Every finding on record at Katherine's Place at Wedington

Based on interviews, record review, document review the facility failed to provide incontinent care during an eight-hour shift for one resident (Resident #30) of four residents reviewed for neglect. The findings include: Review of a quarterly Minimum Data Set (MDS) with assessment reference date of 08/08/2025, revealed that Resident #30 had a Brief Interview of Mental Status score of 14, which indicated that Resident #30 was cognitively intact. The MDS also revealed that Resident #30 required substantial to maximal assistance with toileting hygiene. A review of Care Plan for Resident #30 with initiation date of 02/26/2025 indicated that staff should anticipate and meet the resident's needs. The Care Plan included an intervention with an initiation date of 02/08/2025, for staff to keep Resident #30's skin clean and dry. During an interview with Resident #30 on 09/03/2025 at 2:52 PM, it was revealed that Resident #30's brief was not checked or changed during a night shift back in July. Resident #30 stated that The day shift Certified Nursing Assistants (CNAs) came in and found me in the shape I was in and were upset. Resident #30 revealed that there were dried urine spots on the bed from where urine had dried throughout the night. The resident reported that their brief would hold one incontinent urine episode, but it would leak out with two incontinent episodes. Resident #30 reported that night they did not use the call light and had no mental anguish resulting from incident. During an interview on 09/03/2025 3:28 PM, CNA #6, revealed that on 07/19/2025 she worked the 11-7 shift. CNA #6 revealed that her partner was CNA #16 that night. She revealed that she thought CNA #16 had checked Resident #30, and that she kept having to wake CNA #16 up throughout the shift. CNA #6 reported that she did not check or change Resident #30 that shift and was written up for not making rounds on Resident #30 that night. During an interview on 09/04/2025 at 9:24 AM, the Administrator revealed that CNA #16 was written up for not making rounds on Resident #30 and terminated for sleeping while on the clock. During a telephone interview on 09/04/2025 at 9:27 AM, CNA #17 revealed that Resident #30 was still in bed upon making rounds right after she had gotten to work on dayshift. She went in to check the resident and observed that Resident #30 was soaking wet, had brown rings on both sides of the bed, their brief was falling apart, the urine had soaked through the mattress, and urine was dripping onto the floor. There was so much urine on the floor that she had to call housekeeping to come in and mop the floor. CNA #17 reported that Resident #30 was bleeding on the buttocks from being so wet. She also revealed that the resident had taken off their shirt and put it in between their legs to absorb some of the urine. CNA #17 stated she notified LPN #18, who came to the room. CNA #17 they had also notified the administrator of the incident. During a simultaneous interview with the Administrator in training (AIT) and Director of Nursing (DON) on 09/04/2025 at 10:34 AM, the Director of Nursing (DON) reported that CNA #16 was terminated due to sleeping on the clock on 07/19/2025. She also revealed that unless indicated more often rounds were to be made every two hours, for checking residents who were incontinent and to turn and reposition the residents. The DON continued that incontinent care was provided to prevent skin breakdown, and to promote dignity and independence. The DON stated that the CNAs make rounds every two hours to encourage toileting and for overall care for the residents. The Administrator in training (AIT) reported that CNA #16 was terminated for sleeping on his shift on 07/19/2025. She reported that CNA #16 was responsible for Resident #30 that shift and did not check or change Resident #30 the entire 11-7 shift. During an interview on 09/04/2025 at 10:47 AM, LPN #15, treatment nurse, reported that Resident #30 had a body audit after the incident. LPN #15 did not recall Resident #30 having any skin breakdown, redness, excoriation, or pressure ulcers. LPN #15 reported that Resident #30 had just been treated with a prescription skin cream and the prescription cream was stopped the resident's perineal area because the perineal area did not have any excoriation. During an interview on 09/04/2025 at 12:21 PM, LPN #18 reported that she was notified by the CNA #17 about Resident #30 not being changed. LPN #18 reported that she came in about midway through the resident being changed. She observed the saturated adult brief, brown ringed bed sheets and urine saturated bed linen. She revealed that Resident #30 reported to her that they had not been changed all shift. LPN #18 reported that she applied medicated skin cream to the resident's perineal area and there was some drainage coming from the broken skin. LPN #18 reported that the area had a current treatment that was in place, but she only worked on the weekends, so she was unsure if Resident #30's buttocks or perineal area were any worse or not. She revealed that residents are to be checked, turned and repositioned every two hours to prevent skin breakdown. During an interview on 09/04/2025 at 12:27 PM, CNA #19 reported that CNA #17 and herself observed Resident #30's bed linen was saturated with urine all the way to their neck. She also reported that there was urine on the floor next to bed. CNA #19 revealed that Resident #30 reported they were unsure if the night shift CNAs had changed them or not. If so it had been a while, but Resident #30did not want to get anyone in trouble. CNA #19 reported that LPN #18 came in and doctored Resident #30's perineal area. She reported that she and CNA #17 provided incontinent care and dressed Resident #30, changed the resident's bed linens and then got the resident out of bed. CNA #19 reported that residents were to be rounded on every two hours in order to prevent skin breakdowns. During an interview on 09/04/2025 at 1:07 PM, the Administrator reported that residents were to be checked, changed, turned and repositioned every two hours to prevent skin breakdown and ensure safety. During an interview on 09/05/2025 at 8:21 AM, LPN #20 reported that he was the licensed nurse that was responsible for Resident #30 on 07/19/2025 11-7 PM shift. LPN #20 reported that he had peeked in on Resident #30 during that shift. LPN #20 reported that he was not aware that the CNAs had not made rounds on Resident #30that shift. LPN #20 went on to state that he relied on the CNAs to make rounds on the residents like they were supposed to. LPN #20 reported that the CNAs were to make rounds every two hours and as needed. He reported that Resident #30's perineal area would become excoriated at times from incontinence but was unsure at the time if the resident had any excoriation being treated. During an interview on 09/05/2025 at 1:05 PM, CNA #16 reported that he did not check or change Resident #30 on 07/19/2025 during the 11-7 PM shift. He reported that he and his partner, CNA #6, forgot to round on Resident #30 the last round and that he had thought that his partner, CNA #6, had rounded on Resident #30 during the night. CNA #16 reported that he [CNA #16] slept a lot on that shift and was terminated. A review of Abuse Prevention Program policy revised December 2016, revealed that the residents have the right to be free from neglect. Following the incident, but before the survey team entered the facility, the administration completed the following corrective actions, resulting in this deficiency being cited as past non-compliance: Immediate identification and action. The facility promptly identified the incident of alleged abuse/neglect on 7/22/2025 Staff immediately implemented interventions to protect the resident, including suspending Cna #6 and Cna #16, resident was immediately changed, sheets were changed and LPN #18 applied skin cream to the perinea! area. Social Services interviewed resident #30 and no signs of mental anguish resulted from the incident and no other new allegations were founded. Thorough Investigation A full investigation was initiated from 7/22/2025-7/28/2025 in accordance with facility policy and state/federal regulations. The investigation was completed on 7/28/2025 with findings documented and submitted timely. Cna #16 was found sleeping in car during night shift, employee was terminated for failure to change resident #30 and sleeping during night shift. Cna #6 was written up for failure to change #30 in a timely manner. On 7/23/2025 the Staff Development Coordinator and CNA Preceptor in-serviced staff. The Staff Development Coordinator educated staff on identifying reportable events (abuse, neglect, injuries of unknown source) and quarterly training on abuse and neglect. Body audits were conducted to ensure no further additional concerns for neglect, no negative outcomes were noted. The DON /designee monitored 400 hall peri care, weekly for 4 weeks or until compliance was verified by OLTC to ensure all residents are changed and checked throughout the night. Any new allegations of neglect are to be reported to the Office of Long-term care. Any negative findings will be corrected immediately, and Administrator/Designee notified. During the monitoring, no new allegations were founded. Notification and Reporting The facility promptly notified the resident's representative, the state agency, and law enforcement as required. Documentation reflects that all mandated reporting timelines were met. Corrective Actions and Prevention The facility implemented retraining for all staff on abuse/neglect recognition, reporting, and prevention. Additional monitoring and auditing were put into place to ensure compliance. Policy and procedure reviews were completed with revisions as needed. Status at Time of Survey At the time of survey entrance on 9/2/2025, the incident had been fully resolved. On 9/5/2025 during the exit, the Governing Body, DON, ADON, AIT and Resident council President was present. All corrective actions were in place, staff were retrained, and systemic changes have been implemented. There was no ongoing noncompliance, and no residents were at risk during the survey window.

