Every finding on record at Hudson Memorial Nursing Home

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure foods were stored and prepared under sanitary conditions for residents who received foods from one of one kitchen. The findings include: During the initial tour on 07/12/2025 at 9:55 AM, with Dietary Aide (DA) #1, this surveyor observed a box of opened egg rolls, stored in the walk-in freezer, in a plastic bag open and unsealed. DA #1 indicated that the bag should have been sealed. During an observation and concurrent interview on 07/14/2026 at 10:20 AM, there was a quarter pan found under the food prep-area, identified by the Dietary Supervisor (DS) as ready for use. It was wet and nested inside other quarter pans. The DS indicated that the pans should not be stored wet and should be allowed to air-dry before being stored. -During this observation the 3-compartment sink was observed to be in use. The DS stated the sanitizer-water temperature should be 110-120 degrees Fahrenheit (F). The DS then referred to a reference on the wall and stated that the sanitizer water temperature should actually be 65-75 degrees F. During an observation and concurrent interview on 07/14/2026 at 10:35 AM, DA #2 indicated that she was responsible for the dishwashing and dish machine testing, and that the dish machine was a low-temp machine (A low-temperature commercial dishwasher uses chemical sanitizers (like chlorine) instead of boiling hot water to clean dishes). DA #2 was observed performing a test with a bottle of test strips. DA #2 stated the bottle of test strips had been used since July 1, 2026. DA #2 put the strip into the bottom basin of the dish machine water for 1-2 seconds and compared it with the range on the bottle. The strip ranges were 0 parts-per million (ppm), 12.5 ppm, 25 ppm, and 50 ppm. DA #2 stated the strip should turn purple to indicate the sanitizing solution was at an acceptable level. No purple color was observed, and instead the strip read between 0 ppm and 12.5 ppm. DA #2 and DS referenced the test strip bottle instructions and confirmed the strip should stay in the water for 60 seconds. DA #2 indicated she did not know how long to leave the strip in the water, and she did not have a reference in which to measure time to know how long the strip had been in the water. DA #2 indicated she was educated on the testing process upon hire in August of 2022. During a subsequent observation and concurrent interview on 07/14/2026 at 10:39 AM, DA #2 ran the dishwasher again, performed a test, and again it was observed to register between 0 ppm and 12.5 ppm. DA #2 indicated the dishwasher testing frequency was twice on her shift and once on the evening shift (3 times per day). The July 2026 Test Log was reviewed, and revealed no documentation of testing for the wash water temperature, the rinse water temperature or the sanitizer for the following dates and wash test period: 07/02/2026 – lunch wash 07/06/2026 – breakfast wash 07/06/2026 – lunch wash 07/06/2026 – dinner wash 07/08/2026 – dinner wash 07/10/2026 – dinner wash 07/11/2026 – dinner wash07/13/2026 – dinner wash All entries on the July 2026 Test Log were recorded at 100 ppm, for the sanitizer. During an interview on 07/15/2026 at 8:42 AM, the Dietician stated that the dishwasher should be tested at the start of each day and each shift (3 times per day), and the risk to the resident of dishes not being cleaned/sanitized appropriately was a risk of food not being cleaned off or an allergic reaction. The Dietician also indicated that items stored in the freezer needed to be sealed to prevent anything from touching it and also protecting it from the air or cross-contamination. During an interview on 07/15/2026 at 10:21 AM, DA #2 indicated that when testing the dishwasher, test strips should turn purple, which indicated the solution was 100 ppm. DA #2 was asked by the surveyor how the strips register at 100 ppm when the reference range stops at 50 ppm. DA #2 admitted to not be looking at the range closely and writing down what I thought it was. DA #2 also indicated that some of the strips used in the past did go up to 100 ppm. DA #2 confirmed that she washed dishes in the 3-compartment sink the day before but was not able to speak to the temperature requirements for the 3-compartment sink because it was her first time to use it. DA #2 indicated that water not at the correct temperature, and sanitizer not being at the correct strength could be illness and cross-contamination. DA #2 indicated she was taught how to do her job when she oriented August 15, 2022. During an interview on 07/15/2026 at 12:27 PM, Maintenance indicated that the kitchen was not using the correct test strips, because the chemicals had recently changed earlier this month. They were using Iodine-based strips when they should have been using Chlorine-based strips. During an interview on 07/15/2026 at 2:01 PM, the DS indicated the following information: The cause of the dishwasher issue was that the type of chemical being used was changed on 07/01/2026. The cause of the strips not reading right with the dishwasher was because Iodine strips were still being used and not Chlorine strips. The facility had obtained the appropriate Chlorine strips, and the strips were still not registering in the desired range. The vendor was contacted for a service call and the facility transitioned to disposable serving ware and eating utensils in the interim because the vendor would not be on site until 07/16/2026. 1:1 education was completed with the dishwasher staff to educate them that the water must be in the appropriate range for the 3-compartment sink, as well as the temperature of the wash and rinse water. The DS stated they had verified the reference for the 3-compartment sink on the wall above the sink was the correct cleaning chemical – and the temperature for the sanitizer should be between 65-75 degrees F. Fresh water and sanitizer for the 3-compartment sink was run to the fill line and tested appropriately at 200-400 ppm with temp at 98 degrees F - tested in acceptable range per strips and per wall reference. During observation and concurrent interview on 07/15/2026 at 10:10 AM, a brownish-gray substance was noted to be approximately greater than 6 feet up the walls (extending to the ceiling), on the air-conditioner vent(s) above the steam table, on sprinkler piping above the steam table, and toward the top of the cookstove extending to the top. DA #1 took a white paper towel, wiped some of the substance that was reachable on the wall and the substance was observed to transfer to the white paper towel. DA #1 stated what was on the wall was probably what was on the other areas, and it was dust. DA #1 indicated there was a risk of dust falling into the food. During an interview on 07/15/2026 at 8:42 AM, the Dietician indicated that for sanitary reasons the staff need to make sure the gray substance is not falling into the food. During an interview on 07/15/2026 at 10:33 AM, the [NAME] indicated the substance on the walls, vent, ceiling, sprinkler pipes, and above the stove was gray and was dust or more than dust. The [NAME] also indicated that a result of the respective areas not being clean was it could fall into the food and contaminate it. The [NAME] also indicated that pans should not be stored wet while nested because of the possibility of bacterial growth. During an interview on 07/15/2026 at 12:00 PM, the Infection Preventionist (IP) indicated that the substance on the walls, ceiling, sprinkler pipes, vents, and top of the stove did not need to fall into the food because nobody knows what the substance is and it could cause gastro-intestinal issues. During an observation and concurrent interview on 07/15/2026 at 5:04 PM, the DS indicated the substance on the above referenced areas could be dust or mold. The DS also indicated that they did not have a policy for cleaning the kitchen. A review of the cleaning schedules for the kitchen did not identify the cleaning of the walls greater than approximately 6 feet extending to the ceiling, air-conditioner vents, sprinkler piping, ceiling, and top of stove. A review of the kitchen staff in-service education dated 07/02/2026, indicated, Food stored in freezers shall be wrapped in airtight packages.

Based on observations, interviews, and facility policy review, the facility failed to ensure the menu was followed for one of one kitchen. Specifically, there was an omission of a menu item during a meal. Based on observation and interviews, the facility failed to ensure the menu was followed for one of one kitchen. Specifically, there was an omission of a menu item during a meal. The findings include: Review of the Breakfast Menu for 07/15/2026 revealed items to be served were as follows:Juice of choiceCereal of choiceEgg of choiceSausageHashbrown pattyBiscuit During an observation and concurrent interview on 07/15/2026 at 6:00 AM, the menu was reviewed with the Cook, who confirmed the morning menu included a hashbrown patty. This surveyor observed no hashbrown patties on the steam table. The cook stated that there were no hashbrown patties available, as listed. This surveyor asked the [NAME] if a substitute was available, and the [NAME] stated that she could prepare some sort of potato, but no substitute had been prepared. The breakfast meal service was observed, and no potato dish or substitute was provided. During an interview on 07/15/2026 at 8:42 AM, the Dietician stated that the hashbrown patty should have been substituted with some type of potato alternative and that the menu was formed to ensure a complete meal, with the correct number of servings for carbohydrates, calories, and vegetables. The Dietician also stated that she approved the menus and they should be followed. During an interview on 07/15/2026 at 2:01 PM, the Dietary Supervisor (DS) indicated that there were options in the freezer to substitute the potato serving, but the [NAME] may not have considered it, at that time. Review of the employee training sign-in sheet dated 07/02/2026, indicated training was provided regarding Learning state regulated rules. Attached to the training sign in sheet was Dietetic Services policies which revealed that meals served shall correspond essentially with the posted menus.

Based on facility document review, facility policy review, and interviews, it was determined that the facility failed to ensure residents were supervised when receiving medications that were crushed and placed in liquid supplements resulting in one (Resident #1) of five residents reviewed consuming unprescribed medications. The findings include: Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2025 indicated Resident #1 had diagnosis which included non-Alzheimer's dementia, and body mass index of 19 or less. The MDS also indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which revealed the resident had severe cognitive impairment, and that Resident #1 exhibited no behaviors, required set up with eating, and supervision/touch for mobility. Review of a Nsg (Nursing) – General Note dated 10/23/2025 at 5:54 PM indicated Resident #1 was noted to be drinking from a [named liquid supplement] which did not belong to (Resident #1). A Certified Nursing Assistant (CNA) in the dining room noted Resident #1 took the supplement from the correct resident (to whom the medications in the drink had been prescribed) and picked the second supplement up from the table. Both drinks had crushed medications in them, and Resident #1 drank from both. One supplement contained an expectorant and a medication used to treat the symptoms of Alzheimer's dementia and the second supplement contained an antianxiety and an antidepressant medication. The Advanced Practice Registered Nurse (APRN) was contacted, after the APRN determined the resident was not allergic to any of the medications that had been consumed the nurse was instructed to closely monitor the resident. Review of a form titled, Medication Error Report for Resident #1 dated 10/23/2025 at 5:25 PM, indicated Resident #1 was in the dining room and the resident was noted drinking from a [named liquid supplement] which did not belong to (Resident #1). A CNA in the dining room noted that the resident took the [named liquid supplement] from another resident and picked the [second named liquid supplement] up from the table before drinking from both. Both drinks had crushed medications in them. The [named liquid supplement] contained an expectorant medication and a medication that treats the symptoms of Alzheimer's dementia. The [second named liquid supplement] contained an antianxiety and antidepressant medication. The Medication Error Report also indicated Resident #1 was orientated to person, confused, and had impaired memory, and that the APRN was notified of the incident. Review of the form titled, Medication Discrepancy Report' completed 10/24/2025 for Resident #1 for the incident dated 10/23/2025 at 4:45 PM, revealed Resident #1 took a [named supplement] that contained an antidepressant, an antianxiety, an expectorant and a medication that treats the symptoms of Alzheimer's dementia. The form indicated that these medications were taken by the wrong resident but there was no adverse reaction. The form also indicated the nurse responsible for giving the medications was given a written warning and educated to stay with the resident until medications were taken. Review of the form titled, Employee Discipline (Warning) completed 10/24/25 for the medication error made on 10/23/25 indicated the nature of the violation was carelessness and the LPN #1 was given a written warning. The form indicated LPN #1 mixed medication in supplements for two resident's and left the supplements on the table failing to stay until the supplements were drunk to ensure the medication was taken. This resulted in a resident for whom the medication was not prescribed picking up the two supplements with medications inside and drinking them. The form indicated the LPN was given retraining of protocol for medication administration. Reviewed of the form titled, Re-Training Form dated 10/24/25 signed by LPN #1 indicated residents are to be supervised with medication administration and that a staff member should stay with residents until all medications are taken. During an interview on 11/06/2025 at 3:50 PM, LPN #1 indicated on 10/23/25, at supper time, she crushed an expectorant and a medication used to treat the symptoms of Alzheimer's dementia and placed them in a supplement. LPN #1 indicated she then crushed an antianxiety medication and an antidepressant medication and placed the medication in another supplement. LPN #1 indicated she handed one supplement to the resident they were prescribed for who was in the dining room and put the other supplement on a dining room table next to the resident they were prescribed for. LPN #1 indicated she was running behind with her work and she did not watch either of the residents take their medication. LPN #1 stated that a CNA in the dining room saw Resident #1 drink the supplements and the CNA reported this to her and the Registered Nurse (RN) Supervisor. During an interview on 11/06/2025 at 4:30 PM, the RN Supervisor indicated on October 23,2025, she was sitting at the nurses station and a CNA came to her and informed her that Resident #1 got a milk shake that belonged to another resident and the resident spit a little of the shake out and the aide could see medication in the shake. The RN supervisor stated that she went and evaluated the resident and reported what had occurred to the Director of Nursing who went and spoke with the nurse responsible for administering the medications. During an interview on 11/06/2025 at 4:50 PM, LPN #2 indicated she was at the nurse station during supper time on 10/23/2025 and she heard a staff member state Resident #1 had drunk someone else's supplement with medications in the supplement. LPN #2 stated she was Resident #1's nurse that evening and she had to monitor the resident every hour for any changes in (Resident #1's) condition. LPN #2 stated the resident did not have any condition change during her shift. During a telephone interview on 11/06/2025 at 4:55 PM, CNA #3 indicated when she was working in the dining room during supper on 10/23/25 she saw Resident #1 drink a supplement that did not belong to her. CNA #3 indicated she saw pieces of medication around the top of the supplement container. CNA #3 indicated she and another aide looked at the drink to be sure she was correct about the medication and then reported what she had seen to the nurse (LPN #1) and the RN Supervisor. During an interview on 11/07/2025 at 11:45 PM, the Minimum Data Set (MDS) Coordinator indicated that on 10/24/25, the DON updated her on the incident involving Resident #1 drinking another resident's supplement which contained medications. The DON asked the MDS Coordinator to write up the nurse involved in the incident and re-educate her on correct medication administration. The MDS Coordinator stated that the nurse was instructed that no matter what form medications were given in that she must stay with the resident to ensure the medication was taken before leaving the resident. The MDS Coordinator indicated no other staff were in-serviced regarding the incident and the in-service was just with LPN #1. During an interview on 11/07/2025 at 12:05 PM CNA #4 indicated that on the 3-11 shift of 10/23/25, she was the CNA caring for Resident #1. CNA #4 stated that she was assisting residents to go to the dining room for supper and noted Resident #1 drinking a supplement that she had never seen her drink before and spitting some of it out. CNA #4 stated she gave Resident #1 something to spit into and she saw crumbles that looked like medication. CNA #4 stated she and another aide took the drink from Resident #1 and took it to the RN Supervisor. During an interview on 11/7/2025 at 3:05 PM, the DON confirmed that she had been notified by the RN Supervisor on October 23, 2025, that Resident #1 had picked up another resident's medications and taken (consumed) them. The DON indicated she spoke to LPN #1, who was the nurse responsible for giving the medications. The DON indicated LPN #1 told her that once it was realized Resident #1 had drank the supplements belonging to two other residents, the supplements were taken from the resident, who had not drank all the supplement. The DON indicated she verbally instructed LPN #1 that she should not leave a resident until they had taken all their medication and if she was going to crush the medication and put it in a liquid supplement that she should not put it in the full amount of the supplement, but put some of the supplement in a cup, add the medication and observe the resident until all the medication was taken. The DON indicated the APRN was contacted, and staff were instructed to monitor the resident. The DON confirmed that LPN #1 was given a written warning on 10/24/25 for not observing the residents until they took their medications and a written re-education on medication administration. During an interview on 11/07/2025 at 3:55 PM, the APRN confirmed that on October 23, 2025, she was contacted and notified that Resident #1 had drank someone else's supplements containing medications. The APRN indicated she first determined that the resident did not have any allergies to the medications. The APRN indicated her concern was that the resident might become drowsy because of the antidepressant and she ordered the staff to monitor the resident and let her know of any changes. The APRN indicated that she believed any effects the resident might have from the medications would not last more than 4-6 hours. The APRN stated she was not informed after that of any change in the resident condition. During an interview on 11/07/2025 at 5:10 PM, the Administrator indicated she was informed by the DON on October 23, 2025, that Resident #1 had taken two separate drinks with other resident's medications in them. The Administrator indicated the nurse responsible was given a written warning and retrained on medication administration. Review of the policy titled, Medication Administration - General Guidelines with a revision date of November 2011 indicated, medications are administered as prescribed in accordance with good nursing principles including following the five rights for medication administration of right patient, right dose, right medication, right time and right route. Residents are identified before medication administration and observed after to ensure doses are completely taken.

Based on document review and interviews, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 60 residents. The findings are: A review of the Facility Assessment Tool, dated 07/11/2024, indicated the assessment was reviewed with the Quality Assessment and Assurance and Quality Assurance and Performance Improvement (QAA/QAPI) committee on 07/12/2024. The facility-wide assessment did not include the following: - An evaluation of what policies and procedures may be required in the provision of care and how the facility would meet the current professional standards of practice. - An evaluation of any contracts, memorandums of understanding including third-party agreements for the provision of goods, services. - Description of how the facility would evaluate their infection prevention and control program that included systems for preventing, identifying, reporting, investigating, and controlling infections. On 12/19/2024 at 11:38 AM, the Administrator was interviewed and stated an entire team contributes to the facility assessment. The Administrator was asked to provide a policy for facility assessment. She stated the facility did not have one.

Based on observations, interviews, facility document review, and facility policy review, it was determined the facility failed to ensure foods were stored and prepared under sanitary conditions for residents who received foods from one of one kitchen. The total census was 60. The findings are: A) On [DATE] at 11:27 AM during concurrent observations and rounds with the Dietary Manager (DM) all the kitchen walls, including the ones immediately adjacent to the food prep area and above the 3-compartment sink, had brownish-gray, fine, powdery particles extending up to the ceiling. B) On [DATE] at 11:43 AM, the 3-compartment sink was in use by Dietary Employee (DE) #1. DE #1 was interviewed and stated the sanitizer water temperature (temp) for the 3-compartment sink was to be ,d+[DATE] degrees Fahrenheit (F), the soapy water side was to be 180 degrees F, and the rinse should be lukewarm. C) On [DATE] at 4:00 PM, DE #2 was observed using the dish machine and stated she has worked at this facility since 2018. DE #2 rinsed the cookware, placed the items into the dish machine, and started the cycle. DE #2 was interviewed and stated she did not perform water temperature checks, the day shift person did. This surveyor and DE #2 observed the instructions on the outside of the machine which indicated the wash and rinse temp is to be a minimum of 120 degrees F. DE #2 was unable to demonstrate or verbalize where the temperature gauge was located or where to test the water using the required test strips. DE #2 placed a test strip in the outside drain reservoir and did not blot the test strip prior to observing the results according to the manufacturer's instructions on the outside of the bottle. D) On [DATE] at 8:53 AM, the contracted pest control representative was observed in the kitchen without a beard cover. The pest control representative's beard was observed to be a full beard and approximately 6 inches in length. E) On [DATE] at 8:55 AM, DE #3 was observed using the dish machine and stated to have worked at the facility for 2 years. The test results observed at 8:55 AM, as reported by DE #3, were as follows: wash temp ,d+[DATE] degrees F, rinse temp ,d+[DATE] degrees F. DE #3 stated the minimum temperature of the wash and rinse needed to be 120 degrees F. F) On [DATE] at 9:01 AM and 9:17 AM, the pest control representative was observed walking into the kitchen, past the beard covers available at the door. The beard on the representative was observed to be a full beard, approximately 6 inches in length. G) On [DATE] at 9:03 AM, DE #3 was observed to use the dish machine again. DE #3 stated the wash temperature was 98 degrees F, and the rinse temperature was 110 degrees F. DE #3 was interviewed and stated when the dish machine temperatures were not in range, staff would ask the DM what to do. H) On [DATE] at 9:10, DE #2 was observed using the 3-compartment sink. DE #2 was interviewed and stated the hot water tap temperature for the sink fluctuates at times. DE#2 stated sometimes the water must be boiled on the stove and poured into the sink to get the water hot enough. I) On [DATE] at 10:09 AM, the DM was interviewed, and concurrent observations were made by this surveyor: a. The DM stated beard covers were available, beard covers were in their policy for anyone in the kitchen, and the vendor was managed by another person. b. A dish machine cycle was run again by DE #3 with the DM in attendance. The DM stated that maintenance turned up the temperature that goes to the dish machine. The wash temperature was stated to be 110 degrees F and rinse temperature 120 degrees F. Both DE #3 and the DM stated that the temperatures must be a minimum of 120 degrees F for both the wash and rinse cycle, per the manufacturer's instructions posted on the side of the machine. The DM stated it was important that dish machine temps were high enough to ensure the dishes were clean. Review of the manufacturer's instructions provided by the DM state operating temperature of 120F degrees is the minimum, ,d+[DATE]F degrees is recommended c. A test strip was performed by the DM for sanitizer at the 3-compartment sink. The expiration date on the outside of the bottle was ,d+[DATE]. When asked, the DM stated the test strips were expired and it was important that test strips were in date so they could know the sanitization is accurate. d. For the temperatures of the 3-compartment sink, the DM stated that the rinse needed to be hot. e. The DM was asked by this surveyor to wipe the wall with a paper towel. This surveyor observed brownish-gray, fine, powdery particles which transferred to the white paper towel. The DM stated it was dust, and it is important for the walls to be clean, so dust did not float down onto the food. Upon review of the cleaning schedules provided by the DM, there is no allowance seen for cleaning all the walls to remove dust. J) On [DATE] at 3:40 PM, the DM stated all employees who operate the dish machine should know how to test the dish machine temperatures and sanitizer. K) On [DATE] at 5:00 PM, the DM stated the vendor would have to be called about the dish machine temperatures inaccuracy. L) The DM provided a hair covering policy, undated, titled [Facility Name] Policies and Procedures Dietary Department. The document was reviewed and indicated Facial hair on male employees must be covered.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medication and/or biologics were properly stored for 2 (Resident #37 and Resident #40) sampled residents. The findings include: 1. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2024 revealed Resident #40 had a Brief Interview of Mental Status (BIMS) of 14 indicating cognitively intact. a. A plan of care for Resident #40 (revision date 9/18/2024) revealed Resident #40 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. b. On 12/16/24 at 2:40 PM, this surveyor observed Resident #40 lying in bed. This surveyor noted a white cream, in an unlabeled medication cup, on the shelf next to the resident's bed. c. On 12/16/24 the Assistant Director of Nursing (ADON) stated she believed the white cream was a skin barrier cream but could not say that for certain. The ADON stated the white cream in the medication cup should not be on the shelf next to the bed because residents could come in and grab it. 2. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2024 revealed Resident #37 had a Brief Interview of Mental Status (BIMS) of 15 indicating cognitively intact. a. A plan of care for Resident #37 (revision date 11/8/2024) revealed Resident #37 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. b. On 12/16/24 at 02:24 PM, this surveyor observed Resident #37 lying in bed and noted wound cleanser on the shelf next to the bed. c. On 12/17/24 at 9:30 AM, this surveyor observed Resident #37 lying in bed and noted wound cleanser and antifungal powder on the shelf next to resident's bed. d. On 12/17/24 at 10:00 AM, the ADON stated there was a bunch of items on the shelf next to the resident's bed that should not be there. The ADON stated anything with the label keep out of reach of children should not be out in the open. e. On 12/19/24 at 11:15 AM, the Director of Nursing (DON) stated medications should not be stored in the resident's room accessible to wandering residents. f. A review of policy titled Storage of Medications noted ensure that medications are stored in a safe, secure, and orderly manner.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 3 (Residents #11, #18, and #25) of 6 (Residents #11, #18, #20, #25, #35, and #54) sampled residents who received medications from 2 Licensed Practical Nurses (LPNs). 26 opportunities of medication administration were observed and 3 of the 26 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 11.54%. The findings are: On 12/28/2024, LPN #4 was observed as she conducted the 8:00 AM medication pass to residents. At 8:26 AM, she obtained Resident #25's blood pressure (bp) using a manual blood pressure cuff and stated the bp was 131 over 52 (131/52). Once she gathered the medications, she entered the resident's room, administered the medications to the resident, but withheld the [medication name] (calcium channel blocker) 10 milligrams (mg) tablet. Resident #25's Order Summary Report was reviewed and indicated the resident had a diagnosis of high blood pressure (hypertension). The report indicated an order for [medication name] (calcium channel blocker) 10 mg give 1 tablet by mouth one time a day for high blood pressure. There were no parameters included on the physician's order indicating when to hold the medication. On 12/18/2024 at 8:47 AM, LPN #4 obtained Resident #18's blood pressure manually and indicated the bp was102 over 85 (102/85). At 8:58 AM, LPN #4 entered the resident's room and administered the medications to the resident but withheld the [medication name] (calcium channel blocker) 5 mg tablet. Resident #18's Order Summary Report was reviewed and indicated a diagnosis of hypertension. The report included a physician's order dated 01/03/2022 for [medication name] 5 mg give 1 tablet by mouth one time a day related to hypertension. There were no parameters included on the physician's order indicating when to hold the medication. On 12/18/2024 at 2:38 PM, LPN #4 was interviewed with concurrent observations. She was asked to review Resident #18's physician's orders, and she stated there were no parameters included on the orders to hold the blood pressure medication. She stated she recalled the physician verbally telling her to hold the blood pressure medication for a top number (systolic) below 110. LPN #4 was asked to review the physician's orders for Resident #25, and she stated there were no parameters included on the orders to hold the blood pressure medication. She stated the physician verbally told her to hold the blood pressure medication for a systolic bp below 110 and a bottom number (diastolic) below 60. She was unable to recall when she received the order from the physician and stated she has worked at the facility for three years. On 12/18/2024 at 2:26 PM, the Director of Nursing (DON) provided a copy of a document titled PRN [as needed] Medication Standing Orders which was reviewed and did not include any parameters on when to hold a resident's blood pressure medication. On 12/19/2024, LPN #6 was observed as she conducted the 8:00 AM medication pass for residents. At 8:32 AM, she gathered the 8:00 AM medications for Resident #11, entered the room, and administered the medications to the resident, but she did not have the [medication name] (anti-flatulent medication that helps relieve gas symptoms) 80 mg tablets in the cup with the other medications. The medication cup should have had 6 tablets, but only 5 tablets were inside. Resident #11's Order Summary Report was reviewed and indicated a diagnosis of a condition in which the stomach acid flows back up into the tube connecting the mouth and stomach (esophagus) called gastroesophageal reflux disease (GERD for short). The report indicated a physician's order, dated 12/04/2023, for [medication name] (anti-flatulent medication) 80 mg give 1 tablet by mouth one time a day related to GERD. On 12/19/2024 at 9:35 AM, Resident #11's electronic medication administration record (eMAR) was reviewed and indicated [medication name] (anti-flatulent medication) 80 mg give 1 tablet by mouth one time a day. The 0800 (8:00 AM) box for 12/19/2024 included a checkmark with two letters and two numbers. The follow up codes listed on the eMAR indicated the checkmark equaled (=) the medication was administered. There was no list to indicate what the letters and numbers equated. On 12/19/2024 at 9:55 AM, LPN #6 was interviewed with concurrent observations, and she stated there were 5 pills in Resident #11's medication cup. She was asked to review the resident's electronic medication administration record (eMAR) and look at the [medication name] (anti-flatulent medication) order. As she reviewed the eMAR in the computer, she stated she had missed the [medication name] (anti-flatulent medication). She stated she normally checked the medication administration record (MAR) before she goes in [the resident's room] and especially on halls which she normally does not work. She stated the MAR should be checked to make sure all the resident's medications were given. A Medication Administration policy, dated 2016 and provided by the DON, was reviewed and indicated the purpose was to safely and accurately administer physician-ordered medication to each resident. The policy indicated to remember the six rights of correct administration which included the right drug and the right dose. The policy indicated the physician's order must be followed regarding holding medications based on a vital sign parameter.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was offered individual activities on a consistent basis for 1 (Resident #35) of 2 (Residents #28 and #35) sampled residents reviewed for activities. The findings are: On 12/16/2024 at 12:07 PM, Resident #35 was lying in bed with eyes closed. The resident 's eyes opened to verbal stimuli. The television (tv) was off at this time. Resident #35's Order Summary Report was reviewed and indicated diagnoses of depression and anxiety and indicated the resident needed continued care in a nursing home due to inability to live independently and the need for medication assistance, observation, and planning. A quarterly Minimum Data Set with an Assessment Reference Date of 12/13/2024, was reviewed and indicated Resident #35 had a Brief Interview for Mental Status score of 7, which indicated severely cognitively impaired. Resident #35's care plan, dated 12/16/2024, was reviewed and indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to an inability to move (immobility), physical limitations, and anxiety. Interventions were to invite the resident to scheduled activities and the resident needs one-to-one (1:1) bedside/in-room visits and activities if unable to attend out of room events. On 12/18/2024 at 10:42 AM, Resident #35 was lying supine in bed with eyes closed. There was a 10:30 AM activity in the dining area at this time. The tv was not currently on. On 12/18/2024 2:36 PM, residents were in the dining room playing bingo and Resident #35 was not in attendance. At 2:50 PM, the resident was lying in bed awake. The tv was not on currently. On 12/19/2024 at 9:53 AM, the Activity Director (AD) and Activities Assistant (AA) were interviewed. This surveyor asked the AD if she did one-on-one activities with the residents and she stated they, she and the AA, had not been doing the one-on-one activities. She stated the AA had occasionally been doing them. The AD was asked to clarify occasionally and the AA stated, I usually go by two times a week. I go in and [Resident #35's] usually asleep. If I make a tour around again and [Resident #35]'s awake, I will [do an activity with the resident]. I'm not going to wake [the resident] up to do one [an activity]. This surveyor stated upon review of the resident's documentation in the computer, an activity was last indicated on 12/06/2024. The AD stated what was in the computer was what had been done. An Individual Activities and Room Visit Program policy, not dated, was reviewed and indicated individual activities would be provided for those residents whose situation or condition prevented participation in other types of activities. The policy indicated the activities offered were reflective of the resident's individual activity interests.

