Every finding on record at Kindred Hospital - Louisville

Based on interview, record review, and facility policy review, the facility failed to ensure each resident's medical record included documentation that the resident or their representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization. This failure affected three (Resident (R) 20, R28, and R35) of five sampled residents reviewed for immunizations.The findings include: Review of facility policy titled, Immunization, dated 10/2022, revealed, 2. The information/education provided regarding the benefits and risks of immunization is documented in the patient's medical record. 1. Review of facility Face Sheet revealed the facility admitted R20 on 07/26/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of acute respiratory failure and pneumonia. Review of the facility annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/31/2025, revealed the facility assessed R30 with a Staff Assessment for Mental Status (SAMS) which indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS further indicated the influenza and pneumococcal vaccines were offered and declined. R20's Immunizations Report revealed on 07/26/2205, the influenza and pneumococcal vaccines were refused. Review of R20's record revealed no evidence that information/education regarding the benefits and risks of immunization was provided to the resident and/or their representative. During an interview on 12/29/2025 at 2:56 PM, the Infection Preventionist (IP) stated R20 refused the pneumococcal vaccine on 07/26/2025 and confirmed there were no notes to indicate if the resident or their family were given education regarding the risks and benefits of vaccination.2. Review of facility Face Sheet revealed the facility admitted R28 on 05/24/2023. According to the Face Sheet, the resident had a medical history that included diagnoses of acute and chronic respiratory failure and dependence on a respirator. Review of the quarterly MDS, with an ARD of 10/03/2025, revealed the facility assessed R28 with a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident had intact cognition. The MDS indicated the influenza and pneumococcal vaccines were offered and declined. Review of R28's Immunizations Report revealed on 11/01/2025, the influenza and pneumococcal vaccines were refused. Review of R28's record revealed no evidence that information/education regarding the benefits and risks of immunization was provided to the resident and/or their representative. During an interview on 12/29/2025 at 2:56 PM, the IP stated R28 refused the influenza and pneumococcal vaccine on 11/01/2025. The IP stated she provided verbal education including the benefits and side effects of the vaccines but did not document the education provided.3. Review of a facility Face Sheet revealed the facility admitted R35 on 08/01/2024. According to the Face Sheet, the resident had a medical history that included diagnoses of acute and chronic respiratory failure and dependence on a respirator. Review of the annual MDS, with an ARD of 08/08/2025, revealed the facility assessed R35 with a SAMS indicating the resident was severely impaired in cognitive skills for daily decision making. R35's Immunizations Report revealed the resident received the pneumococcal vaccine on 08/27/2024 and the influenza vaccine on 09/23/2025. Further review of R35's record revealed no evidence that information/education regarding the benefits and risks of immunization was provided to the resident and/or their representative.During an interview on 12/29/2025 at 2:56 PM, the IP stated R35 received the influenza vaccine on 09/23/2025. The IP stated she explained the vaccine to the resident's family but did not document the education that was provided.Interview with the Director of Nursing (DON) on 12/31/2025 at 10:05 AM regarding these three residents revealed the IP was responsible for monitoring the residents' vaccinations. The DON stated she expected vaccine education, as well as administration and declination, to be documented.

Based on interview, record review, and document review, the facility failed to ensure pharmaceutical services, including the accurate receipt and documentation of controlled drugs, was provided for one (Resident (R) 5) of three sampled residents reviewed for abuse. Licensed Practical Nurse (LPN) 3 failed to verify the receipt and recording of fentanyl, a Schedule II controlled drug, when it was delivered to the facility by the pharmacy. The findings include: Review of R5's Face Sheet revealed the facility admitted the resident on 01/19/2022. According to the Face Sheet, the resident had a medical history that included a diagnosis of chronic pain. Per R5's Medication Administration Record (MAR) for 10/2025, the resident had an order, dated 05/10/2025, for fentanyl 25 microgram (mcg) per hour, apply one patch every three days for chronic pain. Review of the pharmacy delivery receipt indicated two fentanyl (a schedule I controlled substance used to treat severe pain) 25 mcg patches ordered for R5 were received in the facility on 10/05/2025 by Licensed Practical Nurse (LPN)3. Review of a facility initial report, dated 10/07/2025, revealed that on 10/07/2025, LPN3 was unable to locate the two fentanyl patches ordered for R5 which were delivered to the facility on [DATE]. The facility final report, dated 10/09/2025, revealed [NAME] a thorough investigation, which included involving local law enforcement and our pharmacy partners, the facility does not substantiate controlled substance diversion or misappropriation. The facility concludes that the nurse who signed the delivery manifest for the 2 controlled substances did not realize that the contents of the disposable pharmacy bag included 2 fentanyl patches for [R5] when she threw it in the trash. During an interview on 12/29/2025 at 8:54 AM, LPN3 stated that when narcotics were delivered from the pharmacy, she would sign a paper from the delivery driver after she verified the medications that were delivered. LPN3 stated she would then take the medications to the responsible nurse, and two nurses would sign the medication in on the narcotic addition and deletion log. Per LPN3, a separate narcotic count sheet was signed by one nurse and placed in the narcotic count book on the medication cart. LPN3 stated fentanyl patches were not delivered in a box and instead, were delivered in a little plastic bag. LPN3 stated the incident involving R5's fentanyl occurred when she was working, and the pharmacy delivery driver handed her a bag of medications. LPN3 stated she did not verify the medications that were received and only felt one blister pack of pills inside the bag. LPN3 stated she threw the pharmacy bag away at the nurse's station and took the blister pack of pills to LPN8. LPN3 stated she did not realize the fentanyl was missing until two days later, on 10/07/2025, when the medication was not available to administer. LPN3 stated the pharmacy was contacted and they informed her that she signed for the fentanyl patches on 10/05/2025. LPN3 said she was surprised and immediately thought she must have thrown them away. LPN3 stated that in response, she immediately notified the Director of Nursing (DON). During an interview on 12/31/2025 at 9:36 AM, LPN8 stated she worked in the facility on 10/05/2025 and did not see R5's fentanyl patches. LPN8 stated she saw LPN3 throw away the pharmacy bag once LPN3 handed her medication that belonged to a resident she was assigned to care for. During an interview on 12/29/2025 at 2:27 PM, Registered Nurse (RN) 6 stated that when medications were delivered by the pharmacy, the nurse should review the delivery sheet, compare it to the medications that were delivered, and then sign the delivery sheet. During an interview on 12/30/2025 at 11:17 AM, the Assistant Director of Nursing (ADON) stated she thought LPN3 accidentally threw away the fentanyl patches ordered for R5. The ADON stated fentanyl patches were delivered in a sealed bag from the pharmacy inside a small plastic bag and sometimes the patches would stick to the inside of the pharmacy bag. During an interview on 12/30/2025 at 11:57 AM, the DON stated LPN3 discovered R5's fentanyl patches were missing on 10/07/2025 when she attempted to administer the 7:00 AM to 10:00 AM scheduled dose. The DON stated the Medical Director was notified, and an order was obtained to administer the fentanyl patch when it was delivered by the pharmacy. According to the DON, once LPN3 notified her, she verified the medication was never logged in on the narcotic addition and deletion log. Per the DON, LPN3 told her she threw the pharmacy bag away at the nurse's station and took another medication that was delivered to LPN8. The DON stated she expected that narcotics were verified when delivered from the pharmacy and were immediately signed in by two nurses. During an interview on 12/31/2025 at 10:10 AM, the Executive Director (ED) stated that he expected that narcotics would not be thrown away and that there was a secure handoff process. The ED stated that the nurses receiving the medications and pharmacy delivering the medication should monitor the medications delivered.

Based on observation, interview, and facility document and policy review, the facility failed to ensure it followed proper food handling practices had the potential to affect all residents who received food from the kitchen. Male dietary staff were observed to not have beard restraints in place while they were in the kitchen. Additionally, review of documentation revealed dietary staff failed to note food temperatures as directed by the policy. The findings include: 1. Review of the facility policy titled, Personal Hygiene, dated 12/05/2022, revealed, 4. Hair Restraints/False Eyelashes: a. Hair restraints are required for any person entering the foodservice areas (kitchen, behind the line cafe, food/supply storage areas) .c. [NAME] & mustache guards must be worn in all foodservice areas as defined above. Guards must fully cover facial hair. Observation on 01/29/2025 at 11:44 AM, revealed [NAME] 18 and the Dishwasher (DW) were in the kitchen without wearing beard restraints. During interview on 01/29/2025 at 12:08 PM, the DW stated he did not know he was supposed to wear a beard net or not. During interview on 01/29/2025 at 12:13 PM, [NAME] 18 stated he knew he was supposed to wear a beard net; however, had forgotten to get one. During interview on 01/29/2025 at 12:17 PM, the Food Service Team Lead Supervisor stated she expected the male dietary staff to wear beard nets. During interview on 01/29/2025 at 12:21 PM, the Dietary Services Manager stated he expected the male dietary staff to wear beard nets. During interview on 01/30/2025 at 4:21 PM, the Executive Director (ED) stated he expected the male kitchen staff to wear beard nets as required. 2. Review of the facility policy titled, Food Temperature Measurement, dated 06/2023, revealed, Food temperature also impacts palatability and measurements must be taken prior to service. The policy specified, 7. All temperatures measurements are documented on the standard food temperature log. Review of the facility Taste/Temperature Record, for the timeframe 01/22/2025 to 01/29/2025, revealed no documented evidence of food temperatures for the lunch meal on 01/28/2025 or for the breakfast meal on 01/29/2025. During interview on 01/29/2025 at 11:48 AM, [NAME] 19 stated steamtable logs were to be completed at each meal. He said he was not sure why the steamtable logs had some meals with no temperatures charted. [NAME] 19 reported he must have forgotten to write them down on those days. During interview on 01/29/2025 at 12:13 PM, [NAME] 18 stated he forgot to write down the steamtable temperatures for breakfast on 01/29/2025. He said he had gotten busy and had not written them down. During interview on 01/29/2025 at 12:17 PM, the Food Service Team Lead Supervisor stated she expected the logbooks to be completed and expected staff to follow the facility's policies. During interview on 01/29/2025 at 12:21 PM, the Dietary Services Manager (DSM) stated he expected the steam table logs to be kept up to date. Per the DSM, the steam table logs being incomplete was unacceptable. He said he failed to review the steamtable log books for completeness. During interview on 01/30/2025 at 4:21 PM, the ED stated that he expected the dietary/kitchen staff to keep the food temperature logs up to date and complete.

Based on observation, interview and facility policy review, the facility failed to provide a clean environment in 11 of 38 residents' rooms. Observation revealed the facility had not maintained cleanliness in residents' Rooms 304, 307, 326, 328, 332, 333, 335, 338, 382, 383, and 384. The findings include: Review of the facility policy titled, Patient's Environment, dated 10/2022, revealed, 4. Housekeeping and maintenance services are provided to maintain a sanitary, orderly, and comfortable interior. However, observation of residents' rooms revealed the following: 1. On 01/28/2025, the following was observed: - At 2:28 PM, an uncleaned intravenous (IV) pole and ventilator machine in room [ROOM NUMBER]; - At 2:35 PM, an uncleaned IV pole and dried tube feeding on the floor and on the geriatric (geri) chair in room [ROOM NUMBER]; - At 2:40 PM, dried tube feeding formula on an IV pole in room [ROOM NUMBER]; - At 2:43 PM, an uncleaned IV pole and ventilator machine in room [ROOM NUMBER]; - At 2:46 PM, an uncleaned IV pole and ventilator machine in room [ROOM NUMBER]; - And at 2:50 PM, dried tube feeding formula on an IV pole in room [ROOM NUMBER]. On 01/29/2025, the following continued to be observed: - At 8:05 AM, an uncleaned IV pole and ventilator machine in room [ROOM NUMBER]; - At 8:10 AM, an uncleaned IV pole and dried tube feeing on the floor and geri chair in room [ROOM NUMBER]; - At 8:18 AM, dried tube feeding formula on an IV pole in room [ROOM NUMBER]; - At 8:20 AM, an uncleaned IV pole and ventilator machine in room [ROOM NUMBER]; - At 8:25 AM, an uncleaned IV pole and ventilator machine in room [ROOM NUMBER]; - And at 8:30 AM, dried tube feeding formula on an IV pole in room [ROOM NUMBER]. During interview on 01/30/2025 at 9:40 AM, Patient Room Cleaner (PRC) 12 stated she did not clean IV poles or ventilator machines (as part of her assigned tasks). The PRC stated she had never been told to clean the IV poles or ventilator machines. PRC 12 further stated the IV pole in room [ROOM NUMBER] was rusty and had tube feeding formula on it. During interview on 01/30/2025 at 9:44 AM, Respiratory Therapist (RT) 1 stated room [ROOM NUMBER] had a dirty IV pole. During interview on 01/30/2025 at 9:50 AM, RT 1 stated the IV pole in room [ROOM NUMBER] had tube feeding milk splattered on it and the legs of the ventilator machine and the geri chair were dirty. RT 1 further stated respiratory therapy was responsible for the cleaning of the ventilator machines. During interview on 01/30/2025 at 10:01 AM and at 10:05, Registered Nurse (RN) 2 stated the IV pole in room [ROOM NUMBER] was rusty/dirty. RN 2 further stated the geri chair in room [ROOM NUMBER] was dirty and the IV pole had tube feeding formula on it. During interview on 01/30/2025 at 10:30 AM, the Assistant Director of Environmental Services (ADEVS) stated he thought nursing was responsible for cleaning the IV poles and was not sure who was responsible for cleaning the ventilator machines. Per the ADEVS, he expected housekeeping staff to clean the geri chairs. During interview on 01/30/2025 at 3:40 PM, the Director of Nursing (DON) stated she expected housekeeping to keep the facility's environment clean. The DON further stated she expected nursing and other departments to keep the equipment clean, such as IV poles and ventilator machines. During interview on 01/30/2025 at 4:21 PM, the Executive Director (ED) stated he expected all the departments to work together to keep the facility clean. He further stated he did not have a policy on which departments were responsible to clean which equipment; however, expected the department that used the equipment to keep their own equipment clean. 22445 2. On 01/28/2025, the following was observed: - At 2:30 PM, dried tube feeding formula on the nightstand and feeding pump pole and a build-up of dust on the bedframe in room [ROOM NUMBER]; - At 2:40 PM, a dirty tube feeding pump in room [ROOM NUMBER]; - At 2:45 PM, a dirty IV pole in room [ROOM NUMBER]; - At 2:50 PM, the window shade, IV pole, and nightstand in room [ROOM NUMBER] had dried tube feeding formula on it and trash lying on the floor behind the nightstand and in the bathroom; - And at 2:55 PM, there was dried tube feeding formula on the feeding tube pole and nightstand in room [ROOM NUMBER]. During interview on 01/30/2025 at 9:00 AM, PRC 26 stated environmental services staff wiped poles, bed rails, and tables in residents' rooms on a daily basis. The PRC further stated however, environmental services was not responsible for cleaning the areas of dried tube feeding formula, as that was the responsibility of the staff who made the mess. During observation on 01/30/2025 at 9:08 AM, with RN 9 of residents' Rooms 332, 333 and 335, the RN confirmed the tube feeding poles had dried tube feeding formula on them and on the surrounding furniture. In interview at the time of observation, RN 9 stated either the nurses or the certified nursing assistants (CNAs) were responsible for cleaning the tube feeding poles daily and removing any spilled tube feeding. The RN said the person who spilled the tube feeding formula was the one responsible for cleaning the formula up because when the tube feeding formula dried it became extremely hard to remove. RN 9 reported if the person that spilled the tube feeding formula failed to clean it up, then whoever found it should clean the formula spill. During observation on 01/30/2025 at 9:53 AM, with CNA 12 of resident room [ROOM NUMBER], the CNA observed the tube feeding pole in the room, and stated the pole was dirty and needed to be cleaned as did the top of the nightstand. The CNA stated the nurses were responsible for cleaning the tube feeding poles and the respiratory therapists were responsible for cleaning the bases of the ventilator machines. CNA 12 further stated both items had dried tube feeding formula on them. During interview on 01/30/2025 at 10:27 AM, the ADEVS stated he expected the housekeepers to clean the resident furniture if needed, and the furniture needed to be moved daily to get any trash underneath. He reported nursing staff was responsible for cleaning the tube feeding and IV poles. The ADEVS further stated the housekeeping department did not clean the ventilator machines. During observation on 01/30/2025 at 10:51 AM, the ADEVS pulled the nightstand from the wall in room [ROOM NUMBER] and saw the trash lying on the floor. The ADEVS stated, at that time, there was no excuse for the trash to be behind the nightstand, and that he expected the housekeepers to clean behind furniture. During interview on 01/30/2025 at 4:43 PM, the ED stated he expected the housekeepers to keep a clean environment and to follow their room cleaning procedures. He reported he expected the tube feeding poles and ventilator machine bases to be as free as possible of tube feeding formula and added high surface dusting was expected to be completed daily. The ED further stated furniture in residents' rooms should be moved to remove the trash from behind the furniture.