Based on record review, observation, interview and facility policy review the facility failed to ensure good hand hygiene was maintained for 1(Resident #54) of 2 sampled (Resident #54 and Resident #101) residents observed during perineal care and reviewed for bowel and bladder. The findings include: Review of a Medical Diagnosis report revealed Resident #54 had diagnoses which included inflammation and swelling of the kidney, urinary tract infection, and inability to voluntarily move the upper and lower body. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 08/19/25 revealed a Brief Interview for Mental Status score of 3, which indicated Resident #54 had severe cognitive impairment. The MDS also indicated Resident #54 was always incontinent with bowel and stool. Review of a Care Plan revealed Resident #54 had bowel incontinence related to advanced disease process and decreased mobility with interventions in place to check the resident every two hours and assist with toileting needs. The Care Plan also indicated to provide perineal care after each episode of incontinence. On 09/03/2025 at 10:36 AM, Licensed Practical Nurse (LPN) #12 and LPN #13 were observed transferring Resident #54 from the chair to the bed with a mechanical lift. LPN #12 explained to Resident #54, that Certified Nursing Assistant (CNA) #11 and CNA #14 would be assisting with perineal care. On 09/03/2025 at 10:46 AM, CNA #11 and CNA #14 presented to the bedside, put on gloves and assisted LPN # 12 and LPN #13 in rolling Resident #54 off the lift pad. CNA #11 pulled down the front of a wet brief and CNA #14 handed clean wipes to CNA #11. Resident #54 was wiped one time in one direction on the left and right side of the perineal area, and wipes were disposed of in a plastic trash bag at the foot of the bed. CNA #11 described the brief as wet from the front to the back. On 09/03/2025 at 10:49 AM, LPN #12 presented at the bedside and asked to observe perineal care to assess Resident #54's buttocks. Resident # 54's buttocks appeared very pink, and this surveyor observed a wound where the right buttocks met the right upper thigh. LPN #12 left to find cream to put on Resident #54's buttocks. On 09/03/2025 at 10:55 AM, CNA #11 was observed turning to the bedside table to the right of Resident #54 bed and without removing contaminated gloves CNA #11 opened the top dresser drawer and handled multiple bottles of lotion and pulled out one to use on Resident #54. On 09/03/2025 at 10:58 AM, LPN #12 presented back to the bedside with a moisture barrier cream to place on Resident #54's buttocks. CNA #11 assisted Resident #54 in staying in position while LPN #12 applied the cream. The resident was then rolled onto their back. CNA #11 was observed putting Resident #54's clothing in position and pulling up linens without performing hand hygiene or removing soiled gloves. CNA #11 removed soiled gloves and dropping them into a plastic garbage sack, CNA #14 gathered two bags of garbage and was followed out by CNA #11. During an interview on 09/03/2025 at 11:03 AM, CNA #11 stated she had not changed gloves when touching linens and opening Resident #54's drawer looking for cream to put on the resident's skin because CNA #11 was nervous. CNA #11 revealed not changing gloves or performing hand hygiene during perineal care and going from dirty to clean tasks can cause cross contamination. During an interview on 09/03/2025 at 1:35 PM, CNA #14 revealed staff rounds every two hours to check and see if residents need to be changed to protect residents' skin and prevent infection. CNA #13 confirmed changing gloves and performing hand hygiene when going from dirty to clean tasks helps prevent cross contamination. During an interview on 09/04/2025 at 3:00 PM, the Administrator revealed to maintain good hand hygiene during perineal care two CNAs would assist with perineal care, and hand hygiene would include washing hands and wearing gloves. The Administrator stated staff round every two hours to keep residents clean and dry to prevent skin conditions. The Administrator revealed staff were trained on perineal care when hired, as needed and during yearly competency. During an interview on 09/04/25 at 3:22 PM, the Director of Nursing (DON) stated staff are expected to round on residents every two hours to prevent skin breakdown. The DON revealed CNA staff came to her yesterday informed her there was a concern during perineal care yesterday, and it appears we need additional peri care training. Review of an in-service titled Handwashing, dated 04/10/25, revealed hands should be washed after encountering body fluids. CNA #11, CNA #14, LPN #13 and LPN #12 signed the Handwashing in-service in acknowledgment to follow procedure. Review of a policy titled Handwashing/Hand Hygiene, 2001, revealed hand hygiene is the primary means to prevent the spread of healthcare infections, and all personnel are regularly in-serviced. Hand hygiene is indicated after contact with blood, contaminated surfaces and bodily fluids. Review of a policy titled Perineal Care, date 2001, revealed the purpose is to provide cleanliness to the residents to prevent skin irritation and infections. To prepare, review resident's care plan and identify special needs and arrange supplies so they are in reach.

Based on record review, interview, and facility policy review, the facility failed to report to the State Licensing Agency an incident of resident allegation of verbal abuse for one (Resident #5) resident of five residents reviewed for abuse. The findings are: A review of facility policy Abuse Investigations and Reporting revealed that all allegations would be reported immediately, but not later than two hours of allegation of abuse to the State Licensing/Certification Agency. A review of Admission Record revealed Resident #5 was admitted on [DATE], with medical diagnoses which included: acute congested heart failure, high blood pressure, muscle wasting and atrophy, and difficulty walking. A review of Resident #5 ' s annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/13/25, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The MDS revealed Resident #5 had adequate hearing, used a mobility device (wheelchair), required maximum assist with transfers, bathing and toileting, and set up assist with oral hygiene and eating. A review of Resident #5 ' s Care Plan, with a revision date of 03/15/2025, revealed Resident #5 had a cognitive communication deficit and had an intervention of staff allow adequate time to respond, staff ensure the resident was understanding, staff anticipate and meet needs, and staff speak on an adult level. During an interview with Resident #5, during initial round, on 04/16/2025, the resident reported that a Certified Nursing Assistant (CNA) stated to the resident to get [pronoun] fat ass over here, while performing care. Resident #5 did not disclose the CNA's name, but it was during a bed bath. Resident #5 reported the incident was immediately reported to the Administrator in Training (AIT) the day the incident occurred, 04/08/25. Review of witness statements on 04/17/2025, revealed the date of 04/08/2025. Initially, the Administrator reported that the dates were done today, and they reflected the date of the incident instead of when they were completed. A phone interview with CNA #1 on 04/17/25 at 2:24 PM, revealed that CNA #1 and CNA #2 gave Resident #5 a bed bath on 04/08/25. The CNAs were giving Resident #5 a bed bath and conversing amongst each other, when CNA #1 told CNA #2 that her niece called her nephew a big back and they both laughed about it. CNA #1 revealed that she was not talking to Resident #5 when she said that, and she did not call the resident that. CNA #1 asked Resident #5 to roll over toward the window, and the resident must have thought CNA #1 was talking to Resident #5. CNA #1 reported that Resident #5 called their nephew, and the nephew called and spoke to the facility. CNA #1 revealed approximately thirty (30) minutes after the bed bath, she was called into the DON's office and spoke to her about it and wrote a witness statement. An interview with the Director of Nursing (DON) on 04/17/2025 at 2:41 PM, revealed she was notified of Resident #5 allegations. She followed up with Resident #5. The resident was not upset and could not recall most of the incident. The DON stated she received witness statements from CNA #1 and CNA #2 and concluded that there was no verbal abuse. It was found that the two CNAs were having a conversation between themselves, and CNA #1 was talking about her family members stating one called another family member a fat back . CNA #1 was not talking to the resident. The DON also reported that any form of abuse was to be reported immediately. An interview with the Administrator on 04/17/2025 at 2:47 PM, revealed abuse was to be reported immediately. She revealed that if there were times she was not there, the DON would gather witness statements on allegations, and 04/16/25 was the first time of hearing of this allegation. An interview with CNA #2 on 04/17/2025 at 3:05 PM, revealed that while giving Resident #5 a bed bath, she and CNA #1 were talking amongst themselves about CNA #1's niece and nephew, and how they were saying mean things about each other. CNA #2 revealed that Resident #5 thought CNA #1 was talking about the resident. CNA #2 reported she was spoken to about the incident by the DON and filled out a witness statement. CNA #2 reported that 04/17/2025 was the first time she had spoken to the Administrator about the incident. CNA #2 stated abuse was to be reported immediately. An interview with the Administrator on 04/17/25 at 3:30 PM, revealed she had been notified of an incident on 04/08/25 and she was not in the office at the time. The Administrator stated the DON and the Administrator in Training had been notified and had spoken to Resident #5 about the allegation of being called a big back by CNA #1. The DON had received witness statements and spoken to the CNAs. She felt like after the investigation it was not considered verbal abuse or a reportable to the State Licensing Agency. She also stated that since the initial allegation, Resident #5 had changed her words from big back to fat ass and she had thought this was a new allegation from Resident #5 and began a new reportable. An interview with the AIT on 04/18/2025 at 8:27 AM, revealed the AIT was notified of an abuse/neglect incident on 04/08/25. The AIT stated he immediately went and spoke to Resident #5, and had felt like the incident had been blown out of proportion and everything was alright. The AIT revealed the resident could not remember a lot about the incident that had occurred. AIT reported the incident to Administrator and the DON spoke to the CNAs and received witness statements. The AIT stated the follow up investigation was completed by the DON. The follow up was completed at the end of that day, but he had left town so was unsure of the outcome. The AIT reported they had felt like it was cut and dry after the interviews with the CNA's were completed.