Based on interview, record review, and policy review, the facility failed to convey a resident's personal funds, to the individual or representative administering the individual's estate, within 30 days, for 1(Resident #163) sampled resident for whom the facility-maintained trust accounts, per a list provided by the Bookkeeper on [DATE] at 9:42 AM. The findings are: 1. On [DATE] at 9:42 AM, the Bookkeeper provided a document titled [Facility name] [Skilled Nursing Facility] SNF Trust Current Account Balance as of [DATE], which was reviewed and indicated a trust account for Resident #163 contained a closing balance of $1,237.24. 2. On [DATE] at 10:00 AM, review of the Record of Death indicated Resident #163 passed away on [DATE]. 3. On [DATE] at 12:00 PM, the Bookkeeper was interviewed with concurrent observations and stated the facility had four (4) days to return a resident's money from a trust account when a resident discharges or expires. The Bookkeeper stated Resident #163 expired on [DATE]. 4. On [DATE] at 12:07 PM, a review of a document titled Trust Transaction History for Resident #163 revealed interest had been paid each month and the balance as of [DATE] was $1,237.24. 5. On [DATE] at 12:29 PM, the Bookkeeper provided an undated policy titled Protection of Resident Funds Policy. The policy was reviewed and indicated upon the death of a resident who has personal funds, the facility will ensure, within 30 days, the resident ' s funds will be conveyed to the individual or probate jurisdiction administering the resident ' s estate or try to locate the responsible party or heir to the estate. 6. During the exit conference on [DATE], the Administrator stated Resident #163's stepdaughter did not want the resident's funds returned to her and the resident had no other person to contact. The Administrator was interviewed and stated she did not reach out to her governing body or the proper state authority for guidance regarding how to handle Resident #163's remaining funds.

Based on record review, interview, and facility document review, the facility failed to coordinate with the proper state agency to ensure a Level 2 (II) pre-admission screening and resident review (PASRR) evaluation report was obtained to determine if a resident required further services for 1 (Resident #15) sampled resident reviewed for a Level II PASRR. The findings are: On 12/17/2024 at 10:00 AM, Resident #15's electronic health record was reviewed and there was no Level II PASRR evaluation report in the resident's record. On 12/17/2024, the Administrator was asked to provide documentation for a Level II PASRR screening for this resident. At 3:26 PM, the Director of Nursing (DON) provided a document titled [outside agency name], dated 02/13/24 [02/13/2024], and indicated the resident could not be admitted until a Level II PASRR was completed. A document titled [outside agency name], dated 02/25/2014, was reviewed and indicated the resident had been approved for nursing home placement of choice. The document indicated the nursing facility must contact the outside agency and provide the resident's admitted to receive the completed PASRR evaluation. Resident #15's Order Summary Report was reviewed and indicated the resident had diagnoses of a nerve disorder caused by damage or abnormal development in the brain which affects movement and posture (cerebral palsy). A quarterly Minimum Data Set with an Assessment Reference Date of 10/23/2024 was reviewed and indicated Resident #15 had a Brief Interview for Mental Status score of 14, indicating cognitively intact, and had other behavioral symptoms, not directed towards others, such as hitting, scratching or verbal/vocal symptoms like screaming. On 12/17/2024, a review of the care plan dated 12/06/2024 indicated the resident had a communication problem related to cerebral palsy and intellectual disabilities and to engage resident in simple, structured activities that avoid overly demanding tasks. There was no PASRR information on the care plan. On 12/19/2024 at 8:40 AM, the Administrator stated she was unable to locate the Level II PASSR evaluation for Resident #15. This surveyor entered the Administrator's office later in the day to request other information and the Administrator stated she had located information from another state agency regarding Resident #15 and PASRR information. She had documents in her hand and stated there was no recommendations listed on the form. This surveyor asked if she was providing documentation for the Level II PASRR, she stated she was not and did not provide the documents to this surveyor for review. On 12/19/2024 at 12:46 PM, the DON provided a document which he stated the facility used as a guide regarding Level II PASRR screening. An undated document titled Who needs a PASRR [Level II) Screening ?????? was reviewed and indicated clients with a developmental disability, such as cerebral palsy, required a Level II PASRR. The document indicated a PASRR evaluation process, which indicated if the client is eligible for admission, the client would enter the nursing facility NF) and the NF would call the outside agency with the admitted and the outside agency would mail the Level II assessment to the NF or guardian.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff applied the proper personal protective equipment (PPE) while providing high contact care to 1 sampled (Resident #3) resident on enhanced barrier precautions (EBP). The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/2024 revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Resident #3 was receiving dialysis. A plan of care for Resident #3 (revision date: 6/17/2022) revealed Resident #3 had chronic renal failure, a condition which involves gradual loss of kidney function, related to end stage renal disease (ESRD), a condition where the kidney reaches advanced state of loss of function. On 12/18/2024 at 9:00 AM, this surveyor observed Certified Nursing Assistant (CNA) #10 enter a resident's room. This surveyor observed an Enhanced Barrier Precautions signposted next to the exterior of the door. On 12/18/2024 at 9:10 AM, this surveyor observed CNAs #9 and #10 at the bedside of Resident #3 providing the resident with a bed bath. CNAs #9 and #10 were not wearing a gown during this observation. On 12/18/2024 at 9:30 AM, during an interview, CNA #9 stated a gown, and gloves should be worn when providing care to Resident #3. CNA #9 confirmed neither she nor CNA #10 had a gown in place during the bathing activity for Resident #3. On 12/18/2024 at10:15 AM, during an interview, Licensed Practical Nurse (LPN) #11 stated Resident #3 received dialysis, and the dressing was removed the next day. On 12/19/2024 at 11:17 AM, during an interview, the Director of Nursing (DON) stated staff should wear a gown and gloves when caring for a resident on EBP to help to protect the resident from any infection that could potentially be brought in. A review of policy titled Enhanced Barrier Precautions noted providers and staff must wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, device care, wound care (any skin opening requiring a dressing).

Based on observation, interview and record review, the facility failed to ensure a resident was receiving oxygen at the flow rate ordered by the physician, and failed to ensure oxygen titration orders included a starting flow rate and maximum flow rate. This failed practice affected 1(Resident #15) of 6 sampled residents (Resident #3, #15, #19, #20, #25, and #266) with oxygen orders. The findings are: Review of a physician's order for Resident #15 dated 11/03/2022 showed oxygen ordered at 2 liters/minute per nasal cannula as needed each shift to keep oxygen saturations at 90% or above. Review of a physician's order dated 12/31/2022 showed titrate oxygen to keep saturation above 90%. Review of Resident #15's care plan with a revision date of 06/27/2023 showed oxygen setting at 2L(Liters) per min as needed to keep oxygen saturation above 90%. On 10/16/2023 at 11:23 AM and 3:15 PM, the Surveyor observed Resident #15 receiving oxygen by nasal cannula at 4 liters. On 10/17/23 at 2:16 PM, the Surveyor observed Resident #15's oxygen concentrator set on 4-4.5 liters of oxygen. On 10/18/23 at 8:26 AM, the Surveyor asked the ADON (Assistant Director of Nursing) if she can tell me how many liters of oxygen Resident #15 was on. The ADON looked at Resident #15's electronic record and stated, She is on 2 liters of oxygen. The ADON confirmed Resident #15's concentrator was set on 4 liters. The Surveyor asked the ADON if she could check the care plan to see what care was planned for titration and are there parameters for how much oxygen is ordered for Resident #15? The ADON said, Your right, the care plan says 2 liters of oxygen as needed to keep her sats at 90% or above, and there are no parameters given for the oxygen. I will contact the doctor today to see if we can get orders for increased oxygen, and I will check her sats to see if she even needs more oxygen. Review on 10/19/2023 at 8:23 AM of policy titled Oxygen Administration dated 1/10/23 showed, set the flowmeter to the rate ordered by the physician, and monitor the Resident's response to therapy with a pulse oximeter as necessary.

Based on observation and interview, the facility failed to ensure food on the steam table was maintained at a temperature greater than 135 degrees Fahrenheit to prevent the potential for foodborne illnesses for residents who received foods from one of one kitchen. The findings are: On 10/18/23 at 11:28 AM, the Surveyor observed Dietary Employee #1 check the temperatures of the food on the steamtable before trays were served. The following temperatures were noted and written on the kitchen log by Dietary Employee #1; smoked sausage 150.8 degrees, hash brown potatoes 140.5 degrees, cabbage 183.0 degrees, mechanical soft smoked sausage 191.5 degrees, pureed smoked sausage 136.3 degrees, pureed hash brown potatoes 126.4 degrees, and pureed cabbage 123.4 degrees. On 10/20/23 at 9:29 AM, the Dietary Manager was interviewed and asked what is the temperature of the food on the steam table supposed to be? The DM stated, At least 165 for 15 seconds. DM was asked what are staff to do when temping food and it is not at the proper temperature? DM stated, Take if off and reheat it for 15 seconds and recheck it. DM was asked how would a new employee know what to do regarding the temperatures of food? DM stated, I go over the temperatures with the new employees and the temperatures are hanging up in the closet for them to see if they need it. Review on 10/20/23 at 10:00 AM, of facility policy titled Food Storage with a revision date of March 2004 showed, Hot foods or potentially hazardous food will leave the kitchen or steam table at 140 degrees F (Fahrenheit) or above.

Based on observation, interview and record review, the facility failed to ensure privacy and confidentiality was maintained for 1 Resident (Resident #2) of 6 sampled residents (Resident #2, #3, #9,#11,#18, and #32). The findings are: During observation on 10/16/23 at 10:38 AM, Licensed Practical Nurse (LPN) #1 walked away from the medication cart with a laptop screen open with Resident #2's picture, and medical information visible on the screen. During interview on 10/16/2023 at 10:39 AM, LPN #1 said when asked what her usual process is with the computer, I usually close it down, but I forgot. It is a HIPAA (Health Insurance Portability and Accountability Act) concern. During interview on 10/18/2023 at 2:50 PM, the Director of Nurses said nurses should lock the medication cart, and make sure nothing hazardous is left on top of the cart. If the computer screen is on, it should be set to hide the screen or close the laptop because it is a HIPAA violation when resident information is not kept confidential. Review on 10/19/2023 at 8:45 AM of facility policy titled Safety and Confidentiality of the Clinical Record. with a review date of 11/01/2019 showed, the facility must safeguard clinical record information against loss, destruction, or unauthorized use.

Based on observation, interview and record review, the facility failed to ensure the minimum data set [MDS] accurately reflected special treatments, procedures and programs including oxygen therapy for 1 Resident (Resident #15) of 6 sampled residents (Resident #3, #15, #19, #20, #25, and #266) with oxygen orders. This failed practice had the potential to affect 14 residents with oxygen orders. The findings are: Review of Resident #15's Order Summary Report showed a physician order dated 11/03/23 oxygen at 2 liters/minute per nasal cannula as needed to keep oxygen saturation at 90% or above. Record review of the annual MDS ( Minimum Data Set) with an assessment reference date [ARD] of 09/30/2023, and the Quarterly MDS with an ARD of 08/06/2023 section special treatments, procedures and programs did not reflect oxygen therapy. Review on 10/18/2023 at 2:00 PM of Resident #15's at vital sign records showed oxygen saturation was 81-97% from 08/30/2023-10/18/2023, while on nasal cannula. On 10/18/2023 at 2:25 PM, the MDS nurse said after looking at the nurse summary reports the oxygen should have been added to the MDS. Review on 10/19/2023 at 8:23 AM, of facility titled Resident Assessment Instrument Process with a revision date of 03/19/2023 showed, individualized care plans will be developed and updated as needed according to the data and resulting analysis.

Based on observation, interview, and record review, the facility failed to ensure two staff were present during van transportation, staff correctly secured residents into the van during transportation and failed to notify the licensed nurse or supervisor in a timely manner prior to transferring/transporting the residents after the facility van had to make an emergency stop when a car ran a stop sign resulting in 2 (Residents #1 and #2) residents being thrown forward out of their wheelchairs. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who required assistance of two people for transfers and sustained fractures to bilateral lower extremities. This failed practice had the potential to affect all 48 residents who may have required transportation in the facility van according to the Immediate Jeopardy Plan of Removal provided by the Administrator on 10/11/22 at 10:15 PM. The Assistant Administrator was notified of the Immediate Jeopardy condition on 10/11/2022 at 8:00 PM. The findings are: 1. Resident #1 had diagnoses of Diabetes Mellitus, [CONDITION(S)], Anxiety and [CONDITION(S)]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/13/22 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was dependent on two plus persons physical assistance for transfers and toilet use, limited physical assistance of one person with bed mobility and was independent with locomotion on and off the unit in a wheelchair. a. The Care Plan with a revision date of 7/14/22 documented, .Focus: The resident has an ADL [Activity of Daily Living] self-care performance deficit r/t [related to] impaired balance . Intervention: The resident requires Total assistance with mechanical lift by 2 staff to move between surfaces and as necessary . b. The DMS [Division of Medical Services] 762 - Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities provided by the Assistant Administrator on 10/11/22 at 1:30 PM documented, .Section I Reporting Information . Date and Time of Incident (if known) 9/14/2022 Time: 4:00PM .Date Incident Reported to OLTC [Office of Long Term Care]: 9/15/2022 Time: 06:00 AM . Section II - Complete Description of Incident: .It was reported by [Van Driver/Activities/Transportation], Resident and another resident were transported by her to [Eye Clinic] and [Doctor]. While in route to return to the nursing home with both residents, a car ran a stop sign at the corner of [Street] and [Street]. The nursing home van was traveling north on [Street]. CNA [Certified Nursing Assistant] braked the van suddenly to avoid hitting the vehicle that ran the stop sign. It was reported the resident slid from under the seat belt and moved forward in her wheelchair hitting the back of the wheelchair in front position of the van. Both wheelchairs were locked down in the van with proper tie downs. Both seatbelts were in place with both residents. However, it was noted when observed by the CNA after stop, that resident had removed her shoulder strap and put it under arm and around waist causing her to move forward in her wheelchair resulting in both knees hitting the back of the other resident's wheelchair. Resident did not hit her head and resident was found slouched in the wheelchair with both knees up against the back of resident in fronts wheelchair. After incident [CNA/Activities/Transportation] had reported this incident to LPN [Licensed Practical Nurse] that cared for both residents. Both residents were evaluated. It was noted by [LPN #1] that resident arrived back to facility at approximately 16:45 [4:45 PM]. Van driver/CNA [Name] reported that she was driving on the way back that a car ran a stop sign and she tried to avoid hitting the car and hit her brakes and resident slid down in her chair. Resident had complaints of leg pain. Range of motion performed. Resident was able to move both lower extremities and also able to move wheelchair back and forward with her legs. Vitals were taken and WNL [Within Normal Limits]. DON [Director of Nursing] and physician were notified. New order for X-ray ordered for bilateral legs and hips. Section III - Findings and Actions Taken - please include resident's current medical condition . X-ray reports concluded that resident had acute fractures of both lower extremities. On call APN [Advanced Practice Nurse] was notified of results that were received and order was given to 11-7 [11:00 PM to 7:00 AM] nurse, to treat for pain and contact primary first thing in morning for Ortho consult - recommends no weight bearing. The 11-7 nurse reported the information to the on-coming shift and [Doctor] received X-ray results. Gave orders to send resident to ER [emergency room ] for further evaluation. [Daughter], daughter/POA [Power of Attorney] at bedside and is notified of orders. Daughter stated she would like to ride with the resident. Non-emergent transport called at this time. After further investigation the following day (9/15/22) it was noted that both residents had claimed neither of them were secured with seat belt at the time of the incident. Both residents have a BIMS of 13 and both alert and orientated x [times] 4. After initial investigation CNA was suspended until investigation is completed. All staff was in-serviced on van policies and procedures. Also, staff was trained to never move resident in an emergent situation unless assessed by the nurse . Signed by the administrator and dated 9/19/22 . c The folder provided by the Assistant Administrator on 10/11/22 at 1:10 PM contained the Facility Reported Incident with the following witness statements: 1) The OLTC Witness Statement Form completed by CNA #1 documented, .Date 9/14/22 Time: a little after 4pm Witness Full Name: [CNA #1] Job Title: CNA Shift 4PM -8PM [4:00 PM to 8:00 PM] .State in your own words what you witnessed (be very descriptive) and sign below. went to the back door where van was, the instructor of the CNA wave me to go back but I step out and look in van. the instructor and [Van Driver] was lifting [Resident #1] from the floor in the lift pad. I turned and came back in the building, and no one said anything else to me about the incident. Signature of witness [CNA #1] Date 9/19/2022 . 2) The OLTC Witness Statement Form completed by CNA #2 documented, .Date 9/14/22 Time 4:15 PM Witness Full Name [CNA #2] Job Title CNA Shift 4-8 . State in your own words what you witnessed (be very descriptive) and sign below. When I made it outside! I saw [Name] (Teacher) Helping [Van Driver] pull [Resident #1] up in w/c [wheelchair] with the lift pad. Signature of witness [CNA #2] Date 9/19/22 . 3) The OLTC Witness Statement Form completed by the Van Driver/CNA/Activities/Transportation] documented, .Date 9/14/2022 Time 4:15PM Witness Full Name [Van Driver] Job Title Activities/Transportation . State in your own words what you witnessed (be very descriptive) and sign below: Two residents were transported by me to [Eye Clinic] and [Doctor]. While in route to return to the nursing home with both residents, a car ran a stop sign at the corner of [Street] and [Street]. The nursing home van was traveling north on [Street], I braked the van suddenly to avoid hitting the vehicle that ran the stop sign. Resident in the rear position slid from under the seat belt and moved forward her wheelchair hitting the back of the wheelchair in the front position. Both wheelchairs were locked down in the van with proper tie downs. Both seat belts were in place on both residents. However, it was noted when observed after stop, that resident in the rear position had removed her shoulder strap and put it under arm and around waist causing her to move forward in her wheelchair resulting in both knees hitting the back of front positioned wheelchair . d. The Health Status Note by LPN #1 dated 09/14/22 at 17:43 (5:43 PM) documented, .Resident arrived back to facility at approximately 1645 [4:45 PM]. Van driver/CNA [Activities/Transportation] reported that as she was driving on the way back that a car ran a stop sign and she tried to avoid hitting the car and hit her brakes and resident slid out of her chair. Resident complains of leg pain. Range of motion performed. Resident was able to move both lower extremities and also able to move wheelchair back and forward with her legs. Vitals were taken and WNL. X-ray ordered for bilateral legs and hips. Will continue to monitor . e. The x-ray report dated 9/14/22 documented, .Femur Right (2V) [2 View] AP [Anterior and Posterior] and Lat [Lateral]: .Findings: Comminuted fracture of femur proximal to distal femoral prosthesis . f. The X-ray report dated 9/14/22 documented, .Femur left (2V) AP and Lat: Findings: There is evidence of a fracture of the medial aspect left distal femoral metaphysis best seen on the AP view . g. The Health Status Note dated 9/15/22 at 03:57 [3:57 AM] documented, .X Ray report read off to on call, [Name] APRN [Advanced Practice Registered Nurse], states to treat to for pain and contact primary first thing in the morning for Ortho [Orthopedic] consult, recommends no weight bearing. Will pass on to oncoming shift to notify family after 0700 [7:00 AM] per facility policy . h. The Health Status Note dated 9/15/22 at 08:59 [8:59 AM] documented, .Dr [Doctor] [Name] received X-ray results this morning. Gave orders to send resident to ER [emergency room ] for further evaluation. [Name], daughter/POA [Power of Attorney], at bedside and is notified of orders. Daughter stated that she would like to ride with resident. Non-emergent transportation called at this time. Report given to ER physician . i. The ED (Emergency Department) Physician Documentation Note documented, .9/15 10:28 [AM] Into the emergency room complaint of pain to bilateral knees. Yesterday she was in van being transported from a clinic visit back to the nursing home. The vein [van] and this showed on the brakes she slid forward and landed on both knees. She had X-rays done at the nursing home that showed fractures bilateral distal femurs have around the prosthesis which were intact. In the emergency room today, she complains of more pain . 09/15 11:20 [AM] ED course: I discussed the case with Dr. [Name]. He is viewed the x-rays. Recommends knee immobilizer and office follow-up . j. The X-ray performed in the emergency room dated 9/15/22 at 11:12 AM documented, .Procedure: Right knee 2 views. Left Knee 2 views . Conclusion: 1. There are bilateral acute distal femoral fractures essentially nondisplaced on the left and minimally impacted on the right, complicating previous bilateral total knee arthroplasties with posttraumatic joint effusion . Severe diffuse osteopenia is noted . k. The Health Status Note dated 9/15/22 at 12:46 PM documented, .resident arrived at this time from [Hospital] ER via ambulance transport x3 EMTS [Emergency Medical Technicians]. Resident is now in bed eating lunch. Received orders from MD [Medical Doctor] for (1) Resident to be non-weight bearing, (2) Knee brace bilaterally, and (3) Consult with [Doctor]. Appointment made at this time for 9/16/22 @ [at] 1:45pm. [Daughter], daughter/POA, is at bedside and is notified . l. The Orders - Administration Note dated 09/16/22 at 04:00 [AM] documented, .[MEDICATION(S)] Tablet 10-325 MG [milligram] Give 1 tablet by mouth every 6 hours as needed for Pain CNA called this nurse into resident's room. Resident has c/o [complaint of] bilateral knee pain that is intense. Resident hollered in pain. PRN [As Needed] medication requested and given at this time . m. The Health Status Note dated 9/16/22 at 20:38 [8:38 PM] by LPN #1 documented, .Resident had DR. appointment today with [Doctor]. Resident came back with orders to wear left knee immobilizer at all times and also no weight bearing to left femur. Resident says that she only wants to take her PRN [MEDICATION(S)] if she is in extreme pain, if not she only wants Tylenol because the [MEDICATION(S)] makes her too sleepy. Will continue POC [Plan of Care] . n. On 10/11/22 at 9:37 AM, Resident #1 was lying in bed with her legs elevated on pillows. The Surveyor asked Resident #1, Do you have a problem with your legs? Resident #1 stated, The left has a soft cast on it, and I must keep the right straight all the time. I hurt them both when I was in the wreck. It has really set me back. The Surveyor stated, I am making rounds, but is it alright if I come back and talk with you? Resident #1 stated, That will be fine. The Surveyor asked, Who were you in the wreck with? Resident #1 pointed to her roommate and stated, We were both going to the doctors that day, so we were in the van together. o. On 10/11/22 at 11:35 AM, Resident #1 was lying in bed with her legs elevated on pillows. The Surveyor asked, When did the accident, when you were in the van happen? Resident #1 stated, I can get mixed up on dates, so I cannot tell you the actual date. The Surveyor asked, Where were you going in the van when the accident happened? Resident #1 stated, I was coming back from an eye doctor's appointment. The Surveyor asked, Was your roommate in the van with you at the time the accident happened? Resident #1 stated, Yes, we were both coming back to the nursing home after our appointments. I did not really see what happened. My roommate had been to another eye doctor. [Van Driver] was driving the van. I saw a car coming but I did not know it was going to run the stop sign. [Van Driver] stopped real quick and we did not have our seat belts on. I was thrown out of the wheelchair, and I think it landed on top of me. My legs were bent the wrong way. [Van Driver] got in the back of the van, and she told me just to stay still. I think one of my legs was bent under my roommate's chair. She left me on the floor and drove back to the nursing home. The Surveyor asked, Did the van driver call anyone when the accident happened? Resident #1 stated, Not that I am aware of, but when she got back to the nursing home there were a few people gathered. The Surveyor asked, Where did the driver park the van at nursing home? Resident #1 stated, She went to the back where she usually parks the van. The Surveyor asked, Were you at the back of the van and your roommate in the front? Resident #1 stated, Yes. She had someone waiting at the door. [Van Driver] told her to come and help me up. The Surveyor asked, How did they get you up from the floor? Resident #1 stated, [Van Driver] got behind. The other lady got in front, and they picked me up and put me in the wheelchair. The Surveyor asked Resident #1, Did it hurt when they moved you? Resident #1 stated, Oh yes. Just moving my legs hurt. The Surveyor asked, What did they do after they got you back in the wheelchair? Resident #1 stated, She went to the back and got me out like she usually does. The Surveyor asked, When the van driver took you to the doctor's appointment, did she put your seat belt on? Resident #1 stated, No. No seat belt was worn at any time. The only thing she did was fix the lift thing in the back to get us out of the van. The Surveyor asked, Is [Van Driver] the one who usually drives the van? Resident #1 stated, Yes. The Surveyor asked, When Van Driver] has taken you to other appointments did she fasten your seat belt? Resident #1 stated, I don't really remember her taking me anywhere else, but other residents have told me she did not buckle them up. The lady across the hall who goes to [CONDITION(S)] told me she doesn't buckle her up. Shouldn't she get some kind of citation for not doing what she is supposed to do. She got fired I believe. She has not been here since. The Surveyor asked, What did the van driver do after she got you off the van? Resident #1 stated, She took me to my room. I do not remember exactly what happened, that was a lot of trauma. The Surveyor asked, Did they take you to the hospital? Resident #1 stated, Yes they did, but that was later. The Surveyor asked, What did they tell you at the hospital? Resident #1 stated, They said both my legs had fractures and the left was worse than the right. I don't like the doctor I saw in the emergency room . I saw a doctor in [City] when I got my knees replaced and I want to see him and the other person he works with. The Surveyor asked, Since this happened have you been able to get out of bed? Resident #1 stated, I stay in bed most of the time. If I do get up, my legs get to hurting and I need to get back to bed. Sometimes it may take a little while for them to get me back to bed. When this happened, I was just about to be walking again and this has thrown me back to the beginning. The Surveyor asked, Were you receiving therapy before the accident? Resident #1 stated, Just a few days a week. Before it happened, I was using my legs to move the wheelchair. I cannot walk in the wheelchair now because I must keep my legs straight. The resident lifted her bed covers and showed the surveyor her legs. There was an immobilizer on the left leg and the right leg was lying straight. Both legs were elevated on a pillow. Resident #1 stated, It is so depressing to not be able to do anything. The facility staff is having a meeting with me and my daughter about this tomorrow. The van driver has been here for [AGE] years, and she knows she was supposed to put my seat belt on. Others have said she should have called the ambulance. We should have been treated earlier. I think she was trying to cover up what happened. When you are riding on the van you are trusting them to do what they are supposed to do. p. On 10/11/22 at 2:30 PM, the Surveyor asked the DON What is [Employee's first name] last name, that first name was written on a witness statement in [Resident #1's] Facility Reported Incident, I did not see anyone with that first name on the CNA or Licensed Nurse schedule? The DON stated, Her last name is [Maintenance Employee #1.] The Surveyor asked, What does she do at the facility? The DON stated, She works Central Storage. The Surveyor asked, Where is she now? The DON stated, She is out driving the van. The Surveyor asked. Is she a CNA? The DON stated, No. The Surveyor asked, What hours does she work? The DON stated, She works 8am to 5 [5:00] pm. The Surveyor asked what hours does [Activity Assistant] work? The DON stated, She works during the week, but she works on the weekend usually on Sunday as an aide. She also works on the weekend doing activities. The surveyor informed the DON that she wanted to speak with [Maintenance Employee #1] when she came back from driving the van. q. On 10/11/22 at 3:05 PM, the Surveyor asked Maintenance Employee #1, How long have you worked for the facility? Maintenance Employee #1 stated, I have worked for the facility 23 or [AGE] years. The Surveyor asked, What department do you work in? Maintenance Employee #1 stated, I work in the Maintenance Department. The Surveyor asked, What are your duties? Maintenance Employee #1 stated, I control storage and put-up supplies. The Surveyor asked, Do you drive the facility van? Maintenance Employee #1 stated, Sometimes I drive the van. The Surveyor asked, Are you familiar with the incident that happened in September with the van? Maintenance Employee #1 stated, Kind of, but not really. I know there was an accident. The Surveyor asked, Who was driving the van that day? Maintenance Employee #1 stated, [ Activities/Transportation] was driving. The Surveyor asked, Were you there when the van came back after the accident happened? Maintenance Employee #1 stated, I was working that day, but I was not around when the van came back. The Surveyor informed Maintenance Employee #1, There is a witness statement that mentions someone being there with the same first name as you helping get the resident back into her wheelchair. There is no last name mentioned in the statement. Maintenance Employee #1 stated, I did not help move the resident. They had a teacher with the same first name as mine who teaches the CNA classes. The Surveyor asked, Was that person just in the facility to teach classes? Maintenance Employee #1 stated, I am not really sure. The Surveyor asked, When you drive the van, does another employee go with you? Maintenance Employee #1 stated, Yes. The Surveyor asked, Are you involved with the resident when you are on the van? Maintenance Employee #1 stated, I am just the driver. They always have a CNA or a nurse go with the patient. The Surveyor asked, Do you strap the resident into the van? Maintenance Employee #1 stated, No ma'am, the other staff member does, but we have all been trained on how to do it correctly. The Surveyor asked, Have you been retrained since the van accident in September? Maintenance Employee #1 stated, Yes ma'am. The Surveyor asked, Who did the training? Maintenance Employee #1 stated, [Employee Name] did the training. The Surveyor asked, What does [Employee Name repeated] do at the facility? Maintenance Employee #1 stated, He is the Maintenance Supervisor. The Surveyor asked, How did he do the training? Maintenance Employee #1 stated, He went through the whole procedure. The lift gait, buckling in the resident. I also watched a video. He covered rolling onto the lift, the belt strap in behind the resident. The importance of communications. Transferring into the van, locking the wheelchair, lock straps and putting on the seat belt. Locking the straps at the bottom and raising the gait. The Surveyor asked, How often do you assist with transport? Maintenance Employee #1 stated, I did not do it that often prior to the incident, but I am doing it more now. r. On 10/11/11 at 3:25 PM, the Surveyor asked LPN #1, How long have you worked at this facility? LPN #1 stated, I started work here January 5th of this year. The Surveyor asked, Where in the facility do you work? LPN #1 stated, I work on A wing. The Surveyor asked, Were you working on September 14th when the accident with the van happened? LPN #1 stated, Yes. The Surveyor asked, When did you find out there had been an accident on the van? LPN #1 stated, I was doing my medication pass at about 4:45 PM. [Resident #2] was wheeling herself in. I asked the aide if [Resident #1] and [Resident #2] went to the doctors together because I had not seen [Resident #1] come back with [Resident #2]. Then I saw [Resident #1] and they were wheeling her in backwards which was not usual. This made me wonder what was going on. Normally she can propel herself with her feet, she tires but she can do it. The Surveyor asked, Who brought [Resident #1] back? LPN #1 stated, [Activities/Transportation] did. [Activities/Transportation] came to me and said that [Resident #1] wanted to get an x-ray. She said her legs were hurting. I was on the hall passing medications close to [Resident #1's] room and I asked [Activities/Transportation] why she needed an x-ray. She told me someone ran a stop sign and she had to jam on the brakes and the resident slid out of her chair. This concerned me. I wondered why this had not been reported to me. I was her nurse. I put [Activities/Transportation] on the phone with [Assistant Director of Nursing (ADON)] and she told him what had happened. I called for an order for x-rays. I got [Resident #1's] vital signs and they were fine, but she complained that both legs were hurting. They came to the facility to do the x-ray, but it was later in the shift. The results came back on night shift, and I found out when I came back to work the next day that her legs had fractures. She had said that certain movement made her hurt bad. I was upset that it was not reported to me when it happened because I would have had them call an ambulance to come and pick her up. The Surveyor asked, Did [Resident #1] go to the hospital? LPN #1 stated, I think they sent her out when they got the results of the x-ray. The Surveyor asked, Did you evaluate [Resident #2] after the accident? LPN #1 stated, It was a while before I knew because they came in separately. I talked to [Resident #1] and [Resident #2] at the same time. I put in a note on [Resident #2]. She told me she was okay, but they did check her out later. The Surveyor asked, Did [ADON] talk with you after he spoke with [Activities/Transportation]? LPN #1 stated, Yes. He told me to chart everything, have [Activities/Transportation] do a witness statement since she was there when the accident happened. The Surveyor asked, Did you have [Activities/Transportation] write the statement? LPN #1 stated, Yes, she wrote the statement that evening and [ADON] stated we would go from there. The Surveyor asked, Was there any training done after the incident? LPN #1 stated, Yes there was a meeting. I cannot remember all the specifics, but I know it covered van safety. The Surveyor asked, Do you know if any other staff member was with [Activities/Transportation] that day when she transported the two residents to the eye doctor? LPN #1 stated, I don't know. The Surveyor asked, Who helped [Activities/Transportation] to get [Resident #1] back into her wheelchair after the accident? LPN #1 stated, I do not know. s. On 10/11/22 at 4:05 PM, the Surveyor asked the DON, Who is the other [Employee's first name] that is referred to in the witness statements to do with the van accident that involved [Resident #1]? The DON stated, She is an LPN who was a CNA instructor. The Surveyor asked, Is she an employee at the facility? The DON stated, No. She came in to teach a class. The Surveyor asked, Is the ADON here today? The DON stated, No he is off, but he will be back tomorrow. The Surveyor asked, Who transports the residents in the van? The DON stated, [Activity Assistant and Restorative Aide] and the Treatment Nurse. The Surveyor asked, Does [Activities/Transportation] still work for the facility? The DON stated, She is suspended. The Surveyor asked, What was the date when she was first suspended? The DON stated, I do not know the date, but I will find out. t. On 10/11/22 at 4:20 PM, the Surveyor asked CNA #1, How long have you worked for the facility? CNA #1 stated, I worked for the facility for [AGE] years and then I stayed home for a year. I came back to work 4:00 PM to 8:00 PM Monday to Wednesday. The Surveyor asked, What do you do from 4:00 PM to 8:00 PM? CNA #1 stated, I float between the halls and pass ice, assist with feeding the residents and putting the residents to bed. The Surveyor asked, Do you know about the accident with the van that happened September 14th? CNA #1 stated, Yes I know about the accident. The Surveyor asked, How did you find out about the accident? CNA #1 stated, I was passing ice and I saw people going to the back door where the van was. I went back there to see what was going on and they told me to go back, but I did step out and looked inside the van. The Surveyor asked, Where was [Resident #1] when you looked inside the van? CNA #1 stated, They were lifting her off the floor of the van. The Surveyor asked, Who was lifting her off the floor of the van into her wheelchair? CNA #1 stated, The CNA Instructor and [Activities/Transportation]. The Surveyor asked, Did the resident say anything? CNA #1 stated, She did not say anything to me. The Surveyor asked, Did the facility do any training after the van accident? CNA #1 stated, [ADON] had us sign a paper saying that we would report straight away if there was an accident or anything like that happened again. The Surveyor asked, Do you drive the van? CNA #1 stated, I used to drive the van, but I don't drive it anymore. The Surveyor asked, When you did drive the van did the facility train you on van safety? CNA #1 stated, Yes, we had a full training course. u. On 4/11/22 at 4:25 PM, the Surveyor asked CNA #2, How long have you worked for the facility? CNA #2 stated, I worked for the facility for [AGE] years. I retired in May of last year and I came back in January of this year. I work 4:00 PM to 8:00 PM Monday through Wednesday. The Surveyor asked, What do you do when you are at work? CNA #2 stated, We assist with patient care, help feed, anything the residents need us to do. The Surveyor asked, Did you work on September 14th when there was an accident with the van? CNA #2 stated, Yes I did. The Surveyor asked, How did you find out there had been an accident with the van? CNA #2 stated, I saw people running to the back of the building. [Activities/Transportation] and the trainer were in the van. I went to the back of the van. [Resident #1] was in the wheelchair. They were straightening her up in the chair using the lift pad when I got out there. The Surveyor asked, Did the facility do any training after the van accident? CNA #2 stated, Not to my knowledge. The Surveyor asked, Do you drive the van? CNA #2 stated, No, I never drove the van. The Surveyor asked, Was [Resident #1] on the floor of the van? CNA # stated, Not when I was there. I just assumed she was because I saw the nurse [CNA Instructor] running out there. v. On 4/11/22 at 4:35 PM, the DON stated, [Activities/Transportation] was suspended on 9/15/22. w. On 4/11/22 at 4:50 PM, the Surveyor asked the Maintenance Supervisor, How long have you worked for the facility? The Maintenance Supervisor stated, I have worked for the facility for [AGE] years. The Surveyor asked, Do you do the training for staff who transport the residents on the van? The Maintenance Supervisor stated, Yes. The Surveyor asked, Are there always to be two people on the van for resident transportation? The Maintenance Supervisor stated, There are supposed to always be two. The Surveyor asked, Were there two people on September 14th when the accident on the van occurred? The Maintenance Supervisor stated, I don't know if there were two that day. The Surveyor asked, Should there have been two people on the van that day? The Maintenance Supervisor stated, They would have had to go up and down on the lift when they got on and off and there should be an operator and an assistant. I always stress the importance of communication during my training. There should always be two people, or they should reschedule the appointment. The Surveyor asked, How many people are trained to do van transportation. The Maintenance Supervisor stated, 6 or 7 people. They know not to do the transport unless there are two people. The Surveyor asked, Have there been any other accidents on the van? The Maintenance Supervisor stated, Yes, there was one in 2018, but it was different circumstances. The Surveyor asked, Do you know what happened on September 14th when the accident occurred? The Maintenance Supervisor stated, I did not see any of it. I did not know there had been an accident until the day after it happened. The Surveyor asked, How do you do the van training? The Maintenance Supervisor stated, I do demonstration and give staff a copy of the DDS [Department of Drivers Services] training. I also go over this. The Maintenance Supervisor handed the Surveyor a copy of the Manufactures Instruction Guide titled, QRT SERIES USER INSTRUCTIONS. The Maintenance Supervisor stated, There is a copy of the sheet on the inside wall of the van so the staff can look at it if they need to. They also have to look at the video . The Surveyor asked, How often do you retrain the staff that do transportation? The Maintenance Supervisor stated, We have just decided that we are going to do it annually from now on. Up to now we just did the initial training, and I would monitor for the first month to be sure they were doing it correctly. We do have one resident that has a port in her chest, and we have to put the seatbelt strap under her arm not across her chest so as not to hit the port. x. The Manufacturers Instruction Guide titled, QRT SERIES USER INSTRUCTIONS, provided by the Maintenance Supervisor on 10/11/22 at 4:50 PM documented, .B SECURE PASSENGER 1. Attach Lap Belts - Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armres[TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure Licensed Practical Nurse (LPN) #1 and #2 washed/sanitized her hands between residents during medication pass observations on 2 (Primrose Hall and Marigold) 4 of halls, to prevent the potential spread of infection. The failed practices had the potential to affect 26 residents who resided on Primrose Hall and Marigold Hall and received care from licensed Practical Nurses (LPNs #1 and #2), according to the list provided by the administrator on 7/18/22. The findings are: On 7/20/22, the following observations were made during a medication pass conducted by LPN #1 and #2 on Primrose and Marigold Halls: a. On 07/20/22 at 11:14 AM, Licensed Practical Nurse (LPN) #1 was walking down the hall and came to the medication cart and started getting gloves and glucometer and supplies out of the drawer. She then put everything on top of the cart, put on her gloves and went into resident's room and proceeded to obtain blood sugar. She then came out of the resident's room, took off her gloves and disposed of them in the trash and then got on to the computer to chart. She got the insulin out, drew up what she needed, put on gloves, and then went into resident's room and administered the insulin without any hand hygiene. She then pushed the cart to the next resident's room, brought up their medications on the computer, grabbed a medication cup and opened the drawer. She was asked, Did you sanitize your hands after taking a resident's blood sugar and then giving insulin? She stated, Oh no ma'am, I got a little nervous with you watching me but normally I do. She then sanitized her hands and then proceeded to set up the resident's medications. She went into resident's room and gave the medications by handing the resident the medication cup and taking it back after she took the medications, then handed her the water cup and took it back after the resident sipped it herself. She asked the resident if she wanted her [MEDICATION(S)] gel and then went to med cart and got the medication tube out, put on gloves and gave her the medicine. She then took off gloves and got on the computer to chart without doing any hand hygiene. She then started setting up another resident's medications and went to that resident with a med cup and administered the medications. She then came back to the cart and got on the computer without doing any hand hygiene. b. On 07/20/22 at 11:51 AM, LPN #2 obtained blood sugar and then went to the computer to chart and put her hand on the med cart handle on the side. She opened drawer and reached in and grabbed an insulin syringe. She went to the medication room and got insulin out of fridge and drew it up. She went back to medication cart and grabbed an alcohol pad and went into the resident's room and put on gloves and gave insulin to the resident, then came back out to cart took off gloves and went to computer and charted insulin. She was asked, Did you do hand hygiene after taking blood sugar and giving insulin? She stated, I used the hand sanitizer on the side of the cart. Surveyor stated, I didn't see you do it. She stated, Well that's what I usually do. c. On 7/21/22 at 10:33 AM, the Director of Nursing (DON) was asked, When should hand hygiene be done during medication pass? He stated, Before and after each resident. Anytime doing blood sugar checks, feeding tube placement checks. I was told if it's wet and not yours do hand hygiene. In between each time going resident to resident. d. A facility policy received from the DON on 7/21/22 titled Medication Administration documents .2. Wash your hands before administering medication to any resident and between contact with other residents or duties. If soap and water are not readily available, use hand sanitizer .

