Every finding on record at Kewaunee Health Services

Based on staff interview and record review, the facility did not ensure they completed mandatory electronic submission of staffing information based on payroll data in a uniformed format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 27 residents residing in the facility. The facility's staffing information for Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. Findings include: The Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal (PBJ), Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: Staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: Quarter 1: October 1-December 31; Quarter 2: January 1-March 31; Quarter 3: April 1-June 30; Quarter 4: July 1-September 30. On 3/4/23, Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D for Fiscal year 2023 (run on 2/27/24) which indicated: Quarter 4 2023 (July 1-September 30 ) triggered metrics: submitted weekend staffing data is excessively low; failed to have licensed nursing coverage 24 hours a day on 7/23/23, 9/3/23, 9/4/23, 9/9/23, 9/10/23, 9/11/23, 9/16/23, 9/17/23, 9/23/23, and 9/24/23. On 3/4/24, Surveyor requested staffing schedules and timecard punches for the triggered days in Quarter 4 from Nursing Home Administrator (NHA)-A. On 3/4/24, Surveyor reviewed the staffing schedules and timecard punches and noted the facility had appropriate nursing staff levels per the Facility Assessment for all triggered days on the PBJ Quarter 4 Report. On 3/4/24 at 11:17 AM, Surveyor interviewed Business Office Manager (BOM)-E regarding the triggered metrics of low weekend staffing and no licensed nursing hours for Quarter 4. BOM-E indicated BOM-E verified the hours and sent the hours to the the central office and stated an employee from the central office sent the hours to CMS. BOM-E indicated BOM-E was aware that agency staff hours were not reported to CMS correctly or at all. BOM-E indicated it was an ongoing issue that the facility and central office were aware of, however, BOM-E was unsure if the issue was corrected. BOM-E stated BOM-E would speak with NHA-A and [NAME] President of Success (VPS)-C about the missing hours and provide further information to Surveyor. On 3/4/24 at 12:29 PM, BOM-E informed Surveyor that VPS-C had information regarding PBJ reporting and had emails regarding missing hours for PBJ reporting from the central office. Surveyor interviewed VPS-C who indicated VPS-C had the hours that triggered as missing on the PBJ Report and was working with the central office to transmit the correct hours to CMS. On 3/5/24 at 12:01 PM, Surveyor again interviewed VPS-C who showed Surveyor emails sent to the central office from the facility that indicated the hours worked by staff. VPS-C indicated VPS-C worked with the facility's central office on the transmission of the hours to CMS because the PBJ Report displayed triggered metrics for staffing hours. On 3/5/24 at 1:43 PM, VPS-C approached Surveyor and indicated the central office was reviewing the PBJ Report and indicated transmission of incorrect staffing hours to CMS was a systematic issue that VPS-C was working on with the central office. VPS-C stated the facility's timecard system directly sends staffing data to CMS and when the hours are low, the facility provides the necessary information. VPS-C could not provide Surveyor with information on why the correct data was not transmitted to CMS, but stated VPS-C would provide the information when discovered. On 3/5/24 at 2:48 PM, VPS-C informed Surveyor that the Human Services Director and Chief Clinical Officer were reviewing the PBJ data and conducting organization-wide audits. VPS-C verified the staffing hours provided by the facility to the central office were correct. On 3/6/24 at 12:17 PM, VPS-C informed Surveyor that the central office discovered staffing hours were not accurately transmitted to CMS because the timecard system was not transmitting agency staff hours. VPS-C indicated that the central office is conducting organization-wide audits to ensure the timecard system is working and indicated the system-wide reporting error will be fixed.

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R5) of 2 sampled residents with non-pressure wounds received care and treatment in a timely manner. R5 had a skin tear on the left leg. R5's medical record did not indicate the origin of the wound, did not contain treatment orders or monitoring instructions, and did not indicate R5's Power of Attorney (POA), Hospice team or Physician was notified. Findings include: The facility's Pressure Injuries and Non-Pressure Injuries policy, revised on 7/20/22 indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise .Examples of impaired skin integrity include, but are not limited to, pressure injuries, venous (stasis) ulcers, arterial (ischemic) ulcers, diabetic (neuropathic) ulcers, surgical wounds, skin tears, and rashes . Resident/Responsible Party Education. 2. Inform resident/responsible parties on the presence of wounds . On 3/4/24 at 8:51 AM, Surveyor observed a bandage with a red stain on R5's left outer calf. R5 could not provide Surveyor with information on how the wound occurred. On 3/4/24, Surveyor reviewed R5's medical record. R5 had diagnoses including diabetes type 2 with chronic kidney disease, dementia without behavioral disturbance, and long-term use of anticoagulant medication. R5's Minimum Data Set (MDS) assessment, dated 2/23/24, contained a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R5 had severely impaired cognition. The MDS also indicated R5 received Hospice services, required full assistance with activities of daily living (ADLs), transferred via Hoyer lift, and used a wheelchair. R5 had an activated POA. R5's most recent skin assessment, dated 2/28/24, indicated R5 did not have skin injuries or wounds. A care plan indicated R5 was at risk for alteration in skin integrity due to incontinence and decreased mobility, and contained the following goal and intervention: R5's skin will remain intact, free from erythema, breakdown, excoriation, or bruising. Observe skin condition with ADL care daily and report abnormalities. R5's medical record did not contain an assessment or care plan regarding R5's left leg wound. In addition, R5's Treatment Administration Record (TAR) did not contain a treatment for the wound. On 3/5/24 at 9:57 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who was not aware of R5's wound and indicated the bandage was possibly a lidocaine patch. LPN-D verified R5's TAR did not contain a wound treatment. On 3/5/24 at 10:03 AM, Surveyor observed the bandage on R5's left leg and noted the bandage was not a lidocaine patch. On 3/5/24 at 12:47 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A who were unaware of R5's leg wound and were unsure if any treatment was provided. NHA-A indicated nursing staff should document and report skin irregularities, wounds, and alterations to the charge nurse so the area is assessed and treated. NHA-A also stated residents with skin irregularities, wounds, and alterations should be placed on the 24-hour report for observation. DON-B and NHA-A indicated they would observe the wound and provide further information to Surveyor. Surveyor did not receive any further information on 3/5/24. On 3/6/24 at 7:36 AM, Surveyor reviewed R5's medical record which contained an observation note, dated 3/5/24 at 9:37 PM, that indicated: R5 had a 1 cm (centimeter) long x 0.1 cm wide skin tear. The skin tear was observed after R5 was transferred to R5's wheelchair via Hoyer lift. R5 did not complain of pain. NHA-A and DON-B aware and notification was placed in the Physician folder. R5's POA was informed at 7:00 PM. A Non-Pressure Weekly tracker, dated 3/5/24 at 9:37 PM, indicated: Wound acquired 3/4/24 .left lower leg skin tear on right front lower left leg .No drainage, tunneling or odor with wound edges distinct and outline clearly visible. No inflammation or suspected infection .Monitor in TAR until healed. Clean with normal saline, pat dry, apply band aide every other day until healed Notify MD for treatment change if wound declines or no change in wound for two weeks. Update family/responsible party with wound changes, continue treatment as ordered, and continue plan of care .Physician and POA notified 3/5/24. On 3/6/24 at 8:38 AM, Surveyor requested R5's 2/28/24 and 3/5/24 skin assessments, current care plan, and TAR from NHA-A. On 3/6/24 at 12:10 PM, Surveyor reviewed R5's 2/28/24 and 3/5/24 skin assessments, care plan, TAR, and a telephone contact sheet provided by NHA-A. The telephone contact summary indicated: Fax sent to Physician on 3/6/24 at 7:35 AM .R5 received skin tear during transfer. Facility believes R5 bumped left lower leg (front) on Hoyer. Tear measures 1 cm long x 0.1 cm wide x 0.0 cm deep. Staff cleaned with normal saline and applied band aid. Please reply with orders if different from above. On 3/6/24 at 8:01 AM, the Physician agreed with the suggested treatment.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. The practice had the potential to affect 27 of 28 residents (one resident was exclusively tube fed). Staff did not test quaternary sanitizing solution per manufacturer's instructions. Staff did not wash hands when moving from dirty to clean activities. Dietary Cook (DC)-E touched ready to eat food with a bare hand. Staff did not date refrigerated items upon opening and did not discard expired beverages. Staff did not discard expired dry storage food. Dietary Manager (DM)-D did not wait two minutes to take microwave reheated food temperature to ensure food was heated evenly. Findings include: On [DATE] at 8:26 AM, DM-D stated the facility used ServSafe, which is based on the Food and Drug Administration (FDA) Food Code, as its standard of practice. Sanitizing Solution Testing Quaternary test strip package insert directions indicated the test solution should be between 65 and 75 degrees Fahrenheit (F) at the time of testing. On [DATE] at 8:47 AM, Surveyor observed DM-D fill a sanitizing solution bucket. DM-D commented DM-D could see steam rising. DM-D tested the sanitizing solution without obtaining the temperature of the sanitizing solution first. DM-D indicated the Parts Per Million (PPM) of sanitizing solution was appropriate based on the color of the test strip. Surveyor reviewed the facility's testing log and noted there was not a space to enter the sanitizing solution temperature. At 9:26 AM, Surveyor reviewed the package insert with DM-D who confirmed the manufacturer's instructions indicated the sanitizing solution should be between 65 and 75 degrees F at the time of testing. Hand Washing FDA Food Code 2022 documents at ,d+[DATE].14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: .(E) After handling soiled EQUIPMENT or UTENSILS On [DATE] at 8:47 AM, Surveyor observed DM-D enter the dishwashing area with dirty dishes. Without washing hands, DM-D moved tray of clean dishes from the dishwashing machine. DM-D then left the dishwashing area, obtained additional dirty dishes, delivered dirty dishes to the dishwashing area and, without washing hands, removed a second tray of clean dishes from the dishwashing machine. On [DATE] at 11:56 AM, Surveyor observed DC-E transport a soiled colander to the dishwashing area. Without washing hands, DC-E began to set up the steam table for the lunch meal service. On [DATE] at 1:01 PM, Surveyor observed Dietary Aide (DA)-F process dirty dishes. DA-F removed dishwashing gloves and, without washing hands, reached into the dishwashing machine to remove a clean steam table tray. Bare Hand Contact FDA Food Code 2022 documents at ,d+[DATE].11 Preventing Contamination from Hands .(B) Except when washing fruits and vegetables as specified under S,d+[DATE].15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT On [DATE] at 11:16 AM, Surveyor observed DC-E prepare individual serving size salads. DC-E removed gloves and began covering the salad bowls with plastic wrap. DC-E used a bare hand to push a piece of spring mix greens back into the salad bowl before covering. Refrigerated Storage FDA Food Code 2022 documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. FDA Food Code 2022 documents at ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A) On [DATE] at 8:58 AM, Surveyor observed and DM-D verified the facility's walk-in refrigerator contained the following open, undated and expired products: - One gallon of 2% milk with no open date; manufacturer best by dated [DATE]. - One 46 ounce (oz) container of tomato juice, open and undated. - One 32 oz container of Silk soy milk, open with a handwritten date of [DATE] on the container. DM-D indicated no residents preferred or used soy milk in the past month. - One 32 oz cranberry juice, open and dated. DM-D indicated the product was opened the day before and wrote ,d+[DATE] on the container at the time of the observation. Dry Storage On [DATE], after the walk-in refrigerator tour which began at 8:58 AM, Surveyor toured the dry storage area with DM-D. Surveyor observed and DM-D confirmed the following expired products shelved for use: - one box of single serving Italian dressing, manufacturer expiration dated [DATE]. - one 5 pound (lb) box of lemon bar filling mix, manufacturer expiration dated [DATE]. - one 3 lb box of lemon bar crust mix, manufacturer expiration dated [DATE]. At the time of the observation, DM-D verified the expired products should be discarded. Microwave Reheating FDA Food Code 2022 documented at ,d+[DATE].11 Reheating for Hot Holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF) for 15 seconds. (B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. On [DATE] at 8:33 AM, Surveyor observed DM-D microwave and reheat pureed egg. DM-D immediately removed the egg from the microwave and temped the egg. Surveyor observed a sign on the microwave that instructed staff to wait two minutes prior to obtaining the temperature. When Surveyor inquired about the microwave temperature procedure, DM-D stated DM-D was in a rush, reheated food, then waited two minutes before temperature monitoring.

Based on observation, staff interview, and record review, the facility did not ensure Centers for Disease Control and Prevention (CDC) respirator use standards were followed during Resident (R) care for 4 residents (R3, R8, R14, and R21). In addition, staff did not perform hand hygiene per standards during personal cares for R12 and did not ensure hand hygiene was offered to 6 (unidentified) of 8 residents prior to meal service. ~Staff bagged and reused N95 respirators while inside the rooms of R3, R8, R14, and R21 who were on droplet transmission-based precautions. ~Certified Nursing Assistant (CNA)-H did not remove gloves when moving from dirty to clean and did not wash hands when gloves were removed during personal cares for R12. ~Staff did not offer hand hygiene to six out of eight residents who ate in the main dining room on 1/10/23. Findings include: According to the Centers for Disease Control and Prevention (CDC) memo titled Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during Shortages 4/9/3021): IF FACILITY IS IN CONTINGENCY FOR SUPPLIES .implement limited re-use of N95 respirators and limit to no more than five uses (i.e., five donnings) per device by the same HCP, unless otherwise specified by the manufacturer. During observations from 1/10/23 through 1/12/23, the facility had a table with a sign stating to use an N95 for one shift or 12 hours. The table contained N95 respirators in brown bags labeled with staff names. 1. On 1/11/23 at 1:28 PM, Surveyor observed CNA-J don an N95 (Makrite NIOSH N95) removed from a paper bag on the table and R8 and R14's shared room. At 1:30 PM, CNA-J exited the room and performed hand hygiene. With the same mask, CNA-J entered R3 and R21's shared room. Both rooms contained a droplet precautions sign which required staff to don an N95, gown, gloves, and eye protection. The rooms had a shared bathroom for R3, R8, R14, and R21. On 1/11/23 at 1:32 PM, CNA-J doffed CNA-J's gown and gloves, exited R3 and R21's room, performed hand hygiene and removed a surgical mask and the N95. CNA-J placed both masks in a brown bag on the table. Surveyor immediately interviewed CNA-J who stated staff had their own bag to store their N95. CNA-J stated CNA-J puts a surgical mask over the N95 for extra protection. CNA-J stated CNA-J uses the N95 for one shift up to twelve hours as long as it does not get wet or soiled. CNA-J stated staff do not count the number of donnings and doffings, just the hours used. CNA-J stated the facility has not run of out N95s. On 1/12/23 at 2:41 PM, Surveyor interviewed Director of Nursing (DON)-B who stated staff can use one N95 for one shift if they put the N95s in brown bags after they take them off. DON-B stated the facility does not use N95s as extended use, but as limited re-use which includes using an N95 for eight hours or sooner if the N95 becomes soiled or contaminated. DON-B stated the facility was doing really well on supplies, including N95s and followed conventional use of N95s, not contingency. DON-B stated some staff throw away their N95 after use, but the nurse who goes into a resident's room twice per shift may re-use their N95. DON-B stated the CNAs throw the N95s away because they go in resident rooms more frequently. DON-B stated the facility had plenty of supply so the staff could throw away. That is North Shore policy. 2. On 1/10/23 at 11:01 AM, Surveyor observed CNA-H and CNA-I during the provision of cares for R12. CNA-H removed R12's incontinence brief and used cleansing wipes to clean R12's peri-area. With the same soiled gloves, CNA-H applied barrier cream to R12's buttocks and placed a clean incontinence brief under R12. CNA-H fastened the brief, put the wipes away, and then removed the soiled gloves. Without performing hand hygiene, CNA-H donned clean gloves. CNA-H and CNA-I transferred R12 via electric lift from bed to wheelchair. CNA-H then removed gloves and washed hands with soap and water. On 1/10/23 at 11:14 AM, Surveyor interviewed CNA-H who stated CNA-H tried to move quickly with R12 as R12 can become moody. CNA-H verified CNA-H should have changed gloves and performed hand hygiene during the provision of incontinence care when moving from dirty to clean parts of care. CNA-H stated DON-B was focused on hand hygiene and the oversight of hand hygiene is on us. On 1/12/23 at 2:50 PM, Surveyor interviewed DON-B who stated DON-B provided hand hygiene education to staff due to COVID-19, RSV (Respiratory Syncytial Virus), and influenza. Additionally, the facility performed spot checks on hand hygiene and did hand hygiene observations with agency staff. DON-B stated staff were expected to perform hand hygiene between soiled and clean tasks during the provision of resident care by changing gloves and using hand sanitizer or soap and water. 32767 3. On 1/10/23 beginning at 12:03 PM, Surveyor continuously observed dining service in the facility's main dining room. By 12:10 PM, eight residents transported themselves or were assisted with transportation to the dining room. Surveyor observed hand hygiene was not routinely offered to each resident who entered the dining room. Surveyor observed an unidentified resident ask CNA-H for a hand wipe which CNA-H provided. On 1/10/23 at 12:15 PM, Surveyor interviewed CNA-H regarding hand hygiene for residents. CNA-H stated some residents depended on staff for care so their hands would have last been washed during morning cares. CNA-H verified CNA-H provided a hand wipe to the resident who asked for one and stated residents know the wipes are there. CNA-H said, Mainly people who use them ask for them. CNA-H verified wipes were provided to the unidentified resident and a tablemate. On 1/10/23 at 12:27 PM, Surveyor observed meal service begin in the main dining room. R28, who was assisted to the dining room earlier, started to wheel R28's wheelchair out of the dining room prior to meal service, but was redirected back to the table. Hand hygiene was not offered to R28 when R28 was initially assisted to the dining room or when R28 was redirected to the table after touching the wheels of R28's wheelchair. On 1/12/23 at 2:38 PM, Surveyor interviewed DON-B who stated staff were expected to wash residents' hands prior to meals by using hand sanitizer, hand sanitizing cloths, or soap and water based on the resident's preference.