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident to meet a resident's medical, nursing, mental and psychosocial needs for one (1) of forty (40) sampled residents (Resident #44). Resident #44's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for injury related to mobility; however, the CCP was not developed with interventions for a Hoyer lift (mechanical lift) for transfers. On [DATE], Resident #44 was being assisted to bed from a wheelchair with the use of a Hoyer lift by Certified Nursing Assistant (CNA) #1 (orientee) and CNA #3. The resident slid from the lift sling and landed on the floor. Upon assessment, the resident was alert and oriented, able to answer questions, and was noted to have a raised area to the back of the head with no additional injuries noted. The resident was transferred back to bed using the lift. The physician was notified, and new orders were received for a Computed Tomography (CT) of the head, but later the resident experienced a change in level of consciousness (LOC). The Medical Emergency Response Team (MET) was called, and the resident was transferred to the hospital emergency room (ER) for evaluation and treatment. Resident #44 expired at the hospital on [DATE] at 10:22 PM. Refer to F689 The facility's failure to ensure the Comprehensive Care Plan (CCP) was developed and implemented for each resident to meet a resident's medical, nursing, mental and psychosocial needs has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated Immediate Jeopardy was removed on [DATE], prior to exit on [DATE]. Non-compliance remained in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656) at a Scope and Severity (S/S) of a D; and 42 CFR 483.25 Quality of Care (F689) at a S/S of a D, while the facility monitors the effectiveness of systemic changes and quality assurance activities. The Findings include: Review of the facility policy titled, Care Plans, revised ,d+[DATE], revealed a comprehensive care plan was developed consistent with the patient's (resident's)specific conditions, risks, needs, behaviors, preferences, and standards of practice. Care Plans should include measurable objectives, interventions/services, and timetables to meet the patient's (resident's) response to the interventions or changes in the patient's (resident's) condition. Further, Care Plans should reflect the patient's (resident's) needs and preferences and align with the patient's (resident's) cultural identity and if history of trauma, describe the corresponding interventions for care in accordance with professional standards of practice. The facility would provide or arrange these services by individuals who have the skills, experience, and knowledge to do a particular task or activity in accordance with the patient's (resident's) plan of care. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and timeframe's and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental,and psychosocial wellbeing. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Resident #44's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, and Muscle Weakness. Resident #44's Annual Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed Resident #44 as totally dependent on staff for chair/bed to chair transfer. Further review revealed the facility assessed the resident as having no falls. Review of Resident #44's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed Resident #44 as totally dependent on staff for chair/bed to chair transfer. Further review revealed the facility assessed the resident as having no falls. Resident #44's Comprehensive Care Plan (CCP), dated [DATE], revealed a focus of Activities of Daily Living (ADL) Self Care Performance Deficit related to Immobility, Activity Intolerance, Weakness, Ventilator Dependent, and Tracheostomy; and required assistance with transfers. The CCP goal stated ADL/Self care needs would be met on a daily basis through next review. However, there were no individualized interventions related to transfer technique nor how many staff was required to transfer the resident. Review of Resident #44's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for injury related to mobility impairment; use of psychotropic medication, and narcotic pain medication; and ADL/Self care Performance deficit related to immobility. The goal stated the resident would be free from falls and fall related injuries through next review. Interventions included: Anticipate and meet needs; provide assistance with mobility and transfers as needed; assist with mobility as needed, and if anxious or restless assess basic needs, or room temperature. However, there were no individualized interventions related to transfer technique. There was no intervention listed for a Hoyer lift. Further, there was no guidance as to how many staff members were required to transfer this resident. Review of the Resident Summary (Nurse Aide Care Plan), dated [DATE], revealed Resident #44 was care planned for Assist x two (2) with a Mechanical/Electrical Lift for transfers. However, this Resident Summary did not specify the type or size of sling to be used, nor did it specify a Hoyer lift was to be used. Review of the Nurse's Progress Note, dated [DATE] at 4:15 PM, entered by Licensed Practical Nurse (LPN) #4, revealed Resident #44 was being assisted to bed from the chair with the use of a mechanical lift. The resident slid from the lift sling landing on the floor, and the Nurse was notified immediately by the CNA. Upon assessment, the resident was alert and oriented and able to answer questions, and was noted to have a raised area to the back of his/her head with no additional injuries noted. Further, the resident was transferred back to bed using the lift. The physician was notified and new orders were received for a CT (Computerized Tomography Scan) of the head, but the resident experienced a change in LOC (level of consciousness). The MET Team (Medical Emergency Response Team) was called and the resident was transferred to the ER (emergency room ) for evaluation and treatment. Resident #44's hospital Discharge Summary, dated [DATE] at 10:22 PM, revealed the resident presented after a fall at the nursing home while attempting to move off his/her chair. The resident was found unresponsive and transferred to the hospital for further evaluation and treatment. The Computed Tomography Scan revealed a massive left convexity with a midline shift and signs of uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another). Further review of the Summary, revealed Resident #44's poor prognosis was explained to his/her family and they expressed their decision to start comfort measures only. Resident #44 was terminally disconnected from the ventilator and then passed away shortly. Time and date of death was [DATE] at 10:22 PM. Resident #44's Incident/Accident Report, dated [DATE], entered by the Executive Director (ED), revealed the facility determined due to the resident's contracted stature and limited range of motion (ROM), the divided leg sling posed an increased risk of shifting out of proper position during mechanical transfer. Two (2) CNAs were present and reported when the resident began slipping they were not able to get to him/her in time. In an interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 8:30 AM, he stated, on [DATE], he was in orientation at the facility and was with his preceptor, CNA #3, when the transfer occurred with Resident #44. He further stated during observation of the use of the Hoyer lift on Resident #44, he noted the sling had what appeared to be an opening made into the lower part of the sling. CNA #1 stated Resident #44 slid out of the sling as it was being used to transfer him/her from the wheelchair to the bed and the resident's head hit the floor. He further stated CNA #3 yelled for staff to help and LPN #4 arrived and assessed the resident. In further interview, he stated immediately after the fall the resident did not appear to have any injuries, but a few minutes later the resident started to have changes and he/she was transferred to the hospital. He stated the resident's care plan was where the information related to transfer technique should be located, but he did not recall checking Resident #44's care plan prior to the transfer. During interview with CNA #3, on [DATE] at 12:27 PM, she stated she had worked at the facility since [DATE]. She further stated she had been assigned to Resident #44 and provided care for the resident in the past and was aware the resident was to be transferred per Hoyer Lift with the assist of two (2) staff without checking the care plan. Further, she stated, on [DATE], she assisted Resident #44 onto the Hoyer lift sling while CNA #1 who was an orientee in training, assisted with putting the loops of the sling onto the sling hooks of the Hoyer lift. She further stated she then locked the wheels of the Hoyer Lift, and began to lift the resident off the wheelchair. CNA #3 stated she then stopped for a brief moment to check the resident for stability, and everything appeared to look good; so she unlocked the wheels and proceeded with moving the resident towards the bed. During continued interview with CNA #3, on [DATE] at 12:27 PM, she stated Resident #44 began to slide out of the sling from the opening that was built into the bottom of the sling. CNA #4 stated Resident #44 fell hitting his/her head on something, as he/she fell to the floor. She further stated she thought the resident had hit his/her head on the bed side dresser as he/she fell . Further, she stated at this point the resident was partially in the sling and partially on the floor with one (1) of his/her legs sticking out of the lift pad. In continued interview she called for help and the shower aide (CNA #4) arrived first and helped her lower Resident #44's leg from the lift. Per interview, CNA #4 then informed LPN #4 of the fall and the nurse immediately assessed the resident. During interview with LPN #4, on [DATE] at 9:28 AM, she stated Resident #44 sustained the fall while being transferred to the bed with a Hoyer lift by CNA #1 (orientee) and CNA #3. LPN #4 stated to her knowledge, CNA #1 had been checked off as being certified to use the mechanical lift prior to assisting CNA #3 with the transfer. Further, she stated upon being notified of the resident's fall, she immediately went to his/her room and noted he/she was lying on the floor. She stated she assessed Resident #44 and noted him/her to be alert and oriented, and to have a knot on the back of his/her head. LPN #4 further stated she initiated neurological checks every fifteen (15) minutes, notified the Medical Doctor and obtained an order for a CT Scan of the head. However, LPN #4 further stated the CT Scan was not obtained because the resident became unstable and had a change in level of consciousness about an hour after the event. She stated the Medical Emergency Response Team (MET) was called, and the resident was subsequently transferred to the hospital. In an interview with RN #4, on [DATE] at 11:49 AM, she stated the MDS Nurse was responsible for developing and revising care plans. Further, it was important for staff to implement the care plan for the safety of the residents. In an interview with the Staff Development Coordinator on [DATE] at 11:00 AM, he stated the floor nurses did not develop care plans, as that was the responsibility of the MDS Nurse. Further, he stated the floor nurses did not revise the care plans, but could initiate interventions after conferring with either the On-Call Manager or the Director of Nursing. He stated it ultimately was the MDS Nurse and Manager's responsibility to update the care plans. Continued interview revealed it was important for residents who were at risk for falls to have individualized fall interventions for staff to implement. During interview with the MDS Nurse, on [DATE] at 4:47 PM, he stated the Comprehensive Care Plan was generated from the MDS Assessments. He further stated he completed MDS Assessments on residents upon admission, quarterly, annually and with a significant change. The MDS Nurse stated it was his responsibility to develop the Comprehensive Care Plan (CCP) and revise them with each MDS Assessment, and he also revised the CCP with any changes in the resident's condition or with any changes necessary. The MDS nurse stated he was responsible for updating the Resident Summary which served as the CNA care plan. In continued interview, he stated human error was the reason he failed to develop/update Resident #44's CCP with interventions to include the type of lift to be used for transfers, as well as, how many staff was required for the transfer. He stated it was important to have all fall interventions on the CCP in order to prevent falls. In an interview with the Interim Director of Nursing (DON), on [DATE] at 11:30 AM, she stated it was the MDS Nurse's responsibility to develop the care plans from the MDS Assessments. Further, she stated the MDS Nurse was also to revise the care plans with necessary information. In continued interview, she stated it was her expectation for the comprehensive care plans to be person-centered and reflect the needs of the resident. The Interim DON stated in order to prevent accidents and falls, it would be important to ensure fall interventions were available to staff on both the CCP and the Resident Summary and to ensure the interventions were implemented. In an interview with the Executive Director on [DATE] at 10:23 AM, he stated it was his expectation the CCP and Nurse Aide Care Plan included specific information to guide staff for safe resident transfers in order to prevent falls. Further, he stated it was his expectation staff implement the interventions. In continued interview he stated it was his expectation the facility followed the Centers for Medicare/Medicaid Services (CMS) regulations and requirements regarding care plans and making updates to care plans. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #44 expired on [DATE] after being transferred to the hospital emergency room . 2. On [DATE], the Executive Director removed the lift and sling used during Resident #44's transfer from service. A visual inspection was performed. No issues were identified. The Executive Director interviewed both CNA #1 and CNA #3, who were present during the transfer of Resident #44 and walked through the event details. 3. On [DATE], a technician from the facility's service department, completed a safety check of the lift and noted no safety issues. 4. On [DATE], as part of the Root Cause Analysis, an event re-enactment was conducted by the District Director of Operations, Executive Director, Interim Director of Nursing, Staff Development Coordinator, Wound Care Nurse, Shower CNA, and one of the CNAs who was present during the event, to gather details of how the event occurred. 5. On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the QAPI Team which included the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Staff Development Coordinator, Infection Control Preventionist, and the facility Medical Director via telephone. The QAPI team, after reviewing the reenactment information, recommended changing the type of sling that the facility was using from a split leg sling to a full body sling that was more appropriate for their specific resident population. The QAPI team also approved the education plan for licensed nurses, CNAs, and Physical and Occupational Therapists who utilized the mechanical lifts and sling pads. 6. On [DATE], the Interim Director of Nursing completed a room-to-room audit to obtain the type and size of the lift sling that each resident was currently using. 7. On [DATE], all split leg slings were removed from residents' rooms and supply rooms by the Interim Director of Nursing, Wound Care Nurse, Executive Director, and the Nurse Managers. 8. On [DATE], the Wound Care Nurse reviewed the weight of each resident that utilized the mechanical lift for transfers to ensure the correct size full body sling was ordered. 9. On [DATE], staff was informed by the Executive Director of the discontinuation and the removal of all split leg slings, and the plan to replace them with full body slings. 10. Beginning [DATE], routine rounding was completed by administration including the Executive Director and other members of the QA team during daily morning huddles which occurred five (5) times per week, Monday through Friday. On weekends this was conducted by the charge nurses to ensure no split leg slings were being utilized on the unit and to provide ongoing communication to staff regarding the plan. 11. Beginning [DATE], Licensed Nurses, CNAs, and Physical and Occupational Therapy Staff completed education and a lift competency related to proper mechanical lift usage, the new universal full body slings, proper response to a resident fall/accident, supervision of residents and comprehensive care planning. The education was conducted by the Interim Director of Nursing, Licensed Nurse Managers, Staff Development Coordinator, and Wound Care Nurse. The education was followed by a post-test to ensure understanding of the information. The facility did employ agency staff, who were included in the education, competency, and post testing. New hires will receive the education. After the alleged date of removal of immediacy, no staff would be allowed to work without having received the education, competency, and completion of the post-test. A score of one hundred percent (100%) was required on the post test. If anyone did not achieve 100% on the first attempt, additional education would be provided and a retest would occur, until 100% was achieved. After three (3) unsuccessful attempts, the Human Resources Performance Improvement process would be executed by the employee's manager. 12. On [DATE], the Executive Director placed an order for the new, appropriately sized, full body slings. Slings were shipped and arrived by Friday, [DATE]. 13. On [DATE], the facility's monthly QAPI meeting was held, and the committee was updated regarding the education progress, full body sling implementation plan, and care plan audit results. 14. On [DATE], an Ad Hoc meeting was held with the QAPI committee. The meeting consisted of the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Licensed Staff Development Coordinator, Licensed Infection Preventionist, and the Medical Director (via Telephone). The purpose of the meeting was to discuss the purchase of the new slings, which had arrived, the completion of staff education, and the plan for ongoing monitoring which would include observation of staff utilizing the new universal full body slings when transferring a resident with the lift. The plan was approved and scheduled to start the same day and occur daily for one (1) week, then decrease to five (5) times a week for one (1) week, then decrease to twice weekly for two (2) weeks, then decrease to monthly for four (4) months. The State Survey Agency validated the facility had taken the following actions: 1. Review of the Progress Note, dated [DATE] at 4:15 PM, entered by LPN #4, revealed Resident #44 was discharged from the facility on [DATE] at 4:15 PM and transferred to the hospital emergency room for evaluation and treatment. Review of the hospital Discharge Summary, dated [DATE] at 10:22 PM, revealed Resident #44 was admitted to the hospital emergency roiagnom on [DATE] at 6:48 PM and expired on [DATE] at 10:22 PM. 2. In an interview with the Executive Director on [DATE] at 10:00 AM, he stated he had the Hoyer Lift and sling used during the transfer of Resident #44 removed from service and visually inspected the lift and sling and noted no issues. He further stated he had CNA #1 and CNA #3 give him an account of the event and write out statements regarding what happened. In an interview with CNA #3, on [DATE] at 12:27 PM, she stated she was interviewed about the transfer involving Resident #44 and gave a written statement to the Executive Director. Review of the Incident Binder, revealed documentation of written statements from CNA #1 and CNA #3 related to Resident #44's fall incident. 