Based on observation, interview and record review, the facility failed to ensure a feeding tube placement was verified before beginning a feeding in accordance with acceptable standards of practice for 1 (Resident #22) of 4 (Resident #22, 41, 43 and one non-sample) residents that have feeding tubes. The findings are: Resident #22 was admitted on [DATE] had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set with an Assessment Reference Date of 5/8/22 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and had a feeding tube. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Care plan with a revised date of 5/29/20 documented, .Check for tube placement and gastric contents/residual volume per facility protocol and record . d. On 07/20/22 at 12:01 PM, Licensed Practical Nurse (LPN) #2 put on gloves and picked up a piston syringe and brought it into the resident's room. She put 60 ml (milliliters) of water in syringe hooked up to PEG [Percutaneous Endoscopic Gastronomy] tube and fed in by gravity. She was asked, Did you check placement? She sighed and stated, No, and I should have. She continued to let the water flow by gravity per syringe into tube. She then poured the feeding into a gravity bag and hooked up the bagged feeding to PEG tube without checking placement. e. On 7/21/22 at 10:33 AM, the Director of Nursing (DON) was asked, When do you check placement of a feeding tube? He stated, Before and after a feeding or medication administration. f. A facility policy titled Enteral Nutritional Therapy received on 7/21/22 from the DON documents . Check position of tube by: a. Listening for breath sounds at end of tube .b. Checking the length of tube for proper positioning .c. Placing stethoscope over stomach and install a small amount of air into enteral feeding tube. Listen for air to enter stomach. d. Check residual stomach contents .

Based on observation, record review, and interview, the facility failed to ensure a nebulizer mask was properly stored to prevent the potential for contamination for 1 (Resident #23) of 8 (Residents #1, #11, #23, #26, #29, #36, #44, and #199) sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #15, #23, #26, #42, and #199) sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/2021 documented the resident scored 9 (8 - 12 indicates moderately impaired) per a Brief Interview Mental Status (BIMS); required extensive to total assistance for activities of daily living self-performance skills with one to two person physical assist and received oxygen therapy. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care dated 04/23/2021 documented, .The resident has altered respiratory status/difficulty breathing r/t [related to] Anxiety, Sleep Apnea, [CONDITION(S)].Give aerosol or bronchodilators as ordered: [MEDICATION(S)] NEBULIZATION SOL [solution] 2.5MG /3ML 0.083% 3ML INHALE ORALLY VIA NEBULIZER BID [twice a day] . c. On 05/03/21 at 11:22 A.M., Resident #23 was lying in bed with O2 (oxygen) at 2 LPM/NC (liters per minute/per nasal cannula). An updraft machine was on the bedside table with the nebulizer mask uncovered. The nebulizer mask was dated 4/17/21. d. On 05/04/21 at 1:31 P.M., Resident #23 was lying in bed receiving O2 at 2 LPM/NC. Nebulizer mask was uncovered. e. On 05/06/21 at 3:47 P.M., Licensed Practical Nurse, (LPN) #2 was asked, How often are the nebulizer masks changed? She stated, Every week. She was asked, What is the date on [Resident #23's] nebulizer mask? She took the nebulizer mask off the updraft machine and looked at the date and stated, 4/17/21. After seeing the date, she stated, It may be every two weeks. LPN #2 was asked if the resident was still receiving updraft treatments using the mask. She stated, Yes, she is getting them twice a day. f. The Facility's Oxygen Therapy Aerosol Treatment Policy documented, Standard-Aerosol treatments . are administered to improve the respiratory status of a resident/patient. Procedures-Store oxygen sets in plastic bag. Change oxygen sets twice monthly or as needed. 2. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an of 02/21/2021 documented the resident scored 8 (8-13 indicates moderately impaired) on a BIMS; required extensive assistance with toileting and bed mobility and received oxygen therapy. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 90 or above . b. The Care Plan with a revision date of 12/10/20 documented, . Focus: The resident has shortness of breath (SOB) R/T HX [History] of Pulmonary Embolism with respiratory failure and nasal congestion . Goal: The resident will have no complications related to SOB (Shortness of Breath) . Intervention . OXYGEN 2-3 L NC PRN SOB OR TO KEEP O2 SATS @ 90% OR ABOVE . c. On 05/03/21 at 11:09 A.M., Resident #13 was sitting up in the recliner with oxygen in use per nasal canula at 1.5 liters minute. d. On 05/03/21 at 12:55 P.M., Resident #13 was lying in bed with her eyes closed. Oxygen was in use at 1.5 liters per minute per nasal canula. e. On 05/04/21 at 8:28 A.M., Resident #13 was sitting up in bed. Oxygen was in use at 1.5 liters per nasal canula. f. On 05/04/21 at 2:22 P.M., Resident #13 was lying in bed with her eyes closed. She had oxygen in place at 1.5 liters per nasal canula. g. On 05/05/21 at 9:50 A.M., Resident #13 was sitting up in her recliner. Oxygen was in use between 1.5 - 2.0 liters per minute per nasal canula. h. On 05/05/21 at 10:15 A.M., LPN #3 was asked to accompany the surveyor to Resident #13's room. LPN #3 was asked, What is [Resident #13's] oxygen flow rate set at? LPN #3 stated, It is set between 1.5 and 2 liters. LPN #3 was asked, Do you know what it should be set at? LPN #3 stated, It should be set at 2 liters. LPN #3 was asked, Who is responsible for making sure the oxygen flow rate is correct? LPN #3 stated, I am responsible, the nurse. LPN #3 was asked, How often should the oxygen flow rate be checked? LPN #3 stated, It should be checked once a shift. LPN #3 was asked, Should doctors' orders for oxygen flow rate be followed? LPN #3 stated, Yes, they should. i. On 05/05/21 at 03:05 P.M., the Assistant Director of Nursing (ADON) was asked, Who is responsible for ensuring that the resident's oxygen is set at the correct flow rate? The ADON stated, It is the nurse's responsibility. The ADON was asked, How often should the residents' oxygen flow rate be checked? The ADON stated, It should be checked at least once daily. The ADON was asked, Should doctors' orders for oxygen flow rate be followed? The ADON stated, They should always be followed. j. An Oxygen Administration policy provided by the Administrator on 05/06/21 at 4:00 P.M. documented, . PURPOSE To deliver oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues . Procedure 1. Check the physicians order for liter flow and method of administration . 5.e. Set the flowmeter to the rate ordered by the physician . 10. At regular intervals, check liter flow .

Based on observation, interview and record review, the facility failed to ensure facial hair was removed for 3 (Resident #30, #31 and #33) and nails were clean and trimmed for 3 (Resident #13, #22 and #33) of 14 (#36, #1, #47, #11, #13, #6, #15, #23, #55, #27, #22, #33, #44 and #31) sampled residents who required assistance with personal hygiene. This failed practice had the potential to affect 32 residents who were dependent on staff for personal hygiene according to lists provided by the Assistant Director of Nursing on 5/6/21. The findings are: 1. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2021 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS); required two person extensive assistance with bed mobility, dressing and personal hygiene; and one person physical assist in bathing activity. a. On 5/3/21 at 11:30 a.m., Resident #31 was in the Dining Room. She had facial hair on her chin approximately ¼ inch long. b. On 5/4/21 at 2:00 p.m., Resident #31 was in her wheelchair propelling herself in the hall. She had facial hair on her chin. c. On 5/6/21 at 1:18 p.m., Resident #31 was sitting in the hall. She had facial hair on her chin. 2. Resident #30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 03/21/2021 documented the resident scored 6 (0-7 indicates severely impaired) on a BIMS; was independent with bed mobility and transfer; required supervision with dressing; personal hygiene and bathing. a. On 5/3/21 at 11:35 a.m., Resident #30 was in the Dining Room. She had facial hair on her chin approximately ½ inch long. b. On 5/3/21 at 1:37 p.m., Resident #30 was sitting in a chair in her room watching TV, she had facial hair on her chin. c. On 5/4/21 at 1:25 p.m., Resident #30 was in her room. She had facial hair on her chin. Resident #30 was asked, Does the facial hair bother you? She states, Yes, I try to pull them out myself. d. On 5/5/21 at 3:21 p.m., Resident #30's facial hair was gone. Resident #30 stated her family member plucked her chin. 3. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 03/07/2021 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS); required extensive assistance with bed mobility, dressing and personal hygiene; and was totally dependent for bathing. a. On 5/3/21 at 11:00 a.m., Resident #22 was in his room lying in bed. His nails were past his fingertips, sharp and had brown debris under the nails. b. On 5/4/21 at 8:40 a.m., Resident #22 was sitting up in a chair at his bedside. His fingernails were long and sharp with brown debris under them. c. On 5/5/21 at 12:30 p.m., Resident #22 was up in a chair, his nails were approximately ¼ inch long with brown debris underneath nails. 4. Resident #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 5/3/21 at 2:21 p.m., Resident #33 was lying in bed. She had facial hair ¼ inch long and her nails were jagged and had brown debris underneath them. (Photo taken.) b. On 5/4/21 at 12:47 p.m., Resident #33 was lying in bed watching TV. She had ¼ inch facial hair and her fingernails were ¼ inch long, jagged and had brown debris underneath them. c. On 5/5/21 at 1:50 p.m., Resident #33 was in her room lying in bed. Her fingernails nails were jagged and had brown debris underneath them and she had ¼ inch facial hair. 5. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 02/21/2021 documented the resident scored 8 (8-13 indicates moderately impaired) on a BIMS, was dependent for bathing, required extensive assistance for personal hygiene and had no rejection of care. a. The Care Plan with a revision date of 06/15/20 documented, . Focus: The resident has an ADL self-care performance deficit r/t [related to] age, frailty and unsteady gait and balance . Interventions: . PERSONAL HYGIENE/[and or]ORAL CARE: EXTENSIVE ASSIST X [times] 1 STAFF . b. On 5/3/21 at 3:27 p.m., Resident #13 was lying in bed with her right hand on the outside of her bed covers. The fingernails on her right hand were jagged and had a brown substance under them. c. On 5/4/21 at 8:31 a.m., Resident #13 was lying in bed. The fingernails on her right hand were jagged and had a brown substance under them. (Photo taken.) d. On 5/5/21 at 9:53 a.m., Resident #13 was sitting up in a chair. The fingernails on each hand extended approximately 1/8 to 1/4 inch past the end of the nail bed, were jagged in appearance, and had a brown substance under some of the nails. 6. On 5/6/21 at 1:23 p.m., Certified Nursing Assistant (CNA) #1 was asked, Who is responsible for nail care? CNA #1 replied, We are unless they are Diabetic and then the nurse trims their nails. CNA #1 was asked, Should the ladies have facial hair? CNA #1 replied, No, we shave them if they want. CNA #1 was asked, How often should nail care and shaving be done? CNA #1 replied, Nail care every Sunday, and if I notice facial hair, I shave it off. 7. On 5/6/21 at 1:35 p.m., CNA #2 was asked, Who is responsible for nail care? CNA #2 replied, We are. CNA #2 was asked, Should the ladies have facial hair? CNA #2 replied, No, we shave them if they want. CNA #2 was asked, How often should nail care and shaving be done? CNA #2 replied, Nail care is done every Sunday, and I shave the ladies facial hair if they want. 8. On 5/6/21 at 1:55 p.m., CNA #4 was asked to accompany the surveyor to Resident #13's room. CNA #4 was asked, Can you describe [Resident #13's] fingernails? CNA #4 stated, Some of the nails are jagged, but she picks and scratches all the time. CNA #4 was asked, How much help does [Resident #13] require with nail care? CNA #4 stated, We have to do her nails, but I did not do them today. CNA #4 was asked, Who is responsible for doing nail care on the residents? CNA #4 stated, We are all responsible. The nurses and the aides. CNA #4 was asked, How often should nail care be done? CNA #4 stated, It should be done when we are giving the residents their bath. CNA #4 was asked, Does [Resident #13] refuse nail care? CNA #4 stated, Sometimes she will, if she wants to sleep. CNA #4 was asked, Why is it important to ensure residents nails are clean and not jagged? CNA #4 stated, Jagged nails can cause skin tears and dirty or jagged nails could cause an infection. 9. On 5/06/21 at 2:00 p.m., Licensed Practical Nurse (LPN) #3 was asked to accompany the surveyor to [Resident #13's] room. LPN #3 was asked, Can you describe [Resident #13's] fingernails to me? LPN #3 stated, The nails are jagged, and her nails need cleaning. LPN #3 was asked, Who is responsible for doing nail care on the residents? LPN #3 stated. Any of the nursing staff can do nail care. The nurses have to cut the diabetic nails. LPN #3 was asked, How often should nail care be done? LPN #3 stated, Normally the residents get their nails cleaned and clipped on the weekend, but they can be done as needed. LPN #3 was asked, Does [Resident #13] refuse nail care? LPN #3 stated, Yes she does refuse at times. LPN #3 was asked, Why is it important ensure resident nails are clean and free of jagged edges? LPN #3 stated, It stops accidental injury if the nails are not jagged or misshaped, and it helps prevent infection it they are clean and cut. 10. On 5/6/21 at 2:20 p.m., the Assistant Director of Nursing (ADON) was asked, Who is responsible for nail care? The ADON replied, The nurses take care of the diabetic residents and the CNA's take care of the rest of the residents. The ADON was asked, Should the ladies have facial hair? The ADON replied, No, their CNA takes care of that. The ADON was asked, How often should nail care and shaving be done? The ADON replied, Nail care is done weekly. 11. A Nails, care of (fingers and toes) policy provided by the ADON on 5/6/21 at 2:52 p.m. documented, . Basic responsibility: Licensed nurse performs the procedure on high risk residents. Nursing assistants may perform the procedure if the resident is not at risk for complication of infection. Purpose: 1. To provide cleanliness 2. To prevent the spread of infection 3. For comfort 4. To prevent skin problems . Procedure: 1. Soak hands if able in basin of warm water, if unable then wash hands well . 3. Trim and clean nails, file smoothly .