Based on observation, staff interview, and record review, the facility did not ensure puree texture food was prepared in accordance with the recipe for 1 Resident (R) (R16) of 1 resident with a pureed diet. Dietary Cook (DC)-E added approximately nine teaspoons of thickener to one serving of green beans during the puree process. The recipe indicated one teaspoon of thickener should be added per one serving of green beans. Findings include: On 1/11/23 at 11:24 AM, Surveyor observed DC-E prepare pureed green beans for the lunch meal service. DC-E placed one half cup of green beans in a food processor. DC-E then added what DC-E estimated was one quarter cup of water and used a two ounce scoop to obtain thickener from a bulk food bin. DC-E estimated approximately half the scoop of thickener was added (one ounce). DC-E processed the food and explained DC-E was adding thickener and water to obtain the desired consistency. DC-E stated DC-E knew how much thickener to add because there was a chart in the recipe book; however, DC-E indicated the chart didn't specify the amount of thickener to add for one serving and DC-E was making one serving of pureed green beans for R16. Surveyor reviewed the chart DC-E referenced. The chart was designed to let staff know what size scoop to use to convert regular texture food serving sizes to puree texture serving sizes. The chart did not address thickener or the type or amount of liquid to use when pureeing food. During the preparation process, Surveyor noted DC-E added additional water and thickener. Approximately three quarters of the two ounce scoop was added to the single serving of green beans. One ounce equaled six teaspoons which calculated to approximately nine teaspoons added to one portion of green beans. On 1/12/23, the facility provided the green bean puree recipe to Surveyor. Dietary Manager (DM)-D verified the recipe was not followed. The green bean puree recipe stated one teaspoon of thickener should be added per one serving of green beans.

Based on staff interview and record review, the facility did not ensure Resident (R) administration of medication was consistent with the ordered dose for 1 (R28) of 6 residents reviewed for medication administration. R28 was administered 15 milligrams (mg) of amlodipine besylate (a calcium channel blocker used to treat high blood pressure) on 1/10/23 following a medication change order on 1/9/23 to decrease amlodipine from 10 mg to 5 mg daily. Findings include: From 1/10/23 through 1/12/23, Surveyor reviewed R28's medical record which documented R28 received dialysis three times weekly. R28 returned from the hospital on 12/29/22 with an order for amlodipine besylate 10 mg daily. A dialysis physician order, dated 1/9/23 and fax time stamped 6:09 PM, documented a new order to decrease amlodipine besylate to 5 mg daily and to change the timing of the dose to HS (bedtime). R28's Medication Administration Record (MAR) documented staff administered 10 mg of amlodipine besylate during the day and 5 mg of amlodipine besylate at bedtime on 1/10/23 (total 15 mg administered on 1/10/23). On 1/11/23 at 12:24 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G regarding R28's amlodipine besylate order. LPN-G confirmed LPN-G worked on 1/9/23 and stated R28 returned from dialysis without R28's dialysis communication binder. LPN-G followed up with the dialysis center via telephone and was told dialysis paperwork would be faxed to the facility; however, LPN-G was unable to obtain the faxed information on 1/9/23 because the fax machine was located in a locked office. On 1/12/23 at 9:59 AM, Surveyor interviewed Director of Nursing (DON)-B regarding the change in R28's amlodipine besylate order. DON-B confirmed 15 mg of amlodipine besylate was administered to R28 on 1/10/23 when 5 mg should have been administered. DON-B stated R28's dialysis schedule changed after R28 returned from the hospital on 12/29/22. Staff identified R28 was not consistently available for the AM dose of amlodipine besylate due to the dialysis schedule change. To ensure R28 received amlodipine besylate, the order was changed to HS administration; however, the 1/9/23 change order was not processed in R28's medical record until after R28 received the previously ordered 10 mg AM dose on 1/10/23. DON-B confirmed staff did not identify the medication was administered twice on 1/10/23 prior to Surveyor's investigation.

Based on staff interview and record review, the facility did not ensure a system was in place to provide written notification of the facility's bed hold policy to a Resident (R) or resident's representative for 1 (R28) of 1 residents reviewed for transfers. The facility did not have a system to ensure provision of written notification of the bed hold policy at the time of resident transfers. The facility did not provide written notification of the bed hold policy to R28's activated Power of Attorney (POA)-K when R28 transferred to the hospital on 12/19/22. Findings include: From 1/10/23 through 1/12/23, Surveyor reviewed R28's medical record which documented R28 transferred to a hospital for care on 12/19/22. R28 had an activated POA (POA-K) who made medical decisions for R28. R28's bed hold and notice of transfer form, dated 12/19/22, documented POA-K was notified via telephone; however the signature and mail lines were blank. Surveyor was unable to locate documentation that written bed hold policy notification was provided to POA-K at or around the time of R28's transfer. On 1/10/23 at 1:07 PM, Surveyor interviewed POA-K regarding R28's hospitalization on [DATE]. R28 did not recall receiving paperwork from the facility related to R28's transfer, including bed hold policy information. On 1/11/23 at 12:24 PM, Licensed Practical Nurse (LPN)-G stated bed hold information was verbally provided via telephone for residents with alternate decision makers, and the forms were then given to Social Worker (SW)-C. On 1/12/23 at 9:44 AM, SW-C verified nursing staff provided SW-C with transfer forms, which included bed hold information. SW-C indicated the forms were filed in residents' charts, but not mailed or provided to residents or resident representatives on-site.

Based on staff interview and record review, the facility did not ensure a system was in place to provide written notification of transfer to a Resident (R) or resident's representative and a copy of written notification to the Office of State Long-Term Care Ombudsman for 1 (R28) of 1 residents reviewed for transfers. The facility did not have a system to ensure provision of written transfer notification at the time of resident transfers. In addition, the facility did not notify the Ombudsman of hospital transfers. The facility did not provide written notification of transfer to R28's activated Power of Attorney (POA)-K or a copy of written notification to the Ombudsman when R28 transferred to the hospital on 12/19/22. Findings include: From 1/10/23 through 1/12/23, Surveyor reviewed R28's medical record which documented R28 was transferred to a hospital for care on 12/19/22. R28 had an activated POA (POA-K) who made medical decisions for R28. R28's bed hold and notice of transfer form, dated 12/19/22, documented POA-K was notified via telephone; however, the signature line and the mail date lines were blank. Surveyor was unable to locate documentation that written transfer notification was provided to POA-K. On 1/10/23 at 1:07 PM, Surveyor interviewed POA-K regarding R28's hospitalization on [DATE]. POA-K did not recall receiving paperwork from the facility related to R28's transfer. On 1/11/23 at 12:24 PM, Licensed Practical Nurse (LPN)-G stated transfer information was verbally provided via telephone for residents with alternate decision makers, and the forms were then given to Social Worker (SW)-C. On 1/12/23 at 8:42 AM, SW-C stated SW-C became aware during Surveyor's investigation that SW-C's duties included communicating transfer information to the Ombudsman. SW-C confirmed the Ombudsman was not notified of transfers and stated SW-C contacted the Ombudsman's office during Surveyor's investigation to develop a system. At 9:44 AM, SW-C verified nursing handed-off transfer forms to SW-C after the forms were filled out. SW-C stated transfer forms were filed in charts, but not mailed or provided to residents or resident representatives on-site.

Based on observation, interview, and record review, the facility did not establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection which had the potential to affect 4 of 14 sampled residents (R) (R16, R22, R25, R26). R26 had a Clostridioides difficile infection (C. diff.) (infection resulting in severe diarrhea and inflammation of the colon) of the gastrointestinal tract upon readmission to the facility 12/21/21. Staff did not utilize and don appropriate personal protective equipment (PPE) when entering R26's room. Staff did not ensure R16's catheter drainage bag was positioned off of R16's floor mat while lying in bed. Certified Nursing Assistant (CNA)-G did not utilize appropriate hand hygiene during the provision of care for R22. Licensed Practical Nurse (LPN)-H did not utilize appropriate hand hygiene during the provision of care for R25. Findings include: 1. The facility policy titled Isolation-Categories of Transmission-Based Precautions, revised 10/2018, states under the section Contact Precautions: ~Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. ~The decision on whether contact precautions are necessary will be evaluated on a case by case basis. ~The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options. ~While caring for a resident, staff will change gloves after having contact with infective material. ~Gloves will be removed and hand hygiene performed before leaving the room. ~Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. ~Staff and visitors will wear a dsiposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. ~When transporting individuals with skin [CONDITION(S)], excretions, secretions, or drainage that is difficult to contain, contact precuations will be taken during resident transport to minimize the risk of transmission. Between 1/11/22 and 1/13/22, Surveyor reviewed R26's medical record. R26 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Brief Interview of Mental Status (BIMS) assessment, completed 12/25/21, indicated that R26 had severely impaired cognition with a score of 6 (severe cognitive impairment). R26's most recent care plan included a focus area related to infection of the gastrointestinal tract due to C. diff. Interventions related to resolution of the infection included administering medications as ordered, maintaining precautions as indicated, recording R26's temperatures, and washing R26's hands with soap and water. On 1/11/22 at 9:05 AM, Surveyor observed R26's room during initial tour of the resident unit. Surveyor observed R26 lying in bed with a curtain drawn between R26 and R26's roommate, R3. Surveyor noted a sign outside of R26's room that stated R26 was under contact precautions. The sign indicated that staff must clean hands upon entering and before leaving the room, put on gloves before room entry and discard upon exit, and put on a gown prior to room entry before disposing upon room exit. On 1/12/22 at 8:29 AM, Surveyor observed CNA-J enter R26's room. Surveyor noted CNA-J did not put on gown or gloves upon entry to R26's room. Surveyor observed CNA-J touch R26's bed frame to lower the bed and apply hand sanitizer before leaving R26's room. At 8:30 AM, CNA-J returned to R26's room with a blanket. CNA-J did not perform hand hygiene upon entering the room with the blanket or don gown and gloves. CNA-J placed the blanket on R26 before moving to R26's roommate. Surveyor observed CNA-J move R3's side table, remove R3's meal tray, and lower R3's bed. CNA-J applied hand sanitizer after exiting R3 and R26's room. At 8:38 AM, Surveyor interviewed CNA-J regarding PPE use in R26's room. CNA-J explained that R26 had an infection that was contained to R26's [CONDITION(S)] bag so CNA-J only donned a gown and disposable gloves when completing personal cares for R26, such as emptying R26's ostomy bag. On 1/12/22 at 11:08 AM, Surveyor observed R26 with R26's family member. Surveyor noted R26 and R26's family member were not wearing gowns or gloves as R26 propelled self in R26's wheelchair down the resident hallway and into the main lobby area of the facility. On 1/13/22 at 8:49 AM, Surveyor observed Registered Nurse (RN)-K enter R26's room to dispense morning medications. RN-K did not don a gown or gloves when entering R26's room. Surveyor noted RN-K utilized the wall-mounted hand sanitizer upon exit of the room. On 1/13/22 at 7:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A related to R26's contact precautions. NHA-A explained that R26 was not infected with C. diff. prior to arriving at the facility but rather went out to the hospital and was diagnosed while at the hospital. NHA-A indicated that R26's C. diff. is contained to R26's ostomy bag. NHA-A expressed that, at times, R26 will empty R26's own ostomy bag but that the CNAs are ultimately responsible for emptying the ostomy bag and ensuring proper precautions are taken to avoid environment contamination when emptying. When asked by Surveyor if R26's environment could potentially become contaminated through empyting of the ostomy bag, NHA-A indicated that there was potential for environment contamination but that the facility interdisciplinary team determined the risk was low. When asked why R26 had a roommate without C. diff. infection, NHA-A explained that R3 and R26 had been placed in the same room due to high risk for falls and that R3 and R26 were closer to the nurses' station for supervision. 2. On 1/11/22, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/22 at 11:24 AM, during initial survey observations, Surveyor observed R16 lying in R16's room in bed. Surveyor noted R16's bed was positioned low to the floor of the bedroom and a fall mat was in place beside R16's bed. Surveyor observed R16's catheter drainage bag uncovered, hooked to the bed frame, but resting on the floor mat next to R16's bed. R16's catheter bag was not suspended off the floor and a barrier was not observed between the catheter bag and the floor mat. On 1/13/22 at 8:48 AM, Surveyor completed additional observations of R16 lying in bed. Again, Surveyor noted R16's catheter bag was hooked to R16's bed frame but was touching R16's floor mat without a barrier between the catheter bag and floor surface. At 9:00 AM, Surveyor interviewed CNA-G related to R16's catheter care. CNA-G indicated that CNA-G was familiar with R16's care. When asked by Surveyor how R16's catheter bag was positioned while R16 laid in bed, CNA-G confirmed with Surveyor that the catheter bag was hooked to the bed frame but was resting on the floor mat next to R16's bed. At 11:56 AM, Surveyor notified Director of Clinical Services (DCS)-C of the observations of placement of R16's catheter bag. DCS-C expressed that the expectation would be that nursing staff position R16's catheter bag off the floor or place a barrier between the catheter bag and floor surface for infection control purposes. 3. Facility provided policy titled Handwashing/Hand Hygiene with no date stated, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff to use to encourage compliance with hand hygiene policies . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% (percent) [MEDICATION(S)] or [MEDICATION(S)] for all the following situations: . j. After removing gloves. 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment . On 1/11/22, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/12/22 at 10:02 AM, Surveyor observed CNA-I and CNA-G provide perineal care to R22. When perineal care was completed, Surveyor observed CNA-G put on gloves and assist R22 with pulling R22's pants up while R22 was lying on bed. Surveyor observed CNA-G remove the glove from CNA-G's right hand and, without performing hand hygiene, touch R22's bed controls with CNA-G's ungloved right hand. Surveyor observed CNA-G remove the glove from CNA-G's left hand and, without performing hand hygiene, closed window blinds, turned light off by R22's bed, placed call light within R22's reach, moved R22's bedside table, assisted R22 with placing eyeglasses on bedside table, gave R22 a cough drop from a container on bedside table per R22's request, placed wrapper from cough drop in garbage can, removed used garbage bag from garbage can, placed new garbage bag in garbage can, opened R22's room door, turned off room light by touching wall light switch, walked down hall to utility room, opened utility room door, placed garbage bag in large container and then perform hand hygiene. On 1/12/22 at 10:14 AM, Surveyor interviewed CNA-G who verified CNA-G should have performed hand hygiene after removal of gloves and before touching anything in R22's room. 4. On 1/11/22, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/12/22 at 11:55 AM, Surveyor observed LPN-H obtain R25's blood sugar reading via a hand-held blood glucose (sugar) monitor which required obtaining a drop of blood from finger-stick procedure. After LPN-H obtained R25's blood sugar reading, Surveyor observed LPN-H remove the glove from LPN-H's right hand and, without performing hand hygiene, open R25's room door with LPN-H's ungloved right hand. Surveyor observed LPN-H removed the glove from LPN-H's left hand and then perform hand hygiene. Surveyor observed LPN-H prepare an insulin (medication used to treat high blood sugar) injection for R25. At 12:00 PM, Surveyor observed LPN-H put gloves on and administer R25's insulin injection. Surveyor observed LPN-H remove the glove from LPN-H's left hand and, without performing hand hygiene, move R25's table and open R25's room door with LPN-H's ungloved left hand. Surveyor observed LPN-H remove the glove from LPN-H's right hand and then perform hand hygiene. On 1/12/22 at 12:01 PM, Surveyor interviewed LPN-H who verified standard of practice was to perform hand hygiene immediately after glove removal. LPN-H stated, It would be nice if there was hand sanitizer in the rooms. On 1/12/22 at 12:06 PM, Surveyor observed hand sanitizer units in hallways and on medication cart. Surveyor observed there are no hand sanitizer units in resident rooms. On 1/12/22 at 2:58 PM, Surveyor interviewed Director of Clinical Services (DCS)-C who verified CNA-G and LPN-H should have performed hand hygiene immediately after glove removal and before touching any items in resident care areas.