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen, the failed practice had the potential to affect 103 residents who received meals from the Kitchen (Total Census: 104). The findings are: 1. On 05/14/2024 at 04:50 PM, the following meat items stored on a shelf in the freezer were not covered or sealed: a. Box of steak finger patties. b. A box of pork rib patties. 2. On 05/14/2024 at 05:16 PM, there was an opened cup from a restaurant that contained chocolate shake in the freezer with a received date of 05/14/2024, exposing it to air and or potential for cross contamination. 3. On 05/15/2024 at 08:07 AM, DE #2, who was on the tray line assisting with breakfast meal, was observed to pick up condiments and place them on the trays. Without washing his hands, he picked plates and placed them on the trays to be used in portioning food items to be served to the residents for breakfast with his thumb inside the plates. 4. On 05/15/2024 at 08:42 AM, DE # 3 wore gloves on her hands, when she picked up scissors to open bags of bread, contaminating the gloves. Without changing gloves and washing her hands, she used her contaminating gloved hand to remove slices of bread from the bag and place them in a pan to make bread pudding. The Surveyor asked DE #3 what should you have done after touching the dirty objects and before handling clean food items? She stated, I should have changed gloves and washed my hands. 5. On 05/15/2024 at 11:38 AM, DE #4 wore gloves on her hands while opening the refrigerator door and retrieving a container of cheese slices and placed it on the counter. She then took a bag of bread from the bread rack in the storage room, untied the bag and placed it on the counter. Afterward she removed slices of bread from the bag and placed them in a saucepan on the stove. Following that, she placed cheese slices on each slice of bread in the saucepan, making grilled cheese sandwiches to be served to the residents who requested it. The Surveyor asked DE #4 what should you have done touching dirty objects and before handling clean equipment of food items? She stated, I should have removed the gloves and washed my hands. 6. A facility policy titled Employee Cleanliness and Hand Washing Technique indicated dietary department employees are required to wash their hands before beginning shift; after breaks; after disposing of handling of trash or food; after handling dirty dishes; after picking up anything from the floor, and any other time deemed necessary.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to revise the resident care plan to reflect current physician orders for 3 (Resident #13, Resident #15, and Resident #46) of 3 residents reviewed for care plan revision. Findings include: 1. A review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2024 revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively Intact. This MDS indicated that Resident #13 is prescribed opioids. B. A review of Resident #13's Care Plan revised, revealed the resident was on pain medication therapy (Tramadol) the interventions included ask physician to review medication if side effects persist. Dated 01/24/2024. C. A review of Resident #13's Order Summary revealed Resident #13 had a Physician's order for, Hydrocodone-Acetaminophen Oral Tablet 5-325 milligram, give 1 tablet by mouth every 6 hours as needed for severe pain. 2. A review of the Order Summary indicated the facility admitted Resident #15 with diagnoses that included presence of prosthetic heart valve and depression. A. A review of the Signification Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 2 which indicated the resident was had severe cognitive impairment. This MDS indicated that Resident #15 was taking an antidepressant medication, and anticoagulant medication. B. A review of Resident #15's Care Plan revealed the resident uses antidepressant medication (escitalopram) related to depression. Interventions included, Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q [every]-Shift. Initiated on 10/03/2023. C. A review of Resident #15's Care Plan revealed the resident was on anticoagulant therapy (Warfarin) related to Atrial Fibrillation. Interventions included, administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness Q-Shift. Initiated on 10/03/2023. D. A review of an Order Summary revealed Resident #15 had a Physician's order that indicated Resident #15 was to receive Remeron Oral Tablet 15 milligram 1 tablet at bedtime; and Xarelto (a blood thinner) 20 milligram tablet in the evening. 3. A review of the Order Summary Report indicated the facility admitted Resident #46 with a diagnosis of chronic kidney disease stage 4 (severe). An order was found that read, Dialysis M-W-F [Monday, Wednesday, Friday] at [Provider named] dialysis center 11 [11:00] AM chair time. A. A review of the Quarterly MDS with an ARD of 03/13/2024 revealed Resident #46 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #46 was receiving dialysis while a resident. B. A review of Resident #46's Care Plan revealed the resident required hemodialysis related to renal failure. Interventions included, Dialysis port to right chest. If bleeding occurs, apply pressure, if bleeding does not subside call 911, also notify [Different Provider Name then on Physician Orders] Dialysis Center at [Phone number], M-W-F Date Initiated: 01/04/2023. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (M-W-F chair time 1500 [03:00 PM], [Different Provider Name then on Physician Orders] [Phone number] Date Initiated 01/04/2023 . 4. During an interview on 05/16/2024 at 12:28 PM, Licensed Practical Nurse (LPN) #3 following review of each resident ' s electronic medical record confirmed Resident #13 had orders for high-risk medications to include opioids, anticoagulants, and antidepressants. LPN #3 confirmed these medications had not been revised on the care plan following physician's orders changes. LPN #3 stated, Medication orders are to be put on the care plan following start-up meeting which is completed daily Monday through Friday. Following the review in start-up the changes are then made to the care plan that day. LPN #3 reviewed Resident #46's electronic medical record and confirmed that the current dialysis order and the dialysis order addressed on the care plan do not match. LPN #3 stated the dialysis order should be reviewed with quarterly care plan meetings and at start-up meeting held Monday through Friday and should be changed with the new physician's order. LPN #3 added, The importance of the care plan being accurate is for good quality of care for the residents. 5. During an interview on 05/16/2024 at 01:02 PM, the Director of Nursing (DON) following review of each resident's electronic medical record confirmed Resident #13 had an order for high-risk medication including opioids, antidepressant, and anticoagulants. The DON confirmed that these medications were not revised on the care plan following physician ' s order changes. The DON added, Once the medication order is in the electronic medical record, it is to be reviewed during the next start-up meeting and changes made on the care plan. Our process is to make the changes daily because any medication that needs intervention or observations by the healthcare staff should be on the care plan. The DON was also asked to review Resident #46's electronic medical record concerning dialysis order. The DON confirmed the physician's order, and the care plan did not match. The DON stated, It is important for the physician ' s order and the care plan to match because staff will get confused and call the wrong dialysis center or take the resident to the wrong center. 6. On 05/15/2024 at 02:23 PM, the Director of Nursing stated the facility did not have a policy for care plan revision for care areas on the care plan. 46723

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to initiate care areas and interventions on the resident care plan for oxygen usage and physician's orders for high risk medications for 3 (Resident #13, Resident #15, and Resident #99) of 3 sampled residents reviewed for care plans and interventions. Findings include: 1. A review of an Order Summary indicated the facility admitted Resident #13 with diagnoses that included atherosclerotic heart disease and type 2 diabetes mellitus. A. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2024 revealed Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. This MDS indicated that Resident #13 had received insulin injections for the past 7 days and was taking an anticoagulant. B. A review of Resident #13's Care Plan on 05/15/24 at 10:22 AM revealed that this resident's care plan did not address anticoagulant use and insulin use. C. A review of Resident #13's Order Summary revealed Resident #13 had a Physician's orders for Apixaban (anticoagulant medication used to treat and prevent blood clots), Insulin detemir (a long-acting, man-made version of human insulin), and Insulin aspart (a rapid-acting insulin). 2. A review of the Order Summary indicated the facility admitted Resident #15 with diagnoses that included essential hypertension, anxiety disorder, and pain. A. The Signification Change MDS with an ARD of 04/25/2024 revealed Resident #15 had a BIMS score of 2 which indicated the resident had severe cognitive impairment. This MDS indicated that Resident #15 was taking an antianxiety medication, diuretic, and opioid medication. B. A review of Resident #15's Care Plan on 05/16/2024 at 09:56 AM revealed that this resident's care plan did not address antianxiety medication, opioid, or diuretic usage. C. A review of Resident #15's Order Summary revealed Resident #15 had Physician's orders for furosemide (a diuretic), lorazepam (a sedative used to treat anxiety), and morphine (a narcotic used to treat severe pain). 3. The 5-day MDS with an ARD of 03/08/2024 revealed Resident #99 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. This MDS indicated the resident was on oxygen at admission and while a resident. A. A review of Resident #99's Care Plan revealed the resident did not have an initiation of oxygen usage on the care plan. B. A review of Order Summary revealed Resident #99 had an order for oxygen as needed for shortness of breath 2-4 liters/minute per nasal cannula. 4. During an interview on 05/15/2024 at 11:57 AM, Registered Nurse (RN) #1 confirmed, following a review of Resident #99's electronic medical record, that oxygen was not addressed on the care plan. 5. During an interview on 05/15/2024 at 12:18 PM, the Director of Nursing (DON) confirmed that oxygen was not addressed on the care plan following a review of Resident #99's electronic medical record. The DON stated, The care plan coordinator is responsible for updating the resident's care plan once it is reviewed in the start-up meeting. 6. During an interview on 05/16/2024 at 12:28 PM, Licensed Practical Nurse (LPN) #3 following review of each resident's electronic medical record confirmed Resident #13 had orders for high-risk medications including insulin and an anticoagulant. Resident #15 had orders for high-risk medications including anti-anxiety, diuretics, and opioids. LPN #3 confirmed that these medications were not identified on the care plan following physician's orders. LPN #3 stated, Medication orders are to be put on the care plan following start-up meeting which is completed daily Monday through Friday. Following the review in start-up the changes are then made to the care plan that day. 7. During an interview on 05/16/2024 at 01:02 PM, the DON following review of each resident ' s electronic medical record confirmed Resident #13 had orders for high-risk medications including insulin and anticoagulants; and Resident #15 had orders for high-risk medications including antianxiety, diuretics, and opioids. The DON confirmed that these medications were not identified on the care plan following physician's orders. The DON added, Once the medication order is in the electronic medical record, it is to be reviewed during the next start-up meeting and changes made on the care plan. Our process is to make the changes daily because any medication that needs interventions or observations by the healthcare staff should be on the care plan. 8. On 05/15/2024 at 02:23 PM, the Director of Nursing stated the facility did not have a policy for care plan initiation for care areas on the care plan.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure that the physicians order for wound care was following during a scheduled dressing change for 2 (Resident #4 and Resident #32) of 2 residents reviewed for wound care management. Findings include: 1. A review of Resident #4's Order Summary Report indicated Resident #4 did not have a medical diagnosis for the wound care received. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident was moderately cognitively impaired. The MDS did not indicate the presence of a current pressure ulcer. b. A review of Resident #4's Care Plan revealed the resident had a pressure ulcer of the left heel related to immobility. Interventions included wound/dressing changes as ordered on Treatment Administration Record (TAR). c. A review of Resident #4's Order Summary Report revealed Resident #4 had an order for L [left] heel ST3 [Stage 3] PU [Pressure Ulcer]: Cleanse with WC [Wound Cleanser]/NS [Normal Saline], pat dry, apply gentamicin to wound bed cut to fit [named brand of dressing] to wound bed, cover with foam, secure into place every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for open wound . Order Date 04/16/2024. d. During an observation on 05/15/2024 at 02:54 PM, Licensed Practical Nurse (LPN) #2 cleansed the wound bed as ordered and immediately applied the gentamicin cream and foam dressing. LPN #2 did not pat dry the wound bed as ordered by the physician during the scheduled dressing change. 2. A review of Resident #32's Order Summary Report indicated the resident had a diagnosis of pressure ulcer of unspecified part of back, unstageable. a. The signification change MDS with an ARD of 04/19/2024 revealed Resident #32 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS indicated there was one Stage 3 Pressure Ulcer present. b. A review of Resident #32's Care Plan revealed the resident had a pressure ulcer to the spine. Interventions included to administer treatments as ordered and monitor for effectiveness. c. A review of Resident #32's Order Summary Report revealed the resident had an order for. T-Spine [Thoracic - the middle section of your spine] ST3 PU: Cleanse wound with NS/WC, pat dry, apply calcium alginate to wound bed, cover with foam, secure into place. every day shift every Mon, Wed, Fri . d. During an observation on 05/15/2024 at 02:37 PM, LPN #2 cleansed the wound bed as ordered and immediately applied calcium alginate dressing to the wound bed. LPN #2 did not pat dry the wound bed as ordered by the physician during the scheduled dressing change. 3. During an interview on 05/15/2024 at 03:59 PM, LPN #2 was asked to read Resident #4 and Resident #32 ' s physician's order for the treatment provided. After reviewing Resident #32's physician's order, LPN #2 confirmed the wound bed was not patted dry as ordered. The Surveyor asked LPN #2 to review Resident #4's treatment order. LPN #2 confirmed the wound bed was not patted dry as ordered. LPN #2 stated, It is very important to follow the physician's order to prevent wound complications and deterioration of the wound. 4. During an interview on 05/15/2024 at 04:37 PM, the Surveyor asked the Director of Nursing (DON) to identify and verbalize the most recent physician's order for wound care for Resident #4 and Resident #32. Once completed the Surveyor asked what is the importance of following the physician's order during a wound care treatment? The DON stated, To make sure the wound heals properly. 5. A review of a facility policy titled, Wound Care dated October 2010, indicated, .1. Verify that there is a Physician ' s order for this procedure .

Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 11 residents who receive meal trays in their rooms on the 100 Hall, 8 residents who receive meal trays on the 200 Hall, 13 residents who receive meal trays in their room on the 300 Hall, 5 residents who receive meal trays in their room on 400 Hall, 25 residents who receive meal trays in their room on the 500 Hall, and 6 residents who receive meal trays in their room on the 600 Hall. The findings are: 1. On 05/15/2024 at 12:17 PM, an unheated food cart that contained 11 trays for lunch was delivered to the 100 Hall by Certified Nursing Assistant (CNA) #2. At 12:39 PM, immediately after the last resident was served in their room on the 100 Hall, the temperature of the food items on the tray used as a test tray was taken and read by CNA #2 with the following results: a. Milk - 50 degrees Fahrenheit. b. Regular chicken with gravy - 113.9 degrees Fahrenheit. c. A carton of vanilla ice cream on the tray was melted. The Surveyor asked CNA #2 to describe the appearance of the ice cream. He stated, It is melted. 2. On 05/15/2024 at 12:46 PM, an unheated food cart that contained 18 trays for the 300 and 400 Hall ' s lunch was delivered to the 400 Hall by CNA #3. On 05/15/2024 at 01:05 PM, immediately after the last resident was served in their room on the 300 Hall, the temperature of the food items on the tray used as test tray were taken and read by CNA #4 with the following results: a. Milk - 57 degrees Fahrenheit. b. Ice cream was melted and was running. The Surveyor asked CNA #4 to describe the appearance of the ice cream. She stated, It is too melted and running.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 9 residents who received pureed diets. The findings are: 1. On 05/14/2024 at 04:47 PM, Dietary Employee (DE) #1 placed 11 dinner rolls into a blender, added whole milk and pureed. DE #1 poured the pureed bread into a pan and placed it in the oven. The consistency of the pureed bread was lumpy and not smooth. 2. On 05/14/2024 at 04:59 PM, the following observations were made on the steam table before meal service: a. A pan of pureed vegetables. The consistency of the pureed vegetables was not formed and was running. b. A pan of pureed beef steak fingers. The consistency of the meat was lumpy and not smooth. There were pieces of meat visible in the mixture. 3. On 05/14/2024 at 05:34 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed beef steak fingers was thick and lumpy. Pureed bread was sticky and had lumps and pureed vegetables was running. 4. On 05/15/2024 at 08:04 AM, the following observations were made during the breakfast meal service: a. Pureed sausage was served to the residents on pureed diets. The consistency of the pureed sausage was lumpy and not smooth. There were pieces of sausage visible in the mixture. b. Pureed bread was served to the residents on pureed diets. The consistency of the pureed bread was thick and not smooth. There were lumps in the mixture. 5. On 05/15/2024 at 08:06 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items on the steam table that were served to the residents on pureed diets. She stated, Pureed sausage, you can see pieces of sausage in it. She should have pureed it longer. Pureed bread was sticky and had lumps.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene was performed before and during wound care to maintain aseptic technique throughout wound care, ensure no cross contamination of Personal Protective Equipment (PPE) and during wound bed cleansing for 2 (Resident #4 and Resident #32) of 2 residents reviewed for wound care. Findings include: 1. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024 revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated the resident was moderately cognitively impaired. a. A review of Resident #4's Care Plan revealed the resident had a pressure ulcer of the left heel related to immobility. Interventions included wound/dressing changes as ordered on the on Treatment Administration Record (TAR). b. A review of Resident #4's Order Summary Report revealed Resident #4 had an order for a left heel stage 3 pressure ulcer to be cleaned and dressed every Monday, Wednesday, and Friday. c. During an observation on 05/15/2024 at 02:42 PM, Licensed Practical Nurse (LPN) #2 began performing wound care by donning gloves without performing hand sanitation. LPN #2 performed multiple glove changes while preparing for the procedure without performing hand sanitation. 2. A review of Resident #32's Order Summary Report revealed the resident had a diagnosis of pressure ulcer of unspecified part of back, unstageable. a. Review of the Signification Change MDS with an ARD of 04/19/2024 revealed Resident #32 had a BIMS score of 15, which indicated the resident was cognitively intact. This MDS indicated the resident had a stage 3 pressure ulcer present. b. Review of Resident #32's Care Plan revealed the resident had a pressure ulcer to spine. Interventions included administering treatments as ordered and monitoring for effectiveness. c. Review of Resident #32's Order Summary Report revealed the resident had an order for, T-Spine [Thoracic - the middle section of your spine] ST3 [stage 3] PU [pressure ulcer]: Cleanse wound with NS [Normal Saline]/WC [Wound Cleanser], pat dry, apply calcium alginate to wound bed, cover with foam, secure into place. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] . d. During an observation on 05/15/2024 at 02:32 PM, LPN #2 met the Surveyors at Resident #32's room where the treatment cart was located outside of the resident's room. LPN #2 immediately applied gloves without performing hand sanitation. LPN #2 removed an individually wrapped germicidal disposable wipe from the cart and removed a pair of scissors from her right pants pocket and wiped the scissors for approximately 4 seconds and then placed the scissors on top of the blue barrier pad for approximately 30 seconds. e. During an interview on 05/15/2024 at 03:59 PM, LPN #2 was asked when preparing for a dressing change, when should you cleanse your hands? LPN #2 responded, hands should be cleansed before and after a glove change, washed with soap after every third alcohol-based hand gel use, or should be cleansed when visibly soiled. The Surveyor asked what are some examples of when gloves become contaminated during wound care preparation and/or a wound care dressing change? LPN #2 responded, examples of glove contamination prior to a dressing change is touching your face, clothes, trash, or medications/creams. Examples of glove contamination during a dressing change include when gloves are visibly soiled, contact with secretions, bowel, bodily fluids, or if you touch your face. LPN #2 confirmed that when gloves become contaminated, they should be removed, and new gloves applied. LPN #2 also confirmed that germicidal disposable wipes were used to cleanse the scissors prior to use and that they were in contact with the wipes for approximately 30 seconds but not a full minute. LPN #2 confirmed by review of the germicidal wipes that there should have been a wet contact time of 2 minutes then air dried prior to use. LPN #2 also confirmed that she did not wear gloves when setting up the biohazard bag and that hand hygiene was not completed immediately after and prior to donning gown. LPN #2 stated that enhanced barrier precautions are in place per the new guidelines to prevent any transmission of bacteria from 1 resident to another off the healthcare provider's uniform. The Surveyor asked what certificates or training/in-services have you received since becoming the treatment nurse? LPN #2 replied she is not certified, but has taken some continuing education courses and has had no in-services since taking the position in January of 2024. f. During an interview on 05/15/2024 at 04:37 PM, the Director of Nursing (DON) was asked when preparing for a dressing change when should you cleanse your hands? The DON responded, before procedure and opening wound care packages. The Surveyor asked what are some examples of when gloves become contaminated during wound care prep and/or a wound care dressing change? The DON responded, examples of glove contamination prior to a dressing change are touching anything not part of the dressing. Examples of glove contamination during a dressing change include when a dressing is removed, and touching any other part of the resident that does not include the wound area. The DON confirmed that when gloves become contaminated, they should be removed, and new gloves applied. The Surveyor asked what is the facility process for using the individually wrapped disposable germicidal wipes? The DON replied, clean the equipment for 30 seconds and let air dry on a clean surface for 5 minutes then ready to use. The DON confirmed by review of the germicidal wipes that there should be a wet contact time of 2 minutes then air dried prior to use. The DON stated that enhanced barrier precautions are in place to prevent contaminants from the healthcare provider's uniform from getting in the wound. The Surveyor asked what certificates or training/in-services has the treatment nurse received? The DON replied, I have not conducted any in-services on wound care, and I have been here a year. g. A review of a facility policy titled, Policies and Practices- Infection Control dated October 2018 indicated, .Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Establish guidelines for implementing isolation precautions, including standard and transmission-based precautions . All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities . h. A review of a facility policy titled, Enhanced Barrier Precautions dated August 2022 indicated, .Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . h. wound care, any skin opening requiring a dressing, but this does not include protective coverings such as transparent covering, band aids, or [brand of wound closure device] used to keep skin flaps in place . i. A review of the use information provided by the Administrator titled, [Brand Name] Germicidal Disposable Wipe indicated, To disinfect and deodorize . unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry .

Based on observation and interview, the facility failed to ensure residents received assistance with dining in a manner that preserved dignity for 1 (Resident #15) sampled resident. Findings include: Review of a modification of Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed Resident #15 had a Brief Interview for Mental Status score of 02 (0-7 indicates severe cognitive impairment). Review of Medical Diagnoses revealed Resident #15 had diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. During an observation on 05/13/2024 at 12:25 PM, Certified Nursing Assistant (CNA) #1 was providing feeding assistance for Resident #15. CNA #1 was standing while attempting to feed a spoonful of food. The Surveyor asked, When feeding a resident that needs help, how should an aide feed the resident? LPN #1 stated, Oh, sitting, I did that because [Resident #15] was far from me. During an interview on 05/15/2024 at 12:10 PM, the Assistant Director of Nursing (ADON) reported that staff have stools that roll from one resident to the other while assisting with eating, because residents are sitting down, and staff need to look them in the eyes. Review of a Policy titled, Dignity indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .

Based on observation, record review, and interview, the facility failed to ensure that meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 29 residents who had mechanical soft diets and 9 residents received pureed diet from 1 of 1 kitchen. The findings are: 1. The menu for lunch meal documented that all residents were to receive mixed greens. Residents on pureed diets were to receive one #8 scoop (1/2) cup of bread pudding. a. On 05/15/2024 at 12:02 PM, Dietary Employee (DE) #3 used a #8 scoop (1/2 cup) to place 6 servings of bread pudding into the blender and pureed to serve to 10 residents who required pureed diets for lunch. At 01:16 PM, the Surveyor asked DE #3 how many servings of bread pudding she prepared for the residents on pureed diets and what scoop size she used to portion bread pudding into the blender to puree. DE #3 stated, I used #8 scoop, and I did 6 servings. We have 10 residents on pureed diets. I gave pudding to the remaining 4 residents. I don't think we will have enough. The Surveyor asked whether enough food should have been prepared to ensure there were leftovers in case any resident asked for more. DE #3 stated, Yes. I had to throw away some of the dessert because some of the edges were burnt. The oven has not been working well enough. It cooks unevenly. b. On 05/15/2024 at 01:15 PM, all residents were served turnip greens, instead of mixed greens as specified on the menu. At 04:39 PM, the Surveyor asked the Dietary Supervisor the reason turnip greens was prepared and served to the residents, instead of mixed greens. She stated, We only have turnip greens available. c. A facility recipe for mixed greens provided by the Dietary Supervisor on 05/15/2024 at 04:33 PM under ingredients documented, Collard greens chopped and chopped turnip greens.

Based on interview, record review, and record review, the facility failed to ensure a bed hold notification was sent to a resident and/or resident representative following a hospital transfer and admission for 1 (Resident #13) of 1 resident reviewed for hospitalization s. Findings include: A review of an eInteract Transfer Form V5 revealed Resident #13 had an unplanned transfer to the local hospital on 03/03/2024 at 05:30 PM for a change of condition. A review of Business Office Manager (BOM) Facility Initiated Transfer-V4, revealed Resident #13 had a form completed on 02/02/2024 for a previous hospital transfer but there was no form located for the transfer on 03/03/2024. During an interview on 05/16/2024 at 12:17 PM, the Business Office Manager (BOM) confirmed that there was not a bed hold notification letter created or sent to the resident and/or resident representative for Resident #13 hospital transfer on 03/03/2024. The Surveyor asked, What is the process for ensuring that residents and/or resident representatives are notified of the bed hold? The BOM stated, The system generates them, and it was a weekend transfer, and I did not catch it. They are typically created within 24 hours of transfer. The BOM added, The bed hold letters are sent out to inform the resident and representative they have a bed available when they are ready to come back. During an interview on 05/16/2024 at 02:22 PM, the Surveyor asked the Administrator, What is the facilities process for bed hold notification letters? The Administrator stated, The bed hold notification letters are to inform the family and resident they have a bed to come back to and to help keep the family informed. The Administrator added, That the facilities electronic medical record software sends a notification when a resident goes to an outside facility. At that point the BOM does an assessment and provides a bed hold notification letter to either the resident or the resident representative. This is completed within 24 hours. During an interview on 05/16/2024 at 02:50 PM, the Administrator confirmed after speaking with the BOM that a bed hold notification letter was not created or sent to the resident and/or resident representative following a hospital transfer on 03/03/2024 for Resident #13. A review of the facility's undated policy titled Bed hold Policy, indicated The resident and the resident's representative must receive a copy of this notice.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the physicians orders were followed on changing oxygen tubing and humidifier bottle for 1 (Resident #99) of 1 resident reviewed for oxygen usage. Findings include: The 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/2024, revealed Resident #99 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. This MDS indicated the resident was on oxygen at admission and while a resident. A review of Resident #99's Care Plan revealed the resident did not have an initiation of oxygen usage on the care plan. A review of the Order Summary revealed Resident #99 had an order for oxygen as needed for shortness of breath 2-4 liters/minute per nasal cannula as needed was ordered on 02/23/2024 and to change and date the O2 (oxygen) tubing and water bottle every week on day shift every 7 days was ordered on 02/23/2024. A review of the Medication Administration Record (MAR) 5/1/2024- 5/31/2024 revealed Resident #99 had an order on the MAR to change and date O2 tubing, and water bottle every week every day shift every 7 days. Order date was 02/23/2024 at 01:15 PM. Per the MAR this order was signed off as completed on 05/05/2024 and 05/12/2024. During an observation on 05/13/2024 at 12:04 PM, Resident #99 was observed lying in bed with oxygen on and nasal cannula in place. The oxygen concentrator was set on 3 liters/minute via nasal cannula, the date on the nasal cannula tubing was 05/05/2024. The humidifier bottle connected to the oxygen concentrator was empty and dated 05/05/2024. During an observation on 05/14/2024 at 02:36 PM, Resident #99 was observed lying in bed with oxygen on and nasal cannula in place. The oxygen concentrator was set on 3 liters/minute. The nasal cannula tubing was dated 05/05/2024. The humidifier bottle connected to the oxygen concentrator was empty and dated 05/05/2024. During a concurrent observation and interview on 05/15/2024 at 12:00 PM, Registered Nurse (RN) #1 entered Resident #99's room with the Surveyors. RN #1 verbalized that the oxygen tubing and humidifier bottle were dated 05/05/2024. RN #1 confirmed the humidifier bottle was empty and the bottle and tubing would need to be changed. RN #1 stated the oxygen setup was changed every 7 days and the humidifier bottles when in place are changed when empty or every 7 days. RN #1 pulled up Resident #99's MAR and confirmed it was signed off as changed but not completed on 05/12/2024. During an interview on 05/15/2024 at 12:18 PM, the Surveyor asked the Director of Nursing (DON) what interventions are put into place when a resident is placed on oxygen? DON stated, Orders to change tubing weekly, sign is placed on door, and oxygen is placed on the care plan. The Surveyor asked what is the reason for changing the oxygen tubing every 7 days? The DON replied to prevent infections. This task is completed by the nurse responsible for the resident. The DON viewed Resident #99's MAR and confirmed that it was marked as completed on 05/12/2024. The Surveyor informed the DON that the tubing and humidifier bottle were dated 05/05/2024 and the bottle was empty.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL's) to maintain good grooming and hygiene for 1 (Resident #49) sampled resident. The findings are: 1. Based on Resident #49's Admission Record, the resident had medical diagnoses of Parkinson's disease and muscle wasting and atrophy. 2. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/2024 indicated a score of 13 (13-15 cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 05/14/2024 at 8:42 AM, the Surveyor observed Resident #49 to have a brown substance underneath the fingernails. b. On 05/14/2024 at 2:53 PM, the Surveyor observed Resident #49 to have a brown substance underneath the fingernails. c. On 05/15/2024 at 3:01 PM, the Surveyor observed Resident #49 to have a brown substance underneath the fingernails. d. On 05/16/2024 at 9:15 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #5 and asked who was responsible for cleaning resident fingernails. CNA #5 said the shower aide does on the long halls, and then whoever the CNA is on the short halls does those. The Surveyor asked who cleans resident's fingernails that are diabetic. CNA #5 stated CNA's and shower aides may clean the nails with orange sticks located in the shower rooms, but the nurse has to trim the nails. The Surveyor asked how the nurse was notified when a resident's nails need trimmed. CNA #5 stated the shower aides and CNA's will let the resident's nurse on duty know that the resident's nails need to be trimmed. e. On 05/16/2024 at 9:47 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #2 and asked who does nail care for residents. LPN #2 stated nurses and CNAs were responsible; shower aides and CNAs will do cleaning and nurses will trim. The Surveyor asked how nurses were made aware that nails need trimmed. LPN #2 stated that the shower aides and CNAs let the nurses know when a resident needs their nails trimmed. f. Review of an Activities of Daily Living (ADLs) policy statement provided by the Administrator revealed, Residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview, record review, and facility policy review, the facility failed to ensure a medication regimen review was completed monthly for 1 (Resident #91) of 1 resident reviewed for unnecessary medication review. Findings include: A review of Resident #91's Order Summary Report indicated the facility admitted Resident #91 on October 13, 2023. A review of Resident #91's electronic medical record on 05/15/2024 at 11:09 AM, indicated there was not a medication regimen review for the month of January 2024. On 05/16/2024, the Director of Nursing (DON) was asked to review Resident #91's electronic medical record and locate a medication regimen review for the month of January 2024 completed by the consultant pharmacist. During an interview on 05/16/2024 at 12:50 PM, the DON stated there was not a medication review completed for Resident #91 during January 2024 by the consultant pharmacist. The Surveyor asked what the importance of a medication regimen review was. The DON replied to make sure that no medication changes need to be fixed to avoid side effects or accidents. The consultant pharmacists are responsible for ensuring they are completed monthly. I should follow up behind the pharmacists to ensure that it was completed for each resident. A review of a facility policy titled, Pharmacy Services- Role of the Consultant Pharmacist, dated April 2007, indicated, The Consultant Pharmacist will provide specific activities related to medication regimen review including: A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines.

Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator were dated, kitchen appliances (deep fryer shelf below the deep fryer) were clean and free of stains and spills; and staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent potential for cross contamination. These failed practices had the potential to affect all 94 residents who received meals from the kitchen (total census: 94), as documented on a list provided by the Dietary Supervisor on 05/16/23.The findings are: 1. On 05/15/23 at 10:19 AM, the bottom shelf of the deep fryer had an accumulation of grease and caked-on food crumbs across the entire surface, 4 pallets next to the shelf of the deep fryer were covered in grease. The Surveyor asked the Dietary Supervisor, How often do you clean it? She stated, We clean it once a week. 2. On 05/15/23 at 10:42 AM, in the Utility Room on the 200 Hall, the following were in the refrigerator: a. One box (Fast Food Establishment) contained one chicken nugget. There was no name or date on the box. The Surveyor asked the Dietary Supervisor to describe the appearance of the chicken. She stated, That was an old chicken nugget. b. A container of leftover rice had no date or name on the it. c. A pitcher of orange juice dated 04/22/23 was separated from the sediment. The Surveyor asked the Dietary Supervisor how long the juice had been in the refrigerator. She stated, It had been there since 04/22/23. The orange juice had been separated from the sediment A second pitcher of orange juice was dated 05/02/23. The sediment was separated from the juice. The Dietary Supervisor stated, I have told them that juice can only last for 3 days in the refrigerator. 3. On 05/15/23 at 11:39 AM, Dietary Employee (DE) #1 opened the refrigerator door and removed a box of nectar thickened liquid and placed it on the counter. Without washing her hands, she picked up a cup by the rim and poured the nectar thickened liquid into the cup to be served to the residents who required thickened liquids with their meals. 4. On 05/15/23 at 12:32 PM, DE #3 was on the tray line assisting with lunch. She picked up cartons of supplements and placed them on trays. Without washing her hands, she picked up glasses that contained beverages by their rims and placed them on trays to be served to the residents for lunch. 5. The facility's policy titled, Employee Cleanliness and Hand Washing Technique, provided by the Dietary Supervisor on 05/16/23 at 9:17 AM documented, .Dietary department employees are required to wash their hands on the occasions listed below: .f. after disposing or handling of trash or food . j. Any other time deemed necessary .

Based on observation, and interview, the facility failed to ensure residents were allowed to have personal property within reach creating a homelike environment and maximizing the resident's independence for 1 (Resident #19) of 58 (Residents #1, #2, #3, #7, #8, #11, #13, #14, #15, #16, #19, #23, #25, #26, #30, #31, #32, #33, #36, #38, #39, #41, #45, #47, #48, #51, #52, #53, #54, #56, #57, #59, #61, #62, #63, #66, #69, #71, #72, #73, #74, #79, #80, #82, #84, #85, #86, #87, #98, #145, #205, #245, #246, #346, #347, #348 and #349) sampled residents. The failed practice had the potential to affect 94 residents as documented on the Matrix provided by the Assistant Director of Nursing (ADON) on 05/15/23 at 11:05 AM. The findings are: 1. Resident #19 had diagnoses Unspecified Fracture of Left Pubis, Subsequent Encounter for Fracture with Routine Healing, Fracture of Unspecified Metatarsal Bone(s), Right Foot, Initial Encounter for Closed Fracture. The Admission Minimum Data Set (MDS) with an Assessment Reference Data (ARD) of 02/04/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required limited physical assistance of one person for bed mobility, extensive physical assistance of one person with transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene. a. On 05/16/23 at 9:07 AM, Resident #19 asked if the Surveyor could get her basket out of the closet. After I got cleaned up, they took my stuff away from me and put it in the top of the closet where I cannot even reach it. b. On 05/16/23 at 9:08 AM, Resident #19 asked Certified Nursing Assistance (CNA) #10 for her basket of lotions out of the closet. You guys put my lotions and cremes up in the closet this morning. CNA #10 said, Everyone's personal items like lotion got put away. Resident #19 asked CNA #10 if she had to call every time she wanted something out of her box. CNA #10 said, Call when you need something, and we will get it. The Surveyor asked CNA #10, Is it a policy that lotions get put away? She said, Yes, when I go in a room, I put them away. The Surveyor observed a small, white box containing five bottles of perfume, and hand cream, lipstick, blush, and body powder sitting in drawers, out in the open. The Surveyor asked permission to take the white box of cremes out of the top of the closet to see the contents. The basket contained a glass case, alcohol free oral rinse, clear nail polish, two hand cremes, lip balm, hairbrush, sunglasses, comb, straws, cuticle stick, nail clippers, emery board, body butter and a blue ink pen. Resident #19 said, Those are my personal possessions that belong to me. I need my hairbrush, glass case, and my sunglasses if I go outside. There is nothing here I could hurt myself or someone else with. I cannot reach it in the top of my closet. c. On 05/17/23 at 9:10 AM, the Surveyor asked CNA #9 if there was any policy that prevented residents from having personal items in reach. The Surveyor asked CNA #9 to look at the items in the basket and if she saw anything that the resident cannot have at the bedside. CNA #9 said, No. Resident #19 said, I cannot even reach it to use it. CNA #9 said, Some items like peri wash we have been told to be put away. I will check and see if she can have her things back. d. On 05/17/23 at 2:15 PM, the Surveyor asked the Director of Nursing (DON) if there was any policy preventing residents from having personal property in reach, as long as it was not a safety issue. The DON said, No, you're talking about the residents' perfumes. The Surveyor told the DON it was a small plastic basket with straws, lotions, emery boards, body butter, a glass case, clear nail polish and sunglasses. The DON said, I think there was a misunderstanding, and I will speak with the resident and make sure she has her things. e. A facility policy titled, Personal Property, provided by the Administrator on 05/17/23 at 12:00 PM documented, Policy Statement Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. Policy Interpretation and Implementation . 2. The resident is encouraged to maintain his/her room in a home-like environment by bringing personal items (i.e. [that is], photographs, knickknacks, etc. [etcetera]) to place on nightstands, televisions, etc . f. The Grievance Report for the last 3 months provided by the Administrator on 05/15/23 at 12:01 PM documented a resident reported an incident on 04/21/23 of being unable to reach personal items.