Complaint # (AR 616) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure the van lift platform was properly positioned prior to offloading a resident in a wheelchair, which resulted in a fall with injuries for 1 (Resident #1) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who required a wheelchair during transport in the facility van. The facility also failed to ensure the van's safety restraints were applied per manufacturer's instructions to prevent potential injury for 1 (Resident #3) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents who required a wheelchair during transport in the facility van. These failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who was offloaded from the van in his wheelchair with the van lift improperly positioned, and Resident #3, whose seat belts were improperly applied, and had the potential to cause more than minimal harm to 21 residents who required a wheelchair when being transported via the facility van in the last 30 days, according to a list provided by the Director of Nursing (DON) on 10/9/19 at 8:15 a.m. The Assistant Administrator was informed of the Immediate Jeopardy condition on 10/8/19 at 1:07 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 9/19/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required limited one person physical assistance for bed mobility, required extensive two-plus person physical assistance for transfers, was independent with locomotion on and off the unit with setup help only, had functional limitation in range of motion in the lower extremity on one side; and required a wheelchair for mobility. a. A facility Incident Report dated 10/2/19 at 11:30 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .This nurse was talking to DON in the hallway on the outside of A-Wing Nurse's Station when Restorative CNAs (Certified Nursing Assistants) opened the van door and yelled, 'We need a nurse'. This nurse and DON ran outside and seen (saw) resident lying on right side on the ground behind the wheelchair van. Resident assessed. Resident stated he bumped his head a little, 0 (no) visible injury, pupils equal and reactive. Resident able to move upper extremities and left leg. Resident c/o (complained of) right hip pain. This nurse ran back inside and called 911, (Hospital Name) ER (emergency room ) and resident's daughter. EMS (Emergency Medical Services) arrived and placed resident on back board with c-collar (cervical collar) and log-rolled resident onto backboard. Resident transported to (Hospital Name) ER for evaluation . Resident assessed and when c/o hip pain 911 was called immediately for transport to ER. All transports on hold until all staff is retrained. Root Cause Analysis . CNA pushed resident's wheelchair while distracted and did not see that lift was not in correct place for resident to be transported on to it. Intervention . CNA suspended pending investigation . All transportation for van lift stopped until all facility staff can be retrained on proper use of the lift . Resident transported to ER for eval (evaluation) by EMTs (Emergency Medical Technicians). Report received from ER shows no fracture and resident was returned to facility. Neuro (Neurological) checks will be initiated for 72 hours per Dr. (Doctor) . Injuries Observed at Time of Incident . Abrasion . Left Elbow . Sacrum . Unable to determine . Right Trochanter (hip) . b. A Health Status Note dated 10/2/19 at 11:30 a.m. documented, .Note Text . This nurse was talking to DON in the hallway on the outside of A-Wing Nurse's Station when restorative CNAs opened the van door and yelled, 'We need a nurse'. This nurse and DON ran outside and seen (saw) resident laying on right side on the ground behind the wheelchair van. Resident assessed. Resident stated he bumped his head, resident scraped lower back on latch on w/c (wheelchair) lift. Resident noted having blood on left elbow. Small scrape to elbow noted. Resident c/o right hip pain. This nurse ran back inside and called 911, (Hospital Name) ER. Spoke to nurse, RN (Registered Nurse) and resident's daughter, PCP (Primary Care Physician) notified of fall and of resident's transport. EMS arrived and placed resident on backboard with c-collar and log-rolled resident onto backboard. Resident transported to (Hospital Name) ER for evaluation . c. A Health Status Note dated 10/2/19 at 13:55 p.m. (1:55 p.m.) documented, .Note Text . ER called and stated resident was ready to be picked up. No fractures and CT (computed tomography) was clear . d. A Health Status Note dated 10/2/19 at 14:20 p.m. (2:20 p.m.) documented, .Note Text . Resident returned to facility from (Hospital Name), transported back to facility via non-emergency transport. Resident is awake and alert, RR (respiratory rate) even and unlabored on RA (room air), SpO2 (oxygen saturation level) 99%. Neuro checks initiated. Abrasions assessed upon arrival. 0 (No) bleeding noted. Son was at ER with resident. Call placed to daughter with 0 answer. (Hospital Name) ER did not send any discharge papers back with resident. Will request ER report and tests from ER . e. A Health Status Note dated 10/2/19 at 14:41 p.m. (2:41 p.m.) documented, .Note Text . returned call and was notified of resident's return and that they reported there was no fractures and CT was clear . f. A Health Status Note dated 10/2/19 at 22:17 p.m. (10:17 p.m.) documented, .Late Entry . Note Text . Contacted (Hospital Name) ER to obtain results of diagnostic exam. Spoke with (Name) . This nurse was informed a Head CT and Right Hip X-ray was completed in ER, and reports would be faxed (to facility) . g. An ED (Emergency Department) Physician Documentation form dated 10/2/19 at 12:16 p.m. documented, .presents to ED via EMS .with complaints of Fall Injury . The patient sustained injury to the head, pain tenderness, neck injury . Associated signs and symptoms . Pertinent positives . headache, nausea, loss of consciousness . The patient experienced no loss of consciousness . Severity of symptoms . At their worst the symptoms were moderate . The patient has not experienced similar symptoms in the past . Disposition . 10/2/19 . 13:35 (1:35 p.m.) discharged to home . Impression . Strain of muscle, fascia and tendon at neck level . Initial encounter . Condition is good . Discharge instructions . Cervical Sprain . h. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) 762 dated 10/2/19 at 1:00 p.m. documented, .Date and Time of Incident . 10/2/19 at 11:30 a.m.Date and Time Reported to OLTC (Office of Long Term Care) . 10/2/19 at 1:00 p.m. Type of Incident . Neglect . Name of Involved Resident . (Resident #1) . Complete Description of Incident . At approximately 11:30 (a.m.) to 11:45 a.m. 3 facility transportation staff members were assisting 3 residents off van following their respective appointments. One ambulatory resident was sitting in front seat of van. Two wheelchair-bound residents were locked in place correctly. Wheelchair bound (Resident #1) was unloaded off van using proper procedure for lift. CNA (Certified Nursing Assistant) who was operating lift turned away from lift to push resident off the lift ramp. CNA who was responsible for loading wheelchair-bound (Resident #1) onto the lift to transfer off the van noticed that the ambulatory resident was unbuckling her seatbelt. CNA responsible for wheelchair-bound (Resident #1) simultaneously pushed wheelchair-bound (Resident #1) as she turned her head to ensure (Resident #3) was not attempting to exit the van unsupervised. She noted too late that the lift (ramp) was still on the ground and not up in place. Resident fell in wheelchair from van to the ground. Nurses who responded assessed resident immediately for injury. Resident was noted to be lying on his right hip with left lower back resting on the outer edge of lift. Resident stated that he just wanted to get off the ground. Nurse explained to him that we needed to assess him first to make sure he did not have any injuries. Resident able to do ROM (range of motion) to left extremities with no signs, symptoms or expressions of pain. When resident attempted to move right leg as requested, resident stated that it hurt and began to massage halfway down his thigh. Supervisor told resident not to move and went to call the ambulance service to have resident transferred to ER (emergency room ) for eval (evaluation) and Tx (treatment). DON (Director of Nursing) stayed with resident, instructed other staff to go get a pillow and made resident as comfortable as possible until ambulance arrived. EMT (Emergency Medical Technician) placed C collar (cervical collar) on resident and placed (resident) on backboard and transported to ER for eval and Tx (treatment) . Findings and Actions Taken . Facility Lift Van immediately taken out of service until further investigation was completed. CNA drug tested with no positive results on drug test. CNA made to watch abuse / neglect video and take test. After CNA gave DON her witness statement, she was placed on suspension pending investigation, and sent home. Immediately began in-servicing all facility staff on (Brand Name) commercial lift video and placed safety procedures in place to ensure this does not reoccur. All facility staff in-serviced that ambulatory residents are to be assisted from transportation van before beginning to unload wheelchair dependent resident to ensure that when unloading wheelchair residents, no one becomes distracted. Also placed safety procedure that no one in a wheelchair is to be moved from their place in the van until the staff responsible for operating the lift states, 'the lift is up and ready'. Only then can the resident's wheelchair be moved. While getting witness statements from the staff and residents in the area when incident occurred, staff and residents all stated that they did not hear the emergency alarm trigger as it should have when pressure was placed on the lift plate. DON, Administrator and Maintenance tested it multiple times and it functioned properly during every test. Appointment made with lift mechanic for 10/7/19 for inspection of safety component and alarm on lift to ensure there is no mechanical malfunction that could affect residents' safety. Lift van will continue to be out of service until clearance is obtained from lift mechanic. ER report stated there were no fractures and no injury after CT of head and spine done. Stated that they had done X ray of right hip as well. Resident sent back to facility via ambulance. When ER records were received at 7 (7:00) p.m., the nurse noted that the ER sent CT results but no X ray results. Stat (immediate) x ray of right hip ordered in facility which showed no fracture of hip . Following stat x ray of left elbow on 10/3/19 when resident's elbow started to swell. No fracture was seen, but resident received a [DIAGNOSES REDACTED]. No further [DIAGNOSES REDACTED]. i. An Office of Long Term Care (OLTC) Witness Statement dated 10/2/19 and signed by Certified Nursing Assistant (CNA) #1 documented, .I was letting a resident down on the (van) lift, down on the ground, pushed resident away from lift. I turned to let lift up, but resident was already falling. When asked if alarm on lift went off when CNA #3 pushed resident towards lift, CNA stated, 'no, I didn't hear anything'. Resident was facing backwards . j. An OLTC Witness Statement dated 10/2/19 and signed by CNA #2 documented, .I heard another employee by lift. While myself and another resident was (sic) walking down side the van, got to the end and resident was lying in chair on ground . k. An OLTC Witness Statement Form dated 10/2/19 and signed by CNA #3 documented, .Was on transport van, had 2 residents in w/c, one ambulatory in front seat. I was in back and the 1st CNA unloaded one res (resident). I unhooked my res and noticed res in front seat getting out unattended. The other CNA was tending her. I was distracted a second, and pushed my res out with lift down, not up. When asked if alarm went off when she pushed resident over pressure pad of lift threshold, she stated, 'no' . l. An OLTC Witness Statement Form dated 10/2/19 and transcribed by the Assistant Director of Nursing (ADON) for Resident #1 documented, .We got back and stopped the van to get everybody out. She unlocked my chair so I could go backwards. She was in front of me pushing the chair, but nobody was in the back like they always do. It happened so fast. I couldn't say stop. I fell 3 to 4 feet to the ground. (Resident was asked), When staff was rolling your wheelchair back off the van did you hear a beeping noise? (Resident's response), 'No' . m. A Health Status Note dated 10/3/19 at 0630 a.m. (6:30 a.m.) documented, .Note Text . right hip x-ray 2 to 3 views with pelvis impression . There are no radiographically evident acute pelvic / right hip abnormalities / fractures . n. A Health Status Note dated 10/3/19 at 0733 a.m. (7:33 a.m.) documented, .Note Text . Went to see resident on rounds. Resident sitting in w/c (wheelchair) in room, smiling and friendly. Asked resident how he was doing and if he was hurting anywhere. Resident states, 'My elbow is just sore'. Assessed left elbow. Large hematoma to elbow. Resident able to move arm and c/o pain. Notified Dr (doctor / physician) . New order for STAT (immediate) x-ray to left elbow in all views. Notified daughter. Notified (Radiology Provider). Awaiting x-ray tech (technician) at this time . o. A Health Status Note dated 10/3/19 at 09:00 a.m. (9:00 a.m.) documented, .Note Text . x-ray of left elbow . Impression .1. No acute fracture or dislocation . 2. Findings which may indicate Olecranon Bursitis. Notified Dr (doctor) . awaiting response . p. A Health Status Note dated 10/3/19 at 10:10 a.m. (10:10 a.m.) documented, .Note Text . states to give Tylenol for pain to elbow. New order to apply ice for 20 mins (minutes) qs (every shift) x (times) 3 days. Called daughter without answer . q. A facility Van Training (in-service) dated Friday, 10/4/19 and provided by Human Resources on 10/8/19 at 8:30 a.m. documented the Maintenance Director and Human Resources (HR) were the instructors to demonstrate proper use of wheelchair van lift for wheelchair and ambulatory residents. Attendees were CNA #4, CNA #1, CNA #2 and CNA #5. The in-service documented, .CNA #5 was placed in a wheelchair and CNA #4 was operating the lift to demonstrate knowledge of the proper procedure of loading a wheelchair resident in the van. Once loaded, CNA #2 demonstrated the proper use of floor tie-down straps and seatbelts. CNA #4, CNA #1, CNA #2, & (and) CNA #5 were informed of new procedures put in place regarding loading and unloading of residents. (1) Ambulatory residents are to be loaded last and unloaded first; (2) No wheelchair is to be unlocked until platform is in place; and, (3) The lift operator is to state the lift is in place and ready for use before any wheelchair is released from tie-down straps. Transportation staff present acknowledged understanding of new procedures put in place for resident safety . r. A written statement dated 10/7/19 from the medical equipment provider documented, .October 7, 2019 . To whom it may concern . (Brand Name and serial number of van lift) had its safety features inspected by (medical equipment company) on 10/7/19 and all safety features were found to function properly as described by the manufacturer of the lift. These features include . Threshold plate audible and visual warning, inner barrier power cutoff, power interlock system and outer barrier locking system . s. A DDS (Department of Developmental Services) Recommended Safe Procedures for Transporting People who use Wheelchairs, provided by the Human Resources (HR) employee on 10/8/19 at 8:30 a.m. as the material used for the retraining of the van drivers, documented, .The vehicle emits a warning sound when the lift is engaged . Safe Procedures . Staff who are involved in transportation should all be trained in the correct procedures for transporting people who use wheelchairs. Here is a checklist you can use: .Unloading passengers . Deploy the lift . Assist the person onto the lift platform . Make certain that the safety gate on the end of the lift platform is engaged . Engage the lift platform safety strap . Go to the outside of the van and use the control to lower the lift . Assist the person to move their wheelchair safely off the lift platform . Safe Planning . When transporting more than one individual who uses a wheelchair it is a good idea to plan the logistics of the procedure beforehand. This will allow staff to focus their attention on supporting the individuals instead of trying to decide which staff will do which step of the process . t. On 10/9/19 at 10:10 a.m., the surveyors checked the threshold plate of the van. The lift of the van was on the ground. CNA #2 stood on the threshold plate of the van lift, and the alarm sounded. u. On 10/8/19 at 11:42 a.m., the Human Resources Director was asked about the retraining of the van drivers. She stated after the incident with Resident #1, she assisted with the retraining of the van drivers. She stated she usually does not do that, but the lead Maintenance Man was out of the facility, so she assisted Maintenance Man #1. They went out to the van, went inside of the van and on the ground outside of the van. They retrained employees on the proper use of the lift for wheelchair and ambulatory residents, and the proper use of floor tie-down straps and seatbelts. She stated one of the CNAs was placed into a wheelchair for the return demonstration. v. On 10/8/19 at 11:53 a.m., CNA #1 was asked about the incident with Resident #1. She stated she was driving the van on the day of the incident with Resident #1. The resident had been at [MEDICAL TREATMENT] and she had picked him up. She stated on the day of the incident there were three residents on the van; two residents were in wheelchairs and one was in the front seat. There were two other assistants on the van, CNA #3 and CNA #2. She stated, I was operating the lift. (CNA #3) undid one resident in a wheelchair and pushed her onto the lift. I then lowered the lift. (CNA #2), the other assistant, was assisting the ambulatory resident in the front seat. I removed the resident from the lift. As I turned around to put the lift back up, I saw (Resident #1) falling from the van. I did not hear any beeping sound that indicates the lift is not up. The lift was on the ground. (CNA #3) and myself were shocked. I went to get the nurse. As the resident was falling, (CNA #3) got off the van to help him. She was really upset. I have been retrained since the incident. We are not to unlock anyone until the lift is up. w. On 10/9/19 at 8:39 a.m., Licensed Practical Nurse (LPN) #1 was asked about the incident with (Resident #1). She stated, .Myself and the DON were outside the A-Wing Nurses Station. (CNA #1) opened the transportation door at the end of the hallway and yelled they needed a nurse. Myself and the DON went outside and resident was on the ground. The resident was lying sideways on his right side, close to the latch of the lift at the end of the lift. They told us they thought the lift was up, but it was on the ground. (CNA #1) was by the door, and (CNA #3) was on the ground with (Resident #1). We assessed the resident. He told us that he had hit his back on the latch. I saw a couple of drops of blood on his [NAME]et and found a small abrasion to his left elbow. The resident told us that his right hip was hurting. I came back into the facility to call the ambulance and Doctor and family . We had training on the van in the springtime. I have not been retrained since the incident . I am not required to drive the van . x. On 10/9/19 at 8:57 a.m., CNA #3 was asked about the incident with (Resident #1). She stated, .The other CNA unhooked the resident in the wheelchair in the back behind (Resident #1) and took her off the van. I was unhooking (Resident #1). I had started pushing him back when I was concerned about the lady in the seat unhooking her seat belt and getting out unattended. I kept pushing (Resident #1), I assume, and the resident fell from the van. I had a hold of his wheelchair arms. I made sure his arms were in the wheelchair. I did not hear the alarm. I do not remember what happened or how the wheelchair got out of the van. I guess I pushed him out. I do not remember how I got out of the van. I remember seeing the resident roll out of the wheelchair. The wheelchair was still on the lift that was on the ground. The resident was at the edge of the lift, the left side of the lift. The resident's lower back was against the lift. I put my hand under resident's back to stop it from hurting him. I stayed there until the ambulance got there and told me to get out of the way. The van driver was operating the lift. I am not sure where the other CNA was at the time the resident fell from the van. I did receive training prior to this incident. I cannot remember when. We were taught how to secure the residents in the van and how to use the lift correctly. I think it was the Maintenance Man that gave us the training. The DON asked me to come inside the building, I had to write out a witness statement. I watched an abuse / neglect film and I was sent home. I have been home since the incident. You can see the platform of the lift when you are removing a resident from the van. I do not remember if I saw the platform that day. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/1/19 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required supervision with bed mobility, was independent with transfer, and required a wheelchair for mobility. a. On 10/8/19 at 10:00 a.m., CNA #4, a van driver, loaded the resident onto the van via the van lift. Resident #3 was sitting in a wheelchair. The van driver opened the door of the van, turned a switch to the on position of the lift, lowered the lift to the ground, assisted the resident onto the lift in the wheelchair, and locked the brakes of the wheelchair. CNA #2 was standing inside the van near the lift door to receive the resident. The van driver lifted the resident up to the floor of the van and did not use safety strap of the lift. The resident was assisted inside the van, near and between the driver and passenger seats. The wheelchair brakes were locked into place. CNA #2 placed a seat belt across the resident's abdomen. She placed the strap through the left side of the wheelchair under the arm rest, brought it across the resident's abdomen to the right hip and wheel of the wheelchair, and fastened it into the floor anchorage. She attached 2 tie-downs to the wheelchair frame and ensured tension was appropriate. She placed 2 more tie-downs to the front frame of the wheelchair. The wheelchair was checked for movement. There was no slack in the straps. CNA #2 and the Van Driver were asked if they were finished securing the resident into the van. They both stated, Yes. They were asked if they could see anything wrong. Neither of them recognized there was no shoulder strap across the resident, and the seatbelt was in contact with the wheel of the wheelchair. The Van Driver was asked to get the Assistant Administrator. The Assistant Administrator and the DON came out to the van and observed the resident sitting in the van. The Administrator did not recognize the problem. The DON asked, Why is the shoulder strap not on? The Assistant Administrator summoned for the Maintenance Supervisor. The Assistant Administrator and Maintenance Supervisor took the seat belt off of the resident and placed the combination strap across the resident's shoulder and across the lower abdomen and attached it to the floor restraint buckle. The belt came into contact with the wheel of the wheelchair. He did not recognize the seat belt was not appropriately placed until the surveyor told him. The belt was then rearranged to fit behind the wheel of the wheelchair and anchored appropriately into the floor buckle. b. On 10/8/19 at 11:42 a.m., the Human Resources Director stated, .I used to drive the van. I used to be the Activity Director and I was trained on using the van. She stated the booklet for the van's restraint system was not used in the training. She stated the van did not have a lift strap. She also stated she watched the training video, and it did not, go in depth about the tie-down of wheelchairs. c. The User Instructions for the van's safety restraints, provided by the Maintenance Supervisor on 10/9/19 at 11:50 a.m., documented, .[NAME] Secure Wheelchair . 1. Place wheelchair facing forward in securement area . Apply wheel locks or turn power off . 2. Attach tie-downs into floor anchorages and ensure they are locked in . 3. Attach the four tie-down hooks to solid frame members or weldments, near seat level . Ensure tie-downs are fixed at approximately 45 degrees and are within angles shown . Do not attach hooks to wheels, plastic, or removable parts of wheelchair . 4. Ensure all tie-downs are locked and properly tensioned . If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack . B. Secure Passenger .1. Attach Lap belts . Use integrated stiffeners to feed belts through openings between seat backs and bottoms, and / or armrests to ensure proper belt fit around occupant . 2. Attach shoulder belt . Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector 3 onto lap belt . 2. Note . Combination lap / shoulder belts serve as both window / side lap belt and shoulder belt . 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort . WARNING . Lap and shoulder belt should not be held away from passengers body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels or frame . Occupant belts should always bear upon the bony structure of passengers body and be worn low across the front of the pelvis, with the junction between lap and shoulder belts located near passenger's hip . d. On 10/9/19 at 9:41 a.m., the Director of Nursing (DON) stated, .Yesterday, the CNAs did not put the shoulder strap on correctly. I was surprised. During my training, I was shown how to put the shoulder strap on. The seat belt should not have been secured over the wheelchair wheel. The van drivers are now being retrained on use of the seat belt and shoulder strap . e. On 10/9/19 at 10:31 a.m., CNA #2 stated, .I do drive the van, usually on Saturday and sometimes during the week. There are two main drivers. There is always a staff member on the van in addition to the van driver. I was trained on the van before the incident; we have watched films. I was trained on the lift, resident safety, the seat belts. We have been retrained since the incident, on the same day as the incident. We were retrained yesterday (10/8/19). I did know about the shoulder harness. I have used it before. I guess yesterday, we used the seat belt like we have been using it, without the shoulder harness. I do not know anything about fastening the seat belt behind the wheel. I was taught to do it behind the wheel. I do not know why we put it over the wheel yesterday. I did not know that there should have been a safety strap on the lift. I do know now, and one has been ordered . f. On 10/9/19 at 2:27 p.m., the Assistant Administrator stated, .The van was back in service yesterday, Tuesday (10/8/19) . We watched the video on the van last week and again yesterday afternoon. There was hands-on training yesterday with (CNA #5). (Maintenance Man #2) did train the other three van drivers yesterday, (CNA #4), (CNA #2) and (CNA #1). They could not use the van again until they had been retrained. I did ask yesterday why they had the two straps around the waist and not on the shoulder. I did not know there should have been a lift strap. Either (Maintenance Man #1) or (Maintenance Man #2) can do the training on the van. For the next couple of weeks either (Maintenance Man #1) or (Maintenance #2) will observe the transportation staff loading and unloading the residents on the van. Until the lift strap comes in, there is to be one person on each side of the lift. g. On 10/9/19 at 3:10 p.m., Maintenance Man #2 was asked about training on the van's lift and restraint systems and stated he had trained the van drivers approximately a year ago, which included the van's restraint system and the lift. He stated, (Maintenance Man #1) did the training after the incident with (Resident #1). He stated he did not know about the lift strap until he read the new training paperwork and that the lift strap had now been ordered. He stated yesterday, he did observe that the shoulder harness was not in place and the seat belt was secured over the wheel of the wheelchair when they were preparing to transport (Resident #3). He stated, All of the van drivers are now going through retraining on everything on the van, to include the lift and the (brand name of the van restraint) system. One of the Maintenance Men will monitor all van runs for the next seven days. 3. The Immediate Jeopardy was removed, and the scope and severity reduced to [NAME] on 10/8/19 at 3:33 p.m., when the facility implemented the following Plan of Removal: a. .On 10/8/19 the DON and Acting Administrator reviewed all transportation schedule for the months of (MONTH) 2019 and (MONTH) 2019. 25 residents were identified to have the potential to be affected by the failure to ensure the van lift platform was engaged to safely unload a resident from the van and to ensure seatbelts were properly placed and secured to prevent potential injury during transport. b. On 10/8/2019, the Maintenance Supervisor in-serviced all transportation staff present on proper procedure to follow to ensure safe transporting of residents using the van lift. Each transportation staff member was then asked to return demonstrate to Maintenance Supervisor their knowledge of proper procedure of loading / unloading residents, securing (brand name restraint system) (tie-down straps) and seat belt placement. c. On 10/8/2019 Maintenance Supervisor gave general safety overview of van lift to all staff during all staff monthly in-service. Acting Administrator also in-serviced all staff on changes made to facility policy and procedure for loading / unloading of residents including all ambulatory residents being loaded last and unloaded first, wheelchair residents are not to be unlocked from the (brand name restraint system) until the staff member operating the lift gives the verbal cue that the lift is in place and ready. d. The Maintenance Supervisor will retrain all transportation staff daily 5 times per week times 2 weeks to ensure all staff are properly trained and can correctly give return demonstration of training. Any failed practice during return demonstration will result in immediate removal of that staff member from transportation duties until they can correctly perform return demonstration. e. The Maintenance Supervisor / Designee will