Based on record review and staff interview, the facility did not ensure that all alleged violations involving abuse, neglect and/or mistreatment were reported to the State Agency (SA) for 1 resident (R) (R22) of 14 residents reviewed for abuse. On 1/9/22, Laundry/Housekeeping Assistant (LA)-E informed Nursing Home Administrator (NHA)-A that Registered Nurse (RN)-F was mean to R22. NHA-A did not submit the allegation to the SA. Findings: R22 was admitted to the facility 12/13/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's medical record indicated R22's cognition is moderately impaired. R22's care plan indicated R22 utilized a wheelchair for locomotion and required staff assistant for locomotion as well as needing assistant from staff for other activities of daily living. Facility policy titled Abuse Prevention Program with an effective date of March 2018 read as follows: Reporting/Responding: Abuse Policy Requirement: The facility must report alleged violations related to mistreatment, exploitation, neglect or abuse; including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframe. Allegations must be reported to the Administrator/designee immediately. The Administrator/designee will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported no later than 2 hours after the allegation is made, if events that cause the allegation are abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the state survey agency or other officials/authorities as needed. Results of the investigation will be reported to the state survey agency within 5 working days of the initial allegation and if the alleged violation is verified, appropriate corrective action must be taken. On 1/11/22 at 8:55 AM, the Surveyor reviewed the facility's grievance files. A grievance concern form dated 1/9/22 (Sunday) related to R22 was noted. Under the form's section What is your concern about? was a handwritten statement that read, Was reported that the resident wanted to go back to room. Laundry aide reported that nurse was forcing resident to take a pill and was being mean to resident. Under the form section When did the problem occur? 1/9/22 was handwritten in. That section of the form was signed by Social Worker (SW)-D, with a signature date of 1/9/22. Under the section Facility Response/Action To Be Taken a handwritten note read, SW followed up with resident. Resident answered interview questions. See attached. No concerns expressed by resident. This section was signed by SW-D and was dated 1/10/22. Under the section Administrator Follow Up a handwritten note read, Writer followed up with resident. Resident had no concerns and is pleased with care received. That section was signed by NHA-A and date of NHA-A's signature was 1/11/22. Two additional pieces of paper were attached to the grievance; one page had R22's name on top and was dated 1/10/22 and read as follows: Do you feel safe here? Yes. Do the staff treat you well? Yes. Are there any staff who don't treat you well? No. Do you have any concerns about your treatments or the care you receive? No. The second attached page to the grievance form also had R22's name on it and was dated 1/10/22 and read as follows: Do you feel or have there been situations were you were forced to take your medication? No. Do you feel that you are isolated in your room and/or cannot come out? No. The Surveyor noted that there was no other information or pages other than these in the grievance file. On 1/11/22 at 9:36 AM, the Surveyor interviewed SW-D. SW-D confirmed helping with abuse and neglect allegation investigations at the facility. SW-D explained that an anonymous complaint was called into a hotline phone number on Sunday 1/9/22 and the facility was alerted to the hotline complaint on Monday morning 1/10/22. SW-D indicated that NHA-A informed SW-D on Monday 1/10/22 that a similar allegation had been reported to NHA-A by LA-E on Sunday morning, 1/9/22. SW-D explained having initiated the grievance form on Monday 1/10/22, but dated it 1/9/22 for this reason. SW-D then interviewed R-22 on 1/10/22 about the specific allegations that were reported on Sunday and Monday. On 1/11/22 at 9:39 AM, the Surveyor interviewed NHA-A. NHA-A confirmed the allegations was not reported to the SA. NHA-A confirmed knowing about the allegation on Sunday at approximately 10:30 AM when LA-E reported RN-F was mean and was trying to force R22 to take R22's medication. NHA-A indicated that NHA-A spoke to RN-F and LA-E on Sunday morning and then checked on R22 before NHA-A left the facility around noon on Sunday. NHA-A indicated that NHA-A asked R22 how R22 was doing and R22 said fine. NHA-A confirmed that NHA-A did not ask R22 specific questions about the alleged incident on Sunday before NHA-A left the facility. NHA-A indicated that the following morning at 8:30 AM, Monday 1/10, the complaint hotline for the facility/organization reported an anonymous call that came in on Sunday which indicated RN-F forced R22 to take medications, makes residents cry and residents are being forced to be kept in their rooms. NHA-A indicated this complaint was told to the Director of Nursing (DON)-B who then called NHA-A (due to NHA-A being out of the facility). NHA-A indicated SW-D then wrote up the grievance form on Monday but dated it Sunday due to NHA-A informing SW-D of the concern LA-E reported to NHA-A the day prior and the two allegations being similar. SW-D then went and asked R-22 about these allegations and interviewed other staff and residents about the allegations as well. The Surveyor noted these interviews typed up and in the additional file (other than the grievance file) provided by NHA-A. NHA-A indicated that an all-staff education was also started on 1/10/22 regarding abuse and confirmed the education was not completed with all staff yet. The Surveyor noted the content of the education within the file as well which included a type-written page dated 1/10/22 that read: All Staff: Please review and sign the education on abuse, neglect, and misappropriation of resident property. Thank you! The education was contained on a separate page that had the definition of abuse, neglect and misappropriation of resident property as well as instruction to report such events to employee's supervisor and the facility Administrator after ensuring the safety of the resident. NHA-A explained to Surveyor further investigation was conducted on 1/10/22 by NHA-A's supervisor, Director of Clinical Services (DCS)-C, and RN-F was removed from the facility and taken off the schedule on Monday, 1/10/22. NHA-A indicated that on Monday 1/10/22 a phone call took place at approximately 3 PM which included NHA-A, DCS-C, as well as other corporate staff, at which time it was decided not to report the allegation to the SA due to it already being past 24 hours of NHA-A knowing about the allegation. NHA-A indicated DCS-C did verbal education with NHA-A on 1/10/22 regarding the need to investigate such allegations immediately and to remove the alleged person. The Surveyor interviewed DCS-C. DCS-C indicated that DCS-C came to the facility on Monday 1/10/22 and did some interviews related to the investigation including an interview with RN-F. DCS-C indicated that DCS-C removed RN-F from resident cares and from the schedule pending results of the investigation. DCS-C confirmed that it was decided not to report the allegation due to it already being past the 24 hour guideline to report and the investigation had essentially been conducted. DCS-C confirmed the allegation should have been reported to SA within 24 hours of NHA-A being aware of the allegation.

Based on observation, interview and record review the facility did not provide pharmaceutical services to assure accurate administration of medications for 1 Residents (R) (R18) of 14 total sampled residents. R18's room contained medication bottles including bowel dietary supplement pills, Vitamin C capsules, and digestive enzyme supplement pills. R18's record did not contain physician orders for the observed medication supplements and the facility self-administration assessment for R18 did not indicate R18 could self-administer medications. Findings include: Between 1/11/22 and 1/13/22, Surveyor reviewed the electronic medical record for R18. R18 admitted to the facility on with diagnoses including [CONDITION(S)], hypertension, [CONDITION(S)], and a history of noncompliance with medication regimen. Per R18's admission Minimum Data Set (MDS) assessment, R18 scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS)(the higher the score the more cognizant). On 1/11/22 at 9:42 AM, Surveyor interviewed R18 as part of the survey initial tour process. During the interview, Surveyor observed three medication bottles on R18's beside table including Dr. Christopher's brand Lower Bowel Formula (a bowel dietary supplement), a bottle of Vitamin C capsules, and Super Papaya Enzyme Plus (a digestive supplement).When asked by Surveyor if R18 currently used the medications, R18 indicated that R18 did currently use the medications. Surveyor further reviewed R18's record and noted that R18's physician orders did not include direction for any of the three medication supplements observed in R18's room. Additionally, R18's admission Medication Self-Administration Assessment from 11/29/21 indicated that R18 did not want to administer R18's own medications or was unable to make their own decisions, and no further evaluation on self-administration was completed. Throughout continuous observations on 1/11/22, Surveyor observed nursing staff and housekeeping staff enter or assist R18 in R18's room. On 1/12/22, at 8:15 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H related to medication administration. LPN-H explained that LPN-H had already been in R18's room to administer morning medications. LPN-H indicated that LPN-H was not aware of any medication supplement bottles on R1's bedside table and stated that, they couldn't have been there yesterday. LPN-H entered R18's room, discussed the medications with R18, and brought the bottles to the nurses' station for follow-up with the physician. On 1/12/22 at 1:51 PM, Surveyor notified Director of Clinical Services (DCS)-C about the medication supplements in R18's room. DCS-C indicated that the supplements should have been evaluated by R18's physician and that the self-administration assessment should have been reevaluated and noted in R18's record.

Based on observation, staff interviews, and record review, the facility did not ensure Resident (R) fall prevention devices were provided and utilized as determined appropriate by therapy for 1 (R3) of 5 sampled residents. Staff did not ensure R3's pommel cushion (cushion contoured up at the front middle) and dycem (anti-slip material) were in R3's wheelchair prior to transferring R3 from bed to wheelchair. Findings include: On 3/22/21, Surveyor reviewed R3's medical record which documented R3 fell at the facility on 1/21/21 and sustained a [MEDICAL CONDITION]. On 1/22/21, R3's fall prevention care plan was updated with interventions including pommel cushion in wheelchair and dycem placed on the cushion seat. On 3/22/21 at 10:56 AM, Surveyor observed Certified Nursing Assistant (CNA)-C and CNA-D assist R3 transfer from bed to wheelchair via full body mechanical lift. Surveyor observed R3's wheelchair had a blue wedge cushion at the time of transfer. On 3/22/21 at 12:44 PM, Surveyor interviewed CNA-C regarding R3's devices (pommel cushion and dycem). CNA-C indicated R3's dycem was blue and visually blended into the wheelchair cushion. At Surveyors request, CNA-C felt surface between R3 and wheelchair cushion; CNA-C indicated the dycem was not felt. CNA-C recalled R3 was placed on a pommel cushion. R3 agreed to transfer to recliner after lunch. On 3/22/21 at 1:03 PM, Surveyor observed CNA-C and CNA-D assist R3 transfer from wheelchair to recliner via full body mechanical lift. Surveyor observed and CNA-C confirmed R3's wheelchair had a blue wedge cushion. CNA-C indicated R3's dycem was between the wheelchair and the cushion so the cushion would not slip out of the wheelchair. CNA-C then lifted the wedge cushion out of R3's wheelchair and verified no dycem was in R3's wheelchair. On 3/22/21 at 1:09 PM, Surveyor interviewed Therapy Director (TD)-E regarding R3. TD-E indicated R3 had a wedge cushion in wheelchair and indicated TD-E visualized the wedge cushion earlier in the day. Surveyor requested assessment for cushion change from pommel cushion to wedge cushion. TD-E indicated TD-E did not perform R3's assessment and proceeded to review therapy department resident assessment binders. TD-E then indicated R3 was not reassessed for a different cushion. TD-E indicted R3's wheelchair should be set up with a pommel cushion with a dycem on top of the cushion for R3's safety. At the end of interview, TD-E provided CNA-C with a new piece of dycem and accompanied CNA-C to locate appropriate cushion for R3's safety.