3. Review of the Incident Binder, revealed a work order dated [DATE] at 2:00 PM, detailing the inspection of the lift and verifying it to be operational. In an interview with the Technician from the service department within the facility, on [DATE] at 12:06 PM, he stated he performed a safety check of the lift that was used during the incident on [DATE] and found no issues. He further stated the lifts were inspected annually and per his records, that particular lift had an annual inspection on ,d+[DATE] with no issues noted. 4. Review of the Incident Binder, revealed documentation of the re-enactment of Resident #44's fall on [DATE]. In an interview with the Executive Director, on [DATE] at 4:55 PM, he stated an event re-enactment was performed by Administration along with some nursing staff members including one of the CNA's that was directly involved in Resident #44's fall incident. He stated this was to gather additional information related to the event. During an interview with CNA #4, on [DATE] at 3:31 PM, she stated she participated in the re- enactment of the event. In an interview with the District Director of Operations, on [DATE] at 5:15 PM, she stated she assisted with the re-enactment of the fall event. 5. Review of QAPI minutes from [DATE], revealed the Root Cause Analysis was completed and the Re-enactment of Resident #44's transfer was reviewed. A recommendation for full body slings was made by the team. Additionally, staff education was discussed related to mechanical lifts. In an interview with the Medical Director, on [DATE] at 5:00 PM, he stated due to illness, he attended this meeting by phone, and they discussed the event and reviewed the re-enactment information. He further stated the QAPI team decided at that time they would change the sling type to full body slings. During interviews with the District Director of Clinical Operations on [DATE] at 5:15 PM, Dietician on [DATE] at 11:01 AM, and the Staff Development Coordinator on [DATE] at 11:17 AM, they verified attendance at the QAPI meeting on [DATE]. Further, they verified reviewing the reenactment information, and discussion related to changing the type of sling that the facility was using from a split leg sling to a full body sling. Additionally, they verified discussing staff education related to utilization of the mechanical lifts and slings. 6. Review of the Incident binder, on [DATE] at 9:55 AM, revealed documentation of room-to-room audits of sling sizes for each resident on [DATE]. In an interview with the Interim Director of Nursing, on [DATE] at 10:49 AM, she stated she performed the audit of sling sizes for the residents. 7. Observation on [DATE] at 2:23 PM, revealed there were no split leg slings in any of the resident rooms or supply rooms. In an interview with the Executive Director, on [DATE] at 10:00 AM, he stated all split leg slings were removed from resident rooms and supply rooms. He stated this was because the Root Cause Analysis related to Resident #44's fall determined the type of sling used for the transfer posed a risk. During interviews with the Interim Director of Nursing, on [DATE] at 10:49 AM, and the Wound Care Nurse, on [DATE] at 12:12 PM, both stated they assisted in removing the split leg slings from all resident rooms. 8. Review of the Incident Binder, revealed documentation of resident weights and sling size documented on [DATE]. In an interview with the Wound Care Nurse, on [DATE] at 11:47 AM, she stated she reviewed each resident's weight to ensure the correct size was ordered for the full-size body sling. 9. Review of the Incident binder, revealed the information sheet, dated [DATE], verified staff was informed of the discontinuation and removal of the split leg sling. Also, lifts were not to be used except for shower transfers until the full body slings arrived. In an interview with the Executive Director, on [DATE] at 10:00 AM, he stated he informed staff on [DATE], they would no longer be using the split leg slings as they were being replaced with full body slings. Further, he stated he informed staff the lifts were not to be used except for shower transfers until the full body slings arrived. In an interview with CNA #1, on [DATE] at 8:30 AM, he stated he was informed by the Executive Director about the slings being removed and not being allowed to use the lift for transfers until the new slings came in. In an interview with CNA #4, on [DATE] at 3:31 PM, she stated she was informed by the Executive Director about the slings being removed and not using the lifts until the new ones arrived. 10. Review of the Incident binder, revealed routine rounding starting [DATE] during daily morning huddles to ensure no split leg slings were being utilized on the unit and to provide ongoing communication to staff regarding the plan. In an interview with the Executive Director, on [DATE] at 4:55 PM, he stated he participated in rounding during daily huddle meetings to ensure no split leg slings were being used on the unit. In an interview with the Staff Development Coordinator, on [DATE] at 11:17 AM, he stated observations were being done to ensure correct usage of the mechanical lifts. In an interview with the Interim Director of Nursing, on [DATE] at 10:49 AM, she stated she participated in the daily huddles and ensured no split leg slings were being used on the unit and also ensured proper usage of the lifts. In an interview with RN #2, on [DATE] at 2:20 PM, she stated there were daily huddle meetings to ensure no split leg slings were being utilized on the unit and to see if staff had any questions related to the lift usage. 11. Review of the Incident binder, revealed verification, that before [DATE], Licensed Nurses, CNAs, and Physical and Occupational Therapy Staff completed education and a lift competency related to proper mechanical lift usage, the new universal full body slings, proper response to a resident fall/accident, supervision of residents and comprehensive care planning. In an interview with the Staff Development Coordinator, on [DATE] at 11:17 AM, he stated he trained the Wound Care Nurse, Nursing Managers, and some nursing staff regarding proper lift usage with new full body slings, proper response to a fall or accident, supervision of residents, and care plan education. During an interview, on [DATE] at 2:20 PM, Registered Nurse (RN) #2 stated she received education regarding proper lift usage with new full body slings and performed a return demonstration on the proper use of a mechanical lift. Further, she verified she received education on proper response to a fall or accident, supervision of residents, and care plan education. RN #2 stated she took a post-test. Review of the Incident Binder revealed documentation of RN# 2's education. In an interview with CNA #2, on [DATE] at 11:05 AM, she stated she received education on usage of the mechanical lift with new full body slings, and performed a return demonstration on the proper use of the mechanical lift. Additionally, she verified she received education on proper response to a fall or accident, supervision of residents, and care plans. She stated she took a post test, which was given to her by the Staff Development Coordinator. Review of the Incident Binder revealed documentation of CNA #2's education. 12. Review of the Incident Binder, revealed documentation of order invoices for the full body slings that were ordered and confirmation of receipt. In an interview with the Executive Director, on [DATE] at 10:00 AM, he stated he ordered the new full body slings. 13. Review of QA minutes from the [DATE] meeting, revealed it was attended by the Executive Director, Respiratory Therapy Manager, Medical Director, Director of Therapy, Infection Control Preventionist, Case Manager, Activities Director, Registered Dietician, MDS Nurse, Clinical Pharmacy Manager, and Staff Nurse. During the meeting discussion included the fall event on [DATE]; the education progress; full body sling implementation plan and care plan audit results. In an interview with the Executive Director, on [DATE] at 4:55 PM, he stated another QAPI meeting was held on [DATE] and the QA team went over the results of the care plan audits and education process. In an interview with the MDS Nurse, on [DATE] at 10:04 AM, he stated he printed off a census sheet and created an audit tool for the transfer status of residents, made corrections if any discrepancies were found, and presented the data to the QAPI Team at the meeting on [DATE]. 14. Review of the QAPI Binder, revealed signatures for all parties listed and documentation of meeting minutes. Per the minutes, discussion included lift audit forms and documentation of the audits. Review of the incident binder, revealed starting [DATE], there was observation of staff utilizing the new universal full body slings when transferring a resident with the lift daily for one (1) week, then five (5) times a week for one (1) week, then twice weekly for two (2) weeks, then to be completed monthly for four (4) months. During interviews with the Interim Director of Nursing, on [DATE] at 10:49 AM; Wound Care Nurse on [DATE] [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents. Additionally, the facility failed to ensure staff were properly trained and knowledgeable of how to safely use the Hoyer lift (mechanical lift) for resident transfers. This affected two (2) of forty (40) sampled residents (Residents #10 and #44). On [DATE], Certified Nursing Assistant (CNA) #1 (orientee) and CNA #3 assisted Resident #44 to the bed from his/her wheelchair with the use of a Hoyer lift. The resident slid from the sling and landed on the floor. Resident #44 experienced a change in his/her level of consciousness (LOC). The Medical Emergency Response Team (MERT) was called. The facility transferred Resident #44 to the hospital emergency room (ER) for evaluation and treatment. Resident #44 expired at the hospital on [DATE] at 10:22 PM. Further observation on [DATE] at 10:30 AM, revealed CNA #2 and CNA #4, positioned Resident #10 on the lift sling while the resident was in the bed. The CNAs pushed the Hoyer lift over to the bed. However, they failed to lock the lift wheels prior to hooking the lift sling to the lift, and raising the resident off the bed. The facility's failure to ensure each resident received adequate supervision and assistance devices to prevent accidents has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at the highest scope and severity (S/S) of a J; and at 42 CFR 483.25 Quality of Care (F689), at the highest S/S of a J, which was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. In addition, Substandard Quality of Care (SQC) was identified at 42 CFR 483.25, Free of Accident Hazards/Supervision/Devices (F689). An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated Immediate Jeopardy was removed on [DATE], prior to exit on [DATE]. Non-compliance remained in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656) at a Scope and Severity (S/S) of a D; and 42 CFR 483.25 Quality of Care (F689) at a S/S of a D, while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: In an interview with the Executive Director on [DATE] at 10:23 AM, he stated the facility did not have a policy regarding the Hoyer Lift and slings. Review of the Manufacturer's Instructions for the Hoyer Lift, revealed staff must receive training and practice before operating a lift. Staff should check a resident's physical capabilities, medical condition, and mental status before using the lift with them; using the appropriate size lift pad (sling) specifically designed for the lift. Continue review revealed instructions to lock both rear wheels on the back of the lift before attempting to lift the resident. Review of the facility's policy titled, Accidents and Supervision to Prevent Accidents, revised ,d+[DATE], revealed the Subacute Unit (SAU) was to provide an environment free from accident hazards over which the SAU has control, and provide supervision and assistive devices to each patient to prevent avoidable accidents. Review of the facility's policy titled, Fall Response and Management, revised ,d+[DATE], revealed the staff in the Subacute Unit (SAU), will attempt to break the resident's fall and take appropriate actions post fall including evaluating the resident for injury, noting any deviations from the resident's baseline condition and notifying the physician of changes immediately. Continued review revealed staff should determine if the resident experienced any head trauma, monitor neurological assessments per physician's orders, and evaluate the resident's limb strength. Further review of the policy, revealed the facility was to investigate the cause after the resident had been stabilized, revise the care plan if necessary, and notify the physician and family. 1. Review of Resident #44's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses which included acute and chronic respiratory failure, and muscle weakness. Review of Resident #44's Falls Risk Assessment, dated [DATE] revealed the legend stated the resident was to be assessed by using the eight (8) criteria listed on this tool which included: mental status, incidence of falls, ambulation/elimination status, vision, mobility, medications, and predisposing diseases. Per the Assessment, if there was a score of ten (10) or above, the resident would be considered high risk for falls. However, there was no fall's score for this resident listed on the Assessment. Per the Assessment, this resident was not a fall's risk and no interventions were required at this time. Review of Resident #44's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated intact cognition. Continued review revealed the facility assessed Resident #44 as totally dependent on staff for chair/bed to chair transfer. Further review revealed the facility assessed the resident as having no falls. Review of Resident #44's Comprehensive Care Plan (CCP), dated [DATE], revealed a focus of Activities of Daily Living (ADL) Self Care Performance Deficit related to Immobility, Activity Intolerance, Weakness, Ventilator Dependent, and Tracheostomy; and required assistance with transfers. The CCP goal stated ADL/Self Care needs would be met on a daily basis through next review. However, there were no individualized interventions related to transfer technique nor was there an intervention to indicate how many staff were required to transfer the resident. Review of the Comprehensive Care Plan, dated [DATE], revealed Resident #44 was at risk for injury related to mobility impairment; use of psychotropic medication, and narcotic pain medication; and ADL/Self Care Performance deficit related to immobility. The goal revealed the resident would be free from falls and fall related injuries through next review. Interventions included: Anticipate and meet resident's needs; provide assistance with mobility and transfers as needed; assist with mobility as needed, and if anxious or restless assess basic needs, or room temperature. However, there were no individualized interventions related to transfer technique. Additionally, there was no intervention listed for a Hoyer lift, nor was there guidance as to how many staff members were required to transfer this resident. Review of the Resident Summary (Nurse Aide Care Plan), dated [DATE] revealed the facility care planned Resident #44 for the assist of two (2) with a mechanical/electrical lift for transfers. However, this Resident Summary did not specify the type or size of sling to be used. Additionally, it did not specify if a Hoyer lift was to be used. Review of Resident #44's Nursing Progress Note, dated [DATE], at 4:15 PM, entered by Licensed Practical Nurse (LPN) #4, revealed the resident was being assisted to bed from the chair with the use of a mechanical lift. The resident slid from the lift sling landing on the floor. The Nurse was notified immediately by the Certified Nursing Assistant (CNA). Upon assessment the resident was alert and oriented and able to answer questions, and had a raised area to the back of the head. No additional injuries were noted. Further review of the Note, revealed the resident was transferred back to bed using the lift. The Physician was notified and new orders were received for a Computerized Tomography (CT) of the head, but the resident experienced a change in level of consciousness (LOC) and the Medical Emergency Response Team (MET) was called. Per the Note, the resident was transferred to the emergency room (ER) for evaluation and treatment. Review of Resident #44's hospital Discharge Summary, dated [DATE] at 10:22 PM, revealed the resident presented after a fall at the nursing home. He/she was found unresponsive and sent to the hospital for further evaluation and treatment. The Computerized Tomography Scan (CT scan) revealed a massive left convexity with a midline shift and signs of uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another). Additional review of the Summary, revealed Resident #44's poor prognosis was explained to his/her family and they expressed their decision to start comfort measures only. Resident #44 was terminally disconnected from the ventilator and passed away shortly. Time and date of death was [DATE] at 10:22 PM. Review of Resident #44's Death Certificate, revealed the cause of death listed was Blunt Force Head Trauma sustained from a fall. Review of the facility's Incident/Accident Report, dated [DATE], entered by the Executive Director, revealed the facility determined due to Resident #44's contracted stature and limited range of motion (ROM), the divided leg sling posed an increased risk of shifting out of proper position during the mechanical transfer. Two (2) CNAs were present and reported when Resident #44 began slipping they were not able to get to him/her in time. Immediate action items put in place included: removal of the lift and sling from service pending the service technician review; removal of all divided leg slings from service and transition to full body slings prior to any more transfers occurring; and begin education and competency training of sling change with plan of one hundred percent (100%) of staff to participate prior to transferring. Per the Report, the service technician review and inspection of the sling used for Resident #44 revealed both in good repair. In an interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 8:30 AM, he stated, on [DATE], he was in orientation with his preceptor, CNA #3, who was training him. He further stated he had not been checked off on the lift (demonstrated proper usage of the lift) and therefore was just observing the use of the Hoyer lift and did not assist with the transfer of Resident #44. He stated the sling being used for the transfer had what appeared to be an opening made into the lower part of the sling. CNA #1 further stated Resident #44 slid out of the sling as it was being used to transfer him/her from the wheelchair to the bed from a high position and the resident's head hit the floor. He stated CNA #3 stopped and yelled for staff help and asked Resident #44 if he/she was okay and the resident responded, Yes. CNA #1 further stated immediately after the fall the resident didn't appear to have any injuries, but a few minutes later the resident started to have changes and he/she was transferred to the hospital. In an interview with CNA #3, on [DATE] at 12:27 PM, she stated she had worked at the facility since [DATE]. She further stated she had provided care for Resident #44 in the past and was aware without checking the care plan the resident was to be transferred per