Complaint # (AR 703) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding signs / symptoms of impaired circulation to the lower extremity, including changes in the appearance and temperature of the lower extremity, increased pain, decreased mobility, and decline in the ability to bear weight and participate in therapy, to enable the physician to promptly evaluate, diagnose and determine any necessary treatment for [REDACTED].#5) of 2 (Residents #3 and #5) case mix residents who were admitted after [MEDICAL CONDITION] and surgical repair. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who experienced post-operative circulatory impairment to the lower extremity and subsequently required transport to the emergency room and was diagnosed with [REDACTED]. The Administrator, Assistant Administrator, Director of Nursing (DON) and Assistant DON (ADON) were informed of the immediate jeopardy on 3/22/19 at 12:50 p.m. The findings are: 1. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/19 documented the resident scored 9 (8-12 indicates moderately impaired) on a brief interview for mental status, required extensive assistance of two plus persons for transfers, bed mobility, dressing, total assistance of 2 plus persons for toilet use and personal hygiene, had functional limitations in range of motion with impairment on one side of the upper and lower extremities, had 'other' ulcers and a surgical wound, received Occupational Therapy (OT) and Physical Therapy (PT). a. An Admission Skin Observation Tool dated 1/29/19 documented, 1) R (Right) thigh old scar, 2)R Hip staples intact, dressing with serous drainage, 4) R arm AC (antecubital) bruising, 5) L(Left) arm AC bruising, 6) L outer FA (forearm) bruising, 7) old healed wound on R buttocks, 8) knot L forehead. There was no documentation of any skin breakdown / eschar to the right lower extremity as of this date. b. The Plan of Care dated 1/30/19 documented, Resident has a right Femoral Neck Fracture s/p (status [REDACTED]. Goal: The resident will remain free of complications related to [MEDICAL CONDITION], such as contracture formation, embolism and immobility through review date. approaches: Assess limb for swelling and skin changes. Take pedal pulses q (every) shift . Assess/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain . Assess/document/report PRN (as needed) s/sx (signs/symptoms) of [MEDICAL CONDITION] complications: Contracture formation, Embolism s/sx (cyanosis, pain, petechiae, increased heart rate ([MEDICAL CONDITION], tachypnea, difficulty breathing (Dyspnea)) . Impaired mobility, Unrelieved pain . Follow MD (Medical Doctor) orders for weight bearing. Give pain medication as ordered by MD: [MEDICATION NAME]/[MEDICATION NAME] 5-325 mg (milligram) 1 tab (tablet) po (by mouth) q (every) 6 hours prn. PT (Physical Therapy), OT (Occupational Therapy) evaluation and treatment per orders. Date Initiated: 01/30/2019 . c. A Nurses' Note dated 2/6/19 at 8:42 a.m. documented, Resident's niece request that I look at her heels. Resident heels were assessed. Resident has an unstageable pressure injury noted to right heel. The area is intact with black eschar. No drainage, no swelling or [MEDICAL CONDITION] noted. Tenderness noted on palpation .Measurements 4.8 cm (centimeters) length X (by) 8.2 cm width, no depth . There was no documentation the physician was consulted regarding the eschar and tenderness to the right heel. d. The Medication Review Report Order Summary documented, Order date: 2/6/19. Cleanse the pressure ulcer to right heel with normal saline. Pat dry. Coat the area with [MEDICATION NAME] solution and apply [MEDICATION NAME] dressing. Then apply dry gauze and place foam heel dressing. Secure the dressing with Kerlix bandage. Treatment done daily .Start date 2/7/19. e. A Skin Observation Tool dated 2/7/19 documented, Resident has a deep tissue injury noted to right heel. Black eschar intact to the area. Old dark discoloration noted to right lower leg down to dorsal of foot. Also, resident had this same discoloration noted left lower leg near the ankle some small blister areas noted to right lower leg. Resident has lump approximate 1.5 diameter noted to right side of back of neck. No other new skin issues noted. f. A Skin Observation Tool dated 2/12/19 documented, Resident continue to have the dark discoloration to right lower leg down to dorsal side of foot. Resident also have (sic) dark discoloration to sole of right foot. The small blister noted to right lower foot (sic) have become one large fluid filled blister. No drainage noted. The blister remain (sic) intact. Some discomfort noted to right lower leg when the extremity is moved or touched. The wound to the right heel remain (sic) intact with black eschar. Some tenderness noted on palpation . g. A Wound Weekly Observation Tool dated 2/12/19 at 6:39 p.m. documented, .MD (Medical Doctor)/Alternate Notified/last updated: 2/6/19 . Current treatment plan: [REDACTED]. Apply dry gauze and place a foam heel dressing. Then secure the dressing with kerlix bandages . Wound Progress: No improvement noted to the wound right heel. The black eschar remain intact . h. A Nurses Progress Note dated 2/13/19 at 9:00 a.m. documented, Dressings changed to right lower leg per orders, small blister noted, warm to touch, right heel dressing changed per treatment orders. Resident's right foot is cold to touch, toes dark and swollen, unable to palpate pulses. Resident denies pain right foot, denies being able to feel nurse touching foot, but does feel nurse touching right lower leg. i. A Nurses Progress Note dated 2/13/19 at 9:25 a.m. documented, Resident's right foot dark in color, cold to touch and unable to feel pedal pulses. MD (Medical Director) notified and 911 called and ER (emergency room ) called and report given. Family notified. j. The Emergency Department Record dated 2/13/19 from Hospital #1 documented, Arrival time: 09:49 (9:49 a.m.) The patient presents with pain. Right foot discoloration, purple in appearance. The complaints affect the right foot.recent right [MEDICAL CONDITION] status [REDACTED]. The pt. (patient) denies any pain in her foot, but says she can't feel anything below the knee .12:05 (p.m.) The pt. has a cool pulseless right foot on exam. I was unable to find a Doppler signal, a dorsalis pedis, or posterior artery either, concerning for a critical ischemia of the right leg. Spoke to doctor in hospital says does not perform peripheral intervention . call (city) hospital (Hospital #2), and the patient was accepted for transfer to the emergency department by (Physician) . The Arterial Doppler Study dated 2/13/19 from Hospital #1 documented, .Impression: Occlusion of the right superficial femoral artery proximally with no flow identified in the remainder of the right lower extremity . k. The Progress Note dated 2/14/19 at 2:59 p.m. from Hospital #2 documented, .Subjective, (Name of Patient) has ischemic right leg. Spoke with the daughter and we have agreed that the patient do need an AKA (above knee amputation) . l. The Progress Note dated 2/15/19 from Hospital #2 documented, Patient has been in a nursing home for some time and not ambulating. She was noted to have a cold right foot on 2/23. Patient reports pain for several weeks. Based on exam the foot is already dead and has been for some time, she has absent motor and absent sensation. She has a right femoral and popliteal signal with movement of the knee, no distal pedal signs on the right. Unfortunately, patient is not a revascularization candidate as her motor and sensation function is already absent. The risks and benefits of surgery were discussed with patient and family and they would like to proceed with operative intervention. Will perform tomorrow. m. On 3/19/19 at 10:20 a.m., Licensed Practical Nurse (LPN) #1 was asked if she remembered the resident and stated that she did. The LPN was asked about the discoloration and area of eschar on the right heel. She stated, .The day before I was off, I did her dressing on her right heel. I did her dressing changes on that day in the evening time at approximately 5 PM. Her leg was not purple but had a discoloration; it was the leg on the same side as her stroke. She had an abduction pillow in place, due to recent hip surgery on the right hip. The leg was not purple, nor the foot. She had some small blisters on her leg, as before. The LPN was asked, when did you do the dressing change? The LPN stated, On 2/12/19. The ADON (Assistant Director of Nursing) called me on 2/13/19 and asked me if the foot was purple the day before, and I told her no, there was no purple, only the discoloration that developed after she got here. The nurse filling in for me on 2/13/19 could not feel any pedal pulses. They sent her to ER (emergency room ). The LPN was asked if she knew how long it was between when the resident was admitted and when the discoloration to the right lower extremity was first identified. She stated, She had a brownish discoloration on admit; it was on her shin and lateral side of the lower leg. The LPN was asked about the blisters and stated, They brought it to my attention that she had tiny blisters on the shin, front part of the leg. They were small, then all the blisters combined into one. They never burst, they were soft, and fluid-filled. The LPN was asked if the blisters were present upon admission and stated, No, the blisters were noted on 2/7/19. The LPN was asked, Did she have anything on the right heel when she came in? She stated, No, the niece mentioned to me on 2/6/19, 'can you look at her right heel?' I looked on the 6th and saw the eschar; this was the first that I saw it. She had no dressing on it until the 6th. She came in on 1/29/19; another nurse did the admission assessment and body audit, and her heel was not dark, and she did not have a sore. The LPN was asked, When did the heel turn dark? She stated, I don't know; it was the resident's niece that (sic) told me the resident's heel was dark. The LPN was asked, Did you see any other areas on the resident's right foot or changes in color? She stated, No. n. On 3/20/19 at 11:42 a.m., Licensed Practical Nurse (LPN) #2 was asked about the resident's leg and stated, The resident's right leg had started being discolored 2 to 3 days prior to discharge. The LPN was asked, where was the discoloration? She stated, On the outer side of the right leg. The LPN was asked if the resident's foot was discolored and stated, If I'm not mistaken, the foot was bandaged. The LPN was asked, did she complain of pain? She stated, Not much, she complained of pain in the right hip about 2 times and had to be given something for pain. She had an abduction pillow in place; they would turn her, but she would turn herself back. Three days prior to discharge, she developed an area to her right leg. The LPN was asked if the resident was on anticoagulant medication (blood thinner). She stated, I think he (physician) had dc'd (discontinued) it. The LPN was asked, did you call the doctor when you noticed the discoloration of the leg? She stated, No, we normally tell the supervisor, and she does it, or report it to the treatment nurse. o. On 3/20/19 at 1:20 p.m., Housekeeper #1 stated, On the right leg, I noticed blisters from the top of the calf to the mid-calf. Then, I was in there with the treatment nurse when she was about to change the dressing on the right hip, and I saw the toes with dark streaks between them on the right foot. The right foot had started to look like it had a change in color, an ashy gray look. She (Treatment Nurse) pulled the sock off, and I saw the foot . I brought it to her (treatment nurse) attention about her right foot. I was in there already when the treatment nurse came in and I moved the resident or something and I asked her (resident) was she in pain and she said 'no', so I lifted her pants, and that's when I saw the blisters. She hurt a lot when she stood up in therapy that day. Housekeeper #1 was asked, do you know if therapy notified the doctor about her starting to have a lot of pain when standing on that leg? She stated, I don't know if they did or not. Housekeeper #1 was asked, did you see the right foot on the morning of 2/13/19? She stated, Yes, oh it was almost black; her foot was purple. This was the second time that I'd seen it; the first time was just the dark streaks on the foot. I went to the ER (emergency room ) with her. They said at ER that it might not be getting any circulation, no pulse. They said they were going to put a doppler on it. They sent her to the hospital in (city) (Hospital #2) from the ER here, because she had some blockage in the leg. Housekeeper #1 was asked what happened at Hospital #2 and stated, The surgeon told the family that she had a blockage and no circulation below the knee and that they had to do an amputation. He told the family also that this should not have happened; it was avoidable. Housekeeper #1 was asked, when the resident was here, and you went into the room, were her heels offloaded? She stated, No, she would always have that pillow between (her legs); that wedge pillow shaped like a triangle, and feet straight on the bed. Housekeeper #1 was asked, how many days, prior to 2/13/19, did you see the black streaks on the right foot? She stated, The week prior is when I saw the black streaks on the foot. I noticed the blisters in therapy, the second week they started therapy. She (resident) said her foot hurt, and I asked therapy why. They said, 'You know she has the blisters on her leg.' I went a little further and asked the nurse that (sic) admitted her if she had the blisters when she was admitted here, and she said, 'No'. Housekeeper #1 was asked, what color were the blisters? She stated, The area around them was dark brown, and the blisters were in the middle of this area. Housekeeper #1 was asked, do you know if the doctor was notified regarding this? She stated, I don't know. p. On 3/20/19 at 2:50 p.m., LPN #3 was asked if she remembered Resident #5 and stated, Yes, I remember the resident. I was not here when she came in. She came in on 3 to 11 (3:00 p.m. to 11:00 p.m. shift); I saw her the next day. The LPN was asked, did her right leg have any discoloration? She stated, No, not to my knowledge, it didn't. The LPN was asked, did you note any changes in her leg after the second day? She stated, No. The LPN was asked if any changes in the resident's right leg were reported to her at any time and stated, Yes, it was the day that the resident was to go home (2/13/19). There was another nurse working as Treatment Nurse that day, and she saw the resident's right foot discolored; dark, but not black . really discolored and no pedal pulses, so she got me. I assessed, called the doctor and sent her out to ER. q. On 3/20/19 at 3:15 p.m., LPN #4 was asked if she remembered Resident #5 and stated, Yes, I remember the resident. I did her admission assessment. The LPN was asked, were there any areas on her right heel on admission? She stated, No. The LPN was asked, were there any discolorations on the right leg? She stated, She did have a bruise on the upper thigh, at her incision. The LPN was asked, did you notice any other discolorations? She stated, She had what looked like an old scar on the lower right leg; all skin intact, with a dark brownish area, measured 1-1/2 inches in length by 1/2 inch in width. The LPN was asked, prior to 2/13/19, had you noticed any changes in her right foot? She stated, No, it was mentioned that she had a darkened area or bruised area on her heel. I can't recall how long after admission that it was brought to my attention that treatment had been initiated for the right heel. On 2/13/19, I came in to sub (substitute) for the treatment nurse that morning. I went in to dress her heel. I went to unwrap her dressing. Her foot was dark and cold. I called the day supervisor to come assist. She came and notified the DON (Director of Nursing), and the DON came in. The foot was dark purple, blue; it wasn't black but, dark. The LPN was asked, was the doctor notified regarding the right leg / foot at any time prior to 2/13/19? She stated, Not by me; that might be in the 24-hour (report) book. The LPN was asked, did the resident complain of pain on the morning of 2/13/19? She stated, She didn't complain of pain in her lower leg. She did not verbalize, but she did have facial grimaces when I went to raise the leg. I reassessed to see if she could feel, but she couldn't feel anything on the foot. The LPN was asked, did you see the blisters on the side of the leg? She stated, Yes, after I noticed about the foot. The LPN was asked if the area around the blisters was darker than the rest of the leg and stated, I don't believe so; I can't recall. The nurse went to the desk with the surveyor, to review the 24-hour report book. There was no documentation in the book regarding pain, color changes in the leg, nor MD notification for this resident. r. On 3/20/19 at 3:55 p.m., the Assistant Director of Nursing (ADON) was asked about the resident and stated. Yes, I remember the resident. There were no discolorations in the right leg that I recall. I did not see her on admission. I don't recall any reports. The ADON was asked, do you know of any changes that took place in the right leg? She stated, Yes, I remember the treatment nurse came and got me. She had some old discoloration and, on top of that, she had some blistering to the outer aspect, and we felt sure it was from the foam wedge. She had an unstageable pressure area to the right heel. The ADON was asked, did she have this pressure area on admission? She stated, I don't think so, but I don't know; I was not here when she admitted . I do remember after about a week here, she had an unstageable area. I remember holding the leg for the treatment nurse to dress it. It may have been the same day that she knew about it. The ADON was asked, when (resident) was sent to theER on [DATE], were there any other changes in the leg? She stated, Yes, the nurse came and got me and another LPN, and we went into the resident's room. The resident's foot was a darker color, very dark, cooler to touch than the left foot. There were no other darker areas, (except) the toes were dark. The ADON was asked, was she on an anticoagulant? She stated, She was, I believe she was on it for 7 days, and after that, he didn't order anymore. She was on it when she came here. s. On 3/21/19 at 11:10 a.m., the Physical Therapist Assistant (PTA) was asked if she remembered Resident #5 and stated, I remember the resident. We did her eval (evaluation) on 1/31/19. She either started (therapy) that day or the next day. The PTA was asked, can you tell me if she had discoloration or changes to her right leg? She stated, The CNA told me she had some red discoloration on the lateral side of her right foot, toward the heel. The PTA was asked, were there any changes in her toes? She stated, No, I noticed some changes more toward her discharge, 3 to 4 days before. The PTA was asked, what type of changes did you notice? She stated, You could tell there were circulatory problems - her foot was cold - it wasn't cold at first. When she first came in, it was warm to touch, up until a couple of days prior to discharge. The PTA was asked, was the doctor notified about the change in temperature of the foot? She stated, I don't know. The nurses normally do the reporting . The day before she dc'd (discharged ), I would have seen her. Her foot was not exposed, so I just did exercises. She was already dressed . t. On 3/21/19 at 11:24 a.m., Certified Nursing Assistant (CNA) #5 was asked, did you notice any discoloration or changes to the resident's leg? She stated, Yes, when I returned to work on the 5th and 6th of (MONTH) 2019. I weighed (residents) on the 7th, so I saw her on the 8th. CNA #5 was asked, when you returned to work, did the leg and the foot look the same or had they changed? She stated, Yes, I questioned the darkness on the outer right leg. CNA #5 was asked, what do you mean by darkness? She stated, It was darker than it was before I left on my days off. Her foot was the same, with the dark spot on the heel; there was no change in that. CNA #5 was asked, did you report the darker area on the leg? She stated, No. CNA #5 was asked, what is the procedure if you find skin issues? She stated, Go tell the nurse, and they tell the treatment nurse . I think I told the nurse on the weekend, but it's not written in stone that I did. The CNA was asked, Did anyone assess the resident's foot or call the doctor? She stated, No, I think something was done on that Monday (February 11) . When therapy came in to help me on the 12th of February, she (Therapy Assistant) said, 'her leg is swollen'. CNA #5 was asked, where was it swollen? She stated, From the top part of the knee up . it wasn't red. I told her I noticed that (the swelling) the weekend of the 9th and 10th. CNA #5 was asked, was the leg cold to touch on that weekend? She stated, Just the swelling, from the hip to the top of the knee. The foot was still the same; it was wrapped up. CNA #5 was asked, did you report the swelling on the 9th and 10th? She stated, I think I reported the swelling. I thought it was just swelling from surgery, and she had gone to therapy 5 days a week. CNA #5 was asked, did you see her foot on the morning of 2/13/19? She stated, No, I didn't see it; she was gone before I made it to the room. CNA #5 was asked, who do you report residents' condition changes to? She stated, To the Charge Nurse, DON (Director of Nursing), ADON (Assistant Director of Nursing) or Administrator. Sometimes, you tell the nurse, and they don't do anything about it. CNA #5 was asked, when you report something on the weekend, do the nurses put it in the 24-hour book? She stated, Sometimes, but not all the time. u. On 3/21/19 at 11:35 a.m., the Occupational Therapy (OT) Director was asked if the resident was making progress when therapy was first initiated and stated, Yes, then she got where she couldn't stand on that leg, because of the pain. The OT Director was asked, was the pain severe? She stated, Yes, only when bearing weight or transferring. The OT Director was asked, was the doctor notified of the sudden severe pain when it first started? She stated, We notified the nurses, and what they did from that point, I don't know. The OT Director was asked, did she have any changes in the temperature of her leg or discoloration? She stated, The PTA could better tell you that. I was a witness to the decline that she was unable to bear weight. The OT Director was asked, when was severe pain and inability to bear weight first noticed? She stated, Probably the 7th or 6th day of February. v. On 3/21/19 at 3:15 p.m., LPN #5 was asked if she remembered Resident #5 and stated, Yes, I recall the resident. When I was there, she'd had a hip replacement on the right side. I did treatments every other weekend. The first time I did her hip (dressing), there was no discoloration. The second time, I noticed she had a bruising, burgundy red in color, on the lower part of the leg. I spoke with the aides and asked, 'wow! what's going on?' They said they were just bandaging it. I just followed orders. LPN #5 was asked, did you think it strange, it being a burgundy red color? Did you call anyone about it or call the doctor? She stated, No, I just followed doctor's orders. I did not see any discoloration in the foot. I work only prn (as needed) weekends. LPN #5 was asked, was it ever reported to you that the leg was swollen or that there were changes in the resident's foot? She stated, No, never reported to me anything about her foot or leg swollen. I did not dress the foot; it had a bandage on it. w. On 3/22/19 at 8:50 a.m., LPN #1 was asked if there were changes in the color of the resident's right foot and stated, I was going to be off on 2/13/19. I did the resident's dressing change. The sole of the right foot was darker. The LPN was asked if she consulted the physician about change in color and stated, I called the family member and told her that the sole of the resident's foot was darker. x. On 3/22/19 at 12:05 p.m., the Medical Director (MD) was interviewed via telephone and was asked if he had been notified regarding changes in the color and temperature of the resident's right leg, the severe pain with weight-bearing, and the decline in the resident's ability to participate and progress with therapy. He stated, No, not this you've just mentioned. The MD was asked, do you think you should have been informed? He stated, Yes. y. The facility's Change of Condition Policy, provided by the Director of Nursing on 3/22/19 at 5:00 p.m., documented, .Any change of condition (change in wound status, change in skin status, change in physical or mental status) . must be . assessed, recorded and reported so proper treatment can be implemented. CNAs are to report all abnormal findings (swelling, bruising, skin tears, skin discoloration, rashes, blisters) to the charge nurse using a STOP and watch sheet. Notify the attending physician/on call physician of change in physical/mental function as soon as feasibly possible . z. The Immediate Jeopardy was removed, and the scope and severity reduced to H on 3/22/19, when the facility implemented the following Plan of Removal: 1.) On (MONTH) 22, 2019 at, the ADON/DON designee reviewed all new admissions and all residents who have received surgeries since 1/29/19. Five residents were identified to have the potential to be affected by the failure to assess peripheral pulses accurately. Assessments were performed on all five residents identified by the DON/designee to have the potential to be affected. No further negative findings. 2.) On (MONTH) 22, 2019 the DON in-serviced all nursing staff on change in documentation on skilled charting and nursing summaries to reflect the checking of radial and pedal pulses with strength of pulses as 0=absent, 1=palpable, but weak and thready, 2=normal, 3-increased pulse and 4=full, bounding. 3.) The DON/ADON/designee will monitor all new admissions and post-surgical residents post operation to ensure assessments of radial and pedal pulses are completed with strength of pulse recorded. Monitoring will be done immediately and 4x (times) weekly x 8 weeks on a peripheral pulse spreadsheet, or until compliance is verified by OLTC (Office Long Term Care). Will then monitor weekly after compliance is reached through OLTC. 4.) On (MONTH) 22,2019, after review of new admissions and new surgeries, five residents had the potential to be affected by the failure to report change of condition to the physician immediately. DON/ADON/designee residents were assessed to ensure that they had not had a change of condition. No negative findings. Assessment included review of physician orders, review of progress notes and assessment of resident. 5.) On (MONTH) 22, 2019, the DON in-serviced all staff on the proper procedure for reporting a change of condition for residents, this included certified nursing assistants to promptly report anything they see to the charge nurse or supervisor. Also included in the in-service was for nursing staff to report any change of condition to resident's primary care physician. 6.) The DON/ADON/designee will monitor any new admissions and any new surgeries post operation to ensure any change of condition is reported to the physician immediately. Monitoring will be done on a change of condition spreadsheet 4x weekly for 8 weeks, or until compliance is verified by OLTC. Will then monitor weekly after compliance is reached through OLTC.

Complaint # (AR 703) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding signs / symptoms of impaired circulation to the lower extremity, including changes in the appearance and temperature of the lower extremity, increased pain, decreased mobility, and decline in the ability to bear weight and participate in therapy, to enable the physician to promptly evaluate, diagnose and determine any necessary treatment for [REDACTED].#5) of 2 (Residents #3 and #5) case mix residents who were admitted after [MEDICAL CONDITION] and surgical repair. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who experienced post-operative circulatory impairment to the lower extremity and subsequently required transport to the emergency room and was diagnosed with [REDACTED]. The Administrator, Assistant Administrator, Director of Nursing (DON) and Assistant DON (ADON) were informed of the immediate jeopardy on 3/22/19 at 12:50 p.m. The findings are: 1. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/5/19 documented the resident scored 9 (8-12 indicates moderately impaired) on a brief interview for mental status, required extensive assistance of two plus persons for transfers, bed mobility, dressing, total assistance of 2 plus persons for toilet use and personal hygiene, had functional limitations in range of motion with impairment on one side of the upper and lower extremities, had 'other' ulcers and a surgical wound, received Occupational Therapy (OT) and Physical Therapy (PT). a. An Admission Skin Observation Tool dated 1/29/19 documented, 1) R (Right) thigh old scar, 2)R Hip staples intact, dressing with serous drainage, 4) R arm AC (antecubital) bruising, 5) L(Left) arm AC bruising, 6) L outer FA (forearm) bruising, 7) old healed wound on R buttocks, 8) knot L forehead. There was no documentation of any skin breakdown / eschar to the right lower extremity as of this date. b. The Plan of Care dated 1/30/19 documented, Resident has a right Femoral Neck Fracture s/p (status [REDACTED]. Goal: The resident will remain free of complications related to [MEDICAL CONDITION], such as contracture formation, embolism and immobility through review date. approaches: Assess limb for swelling and skin changes. Take pedal pulses q (every) shift . Assess/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain . Assess/document/report PRN (as needed) s/sx (signs/symptoms) of [MEDICAL CONDITION] complications: Contracture formation, Embolism s/sx (cyanosis, pain, petechiae, increased heart rate ([MEDICAL CONDITION], tachypnea, difficulty breathing (Dyspnea)) . Impaired mobility, Unrelieved pain . Follow MD (Medical Doctor) orders for weight bearing. Give pain medication as ordered by MD: [MEDICATION NAME]/[MEDICATION NAME] 5-325 mg (milligram) 1 tab (tablet) po (by mouth) q (every) 6 hours prn. PT (Physical Therapy), OT (Occupational Therapy) evaluation and treatment per orders. Date Initiated: 01/30/2019 . c. A Nurses' Note dated 2/6/19 at 8:42 a.m. documented, Resident's niece request that I look at her heels. Resident heels were assessed. Resident has an unstageable pressure injury noted to right heel. The area is intact with black eschar. No drainage, no swelling or [MEDICAL CONDITION] noted. Tenderness noted on palpation .Measurements 4.8 cm (centimeters) length X (by) 8.2 cm width, no depth . There was no documentation the physician was consulted regarding the eschar and tenderness to the right heel. d. The Medication Review Report Order Summary documented, Order date: 2/6/19. Cleanse the pressure ulcer to right heel with normal saline. Pat dry. Coat the area with [MEDICATION NAME] solution and apply [MEDICATION NAME] dressing. Then apply dry gauze and place foam heel dressing. Secure the dressing with Kerlix bandage. Treatment done daily .Start date 2/7/19. e. A Skin Observation Tool dated 2/7/19 documented, Resident has a deep tissue injury noted to right heel. Black eschar intact to the area. Old dark discoloration noted to right lower leg down to dorsal of foot. Also, resident had this same discoloration noted left lower leg near the ankle some small blister areas noted to right lower leg. Resident has lump approximate 1.5 diameter noted to right side of back of neck. No other new skin issues noted. f. A Skin Observation Tool dated 2/12/19 documented, Resident continue to have the dark discoloration to right lower leg down to dorsal side of foot. Resident also have (sic) dark discoloration to sole of right foot. The small blister noted to right lower foot (sic) have become one large fluid filled blister. No drainage noted. The blister remain (sic) intact. Some discomfort noted to right lower leg when the extremity is moved or touched. The wound to the right heel remain (sic) intact with black eschar. Some tenderness noted on palpation . g. A Wound Weekly Observation Tool dated 2/12/19 at 6:39 p.m. documented, .MD (Medical Doctor)/Alternate Notified/last updated: 2/6/19 . Current treatment plan: [REDACTED]. Apply dry gauze and place a foam heel dressing. Then secure the dressing with kerlix bandages . Wound Progress: No improvement noted to the wound right heel. The black eschar remain intact . h. A Nurses Progress Note dated 2/13/19 at 9:00 a.m. documented, Dressings changed to right lower leg per orders, small blister noted, warm to touch, right heel dressing changed per treatment orders. Resident's right foot is cold to touch, toes dark and swollen, unable to palpate pulses. Resident denies pain right foot, denies being able to feel nurse touching foot, but does feel nurse touching right lower leg. i. A Nurses Progress Note dated 2/13/19 at 9:25 a.m. documented, Resident's right foot dark in color, cold to touch and unable to feel pedal pulses. MD (Medical Director) notified and 911 called and ER (emergency room ) called and report given. Family notified. j. The Emergency Department Record dated 2/13/19 from Hospital #1 documented, Arrival time: 09:49 (9:49 a.m.) The patient presents with pain. Right foot discoloration, purple in appearance. The complaints affect the right foot.recent right [MEDICAL CONDITION] status [REDACTED]. The pt. (patient) denies any pain in her foot, but says she can't feel anything below the knee .12:05 (p.m.) The pt. has a cool pulseless right foot on exam. I was unable to find a Doppler signal, a dorsalis pedis, or posterior artery either, concerning for a critical ischemia of the right leg. Spoke to doctor in hospital says does not perform peripheral intervention . call (city) hospital (Hospital #2), and the patient was accepted for transfer to the emergency department by (Physician) . The Arterial Doppler Study dated 2/13/19 from Hospital #1 documented, .Impression: Occlusion of the right superficial femoral artery proximally with no flow identified in the remainder of the right lower extremity . k. The Progress Note dated 2/14/19 at 2:59 p.m. from Hospital #2 documented, .Subjective, (Name of Patient) has ischemic right leg. Spoke with the daughter and we have agreed that the patient do need an AKA (above knee amputation) . l. The Progress Note dated 2/15/19 from Hospital #2 documented, Patient has been in a nursing home for some time and not ambulating. She was noted to have a cold right foot on 2/23. Patient reports pain for several weeks. Based on exam the foot is already dead and has been for some time, she has absent motor and absent sensation. She has a right femoral and popliteal signal with movement of the knee, no distal pedal signs on the right. Unfortunately, patient is not a revascularization candidate as her motor and sensation function is already absent. The risks and benefits of surgery were discussed with patient and family and they would like to proceed with operative intervention. Will perform tomorrow. m. On 3/19/19 at 10:20 a.m., Licensed Practical Nurse (LPN) #1 was asked if she remembered the resident and stated that she did. The LPN was asked about the discoloration and area of eschar on the right heel. She stated, .The day before I was off, I did her dressing on her right heel. I did her dressing changes on that day in the evening time at approximately 5 PM. Her leg was not purple but had a discoloration; it was the leg on the same side as her stroke. She had an abduction pillow in place, due to recent hip surgery on the right hip. The leg was not purple, nor the foot. She had some small blisters on her leg, as before. The LPN was asked, when did you do the dressing change? The LPN stated, On 2/12/19. The ADON (Assistant Director of Nursing) called me on 2/13/19 and asked me if the foot was purple the day before, and I told her no, there was no purple, only the discoloration that developed after she got here. The nurse filling in for me on 2/13/19 could not feel any pedal pulses. They sent her to ER (emergency room ). The LPN was asked if she knew how long it was between when the resident was admitted and when the discoloration to the right lower extremity was first identified. She stated, She had a brownish discoloration on admit; it was on her shin and lateral side of the lower leg. The LPN was asked about the blisters and stated, They brought it to my attention that she had tiny blisters on the shin, front part of the leg. They were small, then all the blisters combined into one. They never burst, they were soft, and fluid-filled. The LPN was asked if the blisters were present upon admission and stated, No, the blisters were noted on 2/7/19. The LPN was asked, Did she have anything on the right heel when she came in? She stated, No, the niece mentioned to me on 2/6/19, 'can you look at her right heel?' I looked on the 6th and saw the eschar; this was the first that I saw it. She had no dressing on it until the 6th. She came in on 1/29/19; another nurse did the admission assessment and body audit, and her heel was not dark, and she did not have a sore. The LPN was asked, When did the heel turn dark? She stated, I don't know; it was the resident's niece that (sic) told me the resident's heel was dark. The LPN was asked, Did you see any other areas on the resident's right foot or changes in color? She stated, No. n. On 3/20/19 at 11:42 a.m., Licensed Practical Nurse (LPN) #2 was asked about the resident's leg and stated, The resident's right leg had started being discolored 2 to 3 days prior to discharge. The LPN was asked, where was the discoloration? She stated, On the outer side of the right leg. The LPN was asked if the resident's foot was discolored and stated, If I'm not mistaken, the foot was bandaged. The LPN was asked, did she complain of pain? She stated, Not much, she complained of pain in the right hip about 2 times and had to be given something for pain. She had an abduction pillow in place; they would turn her, but she would turn herself back. Three days prior to discharge, she developed an area to her right leg. The LPN was asked if the resident was on anticoagulant medication (blood thinner). She stated, I think he (physician) had dc'd (discontinued) it. The LPN was asked, did you call the doctor when you noticed the discoloration of the leg? She stated, No, we normally tell the supervisor, and she does it, or report it to the treatment nurse. o. On 3/20/19 at 1:20 p.m., Housekeeper #1 stated, On the right leg, I noticed blisters from the top of the calf to the mid-calf. Then, I was in there with the treatment nurse when she was about to change the dressing on the right hip, and I saw the toes with dark streaks between them on the right foot. The right foot had started to look like it had a change in color, an ashy gray look. She (Treatment Nurse) pulled the sock off, and I saw the foot . I brought it to her (treatment nurse) attention about her right foot. I was in there already when the treatment nurse came in and I moved the resident or something and I asked her (resident) was she in pain and she said 'no', so I lifted her pants, and that's when I saw the blisters. She hurt a lot when she stood up in therapy that day. Housekeeper #1 was asked, do you know if therapy notified the doctor about her starting to have a lot of pain when standing on that leg? She stated, I don't know if they did or not. Housekeeper #1 was asked, did you see the right foot on the morning of 2/13/19? She stated, Yes, oh it was almost black; her foot was purple. This was the second time that I'd seen it; the first time was just the dark streaks on the foot. I went to the ER (emergency room ) with her. They said at ER that it might not be getting any circulation, no pulse. They said they were going to put a doppler on it. They sent her to the hospital in (city) (Hospital #2) from the ER here, because she had some blockage in the leg. Housekeeper #1 was asked what happened at Hospital #2 and stated, The surgeon told the family that she had a blockage and no circulation below the knee and that they had to do an amputation. He told the family also that this should not have happened; it was avoidable. Housekeeper #1 was asked, when the resident was here, and you went into the room, were her heels offloaded? She stated, No, she would always have that pillow between (her legs); that wedge pillow shaped like a triangle, and feet straight on the bed. Housekeeper #1 was asked, how many days, prior to 2/13/19, did you see the black streaks on the right foot? She stated, The week prior is when I saw the black streaks on the foot. I noticed the blisters in therapy, the second week they started therapy. She (resident) said her foot hurt, and I asked therapy why. They said, 'You know she has the blisters on her leg.' I went a little further and asked the nurse that (sic) admitted her if she had the blisters when she was admitted here, and she said, 'No'. Housekeeper #1 was asked, what color were the blisters? She stated, The area around them was dark brown, and the blisters were in the middle of this area. Housekeeper #1 was asked, do you know if the doctor was notified regarding this? She stated, I don't know. p. On 3/20/19 at 2:50 p.m., LPN #3 was asked if she remembered Resident #5 and stated, Yes, I remember the resident. I was not here when she came in. She came in on 3 to 11 (3:00 p.m. to 11:00 p.m. shift); I saw her the next day. The LPN was asked, did her right leg have any discoloration? She stated, No, not to my knowledge, it didn't. The LPN was asked, did you note any changes in her leg after the second day? She stated, No. The LPN was asked if any changes in the resident's right leg were reported to her at any time and stated, Yes, it was the day that the resident was to go home (2/13/19). There was another nurse working as Treatment Nurse that day, and she saw the resident's right foot discolored; dark, but not black . really discolored and no pedal pulses, so she got me. I assessed, called the doctor and sent her out to ER. q. On 3/20/19 at 3:15 p.m., LPN #4 was asked if she remembered Resident #5 and stated, Yes, I remember the resident. I did her admission assessment. The LPN was asked, were there any areas on her right heel on admission? She stated, No. The LPN was asked, were there any discolorations on the right leg? She stated, She did have a bruise on the upper thigh, at her incision. The LPN was asked, did you notice any other discolorations? She stated, She had what looked like an old scar on the lower right leg; all skin intact, with a dark brownish area, measured 1-1/2 inches in length by 1/2 inch in width. The LPN was asked, prior to 2/13/19, had you noticed any changes in her right foot? She stated, No, it was mentioned that she had a darkened area or bruised area on her heel. I can't recall how long after admission that it was brought to my attention that treatment had been initiated for the right heel. On 2/13/19, I came in to sub (substitute) for the treatment nurse that morning. I went in to dress her heel. I went to unwrap her dressing. Her foot was dark and cold. I called the day supervisor to come assist. She came and notified the DON (Director of Nursing), and the DON came in. The foot was dark purple, blue; it wasn't black but, dark. The LPN was asked, was the doctor notified regarding the right leg / foot at any time prior to 2/13/19? She stated, Not by me; that might be in the 24-hour (report) book. The LPN was asked, did the resident complain of pain on the morning of 2/13/19? She stated, She didn't complain of pain in her lower leg. She did not verbalize, but she did have facial grimaces when I went to raise the leg. I reassessed to see if she could feel, but she couldn't feel anything on the foot. The LPN was asked, did you see the blisters on the side of the leg? She stated, Yes, after I noticed about the foot. The LPN was asked if the area around the blisters was darker than the rest of the leg and stated, I don't believe so; I can't recall. The nurse went to the desk with the surveyor, to review the 24-hour report book. There was no documentation in the book regarding pain, color changes in the leg, nor MD notification for this resident. r. On 3/20/19 at 3:55 p.m., the Assistant Director of Nursing (ADON) was asked about the resident and stated. Yes, I remember the resident. There were no discolorations in the right leg that I recall. I did not see her on admission. I don't recall any reports. The ADON was asked, do you know of any changes that took place in the right leg? She stated, Yes, I remember the treatment nurse came and got me. She had some old discoloration and, on top of that, she had some blistering to the outer aspect, and we felt sure it was from the foam wedge. She had an unstageable pressure area to the right heel. The ADON was asked, did she have this pressure area on admission? She stated, I don't think so, but I don't know; I was not here when she admitted . I do remember after about a week here, she had an unstageable area. I remember holding the leg for the treatment nurse to dress it. It may have been the same day that she knew about it. The ADON was asked, when (resident) was sent to theER on [DATE], were there any other changes in the leg? She stated, Yes, the nurse came and got me and another LPN, and we went into the resident's room. The resident's foot was a darker color, very dark, cooler to touch than the left foot. There were no other darker areas, (except) the toes were dark. The ADON was asked, was she on an anticoagulant? She stated, She was, I believe she was on it for 7 days, and after that, he didn't order anymore. She was on it when she came here. s. On 3/21/19 at 11:10 a.m., the Physical Therapist Assistant (PTA) was asked if she remembered Resident #5 and stated, I remember the resident. We did her eval (evaluation) on 1/31/19. She either started (therapy) that day or the next day. The PTA was asked, can you tell me if she had discoloration or changes to her right leg? She stated, The CNA told me she had some red discoloration on the lateral side of her right foot, toward the heel. The PTA was asked, were there any changes in her toes? She stated, No, I noticed some changes more toward her discharge, 3 to 4 days before. The PTA was asked, what type of changes did you notice? She stated, You could tell there were circulatory problems - her foot was cold - it wasn't cold at first. When she first came in, it was warm to touch, up until a couple of days prior to discharge. The PTA was asked, was the doctor notified about the change in temperature of the foot? She stated, I don't know. The nurses normally do the reporting . The day before she dc'd (discharged ), I would have seen her. Her foot was not exposed, so I just did exercises. She was already dressed . t. On 3/21/19 at 11:24 a.m., Certified Nursing Assistant (CNA) #5 was asked, did you notice any discoloration or changes to the resident's leg? She stated, Yes, when I returned to work on the 5th and 6th of (MONTH) 2019. I weighed (residents) on the 7th, so I saw her on the 8th. CNA #5 was asked, when you returned to work, did the leg and the foot look the same or had they changed? She stated, Yes, I questioned the darkness on the outer right leg. CNA #5 was asked, what do you mean by darkness? She stated, It was darker than it was before I left on my days off. Her foot was the same, with the dark spot on the heel; there was no change in that. CNA #5 was asked, did you report the darker area on the leg? She stated, No. CNA #5 was asked, what is the procedure if you find skin issues? She stated, Go tell the nurse, and they tell the treatment nurse . I think I told the nurse on the weekend, but it's not written in stone that I did. The CNA was asked, Did anyone assess the resident's foot or call the doctor? She stated, No, I think something was done on that Monday (February 11) . When therapy came in to help me on the 12th of February, she (Therapy Assistant) said, 'her leg is swollen'. CNA #5 was asked, where was it swollen? She stated, From the top part of the knee up . it wasn't red. I told her I noticed that (the swelling) the weekend of the 9th and 10th. CNA #5 was asked, was the leg cold to touch on that weekend? She stated, Just the swelling, from the hip to the top of the knee. The foot was still the same; it was wrapped up. CNA #5 was asked, did you report the swelling on the 9th and 10th? She stated, I think I reported the swelling. I thought it was just swelling from surgery, and she had gone to therapy 5 days a week. CNA #5 was asked, did you see her foot on the morning of 2/13/19? She stated, No, I didn't see it; she was gone before I made it to the room. CNA #5 was asked, who do you report residents' condition changes to? She stated, To the Charge Nurse, DON (Director of Nursing), ADON (Assistant Director of Nursing) or Administrator. Sometimes, you tell the nurse, and they don't do anything about it. CNA #5 was asked, when you report something on the weekend, do the nurses put it in the 24-hour book? She stated, Sometimes, but not all the time. u. On 3/21/19 at 11:35 a.m., the Occupational Therapy (OT) Director was asked if the resident was making progress when therapy was first initiated and stated, Yes, then she got where she couldn't stand on that leg, because of the pain. The OT Director was asked, was the pain severe? She stated, Yes, only when bearing weight or transferring. The OT Director was asked, was the doctor notified of the sudden severe pain when it first started? She stated, We notified the nurses, and what they did from that point, I don't know. The OT Director was asked, did she have any changes in the temperature of her leg or discoloration? She stated, The PTA could better tell you that. I was a witness to the decline that she was unable to bear weight. The OT Director was asked, when was severe pain and inability to bear weight first noticed? She stated, Probably the 7th or 6th day of February. v. On 3/21/19 at 3:15 p.m., LPN #5 was asked if she remembered Resident #5 and stated, Yes, I recall the resident. When I was there, she'd had a hip replacement on the right side. I did treatments every other weekend. The first time I did her hip (dressing), there was no discoloration. The second time, I noticed she had a bruising, burgundy red in color, on the lower part of the leg. I spoke with the aides and asked, 'wow! what's going on?' They said they were just bandaging it. I just followed orders. LPN #5 was asked, did you think it strange, it being a burgundy red color? Did you call anyone about it or call the doctor? She stated, No, I just followed doctor's orders. I did not see any discoloration in the foot. I work only prn (as needed) weekends. LPN #5 was asked, was it ever reported to you that the leg was swollen or that there were changes in the resident's foot? She stated, No, never reported to me anything about her foot or leg swollen. I did not dress the foot; it had a bandage on it. w. On 3/22/19 at 8:50 a.m., LPN #1 was asked if there were changes in the color of the resident's right foot and stated, I was going to be off on 2/13/19. I did the resident's dressing change. The sole of the right foot was darker. The LPN was asked if she consulted the physician about change in color and stated, I called the family member and told her that the sole of the resident's foot was darker. x. On 3/22/19 at 12:05 p.m., the Medical Director (MD) was interviewed via telephone and was asked if he had been notified regarding changes in the color and temperature of the resident's right leg, the severe pain with weight-bearing, and the decline in the resident's ability to participate and progress with therapy. He stated, No, not this you've just mentioned. The MD was asked, do you think you should have been informed? He stated, Yes. y. The facility's Change of Condition Policy, provided by the Director of Nursing on 3/22/19 at 5:00 p.m., documented, .Any change of condition (change in wound status, change in skin status, change in physical or mental status) . must be . assessed, recorded and reported so proper treatment can be implemented. CNAs are to report all abnormal findings (swelling, bruising, skin tears, skin discoloration, rashes, blisters) to the charge nurse using a STOP and watch sheet. Notify the attending physician/on call physician of change in physical/mental function as soon as feasibly possible . z. The Immediate Jeopardy was removed, and the scope and severity reduced to H on 3/22/19, when the facility implemented the following Plan of Removal: 1.) On (MONTH) 22, 2019 at, the ADON/DON designee reviewed all new admissions and all residents who have received surgeries since 1/29/19. Five residents were identified to have the potential to be affected by the failure to assess peripheral pulses accurately. Assessments were performed on all five residents identified by the DON/designee to have the potential to be affected. No further negative findings. 2.) On (MONTH) 22, 2019 the DON in-serviced all nursing staff on change in documentation on skilled charting and nursing summaries to reflect the checking of radial and pedal pulses with strength of pulses as 0=absent, 1=palpable, but weak and thready, 2=normal, 3-increased pulse and 4=full, bounding. 3.) The DON/ADON/designee will monitor all new admissions and post-surgical residents post operation to ensure assessments of radial and pedal pulses are completed with strength of pulse recorded. Monitoring will be done immediately and 4x (times) weekly x 8 weeks on a peripheral pulse spreadsheet, or until compliance is verified by OLTC (Office Long Term Care). Will then monitor weekly after compliance is reached through OLTC. 4.) On (MONTH) 22,2019, after review of new admissions and new surgeries, five residents had the potential to be affected by the failure to report change of condition to the physician immediately. DON/ADON/designee residents were assessed to ensure that they had not had a change of condition. No negative findings. Assessment included review of physician orders, review of progress notes and assessment of resident. 5.) On (MONTH) 22, 2019, the DON in-serviced all staff on the proper procedure for reporting a change of condition for residents, this included certified nursing assistants to promptly report anything they see to the charge nurse or supervisor. Also included in the in-service was for nursing staff to report any change of condition to resident's primary care physician. 6.) The DON/ADON/designee will monitor any new admissions and any new surgeries post operation to ensure any change of condition is reported to the physician immediately. Monitoring will be done on a change of condition spreadsheet 4x weekly for 8 weeks, or until compliance is verified by OLTC. Will then monitor weekly after compliance is reached through OLTC.