Based on record review and staff interview, the facility did not ensure 2 Residents (R) (R12 and R19) of 5 sampled residents reviewed for vaccinations were offered or received an influenza immunization and a pneumococcal immunization. R12 was admitted on [DATE] and was not offered a pneumococcal immunization. R19 was admitted [DATE] and was not offered an influenza immunization. Both Residents were eligible to receive the immunizations. Findings: According to the Centers for Disease Control and Prevention (CDC), persons 65 and older should be given one dose PPSV23 ( Pneumococcal [MEDICATION NAME] vaccine). If PPSV23 was administered prior to age [AGE] years, administer one dose PPSV23 at least five years after previous dose. According to the CDC, persons age six months or older should receive one dose of any influenza vaccine appropriate for age and health status annually. The facility's policy and procedure titled Influenza and Pneumococcal Immunizations - Residents dated 6/1/2017 states: PURPOSE All residents will receive immunizations that aid in preventing infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. 1. Because long term care resident are prone to developing serious complications when they contract the flu, all resident are encouraged to receive an influenza vaccination during the fall of each year, unless otherwise ordered by the resident's attending physician or the resident refuses. 2. The resident's attending physician must provide a written order for the vaccination and the order must be recorded in the resident's medical record. 3. Upon admission to the facility, permission must be obtained from the resident or representative to administer pneumococcal vaccine (one time) and influenza vaccine annually (in the fall), unless contraindicated. 4. All new residents will be assessed for pneumococcal vaccine status upon admission. 5. Residents without proof of previous pneumococcal vaccination should receive one (1) dose only of [MEDICATION NAME] unless contraindicated. On 2/24/2021, Surveyor reviewed R12's medical record which stated on 12/3/2020 R12 declined the influenza immunization. R12's medical record did not contain documentation that showed R12 was assessed for, offered, or administered a pneumococcal immunization. R12's medical record did not contain an order for [REDACTED].>On 2/24/2021, Surveyor reviewed R19's medical record which contained an order dated 1/15/2021 stating, May have annual flu vaccine. R19's medical record did not contain documentation that proved R19 was administered an influenza immunization or that R19 was provided education or declined the influenza immunization. On 2/24/2021, Surveyor reviewed the Wisconsin Immunization Registry (WIR) and did not find record proving R12 received a pneumococcal vaccine prior to or during R12's admission at facility. The WIR did not contain documentation that R19 received a 2020/2021 seasonal influenza vaccine prior to or during R19's admission at the facility. On 2/24/21 at 12:30 PM, Surveyor interviewed DON-B who stated that the facility does not have documentation for either R12's pneumococcal immunization or R19's influenza immunization. 02/24/21 12:56 PM, DON-B verified the facility did not have documentation of education being provided to R12 and R19 or if R12 and R19 declined immunizations.

Based on record review and staff interview, the facility did not ensure wound monitoring and care planning was completed per standard of practice for 1 Resident (R) (R124) of 1 resident reviewed with non-pressure related wounds. The facility did not monitor R124's under umbilicus (belly button) wound or ankle surgical site wound by obtaining initial and/or weekly measurements. Findings include: On 2/22/21, Surveyor reviewed R124's medical record which documented the following wounds: Under Umbilicus - 2/10/21 order, to monitor open area to lower umbilicus three times a day. - 2/10/21, initial skin assessment, open area below umbilicus with granulation tissue and scabbing. Measurements: 2.5 centimeters (cm) x 1.6 cm x 0.1 cm. - 2/13/21, communication to [MEDICAL TREATMENT], open area below umbilicus noted. - 2/17/21, weekly skin observation tool, under belly button, scabbed area (no measurements). Left Ankle - 2/10/21, hospital discharge paperwork documented 12/30/2020 left ankle osteo[DIAGNOSES REDACTED] with hardware removal - 2/10/21, initial skin assessment, left ankle, scar-incision (no measurements). - 2/17/2021, weekly skin assessment, no documentation related to left ankle - 2/19/2021, order, dry dressing left ankle with communication from primary care physician to orthopedic physician documenting open area estimated 2 to 3 millimeter (mm) in distal wound with serosanguinous drainage. Surveyor noted nursing notes on same date did not document anything regarding left ankle. Surveyor noted R124's care plan did not address either wound. On 2/23/21 at 3:27 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R124's wounds. DON-B indicated DON-B would have to review R124's record to verify whether or not measurements for wounds were completed. On 2/24/21 at 9:12 AM, DON-B provided Surveyor with R124's wound assessments completed on 2/23/21 after Surveyor inquiry. DON-B reviewed R124's care plan with Surveyor and verified R124's baseline should have addressed the open area under umbilicus present upon readmission on 2/10/21 and should have been revised to include new open area at surgical wound site. R124's 2/23/21 assessments documented measurements as follows: under umbilicus - 0.8 cm x 2.0 cm x 0.1 cm; left ankle - 0.4 cm x 0.5 cm scabbed area. At 12:15 PM, during a follow-up interview, DON-B stated the facility followed a standard of practice that wound measurements occur weekly.

Based on observation, staff interviews, and record review, the facility did not ensure supervision during a Resident (R) transfer was adequate to assure safety for 1 resident (R13) of 1 resident observed during transfer with a mechanical sit to stand lift. Staff (Certified Nursing Assistant (CNA)-E and Regional Nurse Consultant (RNC)-C) did not ensure R13's foot and leg placement was proper during mechanical sit to stand lift transfer. Findings include: On 2/22/21, Surveyor reviewed R13's medical record which documented R13 had a [DIAGNOSES REDACTED]. R13's transfers required extensive assistance by two staff and the use of a mechanical sit to stand lift. On 2/22/21 at 10:01 AM, Surveyor observed CNA-E and RNC-C initiate a mechanical sit to stand lift assisted transfer of R13 from recliner to wheelchair. CNA-E aligned sit to stand lift with R13's recliner and CNA-E and RNC-C assisted R13 with verbal cues and hand on leg guidance to place feet on foot plate of lift. CNA-E assisted from R13's left side and RNC-C assisted from R13's right side to apply upper body sling and attached sling to lift. Surveyor noted R13's right leg was not in the right knee pad groove but was positioned touching the center column with foot all the way forward on the foot plate. CNA-E operated the lift to go up. Surveyor directed staff to stop the transfer when Surveyor observed R13's right leg was straight with knee pressing upward on center column. At the same time, left leg was in proper position and bent at the knee where the knee was in the knee pad groove. Surveyor communicated to CNA-E and RNC-C that R13's right leg and foot were not properly positioned. CNA-E operated the lift back down and RNC-C physically assisted R13 with proper placement before reinitiating and completing safe transfer. Immediately following transfer, Surveyor interviewed RNC-C regarding familiarity with R13. RNC-C indicated RNC-C works in the building approximately once per week and other staff are generally responsible to assist R13 with transfers. On 2/22/21 at 12:24 PM, Surveyor interviewed CNA-E regarding R13's transfer. CNA-E indicated R13 often moves legs around during transfers and CNA-E and RNC-C both should have double checked before engaging the lifting function. On 2/22/21 at 10:32 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding R13's transfers. LPN-F verified assisting with R13's transfers on an occasional basis and indicated transferring R13 is a challenge. LPN-F explained R13 can move legs and placement needs to be double checked. On 2/22/21 at 12:34 PM, CNA-G confirmed assisting R13 with transfers on a regular basis and described R13 as someone who frequently moved legs during transfers so it was important for staff to monitor leg placement. On 2/22/21 at 12:39 PM, Surveyor interviewed CNA-H regarding R13's transfers. CNA-H confirmed being responsible to assist R13 with transfers on a regular basis. CNA-H indicated R13 raises a leg frequently during transfers so CNA-H makes a point to be vigilant about checking R13's legs throughout transfers. On 2/22/21 at 12:46 PM, Therapy Director (TD)-I reviewed therapy notes regarding R13 with Surveyor. TD-I indicated R13 has not been in therapy for over a year. TD-I confirmed R13's knees should be in lift knee pad grooves during a transfer and explained staff should watch leg placement throughout the transfer. TD-I indicated therapy would reassess transfers for any resident if staff made therapy aware of resident leg lifting during mechanical lift transfer.

Based on staff interview and record review, the facility did not ensure a Resident (R) prescribed a high risk medication had a comprehensive care plan developed to address monitoring for possible medication side effects for 1 (R12) of 5 residents reviewed for medications. The facility did not monitor for possible side effects of R12's prescribed opioid medication (narcotic pain medication). Findings include: Nation Library of Medicine (https://pubmed.ncbi.nlm.nih.gov) documents Common side effects of opioid administration include sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression. On 2/23/21, Surveyor reviewed R12's medical record which documented R12 was prescribed [MEDICATION NAME] (opioid/narcotic pain medication) since 10/10/2020. Surveyor noted R12 did not have a care plan to address monitoring for possible side effects of opioid use. On 2/24/21 at 11:08 AM, Registered Nurse Consultant (RNC)-C indicated RNC-C reviewed R12's medical record per Surveyor request and confirmed R12's record did not contain a care plan or other evidence of monitoring for opioid side effects.

Based on staff interview and record review, the facility did not ensure a significant change MDS (Minimum Data Set) assessment was completed for 1 Resident (R) (R20) of 14 sampled residents. R20 was enrolled in hospice on 11/13/20 and no significant change MDS was completed within 14 days after hospice enrollment. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, includes the following: If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). On 2/23/21, Surveyor reviewed R20's medical record which indicated R20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20 was transferred to the hospital on [DATE] for evaluation and treatment due to a change in condition and returned to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. R20 was enrolled in hospice on 11/13/20 related to end stage disease with six or fewer months to live. There was no corresponding significant change MDS in R20's record related to the hospice enrollment. On 02/24/21 at 12:28 PM, Surveyor interviewed Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDS)-F who verified R20 should have had a significant change MDS completed due to enrollment in hospice. LPN/MDS-F confirmed a significant change MDS was not completed for R20 within 14 days after enrollment in hospice.

Based on facility staff interview, [MEDICAL TREATMENT] center staff interview, and record review, the facility did not ensure communication with [MEDICAL TREATMENT] center was obtained post-visit and did not ensure Resident (R) care plan reflected [MEDICAL TREATMENT] related orders for 1 (R124) of 1 resident on [MEDICAL TREATMENT]. The facility did not obtain [MEDICAL TREATMENT] center communication forms for three out of four [MEDICAL TREATMENT] visits R124 had since readmission to the facility on [DATE] and did not update R124's care plan to reflect an order for [REDACTED]. Findings include: On 2/22/21, Surveyor reviewed R124's medical record which documented R124's Brief Interview for Mental Status (BIMS), dated 2/17/2021, as scoring 7 out of 15 (severe cognitive impairment). R124 left the facility for [MEDICAL TREATMENT] treatment on Tuesdays, Thursdays, and Saturdays. R124 previously resided at the facility through 12/30/2020 and was readmitted for care on 2/10/2021. Surveyor noted R124's orders documented R124 should be weighed weekly but R124's care plan documented R124 should be weighed daily. The facility provided a clarification order where staff questioned and confirmed R124's physician ordered weekly weights since R124 was on [MEDICAL TREATMENT] and a frequent practice is to obtain daily weights for residents on [MEDICAL TREATMENT]. Surveyor noted R124's record only contained one [MEDICAL TREATMENT] communication record for visit date 2/13/2021, which was scanned into R124's Electronic Health Record (EHR) on 2/19/2021. Surveyor noted the following [MEDICAL TREATMENT] dates since readmission per R124's treatment schedule: 2/11/21 (didn't go this date per [MEDICAL TREATMENT] center), 2/13/21, 2/16/21, 2/18/21, 2/20/21. Surveyor noted three out of four communications were missing from R124's record. On 2/23/21 at 3:27 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R124's weights. DON-B verified R124 was ordered weekly weights and indicated the care plan should match physician orders. On 2/23/21 at 2:04 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding R124. LPN-F verified R124 left the facility for [MEDICAL TREATMENT] care on Tuesdays, Thursdays, and Saturdays. At that time, LPN-F accessed R124's medical record and verified only one [MEDICAL TREATMENT] communication form was in R124's EHR. LPN-F indicated R124 should have a communication from [MEDICAL TREATMENT] following every visit. LPN-F was uncertain of communication form responsibilities. LPN-F indicated a belief that R124 was responsible to provide the form upon return. Surveyor verified staff had to screen R124 for COVID-19 each time R124 returned to the building. LPN-F was not able to explain why the staff completing COVID-19 screening would not request the form from R124 at the time of return to the facility. At 2:56 PM, LPN-F approached Surveyor and revealed a Certified Nursing Assistant (CNA) was directed to search R124's room and a [MEDICAL TREATMENT] communication, dated 2/18/2021, was located in R124's pocket. On 2/24/21 at 8:48 AM, Surveyor interviewed [MEDICAL TREATMENT] Registered Nurse (RN)-J regarding R124. RN-J indicated the facility should be monitoring R124's weights; daily would be ideal but weekly was acceptable since R124 was weighed before and after treatment at the [MEDICAL TREATMENT] center. RN-J indicated R124's first [MEDICAL TREATMENT] appointment since readmission to the facility was on a Saturday and communication paperwork was sent back to the facility in R124's bag following every treatment. RN-J expected facility staff to ask for and retrieve R124's [MEDICAL TREATMENT] communication following every visit because R124 has known cognitive deficits, including with memory. RN-J described [MEDICAL TREATMENT] staff's practice was to place communication in R124's bag before transport back to the facility and [MEDICAL TREATMENT] staff would fax communication to the facility if the form was not completed prior to R124's transport arriving. RN-J indicated nothing notable occurred during R124's visits for the dates where communication from [MEDICAL TREATMENT] was not in R124's EHR at the facility.

Based on record review, staff interview, and resident interview, the facility did not ensure comprehensive care plans were revised by the interdisciplinary team after each assessment for 1 Resident (R) (R11) of 14 sampled residents and the facility did not include the resident and resident's representatives in care planning conferences for 1 (R12) of 14 sampled residents. R11 was prescribed a diuretic (medication that removed fluid from the body) on 12/19/20 and this was not reflected in R11's care plan. The facility did not conduct a care planning conference for R12 since admission on 9/26/20. Findings Include: 1. R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11's most recent Minimum Data Set (MDS) assessment, completed on 12/29/21, indicates that R11 took a diuretic for 6 of the 7 days during the lookback period. On 2/23/21, the Surveyor reviewed R11's physician orders. On 12/19/20, R11 was prescribed [MEDICATION NAME] (diuretic) 20mg one time per day for [MEDICAL CONDITION] (increased fluid in the body tissues). R11's most recent comprehensive care plan, revised 2/8/21, indicated that R11 was at risk for fluid deficit related to fluid intakes below estimated needs. R11's care plan did not address that R11 was taking a diuretic medication or address R11's indication for use of the diuretic. 2. On 2/22/21 at 11:56 AM, Surveyor interviewed R12. R12 could not recall having a care conference since admission. On 2/22/21, Surveyor reviewed R12's medical record which documented R12's Power of Attorney for Health Care (POAHC) was activated prior to admission and deactivated in October 2020. Surveyor was unable to locate documentation of R12's care conferences. On 2/23/21 at 3:09 PM, Surveyor interviewed Social Worker (SW)-D regarding care conferences. SW-D verified being the staff person primarily responsible for scheduling and organizing care conferences. SW-D explained that the staff member responsible for MDS information used to open a care conference assessment in the Electronic Health Record (EHR) for residents in conjunction with completing required MDS assessments which would initiate the process to plan a care conference meeting with residents and resident representatives. However, when the person filling the MDS role changed in November or December 2020, SW-D became responsible to open the EHR care conference assessment form to initiate meeting. SW-D reviewed R12's medical record with Surveyor and confirmed R12 did not have a care conference to date and R12's representatives were not invited to a care conference on R12's behalf between admission and the date R12's POAHC was deactivated in October 2020. SW-D indicated R12 should have completed one initial and one quarterly care conference to date.