Hoyer Lift with the assist of two (2) staff. Per interview, she stated, on [DATE], she asked Resident #44 if he/she was ready for bed and he/she stated, Yes. CNA #3 stated CNA #1 was in training with her and she was to show him how to use the lift. She stated she assisted Resident #44 onto the sling while CNA #1 assisted with putting the loops of the sling onto the sling hooks of the Hoyer lift. She stated she then locked the wheels of the Hoyer Lift, and began to lift the resident off the wheelchair. CNA #3 further stated she stopped for a brief moment to check the resident for stability, and everything appeared to look good; then she unlocked the wheels and proceeded with moving the resident towards the bed. In continued interview with CNA #3, she stated Resident #44 began to slide out of the sling from the opening that was built into the bottom of the sling lift pad. She further stated Resident #44 fell hitting his/her head on something, which she thought was the bedside dresser as he/she fell to the floor. Further, she stated at this point the resident was partially in the sling and partially on the floor with one (1) of his/her legs sticking out of the lift pad. CNA #3 stated she and CNA #1 tried to break the fall, but were unable to prevent the fall in time. During continued interview with CNA #3, on [DATE] at 12:27 PM, she verified she was the only other person in the room assisting with the transfer besides CNA #1. CNA #3 stated she called for help from additional staff members, and the shower aide (CNA #4) arrived first and helped her lower Resident #44's leg from the lift. CNA #3 stated she then asked CNA #4 to get the nurse and CNA #4 came back with Licensed Practical Nurse (LPN) #4. CNA #3 stated CNA #4 told her (CNA #3), it appeared Resident #44 was placed in the sling incorrectly and the correct way to place the lift pad on the resident was with the lower part of the sling criss-crossed around the resident's legs. CNA #3 stated she used the mesh sling that was already underneath Resident #44 when he/she was sitting in the chair prior to the transfer and did not criss-cross the lower part of the sling around the resident's legs. CNA #3 further stated she was never trained on how to make sure the residents had the correct type or size sling. Additionally, she did not recall being trained on the use of the Hoyer lift and slings in orientation and was unaware of sling size for residents being posted anywhere or care planned. Review of education/training records revealed CNA #3 did receive Hoyer lift training on [DATE] which included type of sling and sling size to be used for residents. Further, the training revealed CNA #3 performed a return demonstration during the training. In an interview with Shower Aide, (CNA #4) , on [DATE] at 3:31 PM, she stated , she was in the hall when she heard the fall happen. Upon opening the door to Resident #44's room, she saw the resident sitting up straight on the floor, with the sling still underneath him/her. She further stated she asked CNA #3 what happened and CNA #3 stated to her, I was just trying to to get [him/her] up from the chair and into bed and [he/she] just fell . CNA #4 stated when she asked Resident #44 if he/she was ok, the resident stated, Yes, but my head hurts. She further stated after LPN #4 evaluated the resident, she (CNA #4) assisted with getting the resident back in bed and she (CNA #4) briefly educated CNA #3 on how to correctly place the sling underneath the resident. She further stated she could tell the sling was incorrectly placed under Resident #44 by the way it was wrapped around his/her legs. CNA #4 stated she had received training on the mechanical lifts when she was hired, but she could not recall if she received any annual training. She further stated there was a chart in the shower room that listed each resident and their weight and it specified which size sling each resident needed. However, she stated she was not aware of the CNAs using this chart to choose slings for the residents. During interview with LPN #4, on [DATE] at 9:28 AM, she stated she had only been employed at the facility for a little more than one (1) month when Resident #44's fall occurred. LPN #4 stated the resident sustained the fall while being transferred to bed with a Hoyer lift by CNAs #1 and #3. She further stated CNA #1 was in orientation and to her knowledge, had been checked off as being certified to use the mechanical lift prior to assisting CNA #3 with the transfer. In further interview, she stated CNA #4 notified her Resident #44 sustained a fall and when she arrived to the resident's room, he/she was lying on the floor swearing at CNA #1 and CNA #3. She further stated she assessed Resident #44 and noted the resident was alert and oriented, and had a knot on the back of the head. LPN #4 stated she initiated neurological checks for every fifteen (15) minutes, notified the Medical Doctor and obtained an order for a CT Scan of the head. LPN #4 further stated the CT Scan was not obtained because the resident became unstable and had a change in level of consciousness about an hour after the event. She stated the Medical Emergency Response Team (MERT) was called, and upon arrival advised her Resident #44 needed to go to the hospital. LPN #4 stated Emergency Medical Services (EMS) and the Fire Department were called and the resident was transferred to the hospital. During interview with Respiratory Therapist (RT) #5, on [DATE] at 11:06 AM, she stated she went to Resident #44's room after the the resident sustained the fall on [DATE]. She further stated when she arrived the resident was awake, alert and oriented, and requested to be suctioned. RT #5 stated she performed suctioning, and LPN #4 was performing fifteen (15) minute checks on the resident. She further stated about thirty (30) minutes later when she returned to check on Resident #44, she found him/her to have agonal breathing (gasping for air), head bobbing up and down, and eyes rolling around. RT #5 stated the Medical Emergency Response Team was called, and they realized it was a neurological issue. RT #5 further stated Resident #44 was transferred to the hospital ER for further evaluation. During an interview with the Respiratory Therapy (RT) Manager, on [DATE] at 4:47 PM, she stated on [DATE], she was sitting at the nurse's station when a nurse (she could not recall the nurse's name), came down the hall and told another staff member, Resident #44 was unresponsive. The RT Manager stated she questioned the nurse about Resident #44 being unresponsive, and the nurse informed her the resident had sustained a fall earlier. The RT Manager stated she entered Resident #44's room and noted the resident was back in bed, but didn't look well so she had another staff member call MERT to assist. In continued interview, she stated EMS and the Fire Department came to transfer the resident to the hospital and she assisted with providing ventilation to Resident #44 while enroute. She stated the primary role of respiratory during resident transfers was to provide protection and assistance with the resident's airway. During interview with the Interim Director of Nursing, on [DATE] at 10:49 AM, she stated she was the Interim DON from [DATE] to [DATE]. She further stated on [DATE] at approximately 5:15 PM, she was notified of Resident #44's fall by the Staff Development Coordinator (SDC). She explained after notification she went to the unit and spoke with LPN #4, who informed her Resident #44 was awake and alert after the fall and then began to decline. The Interim DON further stated she assessed Resident #44 and found the resident to be breathing really hard and at that time the Respiratory Therapist was trying to check the positioning of the resident's tracheostomy tube because of his/her past history of difficulty breathing. The Interim Director of Nursing stated MERT was called and eventually EMS transported Resident #44 to the hospital for further evaluation and treatment once they realized it was more of a neurological issue. She stated the family was notified at the time of transfer of the resident's change in condition. In an interview with the MDS Nurse, on [DATE] at 4:47 PM, he stated MDS Assessments were completed on residents upon admission, quarterly, annually and with a significant change in the resident. In continued interview, he stated it was his responsibility to develop the Comprehensive Care Plan (CCP) and revise them with each MDS Assessment, and he was also to revise the CCP if there were any changes in the resident. Further, he was also to update the Resident Summary which served as a CNA care plan. In continued interview, he stated human error was the reason he failed to develop/update Resident #44's CCP with transfer status and interventions to ensure a safe transfer. In an interview with the Staff Development Coordinator (SDC), on [DATE] at 11:00 AM, he stated he provided annual check offs on Hoyer lifts, and safe lifting ergonomics, with online education yearly and after an event. He stated during the education related to Hoyer lifts, he trained staff on how they were to select the proper size sling according to resident's size and weight. He stated the bindings of the slings were different colors depending on the size of the sling. The SDC further stated orientees were given lift check off training once they hit the floor by their preceptors. The SDC stated the orientees then had to perform another demonstration for him with the Hoyer lift in order to get checked off. During further interview with the SDC, on [DATE] at 11:00 AM, he stated the orientees could be a second assist person, but would not be permitted to operate the lift until they had demonstrated proper use of the lift in front of him and he checked them off. The SDC further stated CNA #1 had been educated on the Hoyer lift prior to the incident involving Resident #44, and was the second assist person during the transfer. However, he stated CNA #1 could not operate the lift as he was observing use of the lift, so that he could be checked off. He further stated prior to the incident the facility did not have any manufacturer's instructions or user manuals on the Hoyer lifts available' However, after deficient practice was identified, they had obtained copies of the instructions and staff had access to them at all times in the orange Education Binder. He also stated there was a copy of the instructions on the computer network drive that staff could utilize. During further interview with the Interim DON, on [DATE] at 10:49 AM, she stated it was her expectation staff was knowledgeable of the proper transfer technique, and proper equipment to be used during a transfer for the safety of the residents. She stated in order to prevent accidents and falls, it would be important to ensure this information was available to staff on the CCP and the Resident Summary. Continued interview revealed the SDC provided training for new orientees on hire related to the Hoyer lifts and also provided this training annually. She stated before the incident involving Resident #44, the facility did not have a clear written process of how to assess residents for the appropriate size sling. She stated the shower aide was initially doing the assessment for size on admission. She stated after the incident, the wound nurses assessed residents for the correct type of sling. In additional interview, the DON stated the facility had completed an investigation related to Resident #44's fall, and the root cause analysis revealed staff was using the wrong type of sling. In an interview with the Medical Director, on [DATE] at 5:00 PM, he stated he was notified of Resident #44's fall on the day it occurred by the Executive Director (ED). He further stated the Quality Assurance Performance Improvement (QAPI) team met the next day to discuss the incident and had been discussing the incident each meeting. In an interview with the Executive Director (ED), on [DATE] at 10:00 AM, and [DATE] at 10:23 AM, he stated he was notified of Resident #44's fall on the same day of the incident and then he notified the Medical Director. He further stated an investigation began immediately and there was an Ad hoc QAPI meeting the next day during which a re- enactment of the event was performed. The ED stated the Root Cause of Resident #44's fall was the split leg sling used with the Hoyer lift and the fact that the resident had contractures that caused him/her to slide out onto the floor. The ED stated it was concluded the split leg slings would be discontinued and replaced with full body slings. He stated prior to Resident #44's fall, the facility had ensured the orientees received education related to Hoyer lifts and demonstrated proper usage of the lifts. The ED stated staff received annual training related to the Hoyer lift usage. However, he stated there was not a quality assurance audit to observe for proper Hoyer lift usage before Resident #44's fall occurred. The ED stated the lift that was used for Resident #44 was put out of service and sent to the facility's service department for inspection. He further stated they removed all the split leg slings from residents' rooms and replaced them with full body slings. The ED explained it was his expectation that staff was knowledgeable and proficient in the proper usage of the Hoyer lift for the safety of the residents. 2. Review of Resident #10's medical record revealed the facility admitted the resident on [DATE] with diagnoses to include Quadriplegia and History of Transient Ischemic Attack. Observation on [DATE] at 10:30 AM, revealed CNA #2 and CNA #4 positioned Resident #10 on the lift sling while the resident was in the bed. The CNAs pushed the Hoyer lift over to the bed. However, they failed to lock the lift wheels prior to hooking the lift sling to the lift, and raising the resident off the bed with the lift. In an interview with CNA #2, on [DATE] at 11:05 AM, she stated she realized she should have locked the wheels on the Hoyer Lift after she positioned the lift over the resident's bed, and prior to hooking the resident's sling to the lift and raising the resident up with the lift. She stated she then should have unlocked the wheels in order to move the resident to the shower bed. In an interview with CNA #4, on [DATE] at 11:10 AM, she stated she did not realize CNA #2 neglected to lock the wheels of the lift prior to raising Resident #10 up with the lift as she was on the other side of resident's bed assisting. During further interview with the SDC, on [DATE] at 11:00 AM, and the Executive Director (ED), on [DATE], they stated monitoring of Hoyer lift usage was ongoing. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Resident #44 expired on [DATE] after being transferred to the hospital emergency room . 2. On [DATE], the Executive Director removed the lift and sling used during Resident #44's transfer from service. A visual inspection was performed. No issues were identified. The Executive Director interviewed both CNA #1 and CNA #3, who were present during the transfer of Resident #44 and walked through the event details. 3. On [DATE], a technician from the facility's service department, completed a safety check of the lift and noted no safety issues. 4. On [DATE], as part of the Root Cause Analysis, an event re-enactment was conducted by the District Director of Operations, Executive Director, Interim Director of Nursing, Staff Development Coordinator, Wound Care Nurse, Shower CNA, and one of the CNAs who was present during the event, to gather details of how the event occurred. 5. On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the QAPI Team which included the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Staff Development Coordinator, Infection Control Preventionist, and the facility Medical Director via telephone. The QAPI team, after reviewing the reenactment information, recommended changing the type of sling that the facility was using from a split leg sling to a full body sling that was more appropriate for their specific resident population. The QAPI team also approved the education plan for licensed nurses, CNAs, and Physical and Occupational Therapists who utilized the mechanical lifts and sling pads. 6. On [DATE], the Interim Director of Nursing completed a room-to-room audit to obtain the type and size of the lift sling that each resident was currently using. 7. On [DATE], all split leg slings were removed from residents' rooms and supply rooms by the Interim Director of Nursing, Wound Care Nurse, Executive Director, and the Nurse Managers. 8. On [DATE], the Wound Care Nurse reviewed the weight of each resident that utilized the mechanical lift for transfers to ensure the correct size full body sling was ordered. 9. On [DATE], staff was informed by the Executive Director of the discontinuation and the removal of all split leg slings, and the plan to replace them with full body slings. 10. Beginning [DATE], routine rounding was completed by administration including the Executive Director and other members of the QA team during daily morning huddles which occurred five (5) times per week, Monday through Friday. On weekends this was conducted by the charge nurses to ensure no split leg slings were being utilized on the unit and to provide ongoing communication to staff regarding the plan. 11. Beginning [DATE], Licensed Nurses, CNAs, and Physical and Occupational Therapy Staff completed education and a lift competency related to proper mechanical lift usage, the new universal full body slings, proper response to a resident fall/accident, supervision of residents and comprehensive care planning. The education was conducted by the Interim Director of Nursing, Licensed Nurse Managers, Staff Development Coordinator, and Wound Care Nurse. The education was followed by a post-test to ensure understanding of the information. The facility did employ agency staff, who were included in the education, competency, and post testing. New hires will receive the education. After the alleged date of removal of immediacy, no staff would be allowed to work without having received the education, competency, and completion of the post-test. A score of one hundred percent (100%) was required on the post test. If anyone did not achieve 100% on the first attempt, additional education would be provided and a retest would occur, until 100% was achieved. After three (3) unsuccessful attempts, the Human Resources Performance Improvement process would be executed by the employee's manager. 12. On [DATE], the Executive Director placed an order for the new, appropriately sized, full body slings. Slings were shipped and arrived by Friday, [DATE]. 13. On [DATE], the facility's monthly QAPI meeting was held, and the committee was updated regarding the education progress, full body sling implementation plan, and care plan audit results. 14. On [DATE], an Ad Hoc meeting was held with the QAPI committee. The meeting consisted of the Executive Director, Interim Director of Nursing, Wound Care Nurse, Registered Dietician, Social Services, Case Manager, Respiratory Therapy Manager, Activity Coordinator, Licensed Staff Development Coordinator, Licensed Infection Preventionist, and the Medical Director (via Telephone). The purpose of the meeting was to discuss the purchase of the new slings, which had arrived, the completion of staff education, and the plan for ongoing monitoring which would include observation of staff utilizing the new universal full body slings when transferring a resident with the lift. The plan was approved and scheduled to start the same day and occur daily for one (1) week, then decrease to five (5) times a week for one (1) week, then decrease to twice weekly for two (2) weeks, then decrease to monthly for four (4) months. The State Survey Agency validated the facility had taken the following actions: 1. Review of the Progress Note, dated [DATE] at 4:15 PM, entered by LPN #4, revealed Resident #44 was discharged from the facility on [DATE] at 4:15 PM and transferred to the hospital emergency room for evaluation and treatment. Review of the hospital Discharge Summary, dated [DATE] at 10:22 PM, revealed Resident #44 was admitted to the hospita [TRUNCATED]