Complaint # (AR 521) was substantiated, all or in part, with these findings. Complaint # (AR 551) was substantiated, all or in part, with these findings. Complaint # (AR 603) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to consistently evaluate falls for causative factors and / or develop new interventions to address those causative factors for 3 (Residents #1, #2 and #3); failed to ensure an assessment / evaluation was conducted to determine the safest and most appropriate mobility device for a resident after the resident experienced a fall from a wheelchair that resulted in head injury for 1 (Resident #1); and failed to ensure a personal alarm was checked for proper functioning prior to use to minimize the potential for further falls / injuries for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents who had falls in the last 6 months. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who fell and sustained a laceration to the head, did not receive any additional fall prevention interventions, and fell again 6 days later, re-opening the previous laceration to the head. The failed practices also had the potential to cause more than minimal harm to 36 residents who fell in the last 6 months, as documented on a list provided by the Director of Nursing (DON) on [DATE] at 2:05 p.m. The Administrator was informed of the immediate jeopardy condition on [DATE] at 12:27 p.m. The findings are: 1. The facility's Fall Protocol, provided by the DON on [DATE], documented, .1. To assess resident at risk for falls 2. To follow up and evaluate all falls 3. To identify the reason for the fall 4. To prepare a plan of care to reduce the potential for injury related to falls. General Guidelines for Assessment may include but limited to: 1. Change in physical and/or cognitive function 2. Pain 3. Medication 4. Environmental 5. Communication deficits 6. Risk factors r/t (related to) disease process, cognitive status, behaviors, etc (et cetera). Assessment Tools: 1. Fall risk assessment and post fall assessment. 2. Event report 2-sided. 3. Fall investigation report and follow up. Note: All residents will be assessed for fall using the fall assessment risk assessment . quarterly, significant change in status and time of the fall. Those residents that are to be determined high risk will have care indicated. Anytime a resident is found on the floor, fall risk protocol should be followed including neuro (neurological) checks if indicated. If a resident rolls off the bed or mattress that is close to the floor, this is considered a fall. Charge Nurse Duties . Neuro checks based upon neuro check policy and procedures . 5. Complete fall investigation report front page 6. Implement intervention to prevent further injury. 7. In-service on new intervention as needed . Duties: 1. Complete a fall risk assessment. 2. Update the care plan with new interventions. Director of Nursing or Designee Duties 1. Complete fall investigation follow-up (back page). 2. Review fall risk assessment for completion. 3. Review fall investigation follow-up and fall risk during standard of care / fall risk meeting. 4. Review interventions for appropriate intervention change as needed. Intervention Resources . 10. Assess for need for assistive devices . Assess for alarms or devices . 2. The facility's Bed/Chair Alarms Policy and Procedure, provided by the DON on [DATE], documented, It is the policy of this facility to maintain a program to promote patient safety. The facility will identify behavior and interventions to be implemented to reduce the risk of fall related injuries . Testing: Alarm testing will be done before resident is placed on alarm device. Alarm volumes will be checked and verified as audible when equipment is placed in use with each user . 3. The Facility's .Wheelchair, Use of policy, provided by the DON on [DATE], documented, Basic Responsibility Licensed Nurse, Certified Nursing Assistant, Restorative Nursing Assistant . To provide mobility for the non-ambulatory resident, safety and comfortably. Assessment Guidelines . Ability to perform ADLs (activities of daily living) . Loss of sitting balance, Loss of voluntary movement of upper extremities . Paresis or paralysis . Equipment Wheelchair Procedure 1. Wheelchair should be the proper size. Enlist assistance of Physical Therapist or DME (Durable Medical Equipment) provider to ensure proper fit . Care Plan Documentation Guidelines . Problem: Identify the appropriate problem under which to list the wheelchair as an approach. Consider listing possible risks and complications . Approaches: Specify necessary monitoring and observation of the resident's endurance and toleration of being up in the wheelchair . Record monitoring for proper body alignment . 4. Resident #1 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 3 (,[DATE] indicates severely impaired) on a Brief Interview for Mental status and required extensive assistance of one person with locomotion on and off unit and had one fall with no injury since the prior assessment. a. The Care Plan dated [DATE] documented, The resident is high risk for falls r/t (related to) confusion, gait/balance problems . unaware of safety needs, wandering. Encourage the resident to use bell to call for assistance . Anticipate and meet needs . Review information on past falls and attempt to determine cause of falls. Record root causes. Alter remove any potential causes if possible . b. A Witnessed Fall form dated [DATE] at 10:01 a.m. documented, .Was called to resident room, noted her sitting on floor, knees up . CNA (Certified Nursing Assistant) lowered resident to the floor to prevent falling. Resident had gait belt around waist . 0 (No) injury noted at this time . There was no documentation as to efforts to determine what caused the incident or of any new interventions that were developed and implemented after the fall, such as evaluating to determine if the transfer method currently in use remained appropriate for the resident's functional abilities, revising the transfer method if needed, and educating staff on appropriate transfer techniques. c. A Morse Fall Scale dated [DATE] documented, .High Risk for falling . Score: 50 . The form documented a score of ,[DATE] indicates low risk; ,[DATE] indicates medium risk; and 45 and above indicates high risk for falls. d. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated [DATE] at 8:50 a.m. documented, .CNA reported to charge nurse that resident was on the floor in her room. Resident had fallen out of her wheelchair. Resident was found lying on the floor next to her wheelchair with blood laceration to her forehead approx (approximately) 4 cm (centimeter). Resident awake and alert, confusion which is her normal. Chair alarm was on but not alarming. Complained of pain to head. 911 called and resident was taken to ER (emergency room ) for eval (evaluation) . Findings and Actions taken .Neuro checks were initiated upon return to facility at 11:49 a.m.staff replaced chair alarm. All nursing staff retrained on proper procedure for checking function of alarms. Resident was placed on 72 hr (hour) hot rack assessments and no new physical or mental problems noted post fall. 1.) Hospital Emergency Department Physician notes dated [DATE] at 9:15 a.m. documented, .Nursing Home report that patient slipped out of bed and struck her head on an unknown object resulting in 2 superficial lacerations to her forehead . laceration(s) that is superficial, that is jagged, of the forehead, of the 2 superficial lacerations noted to center of forehead #1 approx 2.5 cm, #2 approx 2 cm .Wound prep: skin with ,[DATE] Ethilon using Dermabond. 2.) A hospital diagnostic report dated [DATE] at 9:24 a.m. for a computed tomography (CT) scan of the head documented, .Left frontal scalp swelling . 3.) A Nurse Note dated [DATE] at 12:26 p.m. documented, . [MEDICATION NAME] Tablet 325 mg (milligram) give 2 tablet by mouth (po) every 6 hours as needed . Head hurting . at 14:33 (2:33 p.m.) .[MEDICATION NAME] Tablet 325 mg give 2 tablet by mouth every 6 hours as needed . Ineffective Follow-up Pain Scale was: 10 (on a scale of 1 - 10, with 10 being the greatest pain) XXX[DATE] at 17:45 (5:45 p.m.), gave resident Tylenol 325 mg 2 po (by mouth) . 4.) A Nurse Note dated [DATE] at 10:15 a.m. documented, Resident has N.O. (New Order) for [MEDICATION NAME] 50 mg TID (three times daily) PRN (as needed) for pain . staff attempting to put resident in high back wheelchair, but resident was attempting to lean forward in high back recliner w/c. So resident was placed back into original w/c . There was no documentation a physician or therapy evaluation was requested to determine the safest and most appropriate mobility device for the resident at this time. 5.) A Nurse Note dated [DATE] at 6:33 p.m. documented, .Conts (Continues) with light and dark purple bruising to forehead and around eyes. Noted a bruise to lt (left) shoulder possible from recent fall . 6.) There was no documentation in the Nurse Notes, Care Plan, or elsewhere in the clinical record to demonstrate the facility evaluated the [DATE] fall for causative factors and developed new interventions to prevent further falls / head injuries. e. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated [DATE] at 9:05 a.m. documented, .Resident was in wheelchair at nurses station when supervising nurse heard the chair alarm go off and then hear a thump sound. Found resident lying on the floor, laceration to forehead reopened, minimal amount of blood noted. ROM (range of motion) performed and within function. Resident was alert, neuro checks initiated .EMS called and resident transported to Hospital ER for evaluation . 1.) A hospital Emergency Department Nurse Note dated [DATE] at 9:13 a.m. documented, Laceration without foreign body of unspecified part of head . Patient fell from wheelchair again this a.m. (morning) and re-opened the laceration to forehead. Bruising noted to forehead and eyes . Assisted laceration repair of top of head .repair done using staples, dermabond. Dressed with 4 x (by) 4s, Kerlix . 2.) A hospital diagnostic report dated [DATE] at 9:44 a.m. for a CT scan of the head without contrast documented, .Right frontal scalp swelling and evidence of frontal scalp laceration . 3.) A Nurses Note dated [DATE] at 12:22 p.m. documented, Resident returned back from (Hospital) [DATE] at 13:27 (1:37) p.m. administration note [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 50 mg give one tablet every 8 hours as needed with sitter, sitter reports resident has made an attempt of trying to get out of geri chair, redirected, helmet too small & causing resident pain & new one has been ordered and will be in next week. Resident to have head wrapped with padding until helmet arrives . f. A Significant Change Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, was totally dependent on the assistance of one person for locomotion on and off unit, used a wheelchair for mobility, and had a history of [REDACTED]. This reflected a decline in the resident's locomotion abilities, from requiring extensive assistance with locomotion per the [DATE] MDS, to a totally dependent status with locomotion on the current MDS. g. On [DATE] at 7:30 a.m., Certified Nursing Assistant (CNA) #1 was asked to describe the resident's fall on [DATE] and stated, I came in and got her dressed and put her in the wheelchair. I passed out trays and fed her. I went and picked up a few more trays, heard a loud thump, and the alarm didn't go off. I had turned the alarm on after I got her dressed that morning, after I put her in the wheelchair. When you turn the alarm on, it beeps twice. After that fall, they said we are supposed to check the alarm before putting the resident in the wheelchair. I did turn it on; it beeped, so I assumed it was working. I didn't know before she fell that you had to sit on the pad in the wheelchair, then get up to see if the alarms sounds. That how we test. She was asked if she verified the alarm was functioning prior to the fall on [DATE] and stated, No, the Nurses and CNAs were called for in-service the next day or that day. That's when we were told to sit on chair and stand on the fall mat (alarms) to see if it works properly, if it will sound. She was asked if they documented the alarm testing anywhere and stated, Not that I know of. h. On [DATE] at 10:15 a.m., the Assistant Director of Nursing (ADON) was asked how chair alarms were tested , how often, and where this was documented. She stated, Every shift, and it's part of the CNAs care before shift starts. She also stated, Bed alarms are turned on, put pressure on the sensor pad by placing your hand on it, and it should sound if it's functioning properly, and chair alarms are done the same way. She was asked why Resident #1's alarm did not sound on [DATE] and stated, It was either due to positioning, or due to operational defect. They did go back and check it after the fall, and it still didn't alarm. She was asked how often staff were trained on how to test chair alarms for proper functioning and stated, During new staff orientation and during the investigation of a fall, and we do re-training as needed . We did an in-service on alarms that day. i. On [DATE] at 1:00 p.m., the ADON was asked what interventions were implemented after Resident #1 fell on [DATE] and [DATE]. She stated, If the intervention is not on the I &A, the Nurse didn't do an intervention. We in-serviced the staff on alarms the day she fell . j. On [DATE] at 11:00 a.m., the Director of Nursing was asked if the resident was assessed for proper positioning by the therapy department (per facility policy) to determine the safest, most appropriate mobility device. She stated, We did a trial run in the geri-chair for 2 weeks (after the [DATE] fall). There was no assessment or evaluation done for the use of the wheelchair or geri-chair, and we didn't try other devices. Staff did try her in a high back wheelchair. k. The facility removed the immediate jeopardy to Resident #1 and reduced the scope / severity to H on [DATE], as evidenced by the following: 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated [DATE] at 9:05 a.m. documented, .Findings and Actions taken . New orders from PCP (primary care physician) for padded helmet placement. Resident will be on 1:1 (one-on-one) supervision for the rest of (7:00 a.m. to 3:00 p.m.) shift and (3:00 p.m. to 11:00 p.m.) shift for today to monitor UTI (urinary tract infection). 2.) An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated [DATE] at 9:05 a.m. documented, Will start geri-chair trial x (times) 2 weeks with one on one supervision for ,[DATE] shift today. 3.) Care Plan revisions dated [DATE] documented, .bed alarm, Geri chair for locomotion with magnetic alarm . Padded helmet at all times . 4.) As of the date of the survey, the resident had experienced no further falls after the [DATE] interventions were developed and implemented. 5. Resident #2 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 6 (,[DATE] indicates severe cognitive impairment) on the Brief Interview for Mental Status, required extensive assistance of one person with locomotion on the unit, used a wheelchair for mobility, and had history of falls with and without injury. a. The Care Plan dated [DATE] documented, .Alarming mats x (times) 2 .Anticipate and meet the resident needs . Bed and chair alarms to alert staff of transfers .wing mattress . encourage resident to use bell to call for assistance . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated [DATE] at 3:45 a.m. documented, .Charge Nurse was at nurses station charting when she heard resident bed alarm go off . resident on floor bedside bed . Resident assessed for pain and ROM done. Neuro checks initiated. Assisted back to bed . There was no documentation of new interventions related to this fall. c. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated [DATE] at 5:48 p.m. documented, .Resident hollering for help . resident found lying in middle of the floor between bed and bathroom . There was no documentation of any interventions implemented related to this fall. d. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated [DATE] at 8:00 p.m. documented, .Alarm was heard going off by CNA and resident was found on the floor by her bed . There were no documented interventions. e. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated [DATE] at 8:15 p.m. documented, .The nurse heard resident yelling help and went to the room and found resident on the floor on mat bedside the bed . f. The facility's Witnessed Fall form dated [DATE] at 6:19 p.m. documented, .Resident had her legs off the side of the bed and slid to the floor. The bed was completely on the floor and mats were on the side of the bed . Resident has no injuries . g. The facility's Witnessed Fall form dated [DATE] at 3:15 p.m. documented, .When staff was walking by resident room, she was sliding out of bed . h. The facility's Witnessed Fall form dated [DATE] at 15:57 (3:57 p.m.) documented, .Housekeeper noticed resident sliding out of bed on the right side of the bed onto floor mat . i. An I/A Report dated [DATE] at 02:13 (2:13 a.m.) documented, .Found resident on the floor mat beside her bed with her back to the bed. Resident is drowsy and has been asleep. Resident wearing non-skid socks at the time of the incident. j. The facility's Witnessed Fall form dated [DATE] at 15:11 (3:11 p.m.) documented, .while walking down hallway she noticed resident hanging onto bedrail while feet were on floor with buttocks right over fall mat . k. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated [DATE] at 13:32 (1:32 p.m.) documented, .Heard alarm going off .resident sitting straight up on floor, feet out in front of her . Bed alarm and floor mat .effective . l. An I&A dated [DATE] at 11:15 a.m. documented, .Resident found on the floor on the side of her bed . She was brought to the nurses' station . m. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated [DATE] at 21:40 (9:40 p.m.) documented, .Resident found by CNA on the floor beside her bed . Resident then placed in geri-chair and taken to nurses' station for close monitoring . n. An I&A dated [DATE] at 14:30 (2:30 p.m.) documented, .Resident was found on the floor by CNA . Resident was assisted to her gerichair . taken to the front of the nurses' station for observation . o. An I&A dated [DATE] at 1:15 a.m. documented, .Resident was found on floor, no injuries notes . Resident was brought to nurses' station in gerichair per request. p. On [DATE] at 1:00 p.m. the ADON was asked if interventions were developed and implemented for the resident's falls on (MONTH) 3rd, 7th, 11th, and 22nd and stated, I guess the nurses didn't put any on, and I didn't follow-up on the falls. q. On [DATE] at 1:35 p.m., the ADON stated, I have an intervention for the fall on (MONTH) 7, (YEAR). You have to tell the computer to print it, and Medical Records doesn't have access to it and can't print it either. She was asked why the intervention was not documented on the I/A Report and stated, I was out the month of (MONTH) (2018), and the interventions didn't get done . I called the Nurse, and she told me what the intervention was, and I just put it in. The findings and actions taken (after the fall on [DATE]) documented, Bed alarm in place, was effective notifying staff resident was out of bed. Fall mats effective, preventing injuries from falls. r. On [DATE] at 12:30 p.m., the DON was asked if evaluations for causative factors were completed after each fall for this resident. She stated, Well, most of her falls, she would state, 'I was trying to get up and walk' or 'I was trying to get on the floor'. She was asked if the causative factors were documented anywhere and stated, No, we had a fall meeting on [DATE], and we went over the residents that had falls to try to determine the root cause . and we came up with music therapy for (Resident #2). She was asked if new interventions should be documented on the care plan and stated, Yes. 6. Resident #3 had [DIAGNOSES REDACTED]. An Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 5 (,[DATE] indicates severe cognitive impairment) on the BIMS, required limited assistance of one person for walking in room and corridor, used a walker and wheelchair for mobility and had no documented fall since prior assessment. a. A Morse Fall Scale dated [DATE] documented, .High Risk for Falls . Score: 75 . b. A Care Plan revised [DATE] documented, The resident is high risk for fall r/t confusion, gait/balance problems and incontinence . Anticipate and meet the resident's needs . c. An I/A dated [DATE] at 15:15 (3:15 p.m.) documented, .Resident found on the floor laying (sic) diagonal . resident had been exhibiting s/s (signs/symptoms) of personal distress, finding out her dog died and got it confused that her mother had died . d. On [DATE] at 3:00 p.m., the ADON was asked if interventions were developed and implemented after the fall that occurred on [DATE]. She stated, I guess the nurse didn't do interventions, and I didn't follow-up on it.

Complaint # (AR 638) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure staff thoroughly checked for possible resident elopement after elopement alarms sounded on 2 doors, which resulted in failure to promptly identify that a resident had eloped from the facility for 1 (Resident #6) of 1 (Residents #6) case mix residents who were at risk for elopement and had Secure Care (elopement prevention bracelets) in use. The failed practice resulted in past noncompliance at the level of immediate jeopardy for Resident #6, who eloped from the facility and was missing for a period of approximately 2 hours, and had the potential to cause more than minimal harm to 13 residents who were at risk for elopement and had elopement prevention bracelets in use, as documented on a list provided by the Assistant Director of Nursing (ADON) on 11/9/17 at 1:35 p.m. The Administrator was informed of the past immediate jeopardy condition on 11/9/17 at 4:30 p.m. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 3/11/17 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status and did not exhibit wandering behavior. a. A Physician order [REDACTED].Secure Care Bracelet at risk for elopement . b. The Resident Plan of Care for elopement risk was dated as initiated on 9/28/15 and documented, .Elopement: .Resident is at risk for elopement as evidenced by exhibits exit-seeking behavior . Approaches: Monitor resident for tailgating when visitors are in the building . Reassess elopement risk at least quarterly . Use audible monitoring system to alert staff of exit seeking behaviors . Check for proper functioning of the audible alarm system every shift and PRN (as needed) . c. The Wandering Risk assessment dated [DATE] at 1:34 p.m. documented, .Orientation: Disoriented x (times) 2 spheres . Forgetful/short attention span . Behavior/Mood: Does not understand surroundings . Does not understand what is being said (due to language or cognition) . Mobility: Ambulates with one assist . Diagnosis: [REDACTED]. Medications: Taking antipsychotics . Taking antidepressants . The check box next to, History of Wandering was not checked. d. The Incident and Accident (I&A) Report dated 4/24/2017 at 8:40 p.m. and completed by Licensed Practical Nurse (LPN) #1 documented, .Reported per CNA (Certified Nursing Assistant (CNA) #1) to this nurse (LPN #1) at nurse's station that resident was not in room or in his bathroom. All rooms on hall checked at this time d/t (due to) resident had previously been wandering in facility, but was easily redirected to room per staff. All rooms checked throughout the facility. At 9:30 p.m., Code Green called. Staff continues to search all areas of facility and facility grounds. 911 called at this time per (Registered Nurse (RN) Supervisor #1). Administrator notified at this time. 9:31 p.m. (Friend/Power of Attorney (POA)) made aware. 9:40 p.m. Police now here and given description of resident and of last time resident was seen. This was around 8:40 p.m. when resident was last noted in his bed. 10:23 p.m. (Director of Nursing (DON) #1) called to facility to check status, during this conversation, she hollered 'there he is'. All clear was called at 10:25 p.m. When resident was found, assessment revealed a abrasion to palm of right hand. Ambulance called at this time per police to have resident transported to ER (emergency room ) for eval. (evaluation). Resident remains at ER at this time . e. Nurses Notes dated 4/25/2017 at 3:03 a.m. documented, .Returned to facility via ambulance. Resident has a skin tear to right forearm, ER reported that they cleaned and applied steri-strips, laceration to right hand they cleaned and steri-strips applied and they wrapped with gauze, ER also reported that resident had scratches on back, arms, legs, stomach and arms and that they just cleaned and Neosporin was applied, on return to facility this nurse and CNAs started a 30 - minute monitoring sheet . f. On 11/9/17 at 10:30 a.m., Maintenance Employee #1 was asked if he was aware of a resident eloping from the facility in April 2017. He stated, Yes, he (Resident #6) got out the double doors at the service hall . (CNA #1) had turned the alarm off and did not see anybody, and another resident had been setting off the alarm frequently. g. On 11/9/17 at 11:50 a.m., LPN #1 was asked if she was present when Resident #6 eloped in April 2017. She stated, I was working as charge nurse on the 3 to 11 (3:00 p.m. to 11:00 p.m.) shift on 4/24/17, when (Resident #6) eloped. I was approached by a CNA, and she told me that (Resident #6) was not in his bed. I asked her if she had checked his bathroom and she said 'yes', that he wasn't in there. He would get up and go to the bathroom and about the facility but never to an exit door. We started looking around for him. I alerted the RN Supervisor for that evening. She was here and after we couldn't find him after approximately 10 minutes we called a Code Green. (RN Supervisor #1) called the police and employees continued to search different places throughout the facility. After he wasn't found inside the facility we expanded our search to outside the facility. One of the CNAs, I'm not sure which one had last seen him when they were in providing care to his roommate. I last saw him during my med pass around 8:00 p.m., when I was passing meds to his roommate. He was in his bed. During the search, I kept going back and forth into the facility to check on the status. The last time I came in, the phone was ringing, and it was (DON #1); she was checking on the status. She was here and searching outside; just when I was going to tell her there was nothing new, she started screaming, 'There he is, there he is!' She stated, 'out back behind the gazebo. I paged to let everyone know he had been found. At that time, me and (DON #1) started assessing him and noted abrasions on top of his hands. We called the EMS (Emergency Medical Services), and they came, and he was sent to the ER for evaluation. Immediately after the interview with LPN #1, the surveyor accompanied the LPN outside to the area the resident was found. It was approximately 282 yards from the door he exited to the location where he was found. The terrain varied in the area, from even, to sloped, to a drop-off into brush and briars that were approximately 4.5 feet tall. Approximately 4.5 feet from where the resident was located, there was a jagged, rusty culvert. Approximately 10 to 15 feet behind where the resident was located, there was a steep drop into an approximately 8-foot deep ravine. h. On 11/9/17 at 1:40 p.m., the Administrator was asked about the resident's elopement in April 2017. She stated, They informed me; I can't remember the exact time they informed me about (Resident #6) was not in the facility. I immediately started coming to the facility. I notified the DON to meet me at the facility. When I got there, they had begun the search. CNAs were searching inside, and LPNs from A-wing were outside with a flashlight. (LPN #2) had the flashlight, and she was coming outside. The policemen were here and asked if we had a camera and I said, 'yes'. The Administrator stated she did not document the time stamped on the video footage, as to what time the resident exited the facility, and what time he was found and returned to the facility. She stated, I did not write down the time from the camera that he went out and did not write down the time the staff turned the alarms off. (Maintenance Employee #2) found it on the camera system the next day. The policeman and I couldn't find it. (CNA #1) told me she had turned an alarm off. She turned off the double doors and the transportation door. (LPN #3) turned off the door he got out of. She held the door open and looked around for a few seconds, and she came back in. He was found probably 15 to 20 minutes after I got here. i. On 11/9/17 at 2:45 p.m., RN Supervisor #1 was asked about the elopement of Resident #6. She stated, I don't remember what CNA had him that night, but they said (Resident #6) was not in his room. I'm sure they initially told (LPN #1). I don't know what time this was. (LPN #1) told me; I don't know what time she told me. I directed staff to start looking in rooms and bathrooms, and when they reported back, I don't remember how long it took. I was looking as well. (LPN #3), on the other end, went outside and looked around after we couldn't find him. When we couldn't find him, we called the DON, Administrator and the police. Then we started looking outside. The whole time we were looking for him, we were calling his name. The police went to all the places we had already searched. We all had flashlights. I found out, after the fact, the alarms had sounded and had been turned off. j. On 11/9/17 at 3:52 p.m., LPN #3 was asked about the alarm that sounded on the evening Resident #6 eloped from the facility in April 2017. She stated, I did hear an alarm that night; it was down at maintenance. I responded to the alarm and cleared the alarm. I opened the door and looked both ways. I remember being able to see; can't remember what time it was. It seemed like it was a little while after that when I heard the resident was missing. k. On 11/9/17 at 4:03 p.m., CNA #1 was asked about the alarm she heard on the evening Resident #6 eloped in April 2017. She stated, I did turn the alarm off on the double doors off of A Hall. It may have been around my break time for supper, approximately 7:30 p.m. I didn't turn any other alarms off that night. I heard the alarm when I was coming up the hallway, and I saw another resident coming past the double doors. l. The facility removed the immediate jeopardy and corrected the failed practices prior to the survey, as evidenced by the following: 1.) Based on review of the facility's incident / accident documentation and interviews with multiple staff, there had been no further elopements from the facility, by this resident or any other resident, since April 2017. 2.) The facility's Elopement Policy and Procedure, provided by the DON on 11/9/17 at 2:35 p.m., documented, .Policy: It is the responsibility of all staff to provide a safe environment for all residents. In the event of elopement the facility will follow procedure aimed at protecting, searching for, and returning resident home. Procedure: 1. On admission, each resident shall receive an Elopement Risk Assessment, if the assessment shows the resident to be at risk for elopement an Elopement Risk Tracking Log and Care Plan will be initiated immediately with interventions. Elopement Risk Assessment will be updated as needed . 3. If the elopement is due to the Secure Care System and doors not working properly any employee will be stationed at each door and with any high risk resident that could potentially elope until the doors are working properly . Responding to an actual elopement: 1. It is the responsibility of all staff, regardless of the department they are working to respond to activated door alarms and to return residents to their units . 3.) On 11/9/17 at 10:48 a.m., all doors with alarms throughout the facility were checked for proper functioning with Maintenance Employee #1 and all were functioning properly. 4.) On 11/9/17 at 3:52 p.m., LPN #3 was asked what staff were to do if an alarm sounds and stated, When this happens, we are to go to where the alarm is sounding and try to figure out what caused it to go off. Then we do a head count of every resident, whether they have an alarm or not. 5.) On 11/9/17 at 4:03 p.m., CNA #1 was asked what staff were to do when an alarm sounds and stated, Now, the alarms are louder and we go immediately and do room-to-room checks and do head counts and make sure every resident is accounted for. 6.) On 11/9/17 at 4:18 p.m., DON #2 was asked what the facility had done in response to the resident's April 2017 elopement to prevent recurrence. She stated after this incident, they had the alarms made louder. When the alarm sounds, we check the box that tells us where the alarm is sounding. They (staff) go to that door and look for any resident could have set it off. If they can't see what set it off, they immediately initiate a head count and have 15 minutes to complete this. All staff have to respond to this. 7.) On 11/9/17 at 4:30 p.m., the Administrator stated, We now have educated all staff to immediately respond. If you don't find the source of an alarm within 10 minutes, then immediately do a head count.