Based on observation, interview, and record review, the facility failed to ensure Care Plans were implemented and accessible for staff who were responsible for the interventions for 1 (Resident #245) of 1 sampled resident with diet and nutritional interventions for Gastro-Esophageal Reflux Disease (GERD) as documented on a list provided by the Administrator on 05/18/23 at 8:48 AM. The findings are: 1. Resident #245 was admitted on [DATE] and readmitted on [DATE] and had diagnoses of GERD, Anemia, Dementia, Malignant Neoplasm of Colon, and Type 2 Diabetes Mellitus. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/13/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) was on a mechanically altered and therapeutic diet and weighed 217 pounds. a. A Comprehensive Care Plan with an initiated date of 05/10/23 documented, .Provide small frequent meals rather than 3 large ones . b. A Hospital Discharge Record dated 05/10/23 documented, .Assessment and Plan Nutrition . Current nutrition regimen Diet order . appropriate . Oral /modular supplements currently: old fashioned shake BID [twice a day], smoothie w [with]/breakfast . appropriate . Nutrition prescription . Estimated energy needs 1840-1960 kcal/day [calories per day] . Nutrition diagnosis . malnutrition . c. The Diet-Nutrition assessment dated [DATE] documented Resident #245 weighed 216.5 pounds. The Readmit assessment dated [DATE] documented the resident weighed 177.0 pounds a -18.24% weight loss in less than 3 months. 2. On 05/16/23 at 8:58 AM, Resident #245's family member stated, She was on milk shakes, like [nutritional shake], at the hospital and they said she would continue those because when she eats a half of plate of food then her stomach hurts. The Surveyor asked if he had informed anyone. The family member stated, I have told some aides and nurses about my mom not liking gravy on everything and also that she loves the strawberry [nutritional shake]. The family member also stated Resident #245 was trying to build up her strength to be strong enough for chemotherapy. Resident #245 stated, Yes, I want chemotherapy. The Surveyor observed a breakfast food tray with 1/2 of a red juice and 1/8 of the mechanical soft meat and eggs consumed. a. The Tuesday 05/16/23 Breakfast Menu documented, Assorted Juice, Cereal of Choice, Egg of Choice, Bacon or Sausage, Biscuit, Country gravy, Margarine, Milk, and Beverage. b. Resident #245 ' s breakfast tray card documented, .Mech [mechanical] Soft, Consistent Carbohydrate, No Added Salt, Reg [regular]/Thin Liquids . Standing orders: 8 fl [fluid] oz [ounces] Assorted Fruit Juices, Cold Cereal (Frosted Flakes), and 8 fl oz Milk Whole . 3. The Tuesday 05/16/23 Lunch Menu documented, Fried Pork Cutlet with gravy, seasoned pinto beans, mixed greens, cornbread, margarine, lemon parfait and a beverage. a. On 05/16/23 at 12:45 PM, Resident #245's lunch tray contained ground pork, gravy, beans, cornbread, a green food, a lemon dessert, and a cup of red juice. 4. On 05/17/23 at 8:42, Resident #245 was served a piece of toast, scrambled eggs, a bowl of corn flakes, 2 cartons of whole milk, ground sausage with gravy, an 8 oz glass of cranberry juice, a pat of butter, and a packet of jelly for breakfast. At 8:51 AM, Resident #245 ate some of the scrambled eggs, drank a carton of milk and stated, I am done. The Surveyor asked if she likes bread, eggs, corn flakes, and sausage. She answered no to all. But said that she likes, Over easy egg, grits, and ice cream. 5. On 05/17/23 at 9:58 AM, a tray consisting of over easy eggs, a cup of strawberry ice cream, and a bowl of grits was delivered to Resident #245. 6. On 05/17/23 at 3:15 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2 how she knows if the items on a food tray are correct for a resident. CNA #2 stated, We match it to the tray ticket. It has all the information we need. No added salt, dislikes, and if they are on the red napkin program for weight loss. The Surveyor asked if Resident #245 received a full serving size meal as other residents. CNA #2 stated, Yes, she always gets a full meal. I believe she gets the same size as everyone else. They gave her ice cream this morning and she really liked it. The Surveyor asked if she had access to Resident #245 ' s Care Plan. CNA #2 stated, We have a Closet Care Plan and the [Brief Resident Summary]. The Surveyor accompanied CNA #2 to view the Closet Care Plan and the [Brief Resident Summary]. The Surveyor asked if either had documentation or interventions for the number or size of meals Resident #245 should receive. CNA #2 stated, No they don't. 7. On 05/17/23 at 03:20 PM, the Surveyor asked the Dietary Consultant how Dietary Staff and CNAs knew if a meal on the tray cart was correct for a resident. The Dietary Consultant stated, It is all on the tray card. 8. On 05/17/23 at 3:30 PM, the Surveyor asked the Director of Nursing (DON) how CNAs know if the food on a tray was correct for a resident. The DON stated, It should be on the meal ticket and diet order. The Surveyor asked how CNAs access the residents' Care Plans. The DON stated, We have Closet Care Plans in each room that have their diet on there. The Surveyor asked how the Comprehensive Care Plan information was passed on to the CNAs. The DON stated, The Closet Care Plan and [Brief Resident Summary] are connected to the MDS which is done quarterly or for a sig [significant] change. We also have a task record to provide that information. The Surveyor asked the DON to pull up and read Resident #245's Comprehensive Care Plan regarding providing small frequent meals rather than 3 large ones and locate that information on the Closet Care Plan, [Brief Resident Summary] or task record. The DON stated, Yeah, I don't see it on there. I don't know. 9. On 05/17/23 at 4:20 PM, the DON stated, I talked to [Resident #245] and she is having reflux issues and hurting. I talked to Dietary, and we will start following the Care Plan and providing her more meals a day with smaller portions. [Resident #245] said she is getting too much gravy so we will serve it on the side. I will get all of this put on the Closet Care Plans. 10. On 05/18/23 at 8:48 AM, the Administrator informed the Surveyor the facility no longer has anyone on smaller meals and Resident #245's intervention has been resolved. 11. The facility policy titled Care Plans, Comprehensive Person-Centered, provided by the Administrator on 05/18/23 at 8:35 AM documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The policy did not contain documentation regarding ensuring the Care Plans were available to staff responsible for providing the interventions.

Based on observation, interview, and record review, the facility failed to ensure residents' confidential and personal information was not overheard by family members of 16 residents on the 400 Hall during shift change as documented on the Census by Hall provided by the Administrator on 05/15/23 at 10:34 AM. The findings are: 1. On 05/17/23 at 3:10 PM, the Surveyor observed Certified Nursing Assistants (CNAs) #3, #4, #5, #6 and #7 walking together on the 400 Hall speaking loudly, using resident names and room numbers, discussing residents' doctor's appointments, behaviors, peri care, and care needs still to be performed. The Surveyor observed Resident #245's son standing on the 400 Hall 3 to 5 feet from the group of CNAs. a. On 05/17/23 at 3:11 PM, the Surveyor asked the Charge Nurse, Licensed Practical Nurse (LPN) #1 if resident information should be discussed in front of other residents' family members. LPN #1 stated, No, and walked with another nurse to the group of CNAs. The group moved away from Resident #245 ' s son and began to speak quieter. 2. On 05/18/23 at 8:12 AM, the Surveyor asked the Director of Nursing (DON) to explain the walking rounds for shift change. The DON stated that during walking rounds they discuss the residents with oncoming staff. They are to discuss quietly and make sure no one can overhear them discussing the residents. CNAs are to be aware who is around them. 3. The facility policy titled, Confidentiality of Information and Personal Privacy, provided by the Administrator on 05/18/23 at 8:45 AM documented, .Our facility will protect and safeguard resident confidentiality and personal privacy . The facility will strive to protect the resident's privacy regarding his or her: a. accommodations . b. medical treatment . d. personal care .