Based on record review and staff interview, the facility did not ensure all alleged violations involving abuse, neglect, exploitation including misappropriation of resident property were reported to the State Survey and Certification Agency involving 1 Resident (R) (R1) of 3 sampled residents. Facility received allegation on 10/20/20 that Certified Nursing Assistant (CNA)-C rolled R1 out of bed onto floor intentionally. Facility did not report this allegation to the State Survey and Certification Agency. Findings include: Facility provided policy titled Abuse Prevention Program dated March 2018 stated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . There are policies and procedures written in this program on detecting and preventing abuse, neglect and exploitation . The facility must report alleged violations related to mistreatment, exploitation, neglect or abuse: including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. Allegations must be reported to the Administrator / designee immediately. The administrator/designee will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported no later than 2 hours after the allegation is made, if events that cause the allegation abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the state survey agency and other officials / authorities as needed. Results of the investigation will be reported to the state survey agency within 5 working days of the initial allegation and if the alleged violation is verified appropriate corrective action must be taken . On 2/8/21, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to the organs and tissues), Sick Sinus Syndrome (a group of abnormal heart rhythms resulting from the malfunction of hearts primary pacemaker, the sinus node), Presence of Cardiac Pacemaker, Generalized Anxiety Disorder (exaggerated tension, worrying, and nervousness about daily life events), [MEDICAL CONDITION] (condition in which the flow of urine is blocked due to the enlargement of prostate gland), [MEDICAL CONDITION] Reflux Disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus), and Seborrheic [MEDICAL CONDITION] (common skin condition affecting the scalp and resulting in scaly skin). R1's Minimum Data Set (MDS) assessment dated [DATE] stated R1's Brief Interview for Mental Status (BIMS) could not be assessed as R1 was, rarely/never understood. R1 passed away at the facility on 1/3/21. Additionally, R1's medical record contained an Incident Note dated 8/30/19 which stated, (R1) had a Un-Witnessed incident on 08/30/2019 10:00 PM . The following injuries or first aid noted: Resident had immediate redness to the right side of (R1's) face, from (R1's) cheek going around (R1's) eye and towards (R1's) temple. Within about an hour resident was starting to bruise near (R1's) eye. Pain: Staff gave staff Tylenol (medication used for pain) for discomfort per PAINAD (pain assessment for non-verbal patients) and low-grade temp (temperature). Range of motion: limited ROM (range of motion) d/t (due to) contractures, no deformities noted. Resident taken to hospital: No Immediate care plan intervention: Fall mats on both sides of bed, ensure bed is in the lowest position, and resident is positioned in center of bed no matter the position (R1) is in. Notifications: Physician: Name and Designation: (physician name) Telephone: on call for PCP (primary care provider) Family/ Significant Other: . Staff could not get ahold of POA (Power of Attorney for Healthcare Agent) so staff did contact, Contact #1. Staff also updated (managed care organization contact name). On call (physician name) stated to continue with Neuro (neurological) checks and monitor temperature. Comments: Staff were alerted to resident being on the floor next to (R1's) bed. Staff immediately went to residents room and found resident to be laying flat on (R1's) front side with (R1's) right arm underneath (R1's) body and the right side of (R1's) face on the floor. Resident's linens were partially wrapped around the bottom half of (R1's) body. The wedge and (R1's) heel protectors were still on the bed. (R1) was laying on the floor next to (R1's) bed (the side towards the door). Resident bed was in a low position. Resident has Alzheimer's, is non verbal and unable to make (R1's) needs known. Resident also has contractures and has very limited ROM. Staff did not note any discomfort with limited ROM, NEURO's and VS (vital signs) obtained. Resident did have a low grade fever and was given PRN (as needed) Tylenol. Staff did not notice any breaks in the skin. Resident did have immediate redness to the right side of (R1's) face, from (R1's) cheek going around (R1's) eye and towards (R1's) temple . On 2/8/21 at 12:50 AM, Surveyor interviewed Director of Nursing (DON)-B. When questioned if DON-B was aware of any interactions of concern between R1 and CNA-C, DON-B stated, The former NHA (Nursing Home Administrator) handled that. DON-B indicated DON-B was not involved in dealing with the situation and could not provide any information to Surveyor. On 2/8/21 at 1:39 PM, Surveyor interviewed NHA-A, who provided Surveyor with a Grievance Concern document. NHA-A stated, This is all we can find. NHA-A indicated the handwriting at the bottom of the document was written by the former NHA. NHA-A indicated the handwriting in the left side margin of the document was information obtained from Human Resources. NHA-A indicated the person's name at the end of the typed narrative on the document was that of the former MDS Nurse who was also (family member) to R1. NHA-A verified that to NHA-A's knowledge, situation had not been investigated or reported to State Survey and Certification Agency by former NHA. On 2/8/21 at 1:40 PM, Surveyor reviewed the document provided by NHA-A titled Grievance Concern which stated in typed format, (R1) was found face down next to (R1's) bed when night did their first rounds on 8-30-19. It was assumed at the time the pm (evening shift) CNA (CNA-C) had rolled (R1) out of bed and didn't' report it, just left (R1) there face down on the floor. Nights had reported at the time (CNA-C) was in a BIG rush to leave, and it did seem suspicious, but it could never be proven. (R1) had severe dementia and there is no way (R1) rolled (R1's)self out of bed. (R1) doesn't move. On 10-28-20 I answered a call from (name) phone # (number) ((CNA-C)'s (family member)) stating that (family member) needed to get this off of (family member's) chest. (Family member) reported that (CNA-C) was spouting off, making fun of mocking me and laughing about rolling (R1) out of bed and just leaving (R1) there face down on the floor. (R1) wasn't found until the next shift did rounds. There is no way (family member) would have known about this incident if this didn't truly happen. (Family member) stated that (family member) had called several times that day to try to speak with the ED (Executive Director) (name), but could never get through. (Family member) felt like (family member's) calls were being ignored by (ED). I just happened to answer this call so (family member) told me. Handwritten at the bottom of the document was, *spoke with (family member): (family member) shared (family member) felt (family member) needed to keep (family member's) mouth shut d/t (due to) family. (Family member) shared (family member) is telling the information now d/t family conflict @ (at) this time /c (with) individual in question. Employee not allowed in room of the client mentioned going forward. Mandatory abuse inservice for all staff will be held 11/3. D/t age of alleged incident, it was deemed too old to be reportable @ this time. Previous investigation presents no person identified @ time of incident occurrence as a perpetrator and it was an unwitnessed event. Handwritten in left margin of document was, This occurred when the facility was (former company name). We have no knowledge/info (information). CNA (CNA-C) last worked in facility 10/11/20.

Based on observation, record review and staff interview, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection such as COVID-19 for 10 Residents (R) (R2, R3 R4, R5, R6, R7, R8, R9, R10 and R11) of 11 residents in the following areas: COVID-positive and COVID-negative residents were kept together in the same room. COVID-positive and COVID-negative residents who lived in the same room did not wear masks, did not have their privacy curtains pulled, did not practice social distancing and were not encouraged to do so by staff. In addition, the residents' doors were kept open despite the fact other COVID-negative residents resided in the same hallway. R4 was COVID-negative, but was on isolation precautions because R4's roommate (R3) was COVID-positive. During water pass, HA (Hospitality Aide)-C filled R4's mug with water and ice from a cart used to fill COVID-negative residents' mugs. Following the observation, the cart and supplies were placed in a room with an ice machine and racks of clean cups. MR (Medical Records)-D assisted R2 (COVID-positive) and R7 (COVID-negative) with lunch at the same time while wearing the same PPE (personal protective equipment). CNA (Certified Nursing Assistant)-F entered R8's room (COVID-negative) and disposed of gloves used to handle R2's (COVID-positive) meal tray. In the process, CNA-F opened R8's bathroom door after removing soiled gloves and without sanitizing hands. In addition, LPN (Licensed Practical Nurse)-H, SSD (Social Services Director)-E, MR-D and HA-C either did not wear, appropriately don and doff and/or sanitize PPE. The failure to quarantine COVID positive residents from COVID negative residents, to maintain and encourage universal source control, follow hand hygiene protocols and ensure proper donning, doffing and sanitizing PPE, created a finding of immediate jeopardy. The facility removed the jeopardy on 12/3/20; however, the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility continues to implement its action plan. This is evidenced by: Centers for Disease Control (CDC) definitions and information: - Isolation separates sick people with a contagious disease from people who are not sick. - Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. - [MEDICATION NAME] tests are immunoassays that detect the presence of a specific [MEDICAL CONDITION], which implies current [MEDICAL CONDITION] infection. These can be used at point of care and results are available in approximately 15 minutes. Facility policy titled Suspected or Confirmed Positive COVID 19 Management Policy, revision dated 11/6/2020, documents The center will implement isolation procedures (contact and droplet) for residents who are positive for or suspected positive for COVID-19. 1) The center will isolate infected residents: place in private room with private bathroom and door to room to remain closed; if private room is not available cohort with other COVID 19 positive residents; if a COVID 19 positive resident had a roommate before positive [DIAGNOSES REDACTED]. Surveyor reviewed facility COVID-19 surveillance data which documented: One known positive resident was admitted on [DATE]. Four residents tested positive between 10/26/2020 and 11/30/2020. Fifteen staff tested positive between 10/1/2020 and 11/30/2020. Surveyor reviewed the facility's line list of COVID-19 positive residents cases for the month of November 2020 which documented: R2 tested positive via [MEDICATION NAME] testing 11/23/2020 and was asymptomatic. R3 tested positive via [MEDICATION NAME] testing 11/30/2020 and was asymptomatic. R6 tested positive via [MEDICATION NAME] testing 11/30/2020 and was asymptomatic. Surveyor reviewed resident roster which documented: R2 (COVID-19 positive 11/23/2020) shared a room with R7 (COVID-19 negative). R3 (COVID-19 positive 11/30/2020) shared a room with R4 (COVID-19 negative). R6 (COVID-19 positive 11/30/2020 shared a room with R5 (COVID-19 negative). On 12/2/2020 at 10:04 AM, Surveyor interviewed Director of Nursing (DON)-B via telephone regarding facility COVID-19 prevention and control practices. DON-B indicated the facility had three residents (R2, R3, and R6) who tested positive for COVID-19 and were still in the infectious period. DON-B provided Surveyor with room numbers of residents who tested positive. DON-B initially denied having any residents on quarantine but when asked residents who exit the facility for care, DON-B identified R4 went out for [MEDICAL TREATMENT]. Surveyor gathered R4's room number and noted R4 resided in the same room as R3, who tested positive on 11/30/2020. DON-B confirmed R4 resided with R3. At that point, DON-B verified R4 should be identified as a person in quarantine status and that the other two COVID-19 positive residents also had roommates. DON-B verified the facility had single rooms available and explained the facility was not moving exposed roommates because those residents were already exposed. DON-B indicated the Local Health Department (LHD) was updated about cohabitation of isolated and quarantined residents and had no objections initially but during a follow-up conversation the following day, the LHD advised the facility to separate positive and negative residents. DON-B was uncertain of the dates the conversations with LHD took place but thought the conversations were on 11/30/2020 and 12/1/2020. DON-B verified the facility did not follow the LHD recommendation to not house isolated and quarantined residents together. On 12/02/20 at 11:10 AM and 11:50 AM, the Surveyor observed agency LPN-H at one the nurses' stations wearing a face mask and eye glasses. When asked by the Surveyor if eye protection was required in the facility, LPN-H stated eye protection was only required when staff entered residents' rooms. On 12/02/20 at 12:00 PM, the Surveyor observed a plastic cart with a cooler and a water pitcher outside R3 and R4's room. The Surveyor observed HA-C don full PPE and enter the room. HA-C then exited the room with R4's water mug. HA-C placed the mug on the cart and used an ice scoop to fill R4's mug with ice from the cooler. HA-C then placed the scoop on the cart, filled R4's mug from the water pitcher and reentered R4's room. HA-C provided the mug to R4 and began to doff PPE. HA-C removed the gown and gloves and placed them in a receptacle in the room. As HA-C placed the gown and gloves in the receptacle, the plastic bag fell through the receptacle and onto the floor. Without sanitizing hands, HA-C removed the face mask. HA-C then re-donned the mask and exited the room. Without sanitizing hands, HA-C opened a drawer of a PPE cart located outside the room. HA-C donned gloves and a clean gown, and without tying the gown, entered the room and replaced the receptacle's plastic bag. HA-C then removed the gown, gloves and face mask. Without sanitizing hands, HA-C placed HA-C's right forearm over HA-C's mouth and exited the room. Again without sanitizing hands, HA-C opened a drawer of the PPE cart to retrieve a clean face mask. HA-C donned the face mask and sanitized hands, but did not sanitize goggles. The Surveyor then observed HA-C wheel the cart containing the ice cooler, ice scoop and water pitcher into a room next to the nurses' station that contained an eye wash station, an ice machine and racks of clean cups. During the observation, the Surveyor noted R3 was not wearing a facemask and the privacy curtain between R3 and R4 was not pulled. During the observation, the Surveyor noted staff were preparing to move R4 to another room. At 12:09 PM, the Surveyor observed R3 actively coughing without a mask. The door to the room was open and R3 was visible from the hallway. On 12/02/20 at 1:02 PM, the Surveyor interviewed HA-C regarding water pass. HA-C stated HA-C was not finished passing water, but planned to wash the ice scoop and water pitcher after HA-C's break. HA-C verified the cart, cooler, water pitcher and ice scoop were used on a unit with both COVID-positive and COVID-negative residents and were used to refill a cup contained in COVID-positive resident's room. HA-C verified the cart was not taken to the kitchen for sanitization following the observation. HA-C verified staff could have retrieved water and ice from the cart without knowing the items were potentially contaminated. HA-C also verified the Surveyor's earlier hand hygiene observations. On 12/02/20 at 12:15 PM, the Surveyor observed R2 (COVID-positive) and R7 (COVID-negative) sitting side-by-side in wheelchairs in their room. The privacy curtain was not pulled between the residents and neither resident was wearing a mask. The door to the room was open and both residents were visible from the hallway. On 12/02/20 at 12:16 PM, the Surveyor observed R5 (COVID-negative) and R6's (COVID-positive) room. The privacy curtain was pulled between the residents; however, R6, who was in a wheelchair in close proximity to the door, was not wearing a mask. The door to the room was open and R6 was visible from the hallway. On 12/02/20 at 12:20 PM, the Surveyor interviewed LES (Life Enrichment Specialist)-I regarding infection control. LES-I was on the unit to assist with passing meal trays. LES-I verified R2 was COVID-positive and R7 was COVID-negative. LES-I also verified both residents were sitting side-by-side without masks. LES-I stated staff encouraged R2 and R7 to wear masks; however, R2 and R7 did not always allow the masks. The Surveyor and LES-I noted both residents' masks were located across the room and not within their reach. LES-I also verified R3 was COVID-positive. LES-I verified R3 was sitting in a recliner near the window with an unpulled privacy curtain, an open door and no mask. LES-I did not encourage R2, R7 or R3 to don masks. On 12/02/20 at 12:23 PM, the Surveyor interviewed SSD-E regarding infection control. SSD-E was also on the unit to assist with passing meal trays. SSD-E verified R3 was not wearing a mask and stated, (R3) had a few in there. SSD-E also did not encourage R3 to don a mask. On 12/02/20 at 12:30 PM, the Surveyor observed SSD-E deliver R3's meal tray. After donning the appropriate PPE, SSD-E entered the room and delivered the tray. Prior to exiting the room, SSD-E removed the gloves, gown and face mask. SSD-E exited the room and, without sanitizing hands, opened the drawer of a PPE cart in the hallway and retrieved a clean face mask. SSD-E donned the mask and, without sanitizing hands or goggles, entered R11's room. R11's room was next to R3's room; however, R11 was COVID-negative. SSD-E exited R11's room and, without sanitizing hands, donned gloves and a gown and delivered R6's meal tray. SSD-E then removed the gloves, gown and face mask and, without sanitizing hands, exited the room. SSD-E again opened the drawer of a PPE cart, retrieved a clean face mask and, without sanitizing hands, donned the mask. SSD-E then sanitized hands, but did not sanitize goggles. On 12/02/20 at 1:20 PM, the Surveyor interviewed SSD-E regarding the Surveyor's earlier observations. SSD-E verified the Surveyor's PPE and hand hygiene concerns. Regarding eye protection, SSD-E stated SSD-E was not aware goggles needed to be sanitized. On 12/02/20 at 12:32 PM, the Surveyor observed MR-D don a disposable gown outside of R2 and R7's room. The Surveyor noted MR-D did not place MR-D's head through the hole on top of the gown. Therefore, MR-D's upper chest and shoulders were exposed. MR-D also wore a face mask, a face shield and gloves. MR-D delivered R2 and R7's meal trays and remained in the room to assist and cue both residents. The Surveyor observed R2 actively coughing while in close proximity to R7. MR-D stood in front of both residents who were seated side-by-side with tray tables in front of them. MR-D handed R7 containers of food and also encouraged R2 to eat. The Surveyor observed from the hallway as the door to the room was open. The Surveyor also noted R6, who was across the hall, was eating lunch next to an open door and was visible from the hallway. On 12/02/20 at 12:40 PM, the Surveyor heard R3 actively coughing. The Surveyor noted R3's door was open and R3 was not wearing a mask. The Surveyor also observed MR-D hand R2's tray to CNA-F who was standing in the hall outside R2's door. CNA-F placed R2's tray on the bottom of a meal cart and removed gloves. After noting there were no PPE receptacles in the hallway, CNA-F entered R8's room (COVID-negative). With the soiled gloves in hand, CNA-F opened R8's bathroom door, disposed of the gloves in R8's bathroom and washed hands. The Surveyor interviewed CNA-F immediately following the observation, CNA-F verified CNA-F opened R8's bathroom door with uncleansed hands and disposed of soiled PPE in R8's room. The Surveyor also observed MR-D wipe R7's mouth with the same soiled gloves used to hand R2's tray to CNA-F. With the same soiled gloves, MR-D turned off R2 and R7's call light, removed the gown and gloves and, without sanitizing hands or donning clean gloves, picked up R7's meal tray and exited the room. MR-D then sanitized hands, but did not sanitize the face shield. As MR-D exited the unit, HA-C approached MR-D and asked for assistance with R9 (COVID-negative). As MR-D entered R9's room, the Surveyor noted MR-D's face mask was below the nose. With the same soiled face shield and potentially contaminated clothing, MR-D assisted R9, who was not wearing a mask and was not encouraged to do so, to the bathroom. MR-D and HA-C then assisted R9 into bed. MR-D transferred R9 with a gait belt and assisted with positioning R9 in bed. MR-D then approached, stood over and conversed with R10 (COVID-negative) who was lying in a bed near the window. On 12/02/20 at 1:06 PM, the Surveyor interviewed MR-D regarding the Surveyor's earlier observations. At the time of the interview, the Surveyor noted MR-D's mask was still positioned below the nose. MR-D verified the placement of the mask and verified the Surveyor's PPE and hand hygiene concerns. MR-D verified MR-D assisted both R2 and R7 with lunch while wearing the same PPE and turned off the call light with soiled gloves. On 12/02/20 at 9:10 AM, the Surveyor interviewed DON (Director of Nursing)-B regarding the facility's infection control practices. DON-B stated staff were expected to wear face masks and goggles or face shields at all times. DON-B stated staff were expected to don full PPE, which included a face mask, eye protection, a gown and gloves, when they entered the rooms of residents who were COVID-positive or on quarantine precautions. On 12/02/20 at 3:10 PM, the Surveyor interviewed DON-B regarding the infection control observations. DON-B verified the facility was informed of R3's positive COVID test on 11/23/20 as well as R2 and R6's positive COVID tests on 11/30/20. DON-B also verified R3, R2 and R6's roommates (R4, R7 and R5 respectively) tested negative in the facility's latest round of testing. DON-B stated the facility planned to keep the positive and negative roommates together per their policy and on the advice of the public health department; however, DON-B indicated the health department called the facility on 12/01/20 and suggested the residents be separated. DON-B stated the facility planned to separate the residents, but hadn't done so prior to the Surveyor's observations. DON-B verified the rooms containing COVID-positive residents were in the middle of a hallway that also contained COVID-negative residents. DON-B also verified the doors to the rooms were kept open. DON-B indicated DON-B worried about closing R2's door due to R2's risk of falling and disrobing. DON-B also stated DON-B conducted audits of staff donning and doffing PPE. When asked if the audits were conducted in real time, DON-B indicated the audits weren't necessarily conducted inside or outside of residents' rooms and/or during cares. DON-B stated DON-B expected R3, R2, R6 and their respective roommates to wear masks, have their privacy curtains pulled and practice social distancing. Regarding notification, DON-B verified R4's medical record did not contain documentation to indicate R4 was notified when R4's roommate (R3) tested positive for COVID-19. DON-B verified R7's medical record did not contain documentation to indicate R7's POA (power of attorney) was notified when R7's roommate (R2) tested positive for COVID-19. In addition, DON-B verified R5's medical record did not contain documentation to indicate R5's guardian was notified when R5's roommate (R6) tested positive for COVID-19. The failure to quarantine COVID positive residents from COVID negative residents, to maintain and encourage universal source control, follow hand hygiene protocols and ensure proper donning, doffing and sanitizing PPE, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 12/3/20 when it implemented the following: 1. Separation of residents who were COVID-positive from roommates who were COVID-negative. 2. Education of staff regarding infection control procedures to mitigate the risk of transmission. 3. Audits of infection prevention measures to include hand hygiene, appropriative use of PPE, and universal source control.