Based on observation, interview and review of the facility's policy, it was determined the facility failed to prepare, and store food under sanitary conditions. Observations on 11/28/2023 and 11/29/2023 revealed the deep fryer contained dark oil; an ingredient bin was not labeled or dated; a large rice container was not labeled or dated; a staff person's personal jacket was left on top of a rack of cups; and a cook was wearing a stained apron preparing to serve the lunch tray line. The findings include: Review of the facility's policy titled, Food and Supply Storage dated 01/30/1998 revealed the policy established guidelines for food and supplies used in food preparation which were to be stored in a manner to maintain safety and sanitation of the food or supply for human consumption as set forth in the federal and state regulations, and city/county health codes. Continued review revealed proper storage of food and food service supplies minimized the risk of food borne illness. Further review revealed for food products which were opened and not completely used or prepared by the facility and should be labeled as to its contents and use-by date upon being stored. Observation on 11/28/2023 at 9:57 AM, during initial kitchen tour, revealed one (1) ingredient bin not labeled with the ingredient inside and was not dated. Continued observation revealed the white flour ingredient bin had been labeled; however, it was not dated as required. Additional observation of the dry storage revealed a clear container with the appearance of brown rice stored inside that was not labeled or dated as required. Observation on 11/28/2023 at 10:09 AM, during kitchen tour, revealed the same unlabeled clear bin with the appearance of brown rice was still stored in the dry storage area unlabeled and undated. Continued observation revealed the white flour remained labeled but undated. In addition, observation revealed another ingredient bin with the appearance of cornmeal flour was stored inside which was dated; however, it was not labeled. Observation on 11/29/2023 at 11:30 AM, on the clean area of the dish machine room revealed someone's personal jacket was left lying on top of the rack of clean plastic cups. Observation on 11/29/2023 at 11:55 AM, of the kitchen lunch tray line revealed the Cook was wearing a stained apron while preparing to serve food on the lunch tray line. Observation on 11/28/2023 at 9:57 AM and 10:09 AM, during initial kitchen tour and continued tour revealed both deep fryers contained oil which was dark brown in appearance. Observation on 11/29/2023 at 11:45 AM, of the kitchen, revealed both deep fryers contained oil which was dark brown in color and appearance. During interview with the Dietary Supervisor on 12/02/2023 at 10:56 AM, he stated staff must label and date food with the received date. He stated the ingredient bin with cornmeal had a date; however, it needed to have a label for identification. The Dietary Supervisor stated the flour bin was labeled, but it needed to be dated. The Dietary Supervisor stated food could become outdated and not rotated if staff failed to label and date the food. He stated the brown rice container needed to be labeled and dated. The Dietary Supervisor stated the deep fryer oil was to be changed every Tuesday by a company who changed the oil in the fryers. He stated however, the contracted company might have only filtered the fryer oil the past week. The Dietary Supervisor stated he knew when the condition of the oil was when he could not see through the oil and it needed to be changed at that point. He stated if it was not changed the oil would not provide a good food product when used. The Dietary Supervisor stated staffs' personal items were to be kept on the hooks and lockers provided for them. He stated possible contamination of the cups could occur with coat stored over top of the cups. The Dietary Supervisor further stated his expectations for aprons was for them to be changed once or every time the apron was soiled. In addition, he stated staff needed to prevent cross contamination of food. During interview with the Director of Food and Nutrition Services (FNS) on 12/02/2023 at 11:39 AM, she stated staffs' personal items were to be hung on the hanging rack; stored in the lockers provided; or placed in the office. The Director of FNS stated staffs' outside clothes were to be kept away from food and dishware as those items could be a cross contaminate. She stated staff had access to clean aprons throughout their shift, which should be changed as it got soiled. The Director of FNS stated aprons were to be changed as needed when food was spilled on it and a chef'scoat should be worn under the apron. She stated her expectations for the cook was for him/her to change a soiled apron as soon as possible in order not to cross contaminate the food. The Director of FNS stated the process for storing food was for staff to label and date the food received with the opened date as required. She further stated the ingredient storage bins were to be labeled and dated with the name of the ingredient, to ensure staff did not mix ingredients or use the wrong ingredient. The Director of FNS additionally stated the fryers utilized were to be completely changed once a week on Tuesday to ensure the equipment was clean. During an interview with the Director of Nursing (DON) on 12/02/2023 at 2:41 PM, she stated her expectations were for staff to date and label food as required, and for staff to ensure clean and safe operating equipment. She further stated staff should regularly change their aprons when it became soiled. During an interview with the Executive Director (ED) on 12/03/2023 at 3:00 PM, he stated his expectations for safe and high-quality food be sent to the residents' unit.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Pharmacist reviewed residents' drug regimens at least once a month to prevent or minimize adverse consequences related to medication therapy by providing oversight of a licensed Pharmacist, attending Physician, Medical Director, and Director of Nursing (DON) for two (2) of five (5) residents sampled for Medication Regimen Review (Resident #25 and Resident #30). 1. Review of Resident #25's Admission Record revealed inconsistent documented evidence of monthly Medication Regimen Reviews (MRR) as required. 2. Review of Resident #30's Admission Record revealed inconsistent documented evidence of monthly Medication Regimen Reviews (MRR)'s as required. The findings include: Review of the facility's Medication Management Policy, dated October 2022, revealed each month Physician's Orders, Medication Administration Records (MARs) and treatment records were to be validated for accuracy by the Pharmacy. 1. Review of Resident #25's Admission Record revealed the facility admitted the resident on 05/25/2023, with diagnoses that included Acute and Chronic Respiratory Failure, Peritonitis, Diabetes. Depression, and Anxiety. Review of Resident #25's Quarterly Minimum Data Set (MDS) Assessment, dated 08/30/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) which indicated severe cognitive impairment. Review of Resident #25's Medication Record Reviews (MRR) dated 06/2023, 08/2023, 09/2023, 10/2023, and 11/2023, revealed no documented evidence the drug regimen was reviewed monthly as required by the Pharmacist. 2. Review of Resident #30's Admission Record revealed the facility admitted the resident on 09/08/2022, with diagnoses of Acute and Chronic Respiratory Failure, Diabetes, and Necrotizing Fasciitis (a rare flesh eating bacterial infection that spreads quickly and could cause death). Review of Resident #30's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #30's MRR's dated 08/2023, 09/2023, 10/2023, and 11/2023, revealed no documented evidence to support the completion of the MRR's by the Pharmacist. During an interview with the Pharmacist on 12/02/2023 at 4:10 PM, she stated the only medication for Resident #22 that was a Do Not Crush was the Bupropion SR. She stated if that medication was crushed, it would cause the medication not to last the duration expected with a sustained released (SR) medication. The Pharmacist stated the facility's policy should be followed for administering medications, or there should be a Physician's Order in the resident's chart indicating how the medications were to be administered. During an interview with the DON on 12/02/2023 at 5:08 PM, she stated the Pharmacist performed MRR's monthly for all residents. The DON stated she implemented a process in November, to ensure the MRR's were completed by the Pharmacist. Per the DON, after the Pharmacist completed the MMR, she then reviewed the monthly MRR's and followed up to ensure the Physician was signing off with his/her agreement/disagreement of the Pharmacist's recommendations. She stated she was unable to elaborate on why there was no documented evidence of the MRR's having been completed or not completed. The DON stated, she expected the Pharmacist to perform the MRR's monthly and the Physician to review and monitor the Pharmacist's recommendations. She stated she expected the Physicians to document his/her acknowledgement of the Pharmacist's recommendations. The DON stated not completing the monthly MRR's could be detrimental to the health of the residents. During an interview with the Executive Director (ED) on 12/02/2023 at 4:50 PM, he stated the Medical Director attended the monthly Quality Assurance Performance Improvement (QAPI) meetings. He stated the QAPI committee had recently implemented processes to ensure all monthly MRR's were completed, addressed and documented in each resident's record. The ED further stated his expectation was for the MRR's to be completed monthly as per facility policy, and follow through should be completed and documented by the Physicians. During an interview with the Medical Director on 12/03/2023 at 9:56 AM, he stated the MRR's were placed in the Physician's mailbox and were reviewed by the primary Physician for the general medications, and the psychotropic medications were reviewed by the Psychiatrist and/or the Psychiatric Nurse Practitioner. He stated the Pulmonologist also reviewed pulmonary medications. The Medical Director stated during the QAPI meetings he requested the pharmacy reports so he could review the MRR's for recommendations. He stated there should have been no gap in the completion of the MRR's. The Medical Director stated he expected the monthly MRR's to be completed one hundred percent (100%) of the time by the Pharmacist. He further stated the Physician should be signing off on the Pharmacist's recommendations as accepted or not accepted. The Medical Director stated if the facility was aware of any issues with the primary Physician not addressing the Pharmacist's recommendations, he expected to be notified of that information.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure appropriate medication administration per a gastrostomy tube (G-tube) for one (1) of forty (40) sampled residents (Resident #22). Observation of a medication pass on 11/29/2023 at 8:42 AM, revealed Licensed Practical Nurse (LPN) #1 administered eight (8) medications via Resident #22's G-tube. LPN #1 was also observed to crush the enteric-coated medication Bupropion, prior to administering it through the G-tube. The findings include: Review of the facility's policy titled, Medication Administered through an Enteral Tube, dated 10/31/2023, revealed the facility was to administer medications separately and flush the tubing between each medication administered per enteral tube (G-tube). Continued review revealed enteric coated medications and long-acting medication formulations were not to be administered through an enteral tube (G-tube). Further review of the facility's policy revealed a Physician's Order could be put in place for all medications to be administered together if warranted. Review of Resident #22's Admission Record revealed the facility admitted the resident on 05/09/2023, with diagnoses that included: acute and chronic respiratory failure and depression. Review of Resident #22's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #22's Physician Orders for December 2023, revealed an ongoing order for water flushes for the enteral tube (G-tube) with fifteen (15) to thirty (30) milliliters (mls) of water before and after medication administration. Continued review of the Orders revealed the G-tube was to be flushed with fifteen (15) to thirty (30) mls of water between each individual medication. Review of Resident #22's Medication Administration Record (MAR) November 2023 revealed the resident's medications included: Bupropion HCL SR 150 mg tablet, sustained-release every twelve (12) hours per G-tube; Abilify 2 mg one (1) tablet daily; Acidophilus 0.5 mg one (1) capsule daily; Duloxetine 60 mg one (1) daily; Eliquis 2.5 mg. one (1) tab twice daily; Hydrocortisone 10 mg one (1) tab twice daily; Modafinil 200 mg one (1) tab daily; and Thiamine 100 mg one (1) tab daily. Further review revealed all medications were observed to have been signed off by nursing staff as administered. Review of Resident #22's Medication Record Review (MRR) dated 11/09/2023, revealed the Pharmacy recommended Resident #22's Bupropion ER not be crushed per the manufacturer's guidelines, even though the resident had an order to crush his/her medications. Further review revealed the Pharmacy's recommendation was reviewed by the facility's Medical Director and the recommendation was declined with the reason documented as the Resident took by mouth. Observation of the medication pass on 11/29/2023 at 8:42 AM, revealed LPN #1 administered eight (8) medications (Bupropion HCL SR 150 mg tablet, sustained release (SR); Abilify 2 mg; Acidophilus 0.5 mg; Duloxetine 60 mg; Eliquis 2.5 mg; Hydrocortisone 10 mg; Modafinil 200 mg; and Thiamine 100 mg via Resident #22's G-tube. Further observation revealed LPN #1 crushed the enteric-coated medication Bupropion, prior to administering the medication via the resident's G-tube. During an interview with LPN #1 on 11/29/2023 at 4:45 PM, she stated she was aware that during administration of medications through a G-tube the medications were to be administered separately with flushes in between each medication, unless there was a Physician's order to administer them together. She stated she should have administered the medications separately and flushed as ordered in between each medication. During an interview with Resident #22 on 12/03/2023 at 10:25 AM, the resident stated that since being at the facility he/she had received all medications via his/her G-tube. Resident #22 stated he/she was able to eat some by mouth and could take the medications by mouth if needed. During an interview with the Pharmacist on 12/02/2023 at 4:10 PM, she stated the only medication for Resident #22 that was a Do Not Crush was the Bupropion SR. She stated if that medication was crushed, it would cause the medication not to last the duration expected with a sustained released (SR) medication. The Pharmacist stated the facility's policy should be followed for administering medications, or there should be a Physician's Order in the resident's chart indicating how the medications were to be administered. During an interview with the Director of Nursing (DON) on 12/02/2023 at 5:08 PM, she stated the Pharmacist performed monthly Medication Regimen Reviews (MRR) on all the residents. The DON stated she had implemented a process in November, to ensure the MRR's were completed by the Pharmacist. She stated after the Pharmacist's MMR, she then reviewed the monthly MRR's and followed up on recommendations to ensure the Physician was signing off with his/her agreement/disagreement with the Pharmacist's recommendations. The DON stated she could not elaborate on why there was no evidence of documentation in the MRR's to indicate they had been completed or not completed. However, she expected the Pharmacist to perform the MRR's monthly as required, and the Physician should review and monitor the Pharmacist's recommendations. The DON stated that not completing the monthly MRR's could be detrimental to the health of the residents. She stated when there were changes to a resident's medication regimen, the change was inputted into the resident's Electronic Health Record (EMR) by the Charge Nurse on the unit. The DON stated the Charge Nurse then communicated the change(s) to the nurse assigned to the resident, and that information was to be communicated to other nursing staff during shift change report. She stated it was her expectation for nursing staff to follow the facility's policy regarding medication administration and follow the five (5) resident rights when administering medications. The DON further stated not following the facility's medication administration policy could potentially cause harm to the resident. During an interview with the Executive Director (ED) on 12/02/2023 at 4:50 PM, he stated the Medical Director (MD) attended the facility's monthly Quality Assurance Performance Improvement (QAPI) meetings. He stated the QAPI committee had recently put processes in place to ensure all monthly MRR's were completed, addressed and documented in each resident's records. The ED stated his expectation was for the MRR's to be completed monthly per facility policy, followed through with, and documented by the Physicians. He stated the facility's medication administration policy should be followed by all licensed nurses when administering medications via a resident's G-tube. The ED further stated not administering medications correctly to residents could potentially cause the residents not to receive the full benefit of the medications. During an interview with the Medical Director (MD) on 12/03/2023 at 9:56 AM, he stated the MRR's were placed in the Physician's mailbox and were reviewed by the primary Physician with general medications. The MD stated the psychotropic medications were reviewed by the Psychiatrist and/or the Psychiatric Nurse Practitioner. He stated the Pulmonologist also reviewed medications. The MD stated during the QAPI meetings he requested the Pharmacy reports so he could review the MRR's. He stated there should have been no gap in the MRR's. The MD stated he expected the monthly MRR's to be completed one hundred percent (100%) by the Pharmacist, and the Physician should be signing off on the recommendations as accepted or not accepted. He stated if the facility was aware of any issues with the primary Physician not addressing the recommendations, he expected to be notified. The MD stated the only adverse effect of administering the sustained release dose would be the medication would not last the entire duration it was ordered for.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an effective infection prevention and control program for one (1) of forty (40) sampled residents (Resident #10). Observation of a Hoyer (brand name of a mechanical lift) Lift demonstration on 11/30/2023 at 10:30 AM revealed Certified Nursing Assistant (CNA) #4 failed to remove her gloves and perform hand hygiene after providing perineal care to Resident #10. Continued observation revealed CNA #4 proceeded to Resident #10, without removing the gloves and performing hand hygiene during the transfer of the resident with the Hoyer Lift. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised 11/2022, revealed an infection prevention and control program was designed and implemented to identify, report, investigate and control infections and communicable diseases for the residents, staff, visitors, and other individuals who provided care and services for the residents. Continued review revealed the infection and prevention and control program was maintained to provide a safe, sanitary, and comfortable environment involving each department. Per policy review, the program included how to use standard precautions, and monitor for compliance which included, but was not limited to hand hygiene, use of Personal Protection Equipment (PPE), transmission based precautions, exposure screening, immunization programs, and pet and animal assisted therapy. Review of Resident #10's medical record revealed the facility admitted the resident on 09/25/2023, with diagnoses which included Chronic Respiratory Failure, Quadriplegia and history of Transient Ischemic Attack (TIA). Review of Resident #10's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated he/she was unable to complete the Assessment. Review of Resident #10's Comprehensive Care Plan dated 10/02/2023, revealed the facility care planned the resident as requiring the assistance of two (2) staff for performing transfers. Observation of a Hoyer Lift demonstration on 11/30/2023 at 10:30 AM, revealed Certified Nursing Assistance (CNA) #4 failed to remove her gloves and perform hand hygiene after she performed perineal care for Resident #10. Further observation revealed CNA #4 continued to provide care for Resident #10 during and after transferring the resident with the Hoyer Lift. In addition, observation revealed the CNA continued to provide the resident's care with the same gloves the entire time. During an interview with CNA #4 on 12/01/2023 at 3:31 PM, she stated she should have changed her gloves, performed hand hygiene, and donned (put on) a new pair of gloves before continuing with her provision of care for Resident #10. She stated she did not know why she did not do perform hand hygiene and don new gloves. In an interview with the Director of Nursing (DON) on 12/01/2023 at 4:13 PM, she stated her expectations were for staff to correctly perform hand hygiene during all phases of resident care. She stated the Infection Control Preventionist had an audit tool which she used when conducting hand hygiene observations. The DON further stated all new hires were required to demonstrate appropriate hand washing technique as a part of their orientation process. In an interview with the Infection Control Preventionist (ICP) on 12/04/2023 at 2:00 PM, she stated she audited staff for hand hygiene performance and tracked the data for trends. She stated her observations were done weekly to check for compliance with hand hygiene. The ICP further stated any employee found noncompliant during the auditing observation would be reeducated on the facility's infection control process. In an interview with the Executive Director (ED) on 12/02/2023 at 10:23 AM, he stated he expected staff to follow the facility's policy regarding handwashing. He stated the facility conducted audits of handwashing and if staff were found to not be following protocol during the the audit, the personnel conducting the audit was to pull the staff member aside and re-educate them. The ED further stated if a trend was noted regarding staff not following the facility's protocol, disciplinary action would occur.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to develop a Comprehensive Care Plan, to accurately reflect the Comprehensive Initial Minimum Data Set Quarterly Minimum Data Set assessments for one (1) of twenty-two (22) sampled residents (Resident #189). Closed record review revealed the facility assessed Resident #189 to require the extensive assistance of two-plus (2+) persons, physical assist for bed mobility. However, review of the initial and ongoing care plans did not reflect the assessed need for extensive two-plus (2+) persons physical assist for bed mobility. Certified Nursing Assistant (CNA) #6 provided one (1) person physical assist with bed mobility. Resident #189 slide out of bed and fracture his/her leg during the assistance. The findings include: Review of the facility's policy titled, Patient Comprehensive Assessment and Resident Assessment Instrument (RAI), dated 10/03/2019, revealed the facility's Comprehensive Assessment included the completion of the Minimum Data Set (MDS) version 3.0 as well as the Care Area Assessment (CAA) process. The results, of the Comprehensive Assessment, were used to develop, review, and revise the patient's (resident's) comprehensive plan of care. Review of the facility's policy titled, Comprehensive Care Plans, dated 08/31/2012, revealed a comprehensive plan of care was developed for each patient within seven (7) days after completing the comprehensive assessment. The facility communicated new or changed care plans to members of the interdisciplinary team and to caregivers. Review of the closed clinical record for Resident #189 revealed the facility admitted the resident on 06/30/2020 with diagnoses of acute and chronic respiratory failure, hemiplegia following cerebral infarction affecting right dominant side, muscle weakness and need for assistance with personal care. Review of Resident #189's admission Fall Risk Assessments dated 06/30/2020 and 09/30/2020 revealed the facility assessed the resident as a High Fall Risk. Review of Resident #189's (closed record) Comprehensive Assessment, Minimum Data Set (MDS) Resident Assessment and Care Screenings, dated 07/13/2020, 10/07/2020 and 01/20/2020, Section G Functional Status Activities of Daily Living (ADL) Assistance, revealed Resident #189 required two-plus (2+) persons physical assist for his/her Self-Performance of Bed mobility. The MDS defined bed mobility as how the resident moved to and from lying position, turns side to side, and positioned body while in bed or alternate sleep furniture. Review of Resident #189's Care Plan, effective 06/30/2020 revealed interventions that included: observe/assist with ADLs, notify Licensed Nurse (LN) if self-care abilities changed and prevented abdomen compression and respiratory embarrassment (rapid and shallow breathing, blushing or blanching of the face and ears) by routinely checking the resident's position, so that he/she did not slide down in bed. Use turn sheet for repositioning, turn and reposition (resident) every two (2) to three (3) hours as needed, and allow Resident #189 to complete as much of the task as possible. Assist Resident #189 to complete scheduled shower/bath and assist, as needed. Review of the Resident Summary, dated 02/05/2021, revealed Resident #189 required Total Care for Transfer/Positioning. Review of the incident report titled Resident Event Report Worksheet, dated 02/24/2021 at 12:00 AM, revealed Resident #189 fell from the bed in his/her room while he/she received care. The Event's Adverse Effect was a moderate to serious fracture (fracture of the left femoral). Telephone interview with CNA #6 on 03/11/2022 at 8:30 AM revealed she recalled when Resident #189 slid out of bed and fell to the floor. She stated that it took more than two (2) people to put Resident #189 back to bed after the fall. The CNA stated she knew what each resident's specific needs were by looking in the computer at the care plan (the Resident Summary) before she started her workday. CNA #6 stated that she (alone) rolled Resident #189 during his/her bath the day he/she slid out of bed. She stated she provided care for Resident #189 many times previously and could not recall if two (2) persons were required when Resident #189 was rolled in bed. Interview with the Minimum Data Set (MDS), Resident Assessment Instrument (RAI) Coordinator and Director of Nursing (DON) on 03/11/2022 at 12:10 PM, revealed the MDS Assessment reflected all information of the needs and wants of the resident and drove the development of the resident's care plan. Continued interview revealed residents' pertinent care plan information was available to CNAs in the Resident Summary. However, further interview revealed the MDS Coordinator had never reviewed a Resident Summary to see if it accurately reflected that resident's individualized care wants and needs, nor had he ever looked to see if Resident #189's Resident Summary matched his/her MDS and Nursing Care Plan. He stated he did not know if an incorrect care plan would have a direct impact on resident care. Review of the facility's investigation, dated 03/01/2021, revealed it was reported that staff assistance given at the time of Resident #189's fall was Assistance per care plan .CNA #6 stated in the investigation that he/she turned around to get the flat sheet and chucks to place them under the resident's butt, and then noticed that his/her feet started to drop and that she ran around to the other side to try to catch the resident. Further review of the facility's investigation revealed that after Resident #189 fell , the facility began staff education on raising the bottom side rail while performing resident care. The education included anticipating residents' needs, having all needed items available, and within reach, prior to performing care. The facility also educated staff to call for assistance when needed. Interview with the Director of Nursing (DON), on 03/11/2022 at 1:20 PM, and simultaneous review of the facility's ADL Verification Worksheet dated 01/01/2021 through 01/08/2021, revealed if the CNA recorded a resident required two-plus (2+) persons physical assist for his/her support for bed mobility, then the CNA Resident Summary should reflect that two-plus (2+) persons physical assist was required for his/her Support for Bed mobility. However, the CNA Resident Summary did not reflect two-plus (2+) persons physical assist was required for Resident #189's bed mobility support. Interview with the Executive Director (ED), on 03/11/2022 at 1:45 PM revealed the Comprehensive Assessment MDS drove the development of a resident's comprehensive care plan, and the care plan was the blueprint for resident care. Further interview revealed it should include the interventions developed to help each resident, and the care plan should be valid at all times. She stated that she relied on her DON to ensure the clinical pieces were in place. She stated that the MDS Coordinator's weekly meetings with the district MDS staff person was how the ED ensured residents' care plans were correct. The ED stated if the care plan was not accurate it would take away the resident's ability to reach his/her full potential.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistance to prevent accidents for one (1) of twenty-two (22) sampled residents (Resident #189). Resident #189 sustained a fall with injuries from his/her bed, during a bed bath with only one staff assisting. However, according to the facility's Comprehensive Assessment, two (2) or more staff members were required to assist Resident #189 while moving in bed. The findings include: Review of the facility's policy titled, Managing Fall Risk, dated 02/14/2016, revealed interventions were developed and individualized according to the resident's pre-disposing risk factors. The resident's goal(s) and interventions were documented on the resident's care plan. The care plan addressed fall risks and interventions were revised based on the results of the resident's specific risk factors. Care plan interventions that were not successful were considered for removal from care plan. Review of the facility's policy titled, Fall Response and Management, dated 02/14/2016, revealed the procedures for a resident's fall with no injury, and procedures for an unwitnessed fall. However, the policy did not provide procedures for a resident's fall with injury. Review of the facility's policy titled, Activities of Daily Living, dated 09/27/2016, revealed employees, contractors, or volunteers provided appropriate treatment and services, including pain management, to maximize the resident's functional abilities. Further review revealed assistance was provided to residents, who needed extensive or total assistance with maintenance of nutrition, grooming, and personal and oral hygiene. Closed record review of Resident #189's Face Sheet revealed the facility admitted Resident #189 on 06/30/2020 with diagnoses of acute and chronic respiratory failure, hemiplegia following cerebral infarction affecting right the dominant side, muscle weakness, and the need for assistance with personal care. Resident #189's Admission Fall Risk Assessments dated 06/30/2020 and 09/30/2020, revealed he/she was a at high risk for falls. Review of Resident #189's Comprehensive Assessment Minimum Data Set (MDS), Resident Assessment and Care Screenings, dated 07/13/2020, 10/07/2020 and 01/20/2020, Section G Functional Status Activities of Daily Living (ADL) Assistance, revealed Resident #189 required two-plus (2+) persons physical assist for his/her Self-Performance of Bed mobility. The MDS defined bed mobility as how the resident moved to and from lying position; turned side to side; and, positioned his/her body while in bed or alternate sleep furniture. Review of Resident #189's Clinical Notes, dated 02/24/2021 by Registered Nurse (RN) #2, revealed at 12:00 AM on 02/24/2021 Resident #189 fell while CNA #6 gave him/her a bath. Review of the incident report titled Resident Event Report Worksheet, dated 02/24/2021 at 12:00 AM, revealed Resident #189 fell from the bed in his/her room while he/she received care. The Event's Adverse Effect was a moderate to serious fracture (fracture of the left femoral). Further clinical record review revealed Resident #189's Radiology Report, dated 02/24/2021, revealed the report's Clinical Indications were a fall and pain. The findings included an oblique fracture involving the base of the left femoral neck extending into the trochanteric portion of the left femur and involving the lesser trochanter. Review of the facility's investigation, dated 03/01/2021, revealed it was reported that staff assistance given at the time of Resident #189's fall was Assistance per care plan. Per the investigation, CNA #6 stated that she turned around to get the flat sheet and chucks to place them under the resident's butt, and then she noticed that the resident's feet started to drop. The CNA ran around to the other side to try to catch the resident. Further review of the facility's investigation revealed after Resident #189's fall, the facility began staff education on raising the bottom side rail while performing care. The education included anticipating the resident's needs, having all needed items available and within reach prior to performing care, and the need to call for help, as needed. Review of Resident #189's Care Plan Report, from 06/01/2020 - 02/28/2021, revealed Active (Current) Certified Nursing Assistant (CNA) interventions included observe/assist with ADLs, notify the Licensed Nurse (LN) if self-care abilities changed and to prevent abdomen compression and respiratory embarrassment by routinely checking the resident's position so that he or she did not slide down in bed. Use turn sheet for repositioning, turn and reposition (resident) every two (2) to three (3) hours as needed, and allow Resident #189 to complete as much of the task as possible. Finally, assist Resident #189 to complete scheduled shower/bath, and assist as needed. Review of the facility's Certified Nurses Aid Job Description, undated, revealed an essential function of the CNA was to provide general nursing care such as positioning the resident, lifting, turning, bed bath, oral/hair/back care and changing bed linens. Telephone interview with CNA #6, on 03/11/2022 at 8:30 AM, revealed she recalled when Resident #189 fell . She stated while she was washing Resident #189's back, Resident #189 slid out of bed. CNA #6 said after that, she put a pillow under Resident #189's head and went to ask for help. It took more than two (2) people to put Resident #189 back to bed after the fall. She stated she knew what each resident's specific needs were by looking in the computer at the care plan before she started her workday. CNA #6 said she was by herself when she rolled Resident #189 during his/her bath the day he/she slid out of bed. CNA #6 stated she had cared for Resident #189, by herself, many times previously and could not recall if two (2) persons were required to assist when Resident #189 was rolled in bed. Telephone interview with Registered Nurse (RN) #2 on 03/10/2022 at 10:05 AM, revealed she was in the hallway when CNA #6 told her that when she was moved Resident #189, he/she rolled off the bed. She stated it took several people to get Resident #189 back into his/her bed. Review of the document titled, Post Fall Investigation, created by RN #2, and dated 02/24/2021 at 12:49 AM, revealed CNA #6 witnessed Resident #189 fall to the floor. RN #2 assessed Resident #189 for injury, and assisted him/her to bed. Further review revealed Resident #189 verbally expressed to RN #2 that his/her pain level was eight (8) at the time of the fall. RN #2 notified the physician, and Resident #189's family of his/her fall with injury. Review of the Resident Transfer Form dated 02/24/2021 at 3:48 AM revealed Resident #189 was transferred from the facility to the hospital per a Physician's Order. The one main reason for transfer stated on the Resident Transfer Form was Fall Related Major Injury. Interview with the Minimum Data Set/Resident Assessment Instrument (MDS/)RAI Coordinator, and the Director of Nursing (DON) on 03/11/2022 at 12:10 PM, revealed the MDS reflected all information on the needs and wants of the resident and drove the development of the resident's care plan. She stated the residents' pertinent care plan information was made available to CNAs in the document titled, Resident Summary. Further interview revealed the MDS Coordinator had never reviewed a Resident Summary to see if it accurately reflected that resident's individualized care wants and needs, nor had he ever looked to see if Resident #189's Resident Summary matched his/her MDS and Nursing Care Plan. He stated he did not know if an incorrect care plan would have a direct impact on resident care. Review of the document titled Resident Summary, dated 02/05/2021 revealed Resident #189 required Total Care for Transfer/Positioning. Interview with the DON, on 03/11/2022 at 1:20 PM, revealed if CNAs documented that a resident required two-plus (2+) persons physical assist for his/her support for bed mobility, then the Nursing Care Plan and the CNA Resident Summary should reflect two-plus (2+) persons physical assist was required for his/her Support for Bed mobility. Interview with the Executive Director (ED), on 03/11/2022 at 1:45 PM revealed the Comprehensive Assessment MDS would drive the care plan, and the care plan was the blueprint for resident care. The ED stated it should be what the facility implemented to help each resident and the care plan should be valid at all times. She stated she relied on her DON to ensure the clinical pieces were in place. Continued interview revealed she relied on the MDS Coordinator's weekly meetings with the district MDS to ensure residents' care plans were correct. She stated if the care plan was not valid it would take away the resident's ability to reach his/her full potential. The ED stated if all the items CNA #6 needed to care for Resident #189 had been near her, there was a good chance Resident #189 would not have fallen.

