Every finding on record at Kruse Village Senior Living Community

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen.The facility failed to ensure Dietary Aide C used proper hand hygiene between tasks on 05/05/2026. This failure could place residents who ate food from the kitchen at risk for foodborne illness.Findings include:Observation on 05/05/2026 at 11:50 am, revealed Dietary [NAME] C was wearing gloves when she obtained a disinfectant rag out of the disinfectant water container. She touched the rag with all of her fingers on her right hand. Dietary [NAME] C cleaned the food prep area with the disinfectant rag. She placed the rag into the disinfectant container. Dietary [NAME] C reached for an ink pen and began to write information on small pieces of paper. She never changed her gloves during these tasks. Dietary [NAME] C began to place food in a silver container with aluminum foil on top of the containers from the food prep area to the rolling kitchen utility cart. One of the containers with aluminum foil came loose on one side of the container. Dietary [NAME] C placed the aluminum foil on the corner of the silver container and the tip of her fore finger and middle finger touched inside the container, however, did not touch the food. Dietary [NAME] C continued to wear the same gloves. She obtained 2 large containers of spices and a lid to the top of one of the spice containers was loose. Dietary [NAME] C touched the top of the spice container with her middle and ring finger on her right hand as she was placing the top on the spice container. She carried the 2 spice containers to another area of the kitchen (right side of the kitchen and placed it on a shelf). Dietary [NAME] C removed her gloves and washed her hands. She placed new gloves on her hands.Interview on 05/05/2026 at 12:05 pm, Dietary [NAME] C stated she did not change her gloves when she used the disinfectant rag. She stated she did touch the containers of the food and moved the containers from the food prep table to the rolling cart. Dietary [NAME] C stated she was expected to remove her gloves, wash her hands and place new gloves on her hands anytime she touched anything considered contaminated. She stated the disinfectant rag was considered contaminated. Dietary [NAME] C stated she was not a nurse and could not say what may happen to a resident if bacteria was transferred to their food. She did not answer any other questions related to hand hygiene, possibility of transferring bacteria to resident food, and when she touched the container of spices. She stated she had been in-serviced on hand hygiene but did not recall the date.Interview on 05/06/2026 at 8:00 am, the Administrator stated she expected gloves to be changed, hands washed anytime staff touch contaminated items. She stated disinfectant rag and ink pen was considered contaminated. She stated there was a possibility if there was bacteria in food, a resident may develop a food borne illness. The Administrator stated the Dietary Manger was responsible for all protocols in the kitchen and she was responsible to monitor the Dietary Manager. Interview on 05/07/2025 at 10:45 am, the Dietary Manager stated if a staff did not directly touch food the staff was not required to change their gloves. The Dietary Manager stated Dietary [NAME] C did touch the disinfectant rag, touched container of food and the spice containers. She demanded the surveyor to quote the TEFER and the health department guidelines. The Dietary Manager stated she wanted more proof from the surveyor of what the Dietary [NAME] C did wrong with wearing gloves. The Dietary Manager demanded proof from the surveyor, in a loud tone. The surveyor stopped the interview and exited the kitchen.Record review of Dietary [NAME] C's orientation training, dated 04/30/2026, reflected training was completed on the following Sanitation Tasks (signed by the Dietary Manager and Dietary [NAME] C):Prevention of cross contaminationHand HygieneUse of GlovesSanitation buckets Record review of the facility's in-service on Sanitation/ Gove usage, dated 02/12/2026 given by the Dietary Manager reflected the following:Gloves should be removed and hands should be washed after each task.Do not reuse gloves.Hands should be washed after using the bathroom, changing task, eating/drinking, smoking, etc. Record review of the Facility's Policy on Hand Hygiene for Kitchen and Dietary Department, dated 05/2026, reflected All kitchen and dietary staff must adhere to strict hand hygiene practices to prevent foodborne illness, cross-contamination, and compliance violations under CMS regulations and state health codes. Handwashing occurs at designated sinks only, using soap and warm water for a