream when needed, and [MEDICATION NAME] cream when needed. Review of the resident's consolidated physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Apply [MEDICATION NAME] powder or ointment when needed to groin and buttocks. There were no orders for the resident to have pressure relieving devices.: Review of Nurse's Weekly/Monthly Summary dated 11/05/10, Section M: Skin Conditions revealed, No documentation of pressure ulcers. However, under the subcategory, Other Skin Problems, Resident #15 was documented to have an open lesion. Skin treatments documented were turning and repositioning. Review of Nurse's Weekly/Monthly Summary dated 11/12/10, Section M: Skin Conditions revealed, No documentation of pressure ulcers. However, under the subcategory; Other Skin Problems, Resident #15 was documented to have an open lesion. Skin treatments documented were turning and repositioning. In an observation on 11/17/10 at 9:45 a.m. CNA 'C' and CNA 'A' were observed performing incontinent care for Resident #15. While observing care of Resident #15 it was observed that Resident #15 had reddened excoriated areas to his left and right buttocks, crusted yellow creamy substance was observed to folds of groin area and around his scrotum. Resident #15 had a small open area to the back of the right side of his scrotum. Which according to staff was from a surgical procedure. CNA 'C' was asked how often protective cream was applied to Resident #15 and she stated, "Usually the last round per shift." Resident #15 was dressed in a brief and sweat pants and transferred to his wheelchair. No pressure relieving devices were observed in his wheelchair or on his bed. CNA ' C ' was observed to wash her hands before leaving the room. CNA ' A ' did not wash her hands before leaving the room. In an observation on 11/18/10 at 3:20 p.m. CNA 'I' and CNA 'E' were observed performing incontinent care and transfer of Resident #15. Resident #15 had feces and was not cleaned with soap and water as indicated in his care plan. Resident #15 continued to have reddened excoriated areas to both side of his buttocks and an open area on the back right side of his scrotum. Resident #15 was transferred to his wheelchair with the mechanical lift, there was no pressure relieving pillows or devices placed in his wheelchair before he was seated. CNA ' I ' and CNA ' E ' were observed to change their gloves multiple times during incontinent care of Resident #15, however neither CNA was observed to have washed their hands prior beginning incontinent care or before leaving the room. In an observation on 11/19/10 at 7:15 a.m. revealed CNA 'B' and CMA 'A' transferring Resident #15 from his bed to his wheelchair. The resident did not have a pressure relieving pillow or devices with lap-buddy in place. In an observation on 11/19/10 at 3:10 p.m. revealed CNA 'P' and CNA 'Q' transferring Resident #15 from his bed to his wheelchair with no pressure relieving devices. Review of Nurses Notes dated 11/20/10 at 2:00 p.m. revealed [MEDICATION NAME] had been applied to Resident #15's scrotum and buttocks per the PRN (when needed) physicians order. Resident #15's inner buttock was found to be excoriated with a 1 cm x 1 cm superficial excoriation to the left side of Resident #15's scrotum with scattered areas of excoriation to right side of scrotum. In an observation on 11/20/10 at 9:35 p.m. the DON and ADON performed a skin assessment on Resident #15. Resident #15 was resting in bed on an incontinent pad with no brief. Resident #15 continued to have excoriation to both sides of his buttocks and open areas to the back of his scrotum. Resident #15 was observed to have an open area to his left buttocks (approximately the size of a pinpoint) surrounded by a red excoriated area ( approximately 3 cm x 5 cm) and a red excoriated area (approximately 3 cm x 6 cm) to his right buttocks. The DON was asked how the facility identified any potential skin problems with the residents. She stated the CNAs inform the Charge nurses of any problems, the Charge nurse either contacted the physician or they followed the physician's recommendations that have been previously ordered. The DON was asked if she had identified any concerns with Resident #15, she stated Resident #15 was excoriated and the charge nurse had applied cream to his buttocks and scrotum as ordered. She stated the areas observed she felt did not need to be staged. According to the facility's (undated policy) , which was taken from a copy of the Federal Regulation. The following clinical conditions may demonstrate pressure sores were unavoidable, only if adequate preventive care includes turning and proper positioning as well as application of pressure relief devices and good skin care, (i.e.) keeping the skin clean, maintaining dryness from urine, providing clean and dry bed linens, and maintaining adequate nutrition. According to the facility's CMS 802 obtained during the survey there was only one pressure sore identified.