Based on observation, record review, staff and resident interviews, the facility did not ensure that 1 (resident #1) of 6 sampled residents received adequate supervision and assistive devices to prevent accidents. Resident #1 was transferred without the use of a gait belt, which resulted in the resident sustaining a fragmented right hip fracture from a fall. The resident now requires hydrocodone for pain control and the use of an E-Z lift for transfers. Findings Include: The facility's Transfer/gait Belt policy dated 12/19/12 indicated the purpose of the gait belt is to promote comfort and safety. A gait belt will be utilized for resident mobility when the resident requires one or more assist during a transfer or ambulation. The procedure portion of the policy instructs staff to securely apply the gait belt to the resident's waist and assist the resident to transfer and ambulate. The gait belt is to be removed after each use. The current electronic face sheet indicated resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE] documented resident #1 required extensive assistance with transfers. Resident #1's plan of care dated 3/13/15 indicated the resident required minimum/moderate assistance of one staff person, the use of a four wheeled walker, and a gait belt. On 4/1/15 at 9:10 a.m., surveyor # interviewed PTA (Physical Therapy Assistant)-C regarding resident #1's transfer status prior to the fall on 3/21/15. PTA-C stated resident #1 required the assistance of one staff member with a four-wheeled walker and gait belt for all transfers. The facility's completed a self report investigation, dated 3/21/15, documenting that resident #1 was being transferred by CNA (Certified Nursing Assistant)-A from the bathroom to the wheel chair. CNA-A documented that resident #1 was turning to sit into the wheel chair, stepped on the wheel of the chair, and fell forward before the CNA could grab the resident's arm and prevent the fall. On 4/1/15 at 9:47 a.m., surveyor # interviewed RN (Registered Nurse)-B regarding resident #1's the fall. RN-B stated she was walking down the hall when CNA-A exited resident #1's room and informed the nurse that resident #1 had fallen. RN-B entered the room and observed resident #1 lying on the floor between the bathroom door and the resident's wheel chair. RN-B stated she did not observe resident #1 wearing a gait belt at that time, nor was a gait belt observed in the room or around the CNA's waist. RN-B stated she questioned CNA-A why resident #1 did not have a gait belt on and the CNA stated she removed the gait belt, while the resident was standing, just before the resident sat in the wheel chair because the CNA had a grasp on the resident's arm. The resident then lost their footing and the CNA lost grip of the resident's arm and resident #1 fell to the floor. Following the fall, resident #1 complained of pain in the right hip and was sent to the ED (Emergency Department) for evaluation. The ED Provider Note, dated 3/21/15, documented an x-ray was obtained due to right hip pain and the x-ray results indicated an inoperable, mildly displaced fracture fragment of the right greater tuberosity that was determined to be a direct result of the fall. Resident received an order for [REDACTED]. Resident #1's current plan of care dated 3/28/15 indicated resident #1 now requires a stand-up lift and the assistance of two staff for all transfers. Resident #1's March 2015 MAR (Medication Administration Record) included documentation that the resident #1 received Vicodin daily for right hip pain, since the fall on 3/21/15 with the exception of 3/26/15, when the resident was out of the facility. Resident #1 rated the right hip pain level to be between 2-10 on a 1-10 pain scale. On 4/1/15 at 9:10 a.m., surveyor # interviewed PTA-C regarding resident #1. PTA-C stated resident #1 has been having a difficult time progressing in therapy since the 3/21/15 fall, as the result of the pain from the right hip fracture. PTA-C stated resident #1's goal is to return to a prior living arrangement at an Assisted Living Facility, however if the resident does not progress in therapy, the resident may not be able to return to the Assisted Living Facility. On 4/1/15 at 10:36 a.m., surveyor # interviewed DON (Director of Nursing)-D regarding resident #1. DON-D confirmed CNA-A should not have removed the gait belt while resident #1 was standing and before the resident was seated safely in the wheel chair. DON-D confirmed no training had been completed after resident #1's fall, with staff regarding safe transfers. On 4/1/15 at 11:10 a.m., surveyor # interviewed DON-D regarding resident #1. DON-D confirmed resident #1 did not complain of right hip pain prior to the 3/21/15 fall. On 4/1/15 at 11:41 a.m., surveyor # interviewed resident #1 regarding the fall. The resident stated "I went over and now I got a chip (fragmented fracture) in there (right hip)...It (right hip) hurts sometimes and I don't remember it hurting before the fall." Failure of CNA-A to utilize the gait belt properly on 3/21/15 resulted in resident #1 falling. The fall resulted in resident #1 presenting with pain levels ranging between 2-10 on the pain scale of 1-10, as the result of a fragmented fracture to the right hip. In addition, resident #1's mobility deteriorated from a one assist transfer with the use of a walker to two assist with the use of a stand up lift. Resident #1's difficulty progressing in therapy as a result of the fall and fracture may impact the resident's goal to return to an Assisted Living Facility. The facility did not educate staff as a result of resident #1's fall regarding safe transfers and the appropriate use of gait belts.

Based on observation, family and staff interviews and record review, the facility did not respect a resident's choice about aspects of his or her life in the facility that are significant to the resident for 1 (resident #1) of 13 sampled residents reviewed. Resident #1 had been provided with a clock in her room by therapy to assist with bladder training. The clock was to be used by staff to remind the resident when she last went to the bathroom. Staff had been directed to re-set the clock ahead 2 hours after they had finished toileting the resident. Resident #1 put her call light on and requested to use the bathroom. Staff did not toilet resident #1 because it had not been the full 2 hours as indicated on the clock. Resident #1 was found incontinent of urine. Findings Include: Resident #1's face sheet contained within the medical record and dated 8/12/12 indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 7/16/12 indicated resident #1 was cognitively intact and needed assistance from staff for transfers and personal hygiene. The MDS also indicated resident #1 was occasionally incontinent of bladder and continent of bowel. A note from OT (Occupational Therapy) dated 7/19/12 indicated "Toileting, patient has been provided with a face of a clock to be used for bladder training. Please schedule two hours out from the time toileted and refer to the clock when requesting more frequent toileting and try to have patient stick with a two hour schedule." Resident #1's current plan of care dated 7/19/12 indicated "Toilet: patient has a face of a clock, schedule every two hours from time toileted, encourage to stick to two hour time if can." On 9/19/12 at 8:20 a.m. during initial tour with RN (Registered Nurse)-A, RN-A informed surveyor # that resident #1 would not be the best resident to interview regarding her daily life at the facility due to "memory problems", but that family visits the resident often. Surveyor # interviewed FM (Family Member)-C in person on 9/19/12 at 3:10 p.m. regarding resident #1. FM-C indicated she comes to visit resident #1 weekly. FM-C stated, "My only concern is the toy clock in her room. When staff take her (resident#1) to the bathroom they will re-set the clock ahead two hours and that is the next time she is able to go to the bathroom. The clock is upsetting to her and it makes her nervous. She (resident #1) told me about 2 weeks ago she had waited an hour and forty-five minutes to use the bathroom. When she put on her call light staff told her she needed to wait fifteen more minutes, according to the clock. She told me she couldn't wait so she wet herself and staff had to change her. Her (resident #1) oldest son and wife who are the APOAHC (activated Power of Attorney for Health Care) visit often and recently talked to SW(Social Worker)-D regarding disapproval of the clock in her room." On 9/19/12 at 3:50 p.m. surveyor # knocked on the door and walked into resident #1's room. Surveyor # observed a foam clock with a bright red face with black numbers and yellow hands, sitting on her bed side table. Resident #1 was not in the room at the time of the observation. Resident #1 was admitted to the hospital from 9/20/12 to 9/24/12 for aspiration pneumonia, tonic-clonic [MEDICAL CONDITION] and a decreased level of awareness. Surveyor # was unable to interview resident #1. On 9/20/12 at 3:25 p.m. during a daily exit with facility staff surveyors # and # questioned DON (Director of Nursing)-E about the clock in resident #1's room. DON-E stated, "The resident has a lot of anxiety about going to the bathroom, therapy came up with the clock as a reminder to help with her bladder control...after a while I noticed the clock wasn't working or beneficial for her. She is an anxious lady as it is and now the staff are telling her she has to wait two hours before they can take her...I feel she has gotten more anxious since the clock especially at night. I know the family has talked about the clock in one of the care conferences and questioned if she still needed the clock...the intervention has not been re-addressed with therapy and I haven't re-addressed it...I probably should have." Surveyor # then asked DON-E if resident #1 ever had any incontinent episodes since the initiation of the clock. DON-E stated "she has dribbled." On 9/24/12 at 8:35 a.m. surveyor # interviewed CNA(Certified Nursing Assistant)-F regarding the clock in resident #1's room. CNA-F informed surveyor that therapy initiated the clock, "to help with her memory because she wouldn't remember when she last went to the bathroom." CNA-F went on to tell surveyor # that resident #1 appeared to be frustrated with the clock. On 9/24/12 at 8:45 a.m. surveyor # interviewed CNA-H regarding the clock in the resident #1's room. CNA-H stated the clock is from therapy and used for a two hour toileting schedule..."we try to remind her that its better to wait...if she looks anxious or uncomfortable some girls will take her." CNA-H went on to say if resident #1 were to have an incontinent episode it would make her upset..."I don't think the clock is beneficial for her during the day." On 9/24/12 at 9:40 a.m. surveyor # interviewed CNA-G regarding the clock in resident #1's room. CNA-G informed the surveyor the clock came from therapy. CNA-G went on to say, "when we show her the clock as a reminder to when she last used the bathroom she (resident #1) would say, 'I hate that darn clock.'" On 9/24/12 at 1:20 p.m. surveyor # spoke with CNA-F regarding the clock and toileting for resident #1. CNA-F informed the surveyor "some girls where getting reprimanded for making her wait the 2 hours on the night shift. RN-K told us not to stick to the two hours because she observed a staff member doing this on the night shift and wrote her up." On 9/24/12 at 4:40 p.m., surveyor # interviewed APOAHC-B via telephone. APOAHC-B stated that he has expressed disapproval of the clock to SW-D a couple of weeks ago..."I told the SW my mother gets anxious about not being able to go to the bathroom and staff are not always taking her to the bathroom when she rings." APOAHC-B went on to say, "I'm aware of one time my mother wet the bed because staff wouldn't take her because it wasn't time according to the toy clock in her room...Her room-mate told us staff don't take her to the bathroom when she rings if it isn't time. APOAHC-B also stated "I just don't understand why they think they can re-train a bladder on a [AGE] year old women...when she returns from the hospital the clock better be gone." On 9/25/12 at 9:20 surveyor # interviewed resident #2 (the room-mate of resident #1) regarding resident #1's clock in the room. Resident #2 is alert and oriented and cognitively intact according to her most recent MDS on 8/10/12. Resident #2 informed surveyor # that resident #1 "would put her call light on to use the bathroom, staff would come in and turn it off, and tell her the two hours are not up yet...by that time it was too late, she was already dirty and wet...it happened a lot especially in the past month...the family said something to the facility, but it didn't seem to do any good." On 9/25/12 at 9:25 a.m. surveyor # spoke with SW-D regarding the clock in resident #1's room. SW-D informed the surveyor that the clock was an intervention from therapy. SW-D verified that APOAHC-B came into the facility "a week or so ago" and expressed concerns with the clock and felt staff had been denying his mother the use of the toilet due to the clock. SW-D stated she took the concern to DON-E right after the conversation with APOAHC-B. On 9/25/12 at 10:50 a.m. surveyors # and # interviewed DON-E regarding staff members not taking resident #1 to the bathroom when requested. DON-E informed surveyors # and # that she found out about the incident with resident #1 during a morning report, but was uncertain of the date. DON-E went on to say resident #1 "..requested to go to the bathroom and a CNA refused to toilet her because it had not been two hours and resident #1 was incontinent. The CNA was re-educated because she should of toileted her...it was neglectful and it should of been reported...I see that now." On 9/25/12 at 3:20 p.m. surveyor # interviewed RN-K regarding resident #1. RN-K indicated she was working an evening shift approximately 2 weeks ago when she observed resident #1's call light go on. RN-K indicated she observed CNA-L enter resident #1's room, shut off the light and walk back out. RN-K then stated, "I went into the resident room and the resident stated to me, "I told her I had to go to the bathroom. At that point I summoned CNA-L back into the resident's room. I asked the resident if it was CNA-L she told that she needed to use the bathroom...the resident nodded her head "yes." RN-K went on to tell surveyor # that resident #1 was incontinent of urine and needed to be cleaned. The facility did not report this allegation of possible mistreatment and/or neglect to the State Agency nor did the facility conduct a thorough internal investigation regarding the above concern. Surveyor # asked DON-E for the investigation into the above concern on 9/25/12 at 10:50 a.m. At 3:30 p.m., after multiple requests from the surveyor, DON-E provided the surveyor with a written statement about the incident from CNA-L. Additionally, a one page summary of what occurred, written by DON-E was also presented. DON-E had only interviewed CNA-L. The one page summary also noted re-education was provided to CNA-L, and that DON-E "instructed the night nurses to make sure that all the CNA's on the night shift toilet resident #1 when she requests."