Based on observation, interview, record review, and review of the facility's policy review, it was determined the facility failed to ensure residents were free from unnecessary restraints for one (1) of twenty two (22) sampled residents (Resident #139). The findings include: Review of the facility's policy titled, Restraints, dated 11/28/2017, revealed the facility respected the right of patients (residents) to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Review of Resident #139's closed clinical record revealed the facility admitted the resident on 10/18/2021, with diagnoses of Acute and Chronic Respiratory Failure, Unspecified with Hypoxia or Hypercapnia; Heart Disease Unspecified; Acute Kidney Failure Unspecified; Unspecified Atrial Flutter; Gout Unspecified; Anxiety Disorder Unspecified; Essential (Primary) Hypertension; Other Chronic Pain; Alcoholic Hepatitis; Alcohol Dependence with withdrawal; Disorientation; and Wernicke's Encelopathy. Review of Resident #139's Minimum Data Set (MDS) Admission Assessment, dated 10/25/2021, revealed the MDS Assessment did not provide a Brief Interview for Mental Status (BIMS) score, but further review of the MDS revealed the resident was assessed as having an anxiety disorder, and was assessed as having cognitive loss/dementia, and needing assistance with personal care. Review of Resident #139's Comprehensive Care Plan (CCP) dated 12/28/2021, revealed the resident had a behavioral component in the care plan to address behaviors such as self-removal of his/her tracheotomy (trach) tube, self-removal of Gastrostomy (G)-tube, self-removal of midline, and physical aggression with staff during care. The care plan's goal was for the resident to not cause harm or injury to self or others over the next ninety (90) days. Interventions included removing the resident from the situation, allowing time to calm down, and establishing limits for inappropriate behavior. Further review of the CCP revealed the facility care planned Resident #139 for Anxiety. The goals stated periods of distress from anxiety would be reduced/managed through the next review date. Interventions included touch the resident's hands/shoulder to show caring or provide comfort, provide one- to-one (1-1) interaction; read a story/talk about events, give anti-anxiety medications ordered by the physician, and offer non-pharmacological interventions such as diversional activities, massage, therapy, ginger ale, or environmental changes. Interview with Licensed Practical Nurse (LPN) #6 on 03/11/2022 at 5:00 PM, revealed LPN #6 saw Resident #139 at 4:00 AM and he/she was asleep. Around 5:00 AM, LPN #6 went in to give the resident his/her medication. LPN #6 said she pulled back the covers and saw a sheet tied to the bed rail and the resident's arm wrapped in it. LPN #6 removed the resident's arm from the sheet, completed a skin check, and assessed the resident for injury. Further interview revealed there were no injuries. Then, LPN #6 stated she went to the Charge Nurse and informed her of the situation. LPN #6 stated she also did a quick check of other residents on the unit and found no other restraints. She stated she was on her lunch break when CNA (certified nursing assistant) #2 restrained the resident. LPN #6 described Resident #139 as restless at times. Continued interview revealed sitting with Resident #139, talking to him/her, and holding his/her hand helped calm the resident. The LPN stated sometimes it took four to five (4-5) minutes, sometimes it took twenty-thirty (20-30) minutes, as the time spent could vary with this resident. Interview with CNA #2 on 03/09/2022 at 10:45 AM, revealed he was the staff person who secured the resident's arm with a bed sheet. CNA #2 said Resident #139 was pulling on his/her tracheostomy tube and CNA #2 said it was his rather quick judgment to just help to keep the resident still. The CNA stated restraining the resident's arm was not done with an intention to hurt the resident. CNA #2 said he was sitting next to the resident, but then tried to sit outside the room. He stated, first, he used several blankets to try to apply weight to the resident's hands. Then he took the blankets off the resident and loosely looped a sheet around Resident #139's right arm, and secured it to the bed rail. CNA #2 stated he had not done anything like that before. CNA #2 said before the incident, Resident #139 was combative and tried to pull on his/her trach tube. Review of the facility's investigation, signed on 12/31/2021 by the Executive Director, revealed due to Resident #139's cognitive impairment, the facility staff was unable to interview the resident. Further review revealed LPN #6 assessed the resident, with no injuries identified. The facility removed CNA #2 from duty, and suspended him. Skin assessments and psychosocial assessments were performed on all residents with a BIMS scores under eight (8). A Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director. The facility provided education to all staff on Abuse, Resident Rights, the Restraint Policy, what constituted restraint, and the appropriate process for the addition of a restraint device in an urgent resident safety situation. Interview with the facility's Clinical Social Worker (CSW) on 03/09/2022 at 1:15 PM, revealed Resident #139's mental status was altered. He/she had a history alcohol issues and went through withdrawal. The CSW said the resident pulled his/her tubing and tried to get out of bed. The staff tried alternative interventions like adjusting his/her medication and turning the resident in different positions. The CSW said she tried to assess Resident #139 after the incident, but the resident was not able to communicate with her. She said Resident #139 was not able to express his/her feelings. Further interview revealed the CSW stated CNA #2 could have tried alternative interventions such as giving the resident something to hold, something to fiddle with like tubing or a stress ball, hold his/her hand, or sit with the resident. Review of Certified Nursing Assistant (CNA) #2's Education/Competency records dated 03/19/2021, revealed he had taken a training on abuse. Interview with the Director of Nursing (DON) on 03/09/2022 at 1:50 PM, revealed CNA #2 stated he restrained the resident. The DON said Resident #139 had a history of Wernicke's Encelopathy (a neurological disease characterized by three main clinical symptoms: confusion, the inability to coordinate voluntary movement (ataxia) and eye (ocular) abnormalities.) and he/she was a challenge. She said the resident pulled at his/her G-tube (gastro tube/feeding tube) a lot. Continued interview revealed it calmed the resident down if someone sat with him/her and held his/her hand, or would just be present. The DON stated she reported the incident to the resident's physician and family. Interview with Executive Director (ED) on 03/11/2022 at 3:15 PM, revealed she was notified about the incident. She was told that LPN #6 pulled the cover down and saw Resident #139's right arm secured to the bed rail with the sheet. The sheet was tied to the bed rail and then looped around the resident's right arm. The ED said the sheet was not was not tied tight. There were no any injuries. First, she was informed one (1) of the Respiratory Therapists (RT) told CNA #2 to do this. She said the RT and CNA #2 had taken turns staying with Resident #139 that night, but RT did not tell CNA #2 to restrain the resident. The Charge Nurse interviewed the RT, and he was adamant he did not tell CNA #2 to do that to the resident. The ED said CNA #2 was frustrated, he broke down, and that was why he did it. The resident was grabbing his/her tubing pretty consistently. She said the CNA stated it was a pretty bad night. She stated the RT was not involved. The ED stated CNA #2 was suspended from duty. The staff assessed residents who had similar needs as Resident #139. Resident #139 came from a different facility and was heavily medicated. She said the facility staff was able to wean him/her off the ventilator, and he/she was transferred to a facility closer to his/her family. The ED stated facility staff were not to restrain residents physically or chemically. She said staff were re-educated on restraints, abuse, and neglect. And, that nurses continued to spot check their residents. The ED stated the social worker also talked with the residents to determine if they felt safe at the facility. She stated the facility continued to provide education on abuse. The Charge Nurse checked all residents on the unit after the incident. The ED stated the incident was reviewed at the facility's Quality Assurance Performance Improvement (QAPI) meeting.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure controlled substances that required refrigeration were secured within a permanently affixed locked container within the refrigerator in one (1) of (2) medication rooms, the East Unit medication room. The findings include: Review of the facility's policy, Medication Management, dated 08/31/14, revealed medications were stored appropriately according to manufacturer's guidelines, and to prevent unauthorized access. Medication were stored under proper condition of sanitation, light, ventilation, segregation, and security, following manufacturer's recommendations or those of the supplier as well as in compliance with applicable federal and state laws/regulations and accreditation standards. Observation of the East Unit Medication Room, with Registered Nurse (RN) #1, on 08/08/18 at 2:26 PM, revealed the medication refrigerator contained a narcotic box with ten (10) vials of [MEDICATION NAME] 2 milligrams. The narcotic box was locked; however, in was not permanently affixed within the refrigerator. Interview with RN #1, on 08/09/18 at 1:45 PM, revealed someone could possibly pick up the narcotic box and walk out of the facility with it. RN #1 also stated someone could open the vials, remove the contents of the vials, and put the vials back in the refrigerator. Interview with Licensed Practical Nurse (LPN) #1, on 08/09/18 at 1:55 PM, revealed the narcotic box should be kept secured in order to prevent someone from walking out with the narcotics. LPN #1 stated it was very important to make sure all narcotics were secured. Interview with the Director of Nursing (DON), on 08/09/18 at 3:25 PM, revealed it was important to have the narcotic box permanently affixed in refrigerator so people could not steal the medications, as someone could potentially walk away with the narcotic box. The DON also stated if someone took the medication, residents would not be able to get the medication they needed. Interview with the Executive Director, on 08/09/18 4:06 PM, revealed she was not aware there was an issue with the locked box in the medication refrigerator. She stated she reviewed the regulation and determined the box needed to be affixed and the facility's box was not.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, and distribute food in a sanitary manner. Observation during tour of the kitchen revealed expired food, undated food items, no monitoring of the ice cream freezer temperature, and scattered empty boxes and condiment packets on the floor. In addition, staff failed to wear appropriate hair covering and did not know the holding temperatures for food. The findings include: Review of the facility's policy, Personal Hygiene and Handling Food, dated June 2016, revealed staff was to wear hair restraints such as hats, hair coverings, or nets, and beard restraints at all times when in the kitchen. Facial hair should be neatly trimmed and covered by mask or beard guard. Review of the facility's policy, Healthcare Food Storage Guidelines, dated 09/04/12, revealed pasta, uncooked, expired in two (2) to three (3) years, vinegar expired in twelve (12) months after opening, sauces expired in six (6) to twelve (12) months, and mayonnaise in two (2) to three (3) months after opening. Observation during initial tour of the kitchen, on 06/11/17 at 9:00 AM, revealed four (4) bottles of non-dairy creamer with expiration dates of May 2017. The tray line refrigerator contained two (2) crates of fat-free milk with expiration dates of 06/09/17. Further observation revealed in the Cook's refrigerator, there was a pan of gelatin undated and partially gone and a one (1) gallon jug of opened mayonnaise with no date indicating when staff had opened. The dry storage area contained a bag of pasta opened and undated. Further observation during initial tour revealed the freezer for ice cream did not have a thermometer or a temperature log. Interview with the Cook, on 06/11/17 at 09:15 AM, revealed it was important to label all opened food items with a date so everyone would know if it was expired. She stated expired food could make residents sick. Interview with the Kitchen Manager, On 06/12/17 at 2:24 PM, revealed staff did not monitor the temperature of the ice cream freezer. He stated staff would know if the freezer was not working by the frost on the sides of the freezer would melt and water would drain out of the back. He stated if staff did not remove expired milk from the refrigerator, it could be given to a resident and would taste bad. Observation of the kitchen, on 06/13/17 at 11:15 AM, revealed a gallon container of soy sauce opened and undated with residue around the cap and down the side of the container. There was a gallon container of apple cider vinegar opened and undated on the shelf below the stove. Further observation revealed empty cardboard boxes and sugar substitute packets on the floor. Continued observation of the kitchen, on 06/13/17 at 11:17 AM, revealed the Dietary Aide (DA) obtained food temperatures of the tray line. She took the temperature of the turkey patties and announced a temperature of 133 degrees Fahrenheit (F). She proceeded to write the temperature in the temperature log and continued measuring the temperatures of the other food items. After surveyor intervention, the DA obtained the temperature of another turkey patty that resulted 178 degrees F. Interview with the DA, on 06/13/17 at 11:17 AM, revealed she did not know what the appropriate holding temperature was for turkey patties. Further observation of the kitchen, on 06/13/17 at 11:30 AM, revealed the Kitchen Manager did not have his beard covered during tray line service. Interview with the Kitchen Manager, on 06/13/17 at 11:30 AM, revealed he did not have a cleaning schedule and did not keep a cleaning log because it was part of the dietary employees' job descriptions. He stated kitchen cleaning was monitored when he and the Supervisor performed weekly walk through inspections. Interview with the Registered Dietician (RD), on 06/13/17 at 2:00 PM, revealed employees entering the kitchen were required to wear hair and beard coverings. The RD stated they were necessary to protect hair from dropping into food. Further interview revealed food temperatures were obtained to ensure food was served at a safe temperature and staff obtaining the temperatures should be knowledgeable of temperature parameters for food on the steam table. She stated staff would need to know the appropriate temperatures in order to be able to report unsafe temperatures. Observation of the kitchen, on 06/14/17 at 12:25 PM, revealed Registered Nurse (RN) # 2, did not have his hair and beard covered while putting condiments into bags. The cardboard boxes and sugar substitute packets remained on the floor. Interview with RN #2, on 06/14/17 at 12:25 PM, revealed he had been told that a hair net was only required when working the tray line and he was never told to cover his beard. Interview with the Kitchen Manager, on 06/14/17 at 12:25 PM, revealed staff should sweep the floor at end of the shift, which would include the area where the boxes and condiment packets were. He stated some of the boxes observed on 06/14/17, were there from the day before. Interview with the Acting Administrator, on 06/14/17 at 11:25 AM, revealed hair and beard coverings were worn anytime contact with food occurred for sanitary and infection control reasons. Further interview revealed the kitchen should be clean and without debris and dirt. The Administrator stated she did not directly monitor the kitchen and had not received any concerns regarding the kitchen.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to check placement of the gastrostomy tube ([DEVICE]) prior to administering medication for one (1) of twelve (12) sampled residents, Resident #1, and two (2) of three (3) unsampled residents, Unsampled Residents B and C. In addition, staff crushed and placed all of Unsampled Resident B's medications in one (1) cup to be administered. The findings include: Review of the facility's policy, Tube Placement Verification and Gastric Residual Volume (GRV), dated 05/28/15, revealed GRV was checked in enterally fed patients to protect against aspiration pneumonia and to monitor tolerance of enteral feeding and gastric emptying. The placement of the gastric tube was checked by aspiration to validate that the tube was in the stomach. The policy further revealed placement verification should be done before each feeding or flush, before administering medications, and before a residual check. Twenty (20) to thirty (30) milliliters of air should be drawn up in a syringe and instilled through the tube. Review of the facility's policy, Administration of Medication through an Enteral Feeding Tube, dated 05/28/15, revealed the tube should be checked for placement and patency and flushed with warm fresh tap water. The medication should be mixed with warm tap water and administered. After the medication was administered, the tube should be flushed with tap water. The steps were to be repeated until all medications had been given. Observation of medication administration, on 06/12/17 at 11:30 AM, revealed Resident #1 had tube feeding formula infusing per [DEVICE] and Licensed Practical Nurse (LPN) #3 put it on hold. LPN #3 flushed the [DEVICE] with water without verifying placement of the [DEVICE]. LPN #3 checked for residual after flushing the [DEVICE] and then administered the medication. Observation of medication administration, on 06/12/17 at 05:00 PM, revealed LPN #4 administered Unsampled Resident C's medications per [DEVICE] without checking for placement of the [DEVICE] first and did not flush with water prior to medication administration. Observation of medication administration, on 06/13/17 at 9:15 AM, revealed LPN #2 crushed Unsampled Resident B's five (5) medications together then placed them all in one (1) cup and mixed with water. LPN #2 verified [DEVICE] placement, checked for residual, and then administered the cup of mixed medications via the [DEVICE] and flushed with water after administration. Interview with LPN #1, on 06/13/17 at 8:55 AM, revealed staff should always check placement of the [DEVICE] prior to administering fluids or medications because staff would not want to give medications if the tube was not in the proper place. LPN #1 further revealed staff should flush the [DEVICE] with water before and after each medication given. Interview with the Acting Administrator, on 06/13/17 at 1:45 PM, revealed staff should verify [DEVICE] placement prior to administration of medications and fluids. The Administrator stated checking placement ensured medications or fluids were not instilled somewhere they were not supposed to be, for example in the peritoneal area. The Administrator further revealed each medication should be in separate cups and should be flushed with water before and after administration of each medication. Interview with the Director of Nursing, on 06/14/17 at 10:30 AM, revealed nurses should check placement of the [DEVICE] prior to administering medication. [DEVICE] medications should be given individually with a flush of water in between each medication.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain infection control measures to prevent transmission of infection for one (2) of fourteen (14) sampled residents, Resident #1 and #3, and two (2) of three (3) unsampled residents, Unsampled Residents A and B. Observation revealed staff entered Resident #3's isolation room without donning Personal Protective Equipment (PPE) and did not perform hand hygiene prior to exiting the room, and staff failed to clean Resident #1, and Unsampled Residents A and B gastrostomy tube ([DEVICE]) syringes after use. In addition, hand hygiene was not performed after medication administration. The findings include: 1. Review of the facility's policy, Transmission-Based Precautions, dated 09/07/16, revealed staff was to use appropriate PPE when exposure was anticipated and discard the PPE before exiting the resident room. Further review revealed for contact precautions, appropriate PPE was to be used per Standard Precautions, including use of gown and gloves, and to practice hand hygiene prior to leaving the room. Review of Resident #3's clinical record revealed the facility admitted Resident #3 on 07/16/12, with [DIAGNOSES REDACTED]. Further review revealed the physician ordered contact isolation on 04/18/17, due to the history of KPC. Review of Resident #3's Care Plan, revised 05/11/17, revealed staff was to adhere to Contact Precautions to prevent infection related to the presence of a gastrostomy tube and tracheostomy. Observation of Resident #3's door, on 06/11/17 at 9:30 AM, revealed a sign for contact isolation and to see the nurse prior to entering. Observation of Resident #3's wound care, on 06/14/17 at 8:10 AM, revealed Registered Nurse (RN) #1 entered Resident #3's room without donning PPE and exited the room without performing hand hygiene and went to the medication cart. Interview with RN #1, on 06/14/17 at 8:10 AM, revealed he should have donned PPE but was nervous and forgot. Interview with Director of Nursing (DON) and Acting Administrator, on 06/14/17 at 8:45 AM, revealed there was no reason staff should enter an isolation room without putting on PPE. They stated that would present the opportunity to transfer infection to other residents. 2. Review of the facility's policy, Administration of Medication through an Enteral Feeding Tube, dated 05/28/15, revealed the medication administration syringe should be rinsed with fresh tap water until it was clear and stored in a designated location for feeding syringes. Observation of medication administration, on 06/12/17 at 11:30 AM, revealed Licensed Practical Nurse (LPN) #3 had finished the [DEVICE] administration of Resident #1's medications and placed the syringe, used for administering the medication, back into the plastic bag hanging on the pole without rinsing it with water and performing hand hygiene. Observation of medication administration, on 06/12/17 at 05:00 PM, revealed LPN #4 had finished the [DEVICE] administration of the medications for Unsampled Resident C and placed the syringe, used for administering the medication, back into the plastic bag hanging on the pole without rinsing it with water. Observation of medication administration, on 06/13/17 at 9:15 AM, revealed LPN #2 had finished the [DEVICE] administration of the medications for Unsampled Resident B and placed the syringe, used for administering the medication, back into the plastic bag hanging on the pole without rinsing it with water. LPN #2 removed his gloves after putting the syringe in the bag and went back to the medication cart without washing or sanitizing his hands. LPN #2 signed the narcotic sheet and wrote on some papers. Interview with LPN #2, on 06/13/17 at 9:30 AM, revealed he should have washed his hands after he finished giving Unsampled Resident B's medication and before going to the medication cart. Interview with LPN #1, on 06/13/17 at 8:55 AM, revealed staff should rinse the syringe used for administering [DEVICE] medications when finished to keep residual from sitting in the syringe. The syringe could harbor bacteria if left unclean. Interview with the Acting Administrator, on 06/13/17 at 1:45 PM, revealed nurses should rinse the syringes used for administering [DEVICE] medications with water after they used them and wash or sanitize hands before going on to something else. Interview with the DON, on 06/14/17 at 10/30 AM, revealed nurses should clean the [DEVICE] syringe after medication administration to ensure no medication or gastric contents remained in the syringe, it could be an infection control issue. She stated nurses should wash their hands after removing gloves to prevent spreading infection to another resident.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications ready for use were not expired for one (1) of two (2) medication rooms. Two (2) vials of Gentamicin stored in the Emergency Medication Box had expired January 2015. The findings include: Review of the facility's policy titled Emergency Medication Supplies, dated 12/01/07, revealed the facility was to ensure Emergency Medication Supplies remained in the facility until either an item was withdrawn or its contents was about to expire. In either case, the facility contacted the pharmacy for a replacement. The facility implemented an On-Demand Exchange System whereby the pharmacy exchanged the emergency medication supply box on a staggered-exchange scheduled basis. During the interval between exchanges, the facility notified the pharmacy of any withdrawals or discrepancies. The facility returned opened boxes to the pharmacy for review and reconciliation of any discrepancies. Observation of the Central medical room, on 04/01/15 at 1:30 PM, revealed the emergency medication supply box contained two (2) expired vials of Gentamicin 80 mg per two (2) milliliters (ml). The medication expired January 2015. Review of the medication list on the outside of the box, not dated, revealed the medication Gentamicin 80 mg/2 ml, with a quantity of two (2) vials, with an expiration date of January 2015. Interview with Registered Nurse (RN) #1, on 04/01/15 at 1:30 PM, revealed the medication Gentamicin 80 mg/2 ml located in the emergency medication kit had an expiration date of January 2015. The RN stated Gentamicin was an antibiotic medication used to treat certain types of infections. RN #1 stated the RN's could have mixed this medication for patient use if a physician prescribed this medication to a resident. She stated it was the responsibility of the nurse to check the medication's expiration date prior to administering to a resident; however, the potential existed for a nurse to administer the medication to a resident. RN #1 stated the manufacturer placed an expiration date on the medication for a reason she was unsure of, but would not have given an expired medication to a resident, as the medication may not be safe or effective. RN #1 further stated a resident could experience a delay in starting the medication, because the medication in the emergency medication box was expired. The nurse would have to call the pharmacy and have the medication delivered STAT. The RN stated the STAT reorder could take 4 hours, delaying the resident from starting the antibiotic treatment on time. Interview with the Director of Nursing (DON), on 04/01/15 at 2:00 PM, revealed the Pharmacy maintained the medications in the emergency medication boxes. The DON stated the pharmacy replaced the entire medication box twice per week. The DON stated the potential outcome of the medication in the emergency medication box being expired was a nurse could administer the expired medication to a resident. Additionally, there was the potential for a delay in starting the antibiotic treatment prescribed to the resident if the nurse verified the medication was expired prior to administration of the medication. The DON further stated the pharmacy last replaced the emergency medication box on the Center Hall medication room on 03/23/15. Interview with the Pharmacy Representative, on 04/01/15 at 2:30 PM, revealed expired medications in the emergency medication box was a problem because, if administered, the medication could be less effective. The manufacturer did not guarantee the potency of a medication after the expiration date. The Pharmacy Representative discussed the process for checking and changing out the emergency medication box at the facility. A courier delivers the emergency medication box from the facility to the pharmacy. A Pharmacy Technician pulled expired medications and replaced expired or missing medications from the emergency medication box. The Pharmacist visually inspected the emergency medication box to ensure the medications are accurate and in date. If the Pharmacist found expired medication, he would ask the Pharmacy Technician to replace the medication. The pharmacy would then send the emergency medication box to the facility via courier service.