Complaint # (AR 613) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure the plan of care for transfers, including non-weight bearing and use of a leg immobilizer to the right lower extremity, were implemented to prevent a transfer incident with injury and failed to ensure the resident's complaint of severe pain during the transfer incident was immediately addressed, which resulted in a 4-day delay in identifying a femur fracture and an increased risk for further injury while the fracture went untreated for [REDACTED]. This failed practice resulted in a pattern of harm to Resident #5, who sustained a right femur fracture, and had the potential to affect only this resident (the only resident in the facility with a physician order [REDACTED]. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 5-day Admission Minimum Data Set with an Assessment Reference Date of 9/21/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance from 2 people for bed mobility, transfers, and toileting; and was only able to stabilize herself with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off the toilet and during surface to surface transfers. a. A Physical Therapy (PT) Plan of Care with a Start of Care Date of 9/15/17 documented, .Precautions: NWB (non-weight bearing) RLE (right lower extremity): R (right) knee brace at all times; no ROM (range of motion) to R knee . b. The Admission Nursing assessment dated [DATE] documented the resident was limited assistance with transfers, toileting, and bed mobility. c. Daily Nurses' Notes dated 9/16/17 and 9/17/17 documented the resident required extensive 2-person assistance with transfers. d. A PT Daily Treatment Note dated (Monday) 9/18/17 by Physical Therapy Assistant (PTA) #1 documented, .W/C (wheelchair) toilet min/mod A (minimum/moderate assistance) X (times) 2 (people) and needed assistance with toileting. Educated pt (patient) on using immobilizer at all times when WB (weight bearing) on RLE (right lower extremity) and getting out of bed, but we will take immobilizer off when in therapy to work on ROM (range of motion) and mobility. Pt stated that she had an issue over the weekend and someone got her out of bed without the brace on and her knee gave out and bent the RLE. Spoke with nursing about the incident and they are keeping an eye on her RLE for increased pain and swelling . The Nsg (Nursing) Every Shift Skilled Charting dated 9/18/17 at 1:11 p.m. documented, . Knee remains wrapped @ (at) this time. Immobilizer cont (continues) to be in place while oob (out of bed). Res (resident) stated she had an incident this weekend where her left knee buckled and she instinctively shifted her weight to her right knee and bent it as the immobilizer was not in place at the time. Res states her knee hurts worse this shift. No increased swelling or bruising noted @ this time. The notes do not indicate which knee the nurse was referring to. The Nsg (Nursing) Every Shift Skilled Charting dated 9/18/17 at 1:11 p.m. documented, . Knee remains wrapped @ (at) this time. Immobilizer cont (continues) to be in place while oob (out of bed). Res (resident) stated she had an incident this weekend where her left knee buckled and she instinctively shifted her weight to her right knee and bent it as the immobilizer was not in place at the time. Res states her knee hurts worse this shift. No increased swelling or bruising noted @ this time. The notes do not indicate which knee the nurse was referring to. e. A Witnessed Fall Report completed by the DON on Thursday, 9/21/17 (see DON interview below) documented, 9/17/17 (at) 10:42 (a.m.) . Incident Description: Daughter reported that on Sunday evening (9/17/17), a CNA (Certified Nursing Assistant) attempted to get resident up. States a tall, thin, dark haired CNA was getting her up alone (she is a one person assist, toe touch wt (weight) bearing). Stated her mother's good leg gave out causing her to sit back on bed. Daughter feels this caused the fracture to her femur. There was not an I and A (Incident and Accident) done since it was not considered a fall. Resident had a bed side commode that she was going to use when they got her up (pivot from bed to bsc (bedside commode)). Spoke to the resident at 1050 AM 9/22 (Friday) she stated as CNA got her to almost standing position when her good leg gave out. She sat back on bed and laid back on bed d/t (due to) excruciating pain. She states she did tell the CNA she should have her brace on . Immediate Action Taken Description: Daughter called (Physician #1) on 9/21/17 and he called with order to x-ray, make non wt bearing on affected leg and to leave leg brace on while OOB (out of bed). X-ray came back with mid femur fracture. (Physician #1) paged by (Hospital) on Thursday evening but did not return call. (There was no documentation the facility attempted to contact Physician #1). One of our facility doctors was contacted and stated it was non-emergent, to wait for (Physician #1) to return call. After speaking to the daughter, I went to resident's room and assessed her. There is mild swelling to upper leg (above brace). She has yellow discoloration to entire upper part and part of lower leg that was present on admit per tx (treatment) nurse. Patient says pain is about same as it has been since procedure. CNA immediately inserviced on need for brace at all times. In service scheduled for 9/26/17 for all CNAs on closet care plans and transfers. Daughter contacted (Physician #1) office and stated they said we never called. We did get disc with x-rays and daughter hand delivered to (Physician #1) on 9/22/17 at approx (approximately) 1130 (a.m.). (Physician #1) called back and asked that she be sent to ER (emergency room ). Resident taken to hospital . A Radiology Results Report dated 9/21/17 documented, .Examination Date: 9/21/17 . INTERPRETATION: . Reason: Femur fracture, pain . IMPRESSION: 1. Acute mid femoral shaft fracture . f. On 10/30/17 at 1:47 p.m., the DON was asked about the incident that occurred with Resident #5 on 9/17/17. She stated, I found out about this on the day the x-ray was ordered on [DATE]. I think it was (MDS Coordinator) who called me. I want to say it was after I spoke to the daughter. The daughter called them; I can't remember when. The DON was asked when the doctor was first notified and stated, There were no attempts to contact the physician until the 21st of September. When we couldn't get the Orthopedic (Physician #1), we paged one of the doctors from here, (Physician #2). He ordered an x-ray. When the result came back with a fracture, we notified (Physician #2) again. He said to notify (Physician #1). They notified (Physician #1) and received no call back. Notified (Physician #2) again, from what I understand he said wait until you hear from (Physician #1). Daughter was here next day (Friday 9/22/17). She wanted the x-ray disc because she said she had called (Physician #1's) office and they didn't know anything about this. We called the x-ray company and got the disc for her and she took it to (Physician #1's) office. (Resident #5) was sent to the hospital on [DATE] by ambulance. The DON was asked, regarding the Witnessed Fall Report she had filled out for the 9/17/17 incident, when the report was actually done. She stated, On Thursday 9/21/17, when I first became aware of this incident. g. On 10/30/17 at 2:25 p.m., the MDS Coordinator was asked if she was aware of the incident that occurred with Resident #5 on 9/17/17. She stated, I don't believe I was here on the 17th; that was on the weekend. I was here on the 21st, and this was the first time I heard anything about the incident with (Resident #5). On the 21st, the ADON (Assistant Director of Nursing)) had taken a call from (Physician #1), and he told her that (Resident #5) was non-weight bearing and ordered an x-ray. This was after her daughter had called (Physician #1's) office. When (Resident #5) came in the 15th of September, she had a brace, and it was supposed to be on with any weight bearing activities. h. On 10/31/17 at 10:07 a.m., PTA #1, who provided therapy for the resident on 9/18/17, stated, In therapy, she was a 1 person transfer. I would say she should have been a 2-person transfer on the hall. She was asked about the documentation on her note dated 9/18/17 and stated, I reported this to the nurse, (Licensed Practical Nurse (LPN) #1). She said she had heard about it and they were keeping an eye on it. The patient just told me there was a lot of pain when this happened. On the 18th, she was hesitant about moving. She was hurting. So, from there, she told me what happened. She got out of bed with help and the knee brace was not on. When she was getting up from the edge of the bed, her leg gave away. Her good leg (left leg) gave out, and her right leg bent. She did say she did not fall in the floor. She went back on the bed after the left leg gave out and the right leg bent. She stated the pain was really bad. i. On 10/31/17 at 10:17 a.m., LPN #1 was asked if she had been made aware of the incident with Resident #5 on 9/17/17. She stated, On Monday the 18th, when I came on day shift, the 11-7 (11:00 p.m. - 7:00 a.m.) nurse told me she was transferred over the weekend without her brace and she was weak, so her strong leg gave out on her and, with no brace on, she was forced to put weight on her right leg, then she was transferred to the bed. She was asked if she had reported this to anyone and she stated, I did not report this to anyone. I assumed it was taken care of. I talked to the resident about it, and she stated she got out of bed without her brace on. She did report an increase in pain with the incident. She was asked if she had talked to the resident's daughter regarding the incident and stated, I never talked to her daughter about this. She was not on the Hot Rack as an I and A. It was pretty much told to me like, no big deal, this is what happened. j. On 10/31/17 at 10:28 a.m., Nursing Aide (NA) #1, who transferred the resident on 9/17/17, stated, I got on the hall that day, and they told me in report she was a limited assist with 1 person with transfers. She was able to go to the bathroom in her room. I saw the brace in her room; she was a new resident to me. There is a closet care plan; I checked it, and it said she was an extensive one-person transfer. When I first attempted to transfer her, I was by myself. She told me she wanted to go to the bathroom. I told her I didn't know if she should and I asked her if I could bring a bedside commode in there, and she said I could. After getting the bedside commode, I had a gait belt on her. She was sitting on the side of the bed. I had my knees in front of hers and my toes were touching hers. She stood up, and when we were turning to get on bedside commode, she said there was too much pain and she couldn't bear the weight. She asked if she could sit down, so I sat her down. I got help after sitting her back down. She was asked if she had reported this to the nurse and stated, I did report this to a nurse; I can't remember who the nurse was. She was asked if the resident had complained of increased pain and she stated, The resident did complain of pain. k. On 10/31/17 at 11:07 a.m., LPN #2 (who worked the evening of 9/17/17) was asked if she had been notified of the incident on 9/17/17 with Resident #5. She stated, The aide told me she transferred her, but never told me there was an issue with the transfer. All they said, I think it was the daughter, is that they felt more comfortable with 2 people transferring her. There was a person in the room when (NA #1) transferred her. I'm assuming it was a family member. The only reason I knew was because (NA #1) or another aide wanted me to go talk to the person. All I reported to the oncoming nurse was the family wanted her to be transferred with 2 people. I had no knowledge of any fracture. l. On 10/31/17 at 11:19 a.m., CNA #1 was asked if she was aware of the incident with Resident #5 on 9/17/17 and stated, I worked with her on the day of her admission on the 15th and I was told by the off-going aide that she had a hip fracture and, I think, a knee fracture and not to get her up, but put her on the bed pan. I told the person coming on behind me what I was told in report. On the 17th, (NA #1) paged for help, and I told her I would get there as soon as I could. It was approximately 15 minutes before I got there. When I got in there, the resident was sitting on the edge of the bed and I asked, 'What are you doing? We don't get her up; she uses a bedpan', and I explained why. We positioned her back in the bed. I wasn't aware of a brace, because I had never gotten her up. There was no family or visitor in the room on the 17th, just (NA #1). (NA #1) told me the resident had trouble standing. I didn't know she had a fractured femur. I had heard she went back to the hospital. m. On 10/31/17 at 2:07 p.m., PT #1, who completed the resident's initial Physical Therapy Evaluation, was asked what her evaluation had determined the resident's transfer status should have been. She stated, I told the aide after I did her initial evaluation that she needed to be transferred with 2 (staff) and that the knee brace had to be on with every time she was gotten up or transferred. I knew she was going to be tough to do. She was asked if she reported this information to the nurses and stated, Sometimes I do go to the nurses, and sometimes I go to the MDS Coordinator. Normally, I just tell the CNAs on the hall how the residents are to be transferred. n. On 10/31/17 at 2:15 p.m., LPN #1, who completed the Admission Nursing Assessment on 9/15/17, was asked how she made the determination the resident required limited assistance of one person for transfers and toileting and stated, When I did the initial assessment, I didn't transfer her. I watched an aide and the people that brought her. I don't remember who it was; she was in her wheelchair. The other person transferred her. From that transfer, I got she was a limited times one (staff). I knew she was to have a knee brace from the verbal report I had received from the hospital before she got here. She was asked why the resident went from a limited times 1 on 9/15/17 on the initial nursing assessment to extensive times 2 assistance on the Nurses' Notes dated 9/16/17 and 9/17/17. She stated, I'm figuring it had something to do with therapy doing their evaluation.