Based on staff interview and record review, the facility did not ensure 1 (resident #1) of 8 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #1 was admitted to the facility on [DATE] with a fractured neck sustained from a previous fall. Resident #1 was admitted wearing a cervical collar and was receiving Warfarin (anticoagulant). The facility assessed resident #1, on admission, to be at high risk for falls. The facility did not complete a comprehensive assessment related to the resident's capability of using the call light and circumstances surrounding previous falls. The facility determined an alarm sensor pad was to be implemented in an attempt to alert staff if resident #1 attempted to self-transfer. The plan of care for fall prevention did not include the sensor alarm or other interventions for fall prevention. The sensor pad was not placed per the fall risk assessment. On 3/10/11 resident #1 self-transferred and sustained a fall. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. The failure of the facility to thoroughly assess resident #1 to identify and implement appropriate interventions, related to the fact that the resident presented to the facility with a fractured neck, created a situation of Immediate Jeopardy that began on 3/9/11. The facility was formally notified on 3/22/11 that an Immediate Jeopardy situation existed on 3/9/11. The Immediate Jeopardy was determined to have been removed, but not corrected, on 3/24/11. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) until all portions of the facility's action plan are fully implemented and tested . Findings include: The face sheet, dated 3/16/11, indicated resident #1 was admitted to the facility on [DATE] with a fractured neck sustained from a previous fall. Resident #1 was admitted wearing a cervical collar and was receiving Warfarin (anticoagulant). The hospital discharge summary, dated 3/9/11, indicated resident #1 was discharged from the hospital with [DIAGNOSES REDACTED]. The facility completed an "At Risk Assessment for Falls", dated 3/9/11. The facility determined resident #1 was at high risk for falls related to a history of falls, gait/balance problems, received medications that increased fall risk and a wheel chair was the primary mode of locomotion. The only intervention identified for resident #1, who presented with a fractured neck, was to add a sensor alarm. The facility did not assess resident #1's circumstances for previous falls prior to admit, if resident #1 was capable and understanding of using the call light system to call for assistance or if additional interventions such as a low bed, mattress on the floor or frequent monitoring were necessary in attempts to assure the resident's safety. The CNA (Certified Nursing Assistant) Communication Sheet, without date when implemented, was reviewed. The "Mobility" section indicated resident #1 required two assist with bed mobility, one assist with wheeled walker, gaitbelt in room and a wheel chair for distance. The plan of care indicated resident #1 was alert and oriented to person and place. The plan of care did not contain any intervention regarding a sensor pad alarm, nor did the plan of care indicate other comprehensive interventions to prevent future falls The nurses' notes dated 3/10/11 at 4:00 a.m. indicated resident #1 had fallen attempting to self-transfer from bed. The nurses' notes indicated resident #1 was discovered lying on his back, on the floor, by CNA-B. The nurses' notes indicated resident #1 sustained a cut to the back of his head approximately 1-1/2 inches long and was bleeding. Resident #1 was transferred to the emergency room . The emergency department report, dated 3/10/11, indicated resident #1 was assessed at the hospital related to the fall. The report diagnosed resident #1 with a "Y" shaped laceration measuring approximately 2.2 cm (centimeters) on the back of his head, which required "...staples in and pressure to try and hold the bleeding at this point." The report indicated resident #1 had a CT (Computerized Tomography) scan, which showed a small right frontal intraparenchymal bleed. The facility completed an investigation of resident #1's fall on 3/10/11. The facility concluded resident #1 was assessed to be high risk for falls, and a sensor pad was to be placed. At the time of the fall, the sensor alarm pad, the one intervention the facility had identified for resident #1, had not been placed for the resident. On 3/17/11 at 1:30 p.m. surveyor # interviewed DON (Director of Nursing)-E regarding the facility investigation of resident #1's fall on 3/10/11. DON-E verified resident #1 was to have had a sensor pad placed on his bed to alert staff to the resident's attempt to rise, but the intervention was never implemented. DON-E verified the initial plan of care for falls would have been related to the "Mobility" problem. DON-E stated the intervention for the sensor alarm would have been added in the "Mobility" problem, but DON-E verified the alarm was not identified on the plan of care. On 3/17/11 at 2:45 p.m. surveyor # interviewed LPN (Licensed Practical Nurse)-F regarding resident #'1's fall risk assessment. LPN-F verified she had completed the fall risk assessment and confirmed she was to implement a sensor pad alarm system. LPN-F stated she must have forgotten to add the sensor pad intervention to the resident's plan of care. On 3/17/11 at 2:50 p.m. surveyor # interviewed CNA-B regarding resident #1's fall on 3/10/11. CNA-B verified she discovered resident #1 lying on the floor on his back in his room. CNA-B stated the resident was calling out, "Help me." CNA-B stated she observed resident #1's head lying in a pool of blood extending to his shoulders, and urine was on the floor. CNA-B verified an alarm was not sounding when she entered resident #1's room. The failure of the facility to identify and implement appropriate interventions for resident #1 when he presented to the facility with a fractured neck on 3/9/11 created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on 3/24/11 when the facility initiated training to all nursing staff related to screening at time of admission for history of falls, risk for falls and potential for accidents or incidents and the subsequent development and implementation of comprehensive appropriate interventions to attempt to assure resident safety.

Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 (resident #1) of 8 sampled residents. Resident #1 was admitted to the facility on [DATE] with a fractured neck sustained from a previous fall. Resident #1 was admitted wearing a cervical collar and was receiving [MEDICATION NAME] (anticoagulant). On 3/10/11 resident #1 sustained a fall, which resulted in dislodgement of the resident's cervical collar. After resident #1 fell , staff moved the resident several times, without the benefit of the cervical collar. The movement of resident #1, without stabilization to his already-fractured neck, placed resident #1 at risk for significant injury or death and created a situation of Immediate Jeopardy, which began on 3/10/11. The facility was formally notified on 3/22/11 that an Immediate Jeopardy situation existed on 3/10/11. The Immediate Jeopardy was determined to have been removed, but not corrected, on 3/24/11. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) until all portions of the facility's action plan are fully implemented and tested . Findings include: On 3/17/11 surveyor # reviewed resident #1's medical record. According to the hospital discharge summary dated 3/9/11, resident #1 was discharged from the hospital with [DIAGNOSES REDACTED]. The hospital discharge summary indicated resident #1 was to wear the cervical collar most of the time and remove it only briefly to wash or shower. Resident #1 was receiving [MEDICATION NAME] (anticoagulant). Resident #1's face sheet, dated 3/16/11, indicated resident #1 was admitted to the facility on [DATE]. The nurses' notes dated 3/10/11 at 4:00 a.m. indicated resident #1 fell while attempting to self-transfer from the bed. The nurses' notes indicated resident #1 was discovered lying on his back on the floor by CNA (Certified Nursing Assistant)-B. The nurses' notes indicated resident #1 sustained a cut to the back of his head approximately 1-1/2 inches long and was bleeding. Resident #1 was transferred to the emergency room . The facility completed an investigation related to resident #1's fall. CNA-C completed a witness statement on 3/10/11. The statement indicated CNA-B was telling LPN (Licensed Practical Nurse)-A to call an ambulance because resident #1 had fallen and "...busted his head open." LPN-A responded that she couldn't just call an ambulance because she had to have something to go off of. CNA-B stated the resident was bleeding from the head and inquired if that was enough to summon the ambulance. LPN-A directed the CNAs to attempt to get the resident up and in bed, so she could assess him first. CNA-C's witness statement indicated the CNAs attempted to put the sling under resident #1, but the resident's head was not steady. CNA-C's statement indicated the CNAs could not keep resident #1 straight enough to not bend his neck, so they unhooked the sling. CNA-C was unavailable for interview. CNA-D completed a witness statement on 3/10/11 regarding the fall resident #1 sustained. The statement indicated CNA-D heard CNA-B yelling hurry up, indicating resident #1 was bleeding from his head. CNA-D ran down to the room and saw resident #1 laying on the floor. The resident was on his back, and a puddle of blood was behind his head. When LPN-A got to the room, CNA-B told LPN-A to call 911; but LPN-A indicated, "I don't even know what is wrong." LPN-A instructed CNA-B to get the Hoyer lift, so staff could get the resident up. CNA-B left the room to get the lift. At that time LPN-A's number one worry was to untangle the gastrostomy tube. The LPN had resident #1 roll onto his side, so she could disconnect the tube. The LPN tried looking at the back of the resident's head but couldn't see anything from where she was. All the LPN said was there were clots and she would better examine the resident once staff got him back in bed. CNA-B returned with the Hoyer lift. LPN-A sat in the chair and told CNA staff to get resident #1 back in bed. CNA-C and CNA-D got the sling under the resident and hooked him up to the lift. CNA-D's statement indicated staff started to lift resident #1 off the floor; but to her, things just didn't look right. CNA-D indicated she instructed CNA-B, who was operating the lift, to lower the resident back to the floor. CNA-D indicated she didn't feel comfortable moving the resident around so much with no support to his neck. CNA-D's statement indicated resident #1's brace was there but no longer secure -- it was half off at that point. CNA-B completed a witness statement on 3/10/11 regarding the fall resident #1 sustained. The statement indicated CNA-B was walking down the hall, when she heard a crash and the words, "Help me." When CNA-B walked into resident #1's room, she observed the resident lying on the floor. CNA-B stated she did not move the resident. CNA-B immediately called the nurse and told her resident #1 had fallen. CNA-B indicated blood was coming out the back of the resident's head. CNA-B indicated staff attempted to lift resident #1 with the Hoyer lift, per the direction of LPN-A. The investigation summary, dated 3/11/11, indicated LPN-A refused to write a witness statement. The investigation indicated the facility received a written statement from LPN-A on 3/14/11 regarding resident #1 and the fall the resident sustained [REDACTED].#1 had fallen, and she responded immediately. When LPN-A entered resident #1's room, she observed resident #1 on the floor with blood and urine. The LPN asked for a of couple towels and placed them under the resident's head. LPN-A indicated she then sat on the chair for a few minutes just to assess the situation before doing something that might injure the resident more. The LPN indicated she noted the resident was moving his arms and there was no displaced [MEDICAL CONDITION]. Resident #1 was wrapped up in his tube feeding. The LPN's statement indicated she attempted to assess the resident's injuries, but could not get his head up enough to do so. LPN-A felt she needed to get the resident off the floor. She felt the resident's hips and rolled him a few inches in an attempt to disconnect his tube feeding. LPN-A's statement indicated the resident's neck collar was coming off, and she attempted to readjust it. The CNAs came with the Hoyer, and staff attempted to lift the resident. LPN-A's statement indicated she could see the transfer was not a good idea because of the way the resident's neck would bend, and his collar would not stay in place. LPN-A stated she instructed the CNAs to lower the resident to the floor, and she went to call the physician. On 3/17/11 at 1:47 p.m. and on 3/21/11 at 8:15 a.m. surveyor # interviewed LPN-A regarding care provided after resident #1's fall on 3/10/11. LPN-A verified she was the nurse in charge when resident #1 had fallen and also indicated she was the only nurse in the facility. LPN-A stated she was told resident #1 had fallen on the floor, and she immediately went to assess the resident. LPN-A indicated when she entered resident #1's room, she observed the resident lying on his back on the floor with the gastrostomy tube wrapped around his body and blood and urine on the floor. LPN-A indicated she sat down on the chair and observed resident #1 for perhaps a minute before doing anything, as she wanted to think what she should do. LPN-A stated she observed resident #1's cervical collar coming off. Additionally, the gastrostomy tube was wrapped around the resident and was pulling hard on the insertion site. LPN-A indicated she placed towels under resident #1's head and also rolled the resident to his side to free the gastrostomy tube. LPN-A indicated the cervical collar would not stay in place. LPN-A verified she told the CNAs to connect resident #1 to the mechanical lift to transfer into bed. LPN-A indicated the CNAs rolled resident #1 side-to-side to place the lift sling underneath him. LPN-A verified resident #1's neck was not stabilized, and his neck was not in proper alignment while the resident was moved. LPN-A verified she was aware resident #1 was admitted with a cervical fracture. LPN-A stated she thought it was fine to move resident #1, even after the fall, as he was able to be up and moving prior to the fall. On 3/17/11 at 2:50 p.m. surveyor # interviewed CNA-B regarding care provided after resident #1's fall on 3/10/11. CNA-B stated she discovered resident #1 lying on his back in a pool of blood that surrounded his head, extending to his shoulders. CNA-B stated she immediately called LPN-A. When LPN-A responded, she told CNA-B to get a Hoyer lift. When CNA-B returned to resident #1's room with the lift, LPN-A was sitting in the chair just looking at resident #1 lying on the floor. CNA-B stated she told LPN-A not to move resident #1, as the resident had a broken neck. CNA-B indicated resident #1's cervical collar was coming off. Staff attempted to replace the collar many times, but it kept coming off. CNA-B stated staff placed up to six hand towels under resident #1's head to absorb the blood. CNA-B indicated LPN-A directed staff to transfer resident #1 with the use of the mechanical lift from the floor into the bed. CNA-B stated resident #1 was rolled from side-to-side to place the lift sling. CNA-B indicated resident #1's cervical collar was not secure, and resident #1's neck was not stabilized prior to rolling the resident On 3/21/11 at 9:05 a.m. surveyor # interviewed CNA-D regarding care that was provided for resident #1 after the fall on 3/10/11. CNA-D stated when LPN-A responded to resident #1's fall, CNA-B told LPN-A to call an ambulance; but LPN-A stated she needed to look at the resident first. CNA-D stated LPN-A directed CNA-B to get the Hoyer lift so resident #1 could be transferred from the floor into bed. CNA-B left to get the lift, and CNA-D needed to assist another resident. CNA-D indicated she was gone for two minutes; and when she returned, resident #1 was moved from his back onto his right side. CNA-D stated resident #1's cervical collar was half off, and his neck was not stabilized or in proper alignment. CNA-D stated LPN-A's concern was to unwrap the gastrostomy tube from around the resident's body. CNA-D indicated she was surprised LPN-A would move resident #1 around, as the resident had a fractured neck. CNA-D stated she observed LPN-A roll resident #1 from his side to his back, and the cervical collar came completely off when the resident was rolled. CNA-D stated LPN-A placed towels under resident #1's neck to absorb the blood, and there was no support given to the resident's neck. CNA-D indicated CNA-B then returned with the lift, and LPN-A instructed staff to transfer resident #1 into bed. CNA-D stated she and CNA-C rolled resident #1 from side-to-side to place the sling under resident #1, and CNA-B operated the lift. CNA-D stated staff attempted to place the cervical collar around the resident's neck, but the collar was not secured. CNA-D stated staff attempted to lift resident #1 slightly with the lift; but the staff were concerned that there was no support for the resident's neck, so the resident was returned to the floor. LPN-A then left the room to call the physician. On 3/21/11 at 10:30 a.m. surveyor # interviewed DON (Director of Nursing)-E regarding care provided to resident #1 after the fall on 3/10/11. DON-E verified resident #1 should not have been moved after the fall, as the resident was admitted with a neck fracture; and his cervical collar was not stabilized to provide neck support. DON-E verified moving resident #1 without support to his neck could have caused significant concerns, such as paralysis or death. The failure of the facility to protect the safety of resident #1 on 3/10/11, when the resident was moved after a fall without stabilization of his neck, created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on 3/24/11 when the facility initiated training to all nursing staff related to falls and the appropriate response to each resident and their individual condition, i.e., complaining of extreme back pain; inability to move arms, fingers, legs and/or toes; [MEDICAL CONDITION] with significant bleeding, or clear fluid draining from ears or nose, etc.