Based on observation, interview, and record review, it was determined the facility failed to have sufficient nursing staff to provide showers for three (3) of three (3) sampled residents, Resident #1, #2 and #3. The findings include: No policy was provided by the facility regarding staffing. Review of the Nursing Schedule for the Month of April 2014, revealed on 04/03/14, there were two (2) Licensed Practical Nurses (LPN) on duty of the three (3) LPNs scheduled and four (4) Certified Nursing Assistants (CNA) of the five (5) CNA scheduled. On 04/04/14 there were 2.67 LPNs of the three (3) LPNs scheduled and three (3) of the five (5) CNAs scheduled. On 04/06/14 there were two (2) LPNs of the three (3) LPNs scheduled and four (4) of the five (5) CNAs scheduled. On 04/08/14 there were two (2) LPNs of the three (3) LPNs scheduled and four (4) CNAs of the five (5) CNAs scheduled that were on duty. On 04/12/14, there were two (2) LPNs of the three (3) LPNs scheduled and four (4) CNAs of the five (5) CNAs scheduled on duty. On 04/13/14 and 04/14/14, there were two (2) LPNs of the three (3) LPNs scheduled and four (4) CNAs of the five (5) CNAs scheduled on duty. On 04/18/14 there were two (2) LPNs of the three (3) LPNs scheduled and 3.83 CNAs of the five (5) CNAs scheduled on duty. On 04/22/14 there were three (3) CNAs of the five (5) CNAs scheduled on duty. On 04/25/14 there was 3.67 CNAs of the five (5) CNAs scheduled. On 05/01/14 there were 3.83 CNAs of the five (5) CNAs scheduled that were on duty. Record review of the Nursing Schedule for the month of May, revealed on 05/03/14, 05/04/14, 05/06/14 and 05/08/14 there were four (4) CNAs of the five (5) CNAs scheduled. On 05/09/14 there were two (2) LPNs of the three (3) LPNs scheduled and four (4) CNAs of the five (5) CNAs present. On 05/11/14, 05/12/14 05/15/14 and 05/16/14 there were four (4) CNAs of the five (5) CNAs scheduled. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 07/26/12, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) Quarterly assessment, dated 03/18/14, revealed the facility assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which meant the resident was interviewable. Review of Resident #1's Treatment Record for the month of April 2014, revealed out of the thirty (30) days in April, no showers were documented as given. Review of Resident #1's Treatment Record for the month of May 2014, revealed out of twenty-nine (29) days, only one (1) day, 05/23/14, was documented that Resident #1 had received a shower. Observation of Resident #1, on 05/29/14 at 12:32 PM, revealed Resident #1's hair looked oily and matted to the back of his/her head. 2. Review of Resident #2's record, revealed Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's MDS Quarterly assessment dated 04/25/14, revealed the facility assessed Resident #2 with a BIMS score of thirteen (13) which meant the resident was interviewable. Review of Resident #2's Treatment Record for the month of April 2014, revealed no documentation that a shower was given. Review of Resident #2's Treatment Record for the month of May 2014, revealed no documentation that a shower was given. 3. Review of Resident #3's clinical record revealed the facility admitted the resident on 05/29/13, with [DIAGNOSES REDACTED]. Review of Resident #3's BIMS scores revealed the facility assessed Resident #3 with a BIMS of fourteen (14) which meant the resident was interviewable. Review of Resident #3's Treatment Record, for the month of April 2014, revealed out of thirty (30) days, Resident #3 was not given any showers. Review of Resident #3's Treatment Record for the month of May 2014, revealed out of twenty-nine (29) days, Resident #3 was not given any showers. Observations made of Resident #1, on 05/29/14 at 12:32 PM and Resident #3, 05/28/14 at 3:20 PM revealed both Residents #1 and #3 had oily hair. Resident #3 also was observed to have red pea sized patches on the scalp with white flakes. Interview with CNA #2, on 05/30/14 at 8:57 AM, revealed on March 21 st, 2014, CNA #2 had sustained an injury to her head in which she had to be placed on light duty until the first week of May 2014. While on light duty, the Director of Nursing (DON) had instructed the staff to complete full bed baths on residents during their shower days. CNA #2 stated when she came off of light duty, she had completed showers twice a week for three weeks. CNA #2 stated there were some residents who were not receiving their baths and that she was not following the schedule. Interview with the Respiratory Therapist (RT), on 05/29/14 at 11:05 AM, revealed she tried to give every one a shower. The RT stated she knew that they had missed residents, but she had tried to bath those residents who really wanted a shower. The RT stated generally she could bath six (6) to eight (8) patients a day. The RT stated that it was a staffing issue as to why the residents were not receiving showers and not a respiratory concern. Interview with the Unit Manager, on 05/30/14 at 9:49 AM, revealed when CNA #2 was on light duty, management had recognized the difficulties of residents obtaining showers and that was why staff were instructed to give bed baths. The Unit Manager stated that she had utilized CNA #2 in another capacity because she had some staffing challenges. The Unit Manager stated that CNA #2 had been completing some Aid work. The Unit Manager stated normally she tried not to pull the shower aid and that the shower aid was the last resort. The Unit Manager stated if the residents did not receive one shower a week, she would take it to the management team and collectivity try to fix the matter. The Unit Manager stated she was not aware that some of the residents did not receive their one shower as written on the shower log for the last three (3) weeks. Further interview with the Unit Manager, on 05/30/14 at 3:19 PM, revealed the staffing problems were occurring with the aids. The Unit Manager stated it was hard to staff Aids back in April. The Unit Manager stated that when you see four (4) of five (5) staff members on the hall, she would try to give less to the aid that had the split hall or the aid that had the back of the center hall, but the staff would take on ultimately more residents. If you look at the staffing sheet and see three (3) of five (5) aids, then she would have to have one (1) aid take the whole hall and two (2) aids would split center hall. The Unit Manager stated that if the nursing staff were full she would pull a nurse to work as an aid to lighten the load. The Unit Manager stated she was having some nursing concerns as well and if she was short a nurse she could not pull the nursing staff and then they would have to utilize the shower aid to work the floor. The Unit Manager stated that there was high turn over in the month of April. She would hire aids and then when they would do orientation on the unit, they would quit. The Unit Manager stated that she was working on trying to find a way to retain new employee's. Interview with the Director of Nursing (DON), on 05/30/14 at 10:58 AM, revealed CNA #2 was on the schedule to give showers, but did not complete showers everyday. CNA #2 would go around and ask resident's if they wanted showers and if the resident did not want the shower then the resident would receive a bed bath. The DON stated she has not trained another staff member to give showers to the residents. The DON stated that CNA #2 has taken on other assignments and was trying to fill holes because in the last few months she has had some staffing problems. CNA #2 had been pulled and assigned residents. Further interview with the DON, on 05/30/14 at 4:06 PM, revealed she had noticed some staffing changes in the months of March and April. The DON stated she had been hiring to replace and fill the positions. The staff would say that they could handle the residents on the ventilators and as soon as the staff come out of orientation they just stated that they can not handle the job. The new staff can not adjust to the high acuity. The DON stated she tried to describe it for what it was and did not think the staff could grasp it. The DON stated she had tried to come up with ways to retain new employees, like placing there names on the welcome board and having management follow new employees and have frequent meetings. Interview with the Administrator, on 05/30/14 at 4:20 PM, revealed at times he knew they were not able to have a shower aid on the floor and was aware the shower aid was being pulled to the unit. The Administrator felt the unit was never understaffed.

Based on interview, record review and and review of the policy titled Documenting in the Patient's (Resident's) Medical Record, it was determined the facility failed to maintain accurate and complete clinical records for three (3) of three (3) sampled residents, Resident #1, #2 and #3 as it related to the documentation of showers being performed. The findings include: Review of the facility's policy regarding Documenting in the Patient's (Resident's) Medical Record, revised on 04/01/11, revealed medical records were maintained on each patient that were complete, accurately and completely documented with the residents status, the care and services provided. The Medical Record would be clear, concise and complete reflecting the patient responses to treatment, change in condition and changes in treatment and outcomes related to care received. 1. Record review of the shower log revealed Resident #1 was to receive showers on Wednesdays and Fridays. Review of the Treatment Record for the month of April 2014, revealed Resident #1 received partial baths (PB), on 04/01, 04/03, 04/09, 04/22, 04/23 and 04/24. Resident #1 received bed baths (BB), on 04/02, 04/18, 04/21, 04/25 and 04/28. There was evidence Resident #1 received services on 04/04, 04/05, 04/06, 04/07, 04/08, 04/10, 04/11, 04/12, 04/14, 04/15, 04/16, 04/17, 04/19, 04/20, 04/26, 0427, 04/29 and 04/30 during morning shift. No showers were documented for the month of April 2014. Review of the Treatment Record for the month of May 2014, revealed Resident #1 received PB, on 05/08, 05/13, 05/21, 05/25, 05/26, 05/27 and 05/29. Resident #1 received BB, on 05/09, 05/12, 05/16, 05/17, 05/18, 05/20, 05/22, 05/24, 05/28. Resident #1 received a shower (S), on 05/23. There was no evidence Resident #1 received services on 05/01, 05/02, 05/03, 05/04, 05/05, 05/06, 05/07, 05/10, 05/11, 05/14, 05/15 and 05/19 during morning shift. 2. Review of the shower log revealed Resident #2 was to receive showers on Wednesdays. Review of the Treatment Record for the month of April 2014, revealed Resident #2 received PB on 04/01, 04/02, 04/09 and 04/24. Resident #2 received a BB on 05/21. There was no evidence Resident #2 received showers for the month or services on 04/03, 04/04, 04/05, 04/06, 04/07, 04/08, 04/10, 04/11, 04/12, 04/13, 04/14, 04/15, 04/16, 04/17, 04/18, 04/19, 04/20, 04/22, 04/23, 04/25, 04/26, 04/27, 04/28, 04/29 and 04/30 during morning shift. Review of the Treatment Record for the month of May 2014, revealed Resident #2 received a PB on 05/01, 05/02, 05/03, 05/07 and 05/17. Resident #2 received a BB on 05/18. There was evidence Resident #2 received any showers for the month nor any services on 05/05, 05/06, 05/08, 05/09, 05/10, 05/11, 05/12, 05/13, 05/14, 05/15, 05/16, 05/18, 05/19, 05/20, 05/21, 05/22, 05/23, 05/24, 05/25, 05/26, 05/27, 05/28 and 05/29 during morning shift. 3. Review of the shower log revealed Resident #3 was to receive showers on Mondays and Fridays. Review of the Treatment Record for the month of April 2014, revealed Resident #3 received a PB on 04/27 and 04/28. Resident #3 received a BB on 04/09 and 04/15. There was no evidence Resident #3 received any showers for the month of April 2014 nor services on 04/01, 04/02, 04/03, 04/05, 04/06, 04/07, 04/08, 04/10, 04/11, 04/12, 04/13, 04/14, 04/16, 04/17, 04/18, 04/19, 04/20, 04/21, 04/22, 04/23, 04/24, 04/25, 04/26, 04/29 and 04/30 during morning shift. Review of the Treatment Record for the month of May 2014, revealed Resident #3 received a PB on 05/02, 05/03, 05/04, 05/17 and 05/18. Resident #3 did not receive any BB or showers in the month of May. There was no evidence Resident #3 received services on 05/01, 05/05, 05/06, 05/08, 05/09, 05/10, 05/11, 05/12, 05/13, 05/14, 05/15, 05/16, 05/19, 05/20, 05/21, 05/22, 05/23, 05/24, 05/25, 05/26, 05/27, 05/28, 05/29 during morning shift. Interview with CNA #2, on 05/29/14 at 10:11 AM, revealed when she worked on the floor the CNA's were responsible to complete bed baths for the residents who were to have showers. Further interview with CNA #2, on 05/30/14 at 8:57 AM, revealed BB =Bed Bath, PB=partial bath and S=shower. CNA #2 stated the documentation was lacking and the staff needed to document better. CNA #2 stated that she thought the staff were documenting. CNA #2 stated she informed the aids when she had given a resident a shower and thought the aids were documenting the information. Interview with the Unit Manager, on 05/30/14 at 9:49 AM, revealed when she looked at the Treatment Record she seen a lot of signatures, but no documentation of showers being given. The Unit Manager stated she was not aware that CNA #2 was not documenting her showers. CNA #2 should be documenting when she had given her showers. The Unit Manager stated she had not completed any audits of the showers logs since her employment. The Unit Manager stated with nursing the rule was if it was not documented then it did not happen. Interview with the Director of Nursing (DON), on 05/30/14 at 10:58 AM, revealed she was not aware that CNA #2 was not documenting her showers that were given. The DON stated the documentation could be better and that CNA #2 needed to be documenting. Interview with the Administrator, on 05/30/14 at 4:20 PM, revealed he expected the staff to make sure the records were complete and accurate to what had actually taken place with the residents' showers.