Based on observation, record review and interview, the facility failed to ensure planned interventions were consistently implemented to prevent further potential weight loss and that new interventions were promptly developed and implemented after significant weight loss was identified, to prevent further potential weight loss for 2 (Residents #3 and #5) of 4 (Residents #3, #4, #5 and #9) case mix residents who had experienced weight loss. The deficient practices resulted in a pattern of actual harm for Residents #3 and #5, who experienced severe weight loss, and had the potential to cause more than minimal harm for 11 residents who had experienced unplanned weight loss, according to a list provided by the Dietary Manager on [DATE]. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident scored 4 (,[DATE] indicates severely impaired) on the brief interview for mental status (BIMS), required total assistance of one person for eating, had a weight loss and was not on a physician prescribed weight loss regimen. a. A Tip Sheet for Identifying Clinically Unavoidable Weight Loss for the resident with an assessment date of [DATE] and signed by the primary care physician documented, A resident who takes 2 or more of the following medications and/or has 3 or more of the following conditions should be evaluated for the potential of unavoidable weight loss: Drug Therapy: Diuretics, [MEDICAL CONDITION], Conditions: Advanced or End Stage Disease, Decreased mental status varies, Depression / dementia., Refusal to eat or accept other methods of nourishment, Slow eating pace, Nutritional supplements, and Dependent dining . Findings: Poor intake will refuse meals and assist. Periods of pacing/anxiety, looking for deceased family. b. The [DATE] Physician order [REDACTED]. 1.) [DATE], Soft diet. 2.) [DATE] Prostat Sugar-Free Vanilla 30 ml (milliliters) PO (by mouth) QD (every day). 3.) [DATE] increase protein intake, Resource Boost Breeze 8 oz (ounces) PO 3x (three times) daily with meals for protein supplement. c. The Care Plan dated [DATE] documented, At nutrition risk leaves 25% or more of food uneaten at most meals. Weigh and monitor results monthly and PRN (as needed). Monitor and report to the Physician Provide diet as ordered. Report to nurse any S/S (signs and symptoms) chewing/swallowing or other problems consuming meals. Offer substitutes if 50% or less is consumed. Provide dining room/meal accommodations. Allow adequate time to eat. Provide a quiet, calm setting. Diet: Regular Mechanical Soft. Encourage and assist PRN (as needed). d. The facility's Annual ,[DATE] Monthly Weight sheet, received from the Administrator on [DATE], documented the following monthly weights for this resident: 1.) [DATE].0 pounds. 2.) [DATE].0 pounds. 3.) [DATE].0 pounds. 4.) [DATE].0 pounds. 5.) There was no July weight available for review. On [DATE] at 11:36 a.m., the Dietary Manager was asked if she had a [DATE] weight for the resident and stated, I don't have one recorded; I don't know why she doesn't have a July weight. 6.) [DATE].0 pounds. 7.) [DATE].0 pounds. 8.) [DATE].6 pounds. The resident experienced a 6.2% weight loss in 1 month from [DATE] to [DATE]; a weight loss of 7.9% in 3 months from [DATE] to [DATE]; and a 17.9% weight loss in 6 months from [DATE] and [DATE]. e. On [DATE] at 5:22 p.m., during the dinner meal, the resident was served one cheeseburger on bun, mashed potatoes, green beans, mayonnaise, mustard and ketchup, ice cream and cranberry juice. The resident ate 25% of her dinner meal and was encouraged by staff to eat more with little success. There was no Boost breeze served on the resident's tray or offered to the resident during the meal. f. On [DATE] at 11:55 a.m., during the lunch meal, the resident was served chicken Alfredo, penne pasta, green beans, a dinner roll, margarine, cake, mixed vegetables, tea and V8 juice. The resident ate 25% of the meal and was encouraged by staff to eat more with little success. There was no Boost Breeze served on the resident's tray or offered to the resident during the meal. g. On [DATE] at 2:25 p.m., Licensed Practical Nurse (LPN) #1 was asked who was responsible for providing the Boost Breeze to the resident during meals. The LPN stated, The Breeze comes from the nurses. LPN #1 was asked for a copy of the current Medication Administration Record (MAR), which she provided upon request. The LPN was then informed that page 2 was missing from the MAR and stated that she would bring a copy of page 2 when she located it. The LPN stated page 2 was the page where the Boost Breeze was documented for the resident. h. At 3:15 p.m., LPN #1 stated, It (indicating page 2 of October MAR) was in with the September MAR on the chart, so we just followed nursing home protocol. She then handed over a blank October MAR. On [DATE] at 3:15 p.m., page 2 of the MAR was provided by LPN #1 documented, [DATE]: Resource Boost Breeze 8 os (ounce) PO (by mouth) 3 X (three times) daily with meals for protein supplement. There were no signatures or initials on the form to indicate that the supplement had been administered for the month October. i. On [DATE] at 3:25 p.m., the Director of Nursing (DON) was asked why page 2 of the [DATE] MAR was blank, with no documentation that the Boost Breeze was given. The DON stated, It wasn't given; it's considered a medication discrepancy. She was asked where they would document that it was given. She stated, It's not there; it wasn't done. We called the physician and family is the protocol we follow. On [DATE] at 10:40 a.m., Medical Director was asked about the missing page 2 of the October Medication Administration Record and whether or not he was notified. He stated, Yes, they did tell me about that; they didn't give the Resource nor document; maybe it'll change when they become electronic. The facility will follow protocol when there is a weight loss issue. j. On [DATE] at 11:36 a.m., the Dietary Manager was asked if the resident had ever been on a pureed diet. She stated, I can't say with accuracy. It wouldn't be on my current order. I don't see anything on her orders for pureed diet. She was asked what other nutritional interventions had been attempted (besides the Boost Breeze) and stated, Don't know about other nursing interventions . not that I'm aware that we tried other interventions. k. On [DATE] at 3:05 p.m., the resident was asked if she liked oatmeal with sugar. and stated, I don't think I ever had it. I might like it. The resident was asked would you eat it if they gave it to you and stated, I'll try to; if I don't like it, I won't eat it. At 3:10 p.m., the Dietary Cook was asked to give the resident super cereal with her supper tray. l. On [DATE] at 5:05 p.m., during the supper meal the resident stated, I'm not hungry but I'll try; got too much on my mind. At 5:20 p.m., the resident was served pimiento cheese, mashed potatoes, super cereal, peaches and green beans. The resident stated, I like oatmeal; haven't ate it in a long time. The resident willingly opened her mouth as staff fed her and she consumed 5 full spoons of the super cereal. m. On [DATE] at 7:50 a.m., the surveyor entered the resident's room after knocking and being invited to enter by the resident. The resident was in bed. The resident had a breakfast tray set up on the over-bed table. The resident was served regular oatmeal, biscuit and gravy, eggs, 2 strawberries, Boost Breeze, milk and cranberry juice. There was no staff person in the room to assist the resident. The Boost Breeze drink and packet of butter had not been opened for the resident. Certified Nursing Assistant (CNA) #3, who was in the hallway outside the room, was asked to open the resident's Boost Breeze. CNA #3 entered the room and gave the resident a spoonful of the oatmeal. The resident stated, The oatmeal is bitter. The CNA She was asked about what time the resident received her tray and stated, It just got here; it hadn't been 10 minutes since her tray got here. I thought someone was in here with her. The resident consumed 5 spoonsful of oatmeal. The resident was asked by this surveyor if she liked cheese and stated, Yeah, I eat cheese; I like cheese. CNA #3 was asked do you know who brought the resident's tray in and stated, (CNA #5), I believe. n. On [DATE] at 8:08 a.m., CNA #5 was asked about the resident's tray and stated, I brought the tray in. The CNA was asked did you open her Boost Breeze and stated, I didn't open her Breeze. The CNA was asked does she need assistance with eating and stated, Sometimes she needs assistance; she started eating by herself and I left. At 8:09 a.m., the resident was provided with sliced cheese from the kitchen and CNA #3 was asked by the surveyor to assist her with eating it. The resident consumed half of a slice of cheese. o. On [DATE] at 8:21 a.m., Dietary Employee #5 was asked do you know how much she eats and that she doesn't like milk and stated, They don't relay that information to us; we weren't aware of milk but we know she is not a meat eater; you can tell her plate has been stirred around but maybe a couple of bites. The Dietary Employee was asked what does she get for breakfast and stated, Oatmeal, eggs, bread of day, milk and juice. The Dietary Employee was asked what is given in place of meat and stated we give her eggs for meat. The Dietary Employee was asked what about lunch and dinner and stated, We don't have anything to replace the meat; peanut butter was given, yogurt in place of meat. She eats spaghetti, we don't give her anything in place of meat. We were trying to find out about ground meat. If we send meat down the hall, she won't eat it. She'll eat spaghetti. The Dietary Employee was asked if they had made any attempt to provide protein alternatives and stated, When she was eating in the dining room .We need to find substitutes for protein other than what we've been doing . I didn't know she liked cheese. On [DATE] at 8:46 a.m., the resident's diet card, provided by the Dietary Manager on [DATE] at 8:46 a.m., documented, .likes: lunch: grilled cheese sandwich, dinner: cottage cheese and fruit, and cheese toast for breakfast. p. On [DATE] at 12:25 p.m., the resident was in the dining room eating spaghetti. She consumed 4 spoonsful of the spaghetti, feeding herself with a CNA sitting next to her. q. On [DATE] at 8:24 a.m., the Dietary Manager (DM) was asked if she was aware of the resident's weight loss and what type of supplements she would send. The DM stated, She's had a weight loss in the last 6 months, and the only thing I'll be sending her is super ice cream. The Dietary Manager was asked if she knew the resident's likes and dislikes and stated, I know she is not a meat eater; sometimes she eats and sometimes she doesn't. The Dietary Manager was asked what protein items were provided for the resident and stated, Eggs and milk. The Dietary Manager was asked, Do you know that she doesn't like milk? The DM stated, I guess not. The Dietary Manager was asked, What do you give for protein for lunch and supper? The DM stated, I can't answer that .We can try pudding; I wonder if she would drink soy milk. The Dietary Manager was asked, Have you ever thought about small meals? The DM stated, No, I don't send her anything; she isn't on the snack list. The Dietary Manager was asked when was the last time you assessed her likes and dislikes and stated, I did at one point but not recently . several months ago. r. On [DATE] at 11:50 a.m., the Administrator was asked if she was aware of the resident's weight loss and stated, We discussed all the weights, but wasn't aware of the percentage. s. On [DATE] at 11:53 a.m., the Director of Nursing (DON) was asked if she was aware of resident's weight loss and stated, No, I was aware of (Resident #5) because we recently discussed her. Hospice has been heavily involved . Assistant Director of Nurses usually takes care of it, but she left, and the new ADON didn't know she needed to follow-up on that. s. On [DATE] at 2:15 p.m., the DON was asked about the facility's protocol for identifying weight loss and stated, You will have to get with the Dietary Manager, because she is over that. t. On [DATE] at 2:31 p.m., the Dietary Manager was asked about the facility's protocol for identifying weight loss and stated, I got a sheet of paper on that. u. The facility's policy for Weight Assessment and Intervention, received from the Dietary Manager on [DATE] at 2:33 p.m., documented, The nursing staff and the dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents . The CDM (Certified Dietary Manager) will also review the unit weight record by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian whether or not the definition of significant weight change is met . Significant weight changes are defined as: a. More or less than 5% within 30 days and/or more or less than 10% within 6 months . If a weight loss meets the definition of significant, the CDM should discuss with the care plan team if a significant change MDS is necessary. Care plan interventions will consider: severity of change, medical diagnosis (condition, prognosis, stability), ADL (activities of daily living) status, Medications, Psychological status, Family input, Resident preferences, and Input from direct care givers. All team members will provide relevant information from their disciplineto provide an interdisciplinary approach. Interventions for undesirable weight loss should focus first on food (extra food, snacks, calorie-dense foods, etc. (et cetera). Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight . Interventions for negative weight gain should consider resident preferences and rights. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. The CDM will discuss the weight issue with the resident and/or family . Any resident requiring assistance with meals receives help as needed . Additionally: morning, afternoon and hour sleep (HS) snacks are offered. v. On [DATE] at 3:42 p.m., the DON handed the surveyor a letter from the Medical Director in reference of (Resident #5) indicating the hospice [DIAGNOSES REDACTED]. A letter dated [DATE] and signed by the Medcial Director documented, (Resident #5) had been a resident of (facility) since [DATE]. She has a [DIAGNOSES REDACTED]. In nursing documentation dated [DATE] it is charted Appetite poor requiring extensive assist and encouragement from staff but declines to take more bites. She is spoon - fed each meal by staff. Several interventions have been put in place to prevent weight loss. She is currently on ProStat, Resource Boost and Vit (Vitamin) B12. In nurses Notes from Hospice on [DATE], nurse documents the following: Resident continues under the care of (hospice) with the Dx (diagnosis) Protein Calorie Malnutrition. Her diet is soft and she receives multiple nursing home supplements such as Resource Boost Breeze 8 ox (ounce) 3 X daily. She spoon -fed every meal. Her weight loss is expected and unavoidable as she is able to make her wishes known and frequently declines food, nutrition and hydration that is offered and encouraged multiple times daily. Resident and family's wishes are for comfort care only and to try and force her to consume more than she wishes and desires would be disrespectful and potentially harmful. Resident states I don't want anymore, I'm not taking any more, don't try to feed me anymore and to continue to try and feed her causes her anxiety. Resident begs staff not to try and feed her anymore. Resident also with Alzhelmer's Dementia with expected loss of appetite. Resident also has a living will that states she does not wish to have a feeding tube . However, the surveyor was unable to validate that the entirety of the resident's weight loss was unavoidable, due to the facility's failure to develop new interventions to attempt to supplement the residents calorie and protein intake and failure to consistently provide the Boost Breeze as ordered. 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment of mental status, required limited assistance of 1 person with meals, weighed 139 pounds and was not on a physician prescribed weight-loss or weight-gain regimen. a. A physician order [REDACTED].Med Pass 80 cc (cubic centimeters) PO (by mouth), QID (four times daily). b. The Annual ,[DATE] Monthly Weight sheet, received from the Administrator on [DATE], documented the following monthly weights: 1.) [DATE] pounds 2.) [DATE] - no weight documented. On [DATE] at 10:50 a.m., the Dietary Manager was asked about the weight for [DATE] and stated, She (the resident) refused on [DATE]st and [DATE]th to be weighed. 3.) [DATE]: 150 pounds. 4.) [DATE]: 149 pounds. 5.) [DATE]: 148 pounds. 6.) [DATE]: 146 pounds. 7.) [DATE]: 139 pounds. 8.) [DATE]: 138.5 pounds. The was a severe weight loss of 11.78% in the past 6 months. c. Dietary Notes dated from [DATE] through [DATE] documented the following: [DATE]: wt. (weight) down 8# (pounds). Diet regular, receives med pass (supplement). Per staff, feeds self. There were no new nutritional recommendations documented at this time. [DATE]: Wt. down 1# in 1 month, 12# in 6 months. Resident has made no effort to eat. Will ask if resident will allow help with meals. [DATE]: Wt. down 1# in 1 month, down 13# in 6 months. Visited in room as she fed herself. Had some difficulty, will ask if resident will allow help with meals. The recommendation from the previous month was repeated, and there were no new nutritional recommendations documented at this time. No further Dietary Notes were documented until over 2 months later, on [DATE]. [DATE]: Wt. down 7# in 1 month, down 10 # in 3 months, down 18# in 6 months. The med pass continues. Visited resident in room. She fed herself dessert first and was fed other foods. Per CNA (Certified Nursing Assistant) resident likes sweets. Will ask to try sprinkling sugar over foods. As of [DATE], this was the most recent Dietary Note documented in the resident's clinical record, despite the additional weight loss that had been documented on [DATE]. d. On [DATE] at 4:40 p.m., the resident was in the dining room being assisted with the evening meal. There was no sugar sprinkled over any of the food. The resident had super ice cream (thrive) on her tray. The resident consumed all of the thrive and a total of 25% of the meal. e. On [DATE] at 12:30 p.m., the resident was assisted with the lunch meal in her room. The resident had super ice cream (thrive) on her tray. The resident consumed all of the thrive and a total of 25% of the meal. There was no sugar sprinkled over the food on the meal tray. f. On [DATE] at 10:50 a.m., the Dietary Manager (DM) was asked if any interventions had been implemented for weight loss since the med pass was ordered in 2012. The DM stated, Yes, I started giving her the super ice cream for lunch and supper. When asked when she initiated the super ice cream, the DM stated, I don't know. The Dietary Manager was asked if it was 1 month ago, 1 day ago or approximately how long. The DM stated, Oh, I don't know; when I see someone is losing weight, I just give them the super ice cream, because it helps. g. On [DATE] at 11:00 a.m., CNAs #13 and #6 were asked if they assisted the resident to eat during meals and both stated, Yes . she likes sweets. The CNAs were asked if they sprinkled sugar over her food, and both stated, No. The CNAs were asked if they had ever been told to sprinkle sugar over her food and both stated, No. h. On [DATE] at 9:22 a.m., Dietary Worker #1 was asked if she was aware of when the resident started receiving super ice cream and stated, No, I'll ask one of the aides. After returning, the Dietary Worker stated the aides did not know. The Dietary Worker then stated, The Dietary Manager would know, because there should be a pink slip. At 9:22 a.m., the Dietary Manager was asked if the resident was getting super cereal at breakfast and stated, No, she's not getting anything but the super ice cream. i. On [DATE] at 7:55 a.m., CNA #7 was asked if she fed the resident and stated, Yes, I feed her a lot of times. She like sweets and she will eat her dessert and ice cream. The CNA was asked if anyone had ever told her to sprinkle sugar over her food and stated, No, they haven't and I've often wondered since she like sweets so, if we could do that to get her to eat. At 8:05 a.m., CNA #6 stated, She loves sweets; if she got 2 ice creams on her trays, she will eat both of them. The other day, I went and got her another one and she ate them both.

Based on observation, record review and interview, the facility's Nursing Administration and Dietary Administration failed to ensure a reliable, effective system was in place to identify and intervene to address unplanned weight loss for Residents #5. The facility failed to ensure planned interventions were consistently implemented to prevent further potential weight loss and that new interventions were promptly developed and implemented after significant weight loss was identified, to prevent further potential weight loss for 1 (Residents #5) of 4 (Residents #3, #4, #5 and #9) case mix residents who had experienced weight loss. The deficient practices resulted in a pattern of actual harm for Residents #3 and #5, who experienced severe weight loss, and had the potential to cause more than minimal harm for 11 residents who had experienced unplanned weight loss, according to a list provided by the Dietary Manager on [DATE]. The findings are: 1. The facility's Job Description for the Director of Nursing Services, received from the Administrator on [DATE] at 12:10 p.m., documented, .The Director of Nursing is responsible for planning, organizing, staffing, directing, reporting, and budgeting of the nursing department. He/she is to provide goals and expectations, provide nursing management, set resident care standards for all direct care providers, and ensure that quality care for the residents is maintained at all times. He/she is to provide complete supervision and management for the nursing department. 2. The facility's Job Description for the Dietary Supervisor, received from the Administrator on [DATE] at 12:10 p.m., documented, The Dietary Supervisor is responsible to implement and maintain effective, efficient system to operate the dietary department and provide food service to residents in a cost-effective, efficient manner to safely meet residents' needs in compliance with federal, state and local requirements. The Dietary Manager will assess residents' dietary needs and develop appropriate dietary plans in compliance with physician's orders [REDACTED]. 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] documented the resident scored 4 (,[DATE] indicates severely impaired) on the brief interview for mental status (BIMS), required total assistance of one person for eating, had a weight loss and was not on a physician prescribed weight loss regimen. a. A Tip Sheet for Identifying Clinically Unavoidable Weight Loss for the resident with an assessment date of [DATE] and signed by the primary care physician documented, A resident who takes 2 or more of the following medications and/or has 3 or more of the following conditions should be evaluated for the potential of unavoidable weight loss: Drug Therapy: Diuretics, [MEDICAL CONDITION], Conditions: Advanced or End Stage Disease, Decreased mental status varies, Depression / dementia., Refusal to eat or accept other methods of nourishment, Slow eating pace, Nutritional supplements, and Dependent dining . Findings: Poor intake will refuse meals and assist. Periods of pacing/anxiety, looking for deceased family. b. The [DATE] Physician order [REDACTED]. 1.) [DATE], Soft diet. 2.) [DATE] Prostat Sugar-Free Vanilla 30 ml (milliliters) PO (by mouth) QD (every day). 3.) [DATE] Resource Boost Breeze 8 oz (ounces) PO 3x (three times) daily with meals for protein supplement. c. The Care Plan dated [DATE] documented, At nutrition risk leaves 25% or more of food uneaten at most meals. Weigh and monitor results monthly and PRN (as needed). Monitor and report to the Physician Provide diet as ordered. Report to nurse any S/S (signs and symptoms) chewing/swallowing or other problems consuming meals. Offer substitutes if 50% or less is consumed. Provide dining room/meal accommodations. Allow adequate time to eat. Provide a quiet, calm setting. Diet: Regular Mechanical Soft. Encourage and assist PRN (as needed). d. The facility's Annual ,[DATE] Monthly Weight sheet, received from the Administrator on [DATE], documented the following monthly weights for this resident: 1.) [DATE].0 pounds. 2.) [DATE].0 pounds. 3.) [DATE].0 pounds. 4.) [DATE].0 pounds. 5.) There was no July weight available for review. On [DATE] at 11:36 a.m., the Dietary Manager was asked if she had a [DATE] weight for the resident and stated, I don't have one recorded; I don't know why she doesn't have a July weight. 6.) [DATE].0 pounds. 7.) [DATE].0 pounds. 8.) [DATE].6 pounds. The resident experienced a 6.2% weight loss in 1 month from [DATE] to [DATE]; a weight loss of 7.9% in 3 months from [DATE] to [DATE]; and a 17.9% weight loss in 6 months from [DATE] and [DATE]. e. On [DATE] at 5:22 p.m., during the dinner meal, the resident was served one cheeseburger on bun, mashed potatoes, green beans, mayonnaise, mustard and ketchup, ice cream and cranberry juice. The resident ate 25% of her dinner meal and was encouraged by staff to eat more with little success. There was no Boost breeze served on the resident's tray or offered to the resident during the meal. f. On [DATE] at 11:55 a.m., during the lunch meal, the resident was served chicken Alfredo, penne pasta, green beans, a dinner roll, margarine, cake, mixed vegetables, tea and V8 juice. The resident ate 25% of the meal and was encouraged by staff to eat more with little success. There was no Boost Breeze served on the resident's tray or offered to the resident during the meal. g. On [DATE] at 2:25 p.m., Licensed Practical Nurse (LPN) #1 was asked who was responsible for providing the Boost Breeze to the resident during meals. The LPN stated, The Breeze comes from the nurses. LPN #1 was asked for a copy of the current Medication Administration Record (MAR), which she provided upon request. The LPN was then informed that page 2 was missing from the MAR and stated that she would bring a copy of page 2 when she located it. The LPN stated page 2 was the page where the Boost Breeze was documented for the resident. h. At 3:15 p.m., LPN #1 stated, It (indicating page 2 of October MAR) was in with the September MAR on the chart, so we just followed nursing home protocol. She then handed over a blank October MAR. On [DATE] at 3:15 p.m., page 2 of the MAR was provided by LPN #1 documented, [DATE]: Resource Boost Breeze 8 os (ounce) PO (by mouth) 3 X (three times) daily with meals for protein supplement. There were no signatures or initials on the form to indicate that the supplement had been administered for the month October. i. On [DATE] at 3:25 p.m., the Director of Nursing (DON) was asked why page 2 of the [DATE] MAR was blank, with no documentation that the Boost Breeze was given. The DON stated, It wasn't given; it's considered a medication discrepancy. She was asked where they would document that it was given. She stated, It's not there; it wasn't done. We called the physician and family is the protocol we follow. On [DATE] at 10:40 a.m., Medical Director was asked about the missing page 2 of the October Medication Administration Record and whether or not he was notified. He stated, Yes, they did tell me about that; they didn't give the Resource nor document; maybe it'll change when they become electronic. The facility will follow protocol when there is a weight loss issue. j. On [DATE] at 3:05 p.m., the resident was asked if she liked oatmeal with sugar. and stated, I don't think I ever had it. I might like it. The resident was asked would you eat it if they gave it to you and stated, I'll try to; if I don't like it, I won't eat it. At 3:10 p.m., the Dietary Cook was asked to give the resident super cereal with her supper tray. k. On [DATE] at 5:05 p.m., during the supper meal the resident stated, I'm not hungry but I'll try; got too much on my mind. At 5:20 p.m., the resident was served pimiento cheese, mashed potatoes, super cereal, peaches and green beans. The resident stated, I like oatmeal; haven't ate it in a long time. The resident willingly opened her mouth as staff fed her and she consumed 5 full spoons of the super cereal. l. On [DATE] at 7:50 a.m., the surveyor entered the resident's room after knocking and being invited to enter by the resident. The resident was in bed. The resident had a breakfast tray set up on the over-bed table. The resident was served regular oatmeal, biscuit and gravy, eggs, 2 strawberries, Boost Breeze, milk and cranberry juice. There was no staff person in the room to assist the resident. The Boost Breeze drink and packet of butter had not been opened for the resident. Certified Nursing Assistant (CNA) #3, who was in the hallway outside the room, was asked to open the resident's Boost Breeze. CNA #3 entered the room and gave the resident a spoonful of the oatmeal. The resident stated, The oatmeal is bitter. The CNA was asked what time the resident received her tray and stated, It just got here; it hadn't been 10 minutes since her tray got here. I thought someone was in here with her. The resident consumed 5 spoonsful of oatmeal. The resident was asked by this surveyor if she liked cheese and stated, Yeah, I eat cheese; I like cheese. CNA #3 was asked do you know who brought the resident's tray in and stated, (CNA #5), I believe. m. On [DATE] at 8:08 a.m., CNA #5 was asked about the resident's tray and stated, I brought the tray in. The CNA was asked did you open her Boost Breeze and stated, I didn't open her Breeze. The CNA was asked does she need assistance with eating and stated, Sometimes she needs assistance; she started eating by herself and I left. At 8:09 a.m., the resident was provided with sliced cheese from the kitchen and CNA #3 was asked by the surveyor to assist her with eating it. The resident consumed half of a slice of cheese. n. On [DATE] at 8:21 a.m., Dietary Employee #5 was asked do you know how much she eats and that she doesn't like milk and stated, They don't relay that information to us; we weren't aware of milk but we know she is not a meat eater; you can tell her plate has been stirred around but maybe a couple of bites. The Dietary Employee was asked what does she get for breakfast and stated, Oatmeal, eggs, bread of day, milk and juice. The Dietary Employee was asked what is given in place of meat and stated we give her eggs for meat. The Dietary Employee was asked what about lunch and dinner and stated, We don't have anything to replace the meat; peanut butter was given, yogurt in place of meat. She eats spaghetti, we don't give her anything in place of meat. We were trying to find out about ground meat. If we send meat down the hall, she won't eat it. She'll eat spaghetti. The Dietary Employee was asked if they had made any attempt to provide protein alternatives and stated, When she was eating in the dining room .We need to find substitutes for protein other than what we've been doing . I didn't know she liked cheese. On [DATE] at 8:46 a.m., the resident's diet card, provided by the Dietary Manager on [DATE] at 8:46 a.m., documented, .likes: lunch: grilled cheese sandwich, dinner: cottage cheese and fruit, and cheese toast for breakfast. o. On [DATE] at 12:25 p.m., the resident was in the dining room eating spaghetti. She consumed 4 spoonsful of the spaghetti, feeding herself with a CNA sitting next to her. p. On [DATE] at 8:24 a.m., the Dietary Manager (DM) was asked if she was aware of the resident's weight loss and what type of supplements she would send. She The DM stated, She's had a weight loss in the last 6 months, and the only thing I'll be sending her is super ice cream. The Dietary Manager was asked if she knew the resident's likes and dislikes and stated, I know she is not a meat eater; sometimes she eats and sometimes she doesn't. The Dietary Manager was asked what protein items were provided for the resident and stated, Eggs and milk. The Dietary Manager was asked, Do you know that she doesn't like milk? The DM stated, I guess not. The Dietary Manager was asked, What do you give for protein for lunch and supper? The DM stated, I can't answer that .We can try pudding; I wonder if she would drink soy milk. The Dietary Manager was asked, Have you ever thought about small meals? The DM stated, No, I don't send her anything; she isn't on the snack list. The Dietary Manager was asked when was the last time you assessed her likes and dislikes and stated, I did at one point but not recently . several months ago. q. On [DATE] at 11:50 a.m., the Administrator was asked if she was aware of the resident's weight loss and stated, We discussed all the weights, but wasn't aware of the percentage. r. On [DATE] at 11:53 a.m., the Director of Nursing (DON) was asked if she was aware of resident's weight loss and stated, No, I was aware of (Resident #5) because we recently discussed her. Hospice has been heavily involved . Assistant Director of Nurses usually takes care of it, but she left, and the new ADON didn't know she needed to follow-up on that. s. On [DATE] at 2:15 p.m., the DON was asked about the facility's protocol for identifying weight loss and stated, You will have to get with the Dietary Manager, because she is over that. t. On [DATE] at 2:31 p.m., the Dietary Manager was asked about the facility's protocol for identifying weight loss and stated, I got a sheet of paper on that. u. The facility's policy for Weight Assessment and Intervention, received from the Dietary Manager on [DATE] at 2:33 p.m., documented, The nursing staff and the dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents . The CDM (Certified Dietary Manager) will also review the unit weight record by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian whether or not the definition of significant weight change is met . Significant weight changes are defined as: a. More or less than 5% within 30 days and/or more or less than 10% within 6 months . If a weight loss meets the definition of significant, the CDM should discuss with the care plan team if a significant change MDS is necessary. Care plan interventions will consider: severity of change, medical diagnosis (condition, prognosis, stability), ADL (activities of daily living) status, Medications, Psychological status, Family input, Resident preferences, and Input from direct care givers. All team members will provide relevant information from their discipline to provide an interdisciplinary approach. Interventions for undesirable weight loss should focus first on food (extra food, snacks, calorie-dense foods, etc. (et cetera). Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight . Interventions for negative weight gain should consider resident preferences and rights. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. The CDM will discuss the weight issue with the resident and/or family . Any resident requiring assistance with meals receives help as needed . Additionally: morning, afternoon and hour sleep (HS) snacks are offered. v. On [DATE] at 3:42 p.m., the DON handed the surveyor a letter from the Medical Director in reference of (Resident #5) indicating the hospice [DIAGNOSES REDACTED]. A letter dated [DATE] and signed by the Medcial Director documented, (Resident #5) had been a resident of (facility) since [DATE]. She has a [DIAGNOSES REDACTED]. In nursing documentation dated [DATE] it is charted Appetite poor requiring extensive assist and encouragement from staff but declines to take more bites. She is spoon - fed each meal by staff. Several interventions have been put in place to prevent weight loss. She is currently on ProStat, Resource Boost and Vit (Vitamin) B12. In nurses Notes from Hospice on [DATE], nurse documents the following: Resident continues under the care of (hospice) with the Dx (diagnosis) Protein Calorie Malnutrition. Her diet is soft and she receives multiple nursing home supplements such as Resource Boost Breeze 8 ox (ounce) 3 X daily. She spoon -fed every meal. Her weight loss is expected and unavoidable as she is able to make her wishes known and frequently declines food, nutrition and hydration that is offered and encouraged multiple times daily. Resident and family's wishes are for comfort care only and to try and force her to consume more than she wishes and desires would be disrespectful and potentially harmful. Resident states I don't want anymore, I'm not taking any more, don't try to feed me anymore and to continue to try and feed her causes her anxiety. Resident begs staff not to try and feed her anymore. Resident also with Alzhelmer's Dementia with expected loss of appetite. Resident also has a living will that states she does not wish to have a feeding tube . However, the surveyor was unable to validate that the entirety of the resident's weight loss was unavoidable, due to the facility's failure to develop new interventions to attempt to supplement the residents calorie and protein intake and failure to consistently provide the Boost Breeze as ordered.