minimum for 20 seconds. Hand sanitizer is permitted only after handwashing and never a substitute. Purpose: To ensure food safety in the Skilled Nursing Facility dietary department by minimizing pathogen transmission (the process by which infectious agents-such as bacteria, viruses, fungi, or parasites-move from a reservoir (an infected person, animal, or environmental source- to a susceptible host. This spread occurs through direct contact or indirect contact- contaminated objects) during food preparation, handling, service, as required for surveyor review during kitchen inspections.Scope: Applies to all dietary/kitchen personnel, including cooks, aides, servers, and managers in the food service area.When to Perform Hand Hygiene: Staff must wash their hands immediately:Upon entering the kitchen or starting a shift.Before donning gloves or handling clean utensils/equipment.Before preparing or serving ready-to-eat foods.After using the restroom, coughing, sneezing, eating, drinking, or touching face/hair/body.Between tasks or glove changes. Review of the Facility's Protocol for Hand Hygiene is from the Texas Food Establishment Rules, not dated, reflected S228.38. Hands and Arms. S228.38 (b)(3) S228.38 (d)(9).(d) When to Wash. Food employees shall clean their hands and exposed portions of theirarms as specified under subsection (b) immediately before engaging in food preparationincluding working with exposed food, clean equipment and utensils, and unwrapped single serviceand single-use articles.S228.44(2);(5) after handling soiled equipment or utensils;(6) during food preparation, as often as necessary to remove soil andcontamination and to prevent cross contamination when changing tasks;(7) when switching between working with raw food and working with ready-to-eatfood;(8) before donning gloves to initiate a task that involves working with food;and(9) after engaging in other activities that contaminate the hands.

Based on interview, and record review the facility failed ensure the comprehensive care plan, consistent with resident rights, included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of five residents (Resident #41) reviewed for care plans completion. The facility failed to ensure Resident #41's care plan was completed to reflect Resident #41 had a pacemaker.This failure could place residents at risk of not receiving appropriate interventions to meet their medical needs. Findings include:Record review of Resident # 41's face sheet, dated 05/05/2026, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses of presence of cardiac pacemaker ( a small, battery-powered medical device implanted under the skin, usually near the collarbone, to treat abnormal heart rhythms or heart failure), chronic atrial fibrillation, unspecified (an irregular and often very rapid heart rhythm. It can lead to blood clots in the heart. The condition also increases the risk of stroke, heart failure and other heart-related complications), biventricular heart failure (a serious condition where both the left and right ventricles- lower chambers- of the heart are weakened, failing to pump blood efficiently), and acute chronic combined systolic -congestive- and diastolic- congestive heart failure (a severe, emergency situation where the heart cannot effectively pump- systolic or fill- diastolic, leading to sudden worsening of fluid buildup - acute- on top of long-term -chronic- heart issues. Systolic -pressure measures arterial pressure during heart contractions, while diastolic measures pressure when the heart rests between beats)Record review of Resident #41's Quarterly MDS, dated [DATE], reflected Resident #41 had a BIMS score of 8 indicating her cognition was moderately impaired. She was assessed to have a diagnosis of presence of cardiac pacemaker and heart failure. Record review of Resident #41's Comprehensive Care Plan dated 04/08/2026 did not reflect Resident #41 had a pacemaker and a pacemaker transmitter.In an interview on 03/04/2026 at 11:50 a.m. the MDS Coordinator stated Resident #41 had a pacemaker and a pacemaker transmitter. She stated it was not documented on Resident#41's comprehensive care plan. The MDS Coordinator stated she missed documenting it on the care plan. She stated the purpose of having a Comprehensive Care Plan was to inform staff how to give the care each resident needed such as physical, behaviors, emotional, activities, type of diet and any other interventions to prevent falls or any injuries. She stated she was responsible to monitor the care plans to ensure they were correct and completed on time. The MDS Coordinator stated the information the CNAs follows on Kardex came from the care plan. She stated if a resident needed certain