Based on staff interview and record review, the facility did not provide services that met professional standards of quality for 1 (resident #1) of 8 sampled residents. Resident #1 was admitted to the facility on [DATE] with a fractured neck sustained from a previous fall. Resident #1 was admitted wearing a cervical collar and was receiving [MEDICATION NAME] (anticoagulant). On 3/10/11 resident #1 sustained a fall at the facility, which resulted in dislodgement of resident #1's cervical collar. After resident #1 had fallen, the LPN (Licensed Practical Nurse) moved resident #1 and directed CNA (Certified Nursing Assistant) staff to move the resident without stabilization of his neck. The movement of resident #1, without stabilization to his neck, placed the resident at risk for significant injury or death. The failure of facility staff to follow professional standards of practice, when resident #1 was moved after his fall on 3/10/11 without stabilization of his neck, created a situation of Immediate Jeopardy, which began on 3/10/11. The facility was formally notified on 3/22/11 that an Immediate Jeopardy situation existed on 3/10/11. The Immediate Jeopardy was determined to have been removed, but not corrected, on 3/24/11. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) until all portions of the facility's action plan are fully implemented and tested . Findings include: Chapter N6, "Standards of Practice of Licensed Practical Nurses" dated June 2002 indicates: Performance of acts in basic patient situations, the LPN shall under the general supervision of an RN (Registered Nurse) or the direction of a physician...a) accept only patient care assignments which the LPN is competent to perform, b) provide basic nursing care, c) record nursing care given and report to the appropriate person changes in the condition of a patient, d) consult with an RN or physician in cases where an LPN knows or should know a delegated nursing or medical act may harm a patient. According to MayoClinic.com, no date when written, "A fracture is a broken bone. It requires medical attention. If the broken bone is the result of major trauma or injury, call 911. Also call for emergency help if: a) there is heavy bleeding, b) you suspect a bone is broken in the neck, back or head. Don't move the person except if necessary to avoid further injury. Take these actions immediately while waiting for medical help: a) immobilize the injured area. According to "First Aid" from the Departments of Army, Navy and the Air Force, dated December 2002, a fractured neck is extremely dangerous. Bone fragments may bruise or cut the spinal cord just as they might in a fractured back. A) If the casualty is not to be transported until medical personnel arrive, caution him not to move. Moving may cause permanent injury or death. B) Leave the casaulty in the position in which he is found. If his neck and head (cervical spine) are in an abnormal position, immediately immobilize the head and neck. C) Keep his head still, if the casualty is lying face up, raise his shoulders slightly, and slip a roll of cloth that has the bulk of a bath towel under his neck. The roll should be thick enough to arch his neck only slightly, leaving the back of his head on the ground. DO NOT bend his neck or head forward. DO NOT raise or twist his head... On 3/17/11 surveyor # reviewed resident #1's medical record. According to the hospital discharge summary dated 3/9/11, resident #1 was discharged from the hospital with [DIAGNOSES REDACTED]. The hospital discharge summary indicated resident #1 was to wear the cervical collar most of the time and remove it only briefly to wash or shower. Resident #1 was receiving [MEDICATION NAME] (anticoagulant). Resident #1's face sheet, dated 3/16/11, indicated resident #1 was admitted to the facility on [DATE]. The nurses' notes dated 3/10/11 at 4:00 a.m. indicated resident #1 had fallen attempting to self-transfer from bed. The nurses' notes indicated resident #1 was discovered lying on his back on the floor by CNA-B. The nurses' notes indicated resident #1 sustained a cut to the back of his head approximately 1-1/2 inches long and was bleeding. Resident #1 was transferred to the emergency room . The facility completed an investigation related to resident #1's fall. CNA-C completed a witness statement on 3/10/11. The statement indicated CNA-B was telling LPN-A to call an ambulance because resident #1 had fallen and "...busted his head open." LPN-A responded that she couldn't just call an ambulance because she had to have something to go off of. CNA-B stated the resident was bleeding from the head and inquired if that was enough to summon the ambulance. LPN-A directed the CNAs to attempt to get the resident up and in bed, so she could assess him first. CNA-C's witness statement indicated the CNAs attempted to put the sling under resident #1, but the resident's head was not steady. CNA-C's statement indicated the CNAs could not keep resident #1 straight enough to not bend his neck, so they unhooked the sling. CNA-B completed a witness statement on 3/10/11 regarding the fall resident #1 sustained. The statement indicated CNA-B was walking down the hall, when she heard a crash and the words, "Help me." When CNA-B walked into resident #1's room, she observed the resident lying on the floor. CNA-B stated she did not move the resident. CNA-B immediately called the nurse and told her resident #1 had fallen. CNA-B indicated blood was coming out the back of the resident's head. CNA-B indicated staff attempted to lift resident #1 with the Hoyer lift, per the direction of LPN-A. On 3/17/11 at 2:50 p.m. surveyor # interviewed CNA-B regarding care provided after resident #1's fall on 3/10/11. CNA-B stated she discovered resident #1 lying on his back in a pool of blood that surrounded his head, extending to his shoulders. CNA-B stated she immediately called LPN-A. When LPN-A responded, she told CNA-B to get a Hoyer lift. When CNA-B returned to resident #1's room with the lift, LPN-A was sitting in the chair just looking at resident #1 lying on the floor. CNA-B stated she told LPN-A not to move resident #1, as the resident had a broken neck. CNA-B indicated resident #1's cervical collar was coming off. Staff attempted to replace the collar many times, but it kept coming off. CNA-B stated staff placed up to six hand towels under resident #1's head to absorb the blood. CNA-B indicated LPN-A directed staff to transfer resident #1 with the use of the mechanical lift from the floor into the bed. CNA-B stated resident #1 was rolled from side-to-side to place the lift sling. CNA-B indicated resident #1's collar was not secure, and resident #1's neck was not stabilized prior to rolling the resident CNA-D completed a witness statement on 3/10/11 regarding the fall resident #1 sustained. The statement indicated CNA-D heard CNA-B yelling hurry up, indicating resident #1 was bleeding from his head. CNA-D ran down to the room and saw resident #1 laying on the floor. The resident was on his back, and a puddle of blood was behind his head. When LPN-A got to the room, CNA-B told LPN-A to call 911; but LPN-A indicated, "I don't even know what is wrong." LPN-A instructed CNA-B to get the Hoyer lift, so staff could get the resident up. CNA-B left the room to get the lift. At that time LPN-A's number one worry was to untangle the gastrostomy tube. The LPN had resident #1 roll onto his side, so she could disconnect the tube. The LPN tried looking at the back of the resident's head but couldn't see anything from where she was. All the LPN said was there were clots and she would better examine the resident once staff got him back in bed. CNA-B returned with the Hoyer lift. LPN-A sat in the chair and told CNA staff to get resident #1 back in bed. CNA-C and CNA-D got the sling under the resident and hooked him up to the lift. CNA-D's statement indicated staff started to lift resident #1 off the floor; but to her, things just didn't look right. CNA-D indicated she instructed CNA-B, who was operating the lift, to lower the resident back to the floor. CNA-D indicated she didn't feel comfortable moving the resident around so much with no support to his neck. CNA-D's statement indicated resident #1's brace was there but no longer secure -- it was half off at that point. The investigation summary, dated 3/11/11, indicated LPN-A refused to write a witness statement. The investigation indicated the facility received a written statement from LPN-A on 3/14/11 regarding resident #1 and the fall the resident sustained [REDACTED].#1 had fallen, and she responded immediately. When LPN-A entered resident #1's room, she observed resident #1 on the floor with blood and urine. The LPN asked for a of couple towels and placed them under the resident's head. LPN-A indicated she then sat on the chair for a few minutes just to assess the situation before doing something that might injure the resident more. The LPN indicated she noted the resident was moving his arms and there was no displaced [MEDICAL CONDITION]. Resident #1 was wrapped up in his tube feeding. The LPN's statement indicated she attempted to assess the resident's injuries, but could not get his head up enough to do so. LPN-A felt she needed to get the resident off the floor. She felt the resident's hips and rolled him a few inches in an attempt to disconnect his tube feeding. LPN-A's statement indicated the resident's neck collar was coming off, and she attempted to readjust it. The CNAs came with the Hoyer, and staff attempted to lift the resident. LPN-A's statement indicated she could see the transfer was not a good idea because of the way the resident's neck would bend, and his collar would not stay in place. LPN-A stated she instructed the CNAs to lower the resident to the floor, and she went to call the physician. On 3/17/11 at 1:47 p.m. and on 3/21/11 at 8:15 a.m. surveyor # interviewed LPN-A regarding care provided after resident #1's fall on 3/10/11. LPN-A verified she was the nurse in charge when resident #1 had fallen and also indicated she was the only nurse in the facility. LPN-A stated she was told resident #1 had fallen on the floor, and she immediately went to assess the resident. LPN-A indicated when she entered resident #1's room, she observed the resident lying on his back on the floor with the gastrostomy tube wrapped around his body and blood and urine on the floor. LPN-A indicated she sat down on the chair and observed resident #1 for perhaps a minute before doing anything, as she wanted to think what she should do. LPN-A stated she observed resident #1's cervical collar coming off. Additionally, the gastrostomy tube was wrapped around the resident and was pulling hard on the insertion site. LPN-A indicated she placed towels under resident #1's head and also rolled the resident to his side to free the gastrostomy tube. LPN-A indicated the cervical collar would not stay in place. LPN-A verified she told the CNAs to connect resident #1 to the mechanical lift to transfer into bed. LPN-A indicated the CNAs rolled resident #1 side-to-side to place the lift sling underneath him. LPN-A verified resident #1's neck was not stabilized, and his neck was not in proper alignment while the resident was moved. LPN-A verified she was aware resident #1 was admitted with a cervical fracture. LPN-A stated she thought it was fine to move resident #1, even after the fall, as he was able to be up and moving prior to the fall. On 3/21/11 at 10:30 a.m. surveyor # interviewed DON (Director of Nursing)-E regarding care provided to resident #1 after the fall on 3/10/11. DON-E verified resident #1 should not have been moved after the fall; as resident #1 was admitted to the facility with a neck fracture, and his cervical collar was not stabilized to provide neck support. DON-E verified moving resident #1 without support to his neck had the potential to cause significant concerns such as paralysis or death. DON-E stated LPN-A was the only nurse on the night shift when she worked. DON-E indicated LPN-A worked six nights in two weeks. DON-E indicated it was the facility's expectation that LPN-A would call the DON if a resident fell ; however, LPN-A did not call DON-E regarding resident #1's fall on 3/10/11. The failure of facility staff to follow professional standards of practice, when resident #1 was moved after his fall on 3/10/11 without stabilization of his neck, created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on 3/24/11 when the facility initiated training to nursing staff related to standards of practice related to moving a resident who has a suspected head, neck or back injury; who has pain with passive range of motion of an extremity or has visible shortening of an extremity; or who has visible external or internal rotation of an extremity following a fall. Additionally training was initiated for all licensed nursing staff related to standards of practice on the scope of licensure and delegation of tasks.