Complaint # (AR 537) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure residents were transferred with the assistance of 2 staff members, in accordance with the plan of care to prevent injury for 2 (Residents #11 and #9) of 5 (Residents #3, #9, #11, #13 and #18) case mix residents who required the assistance of two persons for transfers and that a right knee brace was applied prior to transferring the resident, as per the plan of care, to minimize the risk for falls during a manual transfer for 1 (Resident #11) of 1 case mix resident care planned for a right knee brace. These failed practices resulted in actual harm for Resident #11, who fell and sustained a right femur fracture after being improperly transferred by one staff member. The facility also failed to ensure staff avoided using the waistband of a resident's pants to support the resident during a transfer to decrease the potential for injury for 1 (Resident #9) of 5 (Resident #3, #9, #11, #13 and #18) case mix residents who required the assistance of two persons for transfers. The failed practices had the potential to cause more than minimal harm to 10 residents who required the assistance of two persons for transfers according to a list provided by the DON on 10/14/16 at 8:50 a.m. The findings are: 1. Resident #11 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/8/16 documented the resident scored 13 (13-15 indicated cognitively intact) on a brief interview for mental status (BIMS), was totally dependent on two plus persons for transfers, was non-ambulatory, required the use of a wheelchair and extensive assistance of one person for locomotion, had functional limitation in range-of-motion to the lower extremities on both sides and was not steady, and only able to stabilize with staff assistance when moving on and off toilet and surface-to-surface transfers a. The Plan of Care dated 4/15/16 documented, Problem Date: 9/8/16, Resident has ADL (Activities of Daily Living) Self-Care Deficit Needs assistance with Transfer: Tot (Total) x (times) 2 (staff); Walking: Non Ambulatory; Locomotion: Extensive X 1. The Preference Care Card not dated, provided by the DON on 10/11/16 at 5:10 p.m. documented, TRANSFERS: Extensive Assistance, Assist of 2, Gait Belt, Brace on R (right) knee. b. A Nurse's Note dated 9/22/16 at 6:45 p.m. documented, Called to resident's room by resident's roommate. Upon entering room noted Certified Nurse Assistant (CNA) positioned on floor (with) resident holding torso upright. Noted assessed for injuries. ROM (range-of-motion) provided. Assisted to bed (with) staff x (times) 3. When ask what happened CNA stated, resident was assisted from shower chair to bedside and then slid backwards and had to be lowered to floor, no injuries noted. Notified ADON (Assistant Director of Nursing) also placed call to DIL (daughter-in-law) and notified her of being slid to floor. Appreciative of call. DR. (Doctor) also notified. c. A Nurse's Note dated 9/22/16 at 8:00 p.m. documented, Resident in bed (with) eyes open has some c/o (complaint of) discomfort. Tylenol 500 mg (milligram) two tabs adm (administered) PO (by mouth) for general discomfort. Also continues on ABT (antibiotic) therapy for cough/congestion . 9/23/16 at 12:30 a.m., R (Resident) calling for something for pain D/T (due to) fall today. R said she hit her (right) knee hard on floor and it is getting worse. Swelling to (right) knee noted WCTM (will continue to monitor) (right) knee & (and) report to supervisor on A.M. (morning). There was no documentation to indicate the physician was notified of the resident's right knee swelling and pain. d. A Nurse's Notes dated 9/23/16 at 7:00 a.m. and signed by LPN #4 documented, R crying (with) severe (right) knee pain. Gave Oxycodone 5/325 mg (milligram) two po (by mouth) . 9/23/16 at 7:00 a.m. Resident c/o severe pain in Rt. (right) knee. Rt. knee very swollen ice applied. Lt (left) knee also has some edema, also. Resident states she fell on her knees. (Physician's Office) called and this nurse was told by answering service that they are not taking calls until 8 a.m. This nurse wrote order D/T (due to) no (Physicians Office)MD (Medical Doctor) would respond to call to send to ER (emergency room ) for eval (evaluation). ER called and report given. Resident crying and requesting to go to ER. (Family Member) notified and ambulance here at 7:15 a.m. to transfer to ER. T (temperature) 98.4, HR (heart rate) 85, B/P (blood pressure) 144/55 . 9/23/16 at 8:45 a.m., (Family Member) called and stated she was going to be admitted to (hospital) Dx (diagnosis) Fx (fractured) femur above Rt. knee cap. That resident was going to be placed in traction and then probably surgery . 9/23/16 at 12 p.m., (Resident) to be in traction until Sunday night. Will have surgery Sunday night @ (at) 7:00 p.m. e. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities dated 9/23/16 at 11:00 a.m., documented, Section II - Complete Description of Incident . As reported to ADON (Assistant Director of Nursing) on 9/23/16 at 9 a.m.: Reported incident of resident having a fall which resulted in resident being sent out to the hospital with reported Rt (right) femur fracture. (CNA #2) was bringing resident in (room number) back to her room after the resident's shower. Resident was in the shower chair in her room when CNA attempted to transfer her by pivoting her from the shower chair to her bed. CNA stated once the resident was sitting on the bed she slid down onto the floor supported by the CNA with the resident's knee bent. CNA stated she was holding the resident the whole time and put a pillow under her for support and asked her roommate to push her call button for assistance. Resident's roommate had reported she then left the room to go get the charge nurse. The charge nurse and another CNA came into the room with the Vanderlift with full body sling to transfer resident back to bed. Charge nurse stated she assessed the resident for any injuries and no apparent injuries were found. She stated she provided ROM (range-of-motion) to some extent due to osteoarthritis. Resident had complained of Rt (right) knee pain and had seen her orthopedic doctor earlier in the day and stated she 'got a shot in her knee'. On 9/23/16 resident was sent to ER (emergency room ) with [DIAGNOSES REDACTED]. Section III - Findings and Actions Taken: Diagnosis: [REDACTED]. Resident is 2 person max (maximum) assist with gait belt with use of Vanderlift PRN (as needed) which has been documented on the resident's care plan and card-x in resident's room. An investigation was conducted and witness statements collected. CNA was suspended during investigation and will remain on suspension until determination made by OLTC (Office of Long Term Care). If unfounded, CNA will complete abuse/neglect retraining and testing and require job shadowing with another CNA for 2 weeks. An OLTC Witness Statement Form, signed by CNA #2 and dated 9/22/16 at 6:45 p.m. documented, After bringing (Resident #11) back into the room from getting a shower, I (CNA #2) pivot (Resident #11) from the shower chair to the bed. While (Resident #11) was on the bed she slid onto the floor. While she was on the floor I asked her what was wrong and she stated that her knee was hurting. I then asked (roommate) to push her call light 2 times and asked (Resident #11) if she could reach her light and push it as well since I was still holding her. After (roommate) left (Resident #11) said she had to sit down so I eased her onto the floor and moved her away from the bed & (and) chair I let her know that I had to straighten out her leg since her leg was bent to the side and continued to say that it hurts. 1.) On 10/13/16 at 9:45 a.m., CNA #2 was asked, were you in the room when (Resident #11) fell and stated, Yes. The CNA was asked, can you tell me what happened and stated, I was pivoting her from the shower chair to the bed. I got her over to the bed I looked down and she was on the floor and I said what are you doing, let's get back in bed. She said, 'I can't my leg hurts'. The CNA was asked, you looked down and she was on the floor and stated, I pivot her and put her on the bed. She slid, I'm still holding her and I finished sliding her onto the floor. I asked (roommate) to turn her light on, her roommate, I finished getting (Resident #11) situated. The CNA was asked, by situated, you mean what and stated, I mean she was sitting on the floor and her leg was bent some, so I had to bring her back away from her bed and recliner and straighten her leg out. The CNA was asked, which one did you straighten out and stated, The one she fractured. The CNA was asked, did she complain of her leg hurting and stated, She kept complaining her leg hurt. That's when (Licensed Practical Nurse (LPN) #2) and (CNA #12) came into the room. We got the Vanderlift, put it up under her and we had her leg elevated and her head elevated too on pillows. The CNA was asked, who put her leg up on the pillow and stated, I did and I put it under her head as well. The CNA was asked, you got the lift pad under her and all three lifted her to bed with the lift and stated, Yes. She said her leg was hurting and I think the nurse gave her some Tylenol and we elevated her leg on the pillow on the bed. The CNA was asked, were you using a gait belt and stated, Yes. The CNA was asked, were there one or two of you transferring her and stated, It was just me. The CNA was asked, how was she supposed to transfer and stated, Before I left for the weekend, she was on the lift PRN (as needed) and she said her therapy had her trying to walk. The CNA was asked, what were the instructions on the Card-x for transfers and stated, I didn't read the Card-x. Her and (roommate) was telling me what they were doing with her. The CNA was asked, did she have the brace on her right knee and stated, No, because she was just getting out of the shower and she couldn't wear it in the shower. The CNA was asked, was she supposed to have it on when she transferred and stated, Not that I'm aware of. The CNA was asked, did therapy/restorative work with you to show you how to transfer (Resident #11) and stated, No. 2.) On 10/11/16 at 5:21 p.m., LPN #2 was asked, were you the first one in the room after (Resident #11) fell and stated, Yes. The LPN was asked, can you tell me what happened and stated, Her CNA was in there, (Resident #11) was sitting on her bottom on the floor, her CNA was standing behind her keeping her upright. The LPN was asked, did you see a gait belt on (Resident #11) and stated, I don't recall seeing one. I know she was coming from having a whirlpool, so she had a gown on. I saw her coming back to her room. The LPN was asked which way Resident #11 was facing on the floor and stated, She was facing toward the bed. The LPN was asked, so what else happened and stated, I got down on the floor with her, asked her if she was okay. Did a little range-of-motion. She was very anxious, saying get me up, flailing her arms. The aide was in the room, she got a pillow and I laid her back a little more so I could examine her, because she was upright at this point. I had another CNA in the room with us and I sent her out to get the lift because at this point it was the safest mode of transfer. Myself, and the 2 CNAs got her on the lift pad, got her up and placed her in her bed. I checked to make sure she didn't have any open areas, bruising and she didn't have. At this time she wasn't complaining of any pain. She was just glad she was up off the floor. The LPN was asked, when you got her on the lift pad did you see a gait belt on her and stated, I still didn't see one on her, but it could have been there. I was more focused on getting her up. The LPN was asked, when did she start complaining of pain and stated, I don't remember. The LPN was asked, what position were her legs in and stated, They were straight. The LPN was asked, straight out in front of her and stated, Yes. f. A Hospital Consultation Report dictated 9/23/2016 at 9:44 a.m. documented, CHIEF COMPLAINT: Right knee pain. HISTORY: The patient is a [AGE] year-old white female known to me from previous orthopedic encounters, I gave a corticosteroid injection yesterday, September 22, 2016, in her right knee. Apparently, she fell at her nursing home this morning. She had a distal right femur fracture. The patient is admitted to the hospitalist service and .Internal fixation by me on the evening of September 25, 2016, when I get back in town. She understands the risks of surgery, accepts them, wishes to proceed. Risks discussed were bleeding; infection; damage to nerves, vessels, or tendons; loss of function; failure of operation; and possibility for surgery later . IMPRESSION: Right distal femur fracture. g. On 10/11/16 at 4:45 p.m., the Director of Nursing (DON) was asked, what does (Resident #11's) Cardex indicate related to how she is supposed to transfer and stated, It states resident is a 2 person max (maximum) assist with gait belt with use of the Vanderlift prn (as needed). The DON was asked, who decides when the lift is used and stated, By her. The DON was asked, the resident and stated, Right, she can tell you when she's weaker and needs more help; she is very with it. The DON was asked, when she fell was she a 1 or 2 person assist and stated, It's my understanding she was a 2 person assist, but therapy was working with her. The DON was asked, what was therapy's goal and stated, For her to be a 1 person assist, to improve her transfers and mobility. It meant a lot to her to go to this pageant if possible. The DON was asked, had they released her to be a one person assist and stated, I don't know, we had her down as a 2 person assist. Therapy was working with her to be a 1 person assist with transfer. We still had her down as a 2 person assist on her care plan. h. On 10/12/16 at 8:44 a.m. the Director of Rehabilitation Services / Certified Occupational Therapy Assistant (COTA) #1 was asked, did you work with (Resident #11) and stated, We worked with her. She was coming off Part B when she fell . We were working with her to get her ready to go to the pageant. She was being discharged because she wasn't making any progress. The COTA was asked, what was her status for transfers at the time of discharge and stated, Before we had taken her off the Vanderlift because she was walking with us, and then the weekend staff had issues with saying she wasn't doing well with them so we put the lift back on her prn (as needed) because her right knee started to buckle. The COTA was asked, the weekend staff was saying she wasn't doing well with transferring and stated, Yes. That last week when she was getting ready to discharge, her right knee was starting to buckle and she was declining, and the day she had the fall on the 22nd she did have a shot in her knee for the pain. The COTA was asked, so on the card-ex it says brace on right knee d/c'd (discontinued) 9/16/16, is that correct and stated, No, that was the lift. She was supposed to have the brace on with any transfers. The COTA indicated the arrow on the cardex, which was pointing down, was for the lift. The COTA was asked, did you work with the staff to show them how to transfer her and stated, Yes, but not with the weekend staff, but we trained the restorative staff and (restorative aide) works weekends; they rotate weekends. The COTA looked at the Cardex and stated, The downfall is when they put her back on the lift, it wasn't put on the cardex. The COTA was asked, based on your assessments, was she safe to transfer with one person and stated, No, and we never used one person, and on the care plan it says assist of 2 persons. The COTA was asked, was she still not safe to transfer with one person at the time of the fall and stated, No, she was declining. She had just got a shot in that knee and her knee was buckling that week. 2. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/28/16 documented the resident scored 3 (0-7 indicates severely impaired) on the BIMS and required total assistance of 1 person for transfers. a. The Plan of Care dated 7/28/16 documented, Resident has ADL (Activities of Daily Living) self-care deficit as evidenced by needs with assistance with Transfer: Total performance X (times) 2 staff. b. On 10/11/16 at 10:40 a.m., CNA #11 prepared to transfer the resident from a wheelchair to bed without the assistance of a second staff member. A gait belt was placed around the resident's waist, and the CNA stood in front of the resident. The CNA assisted the resident to stand. The resident was unsteady as her stood from the wheelchair and shuffled her feet as the CNA held onto the sides of the waistband of the resident's pants and pulled upward, causing the pants to be pulled tightly into the resident's groin area. The CNA did not grasp the gait belt to support the resident. After the resident was in bed, the CNA was asked so you use the pants to assist in transferring the resident and stated, Yes, that way you have more support. The CNA was then asked should you have used the pants to assist in transferring the resident and stated, No. c. On 10/13/16 and 10/14/15, 5 CNAs were asked, Should you use a resident's clothing / pants to assist during a transfer? The CNAs responded as follows: 1.) On 10/13/16 at 6:55 p.m., CNA #8 stated, No, you should use a gait belt. 2.) On 10/13/16 at 6:58 p.m., CNA #9 stated, No, use a gait belt. 3.) On 10/13/16 at 7:10 p.m., CNA #10 stated, No, use the gait belt. 4.) On 10/14/16 at 7:55 a.m., CNA #7 stated, No, never. Use a gait belt. 5.) On 10.14.16 at 8:05 a.m., CNA #6 stated, No. Sometimes we do, for support, even with the gait belt.

Based on record review and interview, the facility failed to ensure the physician was consulted and interventions were developed and implemented promptly to prevent continued weight loss for 2 of 2 (Residents #4 and #9) case mix residents with significant weight loss. This failed practice resulted in a pattern of harm for Residents #4 and #9, who experienced severe, unplanned weight losses, and had the potential to cause more than minimal harm for 11 residents who were at risk for weight loss, according to a list provided by the Administrator on 5/18/12. The findings are: 1. A policy and procedure titled, " ...POLICIES AND PROCEDURES Dietary Department", received from the Administrator on 5/17/12 at 6:10 p.m. documented, "...Policy: The nursing staff and the dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents... Procedure: ...3. Any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing... 5. Negative trends will be assessed and addressed by the dietitian whether or not the definition of significant weight change is met. 6. Significant weight changes are defined as: a. More or less than 5% within 30 days and/or b. More or less than 10% within 6 months... 10. Interventions for undesirable weight loss should focus first on food (extra food, snacks, calorie-dense foods, etc). Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight... The physician may order tests, appetite stimulants or medications as appropriate..." 2. Resident #4 was admitted [DATE] and had [DIAGNOSES REDACTED]. a. The Admitting Nutritional assessment dated [DATE] documented the resident weighed 142.5 pounds. The Nutritional assessment dated [DATE] and signed by the Certified Dietary Manager (CDM ) included a section for documentation of the resident's food likes and dislikes; however, this section of the assessment was blank. b. The Registered Dietitian (RD) Notes from October, 2011 through December, 2011 documented the following: 10/17/11: "...resident wanders up and down halls and may show a weight loss... weight down 2.8 (pounds) since admission... If weight loss occurs offer between meal and HS (hour of sleep) snacks." 12/20/11: "...Weight 136 (pounds) (down) 5 (pounds) since admission... Resident feeds self but has confusion... Recommend MVI (Multivitamin) (with) Minerals... Recommend 30 cc (cubic centimeters) 2.0 (a liquid nutritional supplement) x (times) 3 daily... " The February 2012 Physician order [REDACTED]. There was no documentation a physician order [REDACTED]. c. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 1/6/12 documented the resident scored 0 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent for eating, weighed 132 pounds, had swallowing difficulty and was not on a physician prescribed weight loss regimen, but experience a weight loss of 5% or more in 3 months or 10% or more in 6 months. d. The current Care Plan documented a problem dated 1/5/12, "...Resident is at nutrition risk for weight loss d/t (due to) dx (diagnosis) of adult failure to thrive... Administer nutritional support as ordered (see current physician orders/MAR (Medication Administration Record)..." e. Nutritional Progress Notes dated 1/16/12 and signed by the RD documented, "...Hospice Services started 1/4/12... Weight 132 # (pounds) (down) 4 # past 30 days... per records resident usually consumes 50% of a regular diet and since wt. (weight) loss identified is now receiving 80 cc 2.0 med pass x (times) 3 daily to address weight loss. Recommend MVI w/mineral." There was no documentation on the February 2012 through May 2012 Physician order [REDACTED]. f. Nutritional Progress Notes dated 3/13/12 and signed by the RD documented, "Weight 129# (down) 11#... is spoon fed meals by staff which per records resident consumes approx (approximately) 25-50% being totally dependent at meals... receives Hospice services. Per chart review is having difficulty swallowing meds (medications). Is offered nutrition prn (as needed) besides meals if food is requested." There were no specific interventions documented to address how or how often any additional nutrition would be offered, other than at meal times and 2.0 supplements at med pass time. g. Nutritional Progress Notes dated 4/16/12 and signed by the RD documented, "Weight 123#... continues to receive 80 cc 2.0 supplement TID (three times a day)... continues to receive a regular diet and prn beverages or food if requested... No new recommendations. " h. The Annual Weight Report was provided by the Certified Dietary Manager (CDM) on 5/15/12 and the resident's Weekly Weight list was provided by the CDM on 5/17/12; these lists documented the following weights for the resident: 1) November 2011 - 141 pounds (Annual Weight Report) 2) December 2012 - 136 pounds (Annual Weight Report) 3) January 2012 - 132 pounds (Annual Weight Report) 4) February 2012 - 140 pounds (Annual Weight Report) (There was no documentation the resident was reweighed, as per the facility's policy, to determine if this documented 8-pound weight gain was accurate. The next documented weight was in March 2012). 5) March 2012 - 129 pounds (Annual Weight Report) 3/21/12 - 128 (Weekly Weight list) 3/28/12 - 122 (Weekly Weight list) 6) April 2012 - 123 pounds (Annual Weight Report) 4/4/12 - 123 (Weekly Weight list) 4/11/12 - 122 (Weekly Weight list) 4/18/12 - 120 (Weekly Weight list) 4/25/12 - 124 (Weekly Weight list) 7) May 2012 - 118 pounds (Annual Weight Report) 5/2/12 - 118 (Weekly Weight list) 5/9/12 - 118 (Weekly Weight list) 5/16/12 - 123 (Weekly Weight list) i. As of 5/17/12 at approximately 4:30 p.m., there was no documentation in the clinical record that the Physician had been consulted regarding the resident's continued weight loss, no documentation the RD recommendation for a multivitamin with minerals was implemented and no documentation that any other interventions had been implemented to prevent further weight loss since 1/9/12. The Director of Nursing (DON) was asked for documentation of physician consultation regarding the resident's weight loss and interventions implemented to prevent further weight loss. On 5/18/12 at 8:30 a.m., the CDM provided a copy of a Nurse's Note dated 5/17/12 that documented, "8:30 p.m. Daughter notified of #17 (pounds) weight loss in 6 months per cell phone message. (Advance Practice Nurse (APN)) notified per fax." j. On 5/17/12 at 3:35 p.m., the CDM was asked what had been done to address the resident's weight loss and stated, "They try to feed her; sometimes she eats and sometimes she doesn't." The CDM looked in the computer and stated, "She gets 2.0 three times a day." She was asked if she knew what the resident's food likes and dislikes were and stated, "Not anymore." She was asked what other things had been tried and stated, "I haven't tried anything else." On 5/17/12 at 4:51 p.m., Dietary Employee #1 stated, "We don't do 10:00 a.m. and 2:00 p.m. snacks anymore because they waste it. We give it only to the ones that have MD (physician) orders for it. That was started about 4 months ago..." On 5/17/12 at 5:02 p.m., the CDM stated, "I think we only have 2 residents on 10:00 a.m. and 2:00 p.m. snacks and we send their snacks to them." The CDM provided a list of residents who received between meal supplements from the dietary department, Resident #4 was not included on the list. On 5/17/12 at 2:17 p.m., the resident was weighed by Certified Nursing Assistant #1 (CNA) and CNA #2; the resident's weight was 124.6 pounds. This was an 11.0% (February 2012 to 5/17/12) weight loss in 3 months and an 11.6% (November 2011 to 5/17/12) weight loss in 6 months. 3. Resident #9 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/17/12 documented the resident was admitted [DATE], scored 11 (8-12 moderate cognitive impairment) on the BIMS, had a swallowing disorder, weighed 97 pounds and had experienced a weight loss of 5% or more in 3 months or 10% or more in 6 months, but was not on a physician prescribed weight loss regimen. a. The Resident Plan of Care dated 4/17/12 documented, "At risk for poor nutritional / Hydration status r/t (related to) lack of desire for food... [MEDICAL CONDITION] reflux, dyspepsia and Hx (history) of constipation. [MEDICAL CONDITION] with dysphagia... Monitor nutritional intake and weights. Report any significant weight loss or gain promptly to physician." b. The Annual Weight Report was provided by the Certified Dietary Manager (CDM) on 5/15/12 and documented the resident's weights as follows: 1) November 2011 - 110 pounds 2) December 2011 - 105 pounds 3) January 2012 - 110 pounds 4) February 2012 - 102 pounds 5) March 2012 - 107 pounds 6) April 2012 - 97 pounds 7) May 2012 - 98 pounds This was a 10.9% weight loss in 6 months (November 2011 to May 2012). c. As of 5/17/12 at 2:50 p.m., there were no interventions for the resident's weight loss in the resident's care plan and no documentation in the dietary notes since February 2012. There was no documentation in the clinical record that the Physician had been consulted or the resident's family had been notified of the resident's weight loss. 1) As of 5/17/12 at approximately 4:30 p.m., there was no documentation in the clinical record that the Physician had been consulted regarding the resident's weight loss and no documentation of RD recommendations to prevent further weight loss since February 2012. The Director of Nursing (DON) was asked for documentation of physician consultation regarding the resident's weight loss and interventions implemented to prevent further weight loss. As of 5/18/12 at 1:15 p.m., no documentation was provided. 2) On 5/17/12 at 6:30 p.m., the Certified Dietary Manager (CDM) was asked if the family had been notified, or the resident's Physician had been consulted, regarding the resident's weight loss; the CDM stated, "No."