type of care or had behaviors and it was not care planned, the CNAs or nurses would not have that information to know what type of care to give the residents.In an interview on 03/04/2026 at 12:40 p.m. the DON stated her expectations was the care plan to be revised as needed. She stated Resident #41's pacemaker and pacemaker transmitter were expected to be care planned. She stated the care plan for each resident was a communication tool for all staff to know exactly what type of care and needs each resident needed. She stated anytime a health issue is documented on the MDS it was expected to be care planned.In an interview on 05/07/2026 at 8:20 am the Administrator stated her expectations of care plans was the IDT discuss care of each resident and if there was a change with anything including resident preferences the care plan was expected to be revised. She stated the IDT was expected to ensure the resident's information to give appropriate care to each resident was documented on the care plan whether it was physical, emotional, resident preference, activities, etc. The Administrator stated the charge nurse could make revisions to the care plan but ultimately it was the MDS Coordinators responsibility to ensure the care plan was completed and correct. She sated the IDT consisted of the following disciplines: DON, Social Worker, MDS Coordinator, Dietary Manager, Activity Director, Resident and Family. She stated staff had been in-serviced on how to document on the care plan; however, she did not recall the date of the in-service.Review of the facility's Care Plan Policy, dated 11/24/2025, reflected Residents receiving services will have a care plan in place. Care plans are based on the outcomes of initial and subsequent assessments, reassessments, monitoring, and individual reviews of the residents' needs and preferences. A care plan is a document that outlines the specific medical and rehabilitative services a patient needs and who will provide them. Developed by a team of healthcare professionals with input from the patient and/or their family, it is based on a comprehensive assessment of the patient's health status and helps guide their stay in the community. Care plans will be revised, if needed, based on resident assessments and monitoring.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #41) reviewed for quality of care. The facility failed to ensure that nursing staff ensured the pacemaker was being transmitted on Resident #41. This failure could place residents at risk for not being provided the care and treatment to meet their needs. Findings included: Record review of Resident # 41's face sheet, dated 05/05/2026, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses of presence of cardiac pacemaker (a small, battery-powered medical device implanted under the skin, usually near the collarbone, to treat abnormal heart rhythms or heart failure), chronic atrial fibrillation, unspecified (an irregular and often very rapid heart rhythm. It can lead to blood clots in the heart. The condition also increases the risk of stroke, heart failure and other heart-related complications),biventricular heart failure (a serious condition where both the left and right ventricles- lower chambers- of the heart are weakened, failing to pump blood efficiently), and acute chronic combined systolic -congestive- and diastolic- congestive heart failure (a severe, emergency situation where the heart cannot effectively pump- systolic or fill- diastolic, leading to sudden worsening of fluid buildup - acute- on top of long-term -chronic- heart issues. Systolic -pressure measures arterial pressure during heart contractions, while diastolic measures pressure when the heart rests between beats).Record review of Resident #41's Quarterly MDS, dated [DATE], reflected Resident #41 had a BIMS score of 8 indicating her cognition was moderately impaired. She was assessed to have a diagnosis of presence of cardiac pacemaker and heart failure.Record review of Resident #41's Comprehensive Care Plan dated 04/08/2026 did not reflect Resident #41 had a pacemaker and a pacemaker transmitter.Observation on 05/05/2026 at 11:03 am revealed an unplugged pacemaker monitor located on the floor of Resident #41's room. Resident #41 was not in her room.Interview on 05/05/2026 at 11:15 am Resident #41 did not respond to questions appropriately. She stated she was going to town with her mother.Interview on 05/05/2026 at 1:00 pm the DON stated her expectations for Resident # 41's pacemaker monitor was to be plugged in at all times. She stated any resident with a pacemaker needed to be transmitted via monitor. She stated if the pacemaker monitor was not plugged in there was a possibility Resident #41 may have heart issues without the staff knowing it. The DON stated she did not know why the monitor was not plugged in the electrical outlet. She stated no one had reported to her any issues with Resident #41's pacemaker monitors not being plugged in or found on the floor.Interview on 05/05/2026 at 1:30 pm the Primary Care Physician stated Resident #41 had not had any change of condition reported to him from the nursing staff. He stated Resident #41 had multiple heart issues and if she was having any changes with her heart the symptoms would be shown immediately related to her history with congestive heart failure (a chronic, progressive condition where the heart muscle becomes too weak or stiff to pump blood efficiently, causing blood and fluid to back up into the lungs, legs, and other tissues).Interview on 05/05/2026 at 1:50 pm LVN H stated it had been a busy day, and he did not recall if the pacemaker monitor was unplugged when he entered Resident #41's room to administer medication.Interview on 05/06/2026 at 8:40 am the DON stated she tested the pacemaker monitor on 05/05/2026 and the pacemaker was working and did transmit. She stated she contacted the cardiologist office and someone (she did not ask the person's name) stated there was no issue with the transmission and Resident #41 did not have any concerns about her heart or the pacemaker. Interview on 05/06/2026 at 8:45 am the Medical Assistant from the Cardiologist Office stated transmission came through on 05/05/2026 and there were no concerns. She stated Resident #41's chronic atrial fibrillation was well controlled. The Medical Assistant stated she had set up an appointment for Resident #41's routine checkup for 05/12/2026. She stated at this time there was no reason for any concern with Resident #41's pacemaker or her heart condition.Interview on 05/06/2026 at 8:50 am the DON stated her expectations were for the staff to check Resident #41 's pacemaker monitors every time a staff enters the room. She stated if the light was not on the monitor or if the monitor was unplugged, she expected the nurse supervisor and herself to be notified immediately. She stated she did not know how Resident #41's pacemaker monitor became unplugged. The DON stated Resident #41 was not interviewable and did not respond to the questions about the pacemaker monitor appropriately. Interview on 05/06/2026 at 9:15 am LVN Charge Nurse A stated the pacemaker monitor was plugged when she entered Resident #41's room on 05/06/2026. She stated, When I went into [Resident #41's] room the pacemaker monitor was always plugged in except for one time and that was almost a month ago. LVN Charge Nurse A stated, I in-serviced the staff on ensuring [Resident #41's] pacemaker monitor was always plugged into the electric outlet. She stated sometimes when the staff moved Resident #41's bed the monitor would come unplugged, but the staff would always plug it back into the outlet. LVN Charge Nurse A stated she was not completely certain what could happen if the pacemaker monitor was not plugged in for a very long period of time. She stated Resident #41 showed signs and symptoms of heart issues immediately due to having a lot of heart problems. LVN Charge Nurse A stated Resident #41 would have shortness of breath and become very dizzy. Requested the in-service LVN Charge Nurse A completed with the staff about the heart monitor being unplugged and it was not provided at time of exit.Interview on 05/07/2026 at 9:30 am LVN D stated he had given care to Resident #41 as a nurse and as a CNA numerous times since she was admitted to the facility approximately 6 months ago. He stated when he had entered Resident #41's room the pacemaker monitor has always been plugged in and sitting on her bedside table. He stated no one had mentioned to him of Resident #41's pacemaker monitor being unplugged. Interview on 05/07/2026 at 9:45 am CNA E stated she had given care to Resident #41 when she was first admitted to the facility for several weeks. She stated when she gave care to Resident #41 her pacemaker monitor was always plugged in and was located on the bedside table. CNA E stated no one had reported to her of finding Resident #41's pacemaker unplugged.Interview on 05/07/2026 at 10:00 am LVN Charge Nurse F stated she had given care to Resident #41 several times. She stated Resident #41's pacemaker monitor was always plugged in, and the light on the monitor was showing it was on and was working appropriately. She stated no one had reported to her of Resident #41 pacemaker monitor being unplugged. Review of the facility's policy of Nursing Services: Quality of Resident Care (General), revised on February 2023 reflected Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility ensures that each resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Quality resident care is comprised of an approach that meets the physical, psychological, social, and spiritual needs of the facility's residents, as determined through use of the nursing process.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #5). The facility failed to ensure Resident #5's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.Findings included:Record review of Resident #5's face sheet, dated 05/05/2026, reflected an [AGE] year-old-male admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, stage 3 unspecified (the kidneys are moderately damaged, with a 40-70 percent reduction in function. The exact substage is not defined), neuromuscular dysfunction of bladder, unspecified (a condition where nerve damage disrupts communication between the brain and bladder muscles, leading to inability to control urination), paraplegia, incomplete (a spinal cord injury that causes partial loss of motor function or sensation below the injury site, affecting only the legs and lower body).Record review of Resident #5's Annual MDS Assessment, dated 03/06/2026 reflected Resident #5 had a BIMS score of 15 indicating his cognition was intact. He was dependent on staff for the following ADLs: showers, toileting hygiene, lower body dressing, and transfers. Resident #5 was assessed to have an indwelling catheter.Record review of Resident #5's Comprehensive Care Plan, dated 03/16/2026, reflected Resident #5 had a potential for complications with bowel and bladder related to current medical and physical status. Resident #5 had supra pubic catheter (a thin, flexible, hollow tube inserted into the bladder through a small surgical incision in the lower abdomen, just above the pubic bone, rather than through the urethra ( a muscular elastic tube connecting he urinary bladder to exterior environment) 22 French with 10 balloon (Date initiated 09/25/2023 and revised on 4/19/2024) Interventions (date initiated on 3/13/2026) Resident #5 had catheter: 22 French/10 mL. Silicone catheter, position catheter bag, and tubing below the level of the bladder. Check that anchor is in place, tubing is not kinked, is off the floor, below the bladder and in a privacy bag. Record review of Resident #5's Consolidated physician's orders reflected an order date 08/21/2023 Catheter: check placement of leg strap every shift and prn.Record review of Resident #5's MAR for the months of April 2026 and May 2026 reflected an entry for catheter care every shift and PRN. Use catheter anchor and check placement every shift. Observation on 05/05/2026 at 1:00 pm Resident #5 was observed to have a supra pubic catheter. Resident #5 did not have a secure catheter. Interview on 05/07/2026 12:55 pm LVN G stated Resident #5 should have a secure catheter. She stated the nurses were in charge of monitoring catheters. LVN G stated she did observe Resident #5 catheter was not secured on 05/05/26. Interview on 05/07/2026 at 1:20 pm LVN G stated there was a possibility the catheter may pull out if not anchored and a possibility of infection around the stoma area. Interview on 05/07/2026 at 10:30 am the Director of Nurses stated she expected the nurses to follow physician's orders and care plan. She stated if Resident #5's catheter was not anchored there was a potential the pubic catheter could be pulled, irritate the stoma (a surgically created opening on the abdomen that allows waste ( stool or urine) to leave the body, bypassing a diseased or damaged section of the intestine or bladder), the stoma site may erode related to the tubing against the edge of the stoma and cause an infection. She stated Resident #5 pubic catheter was expected to be anchored at all times. Record review of the facility Catheter Care policy, revised on 10/2022, reflected Proper care will be provided for the management of a foley catheter to drain urine from the bladder and to prevent reflux of urine back into the bladder. The catheter may be anchored or stabilized to prevent urethral tension. It is recommended to anchor on the upper thigh in women or the abdomen in men.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage.The facility failed to ensure Medication Cart #1 was locked and medications were secured.This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.Findings included Observation on 05/07/2026 at 7:42 a.m. revealed the locking mechanism was protruding outward (indicated the medication cart was unlocked) on Medication cart #1 located on 400 hall near room # 404. There was not any staff in the hallway or at the nurses desk near the entrance to 400 hall. The door to room [ROOM NUMBER] was closed. Med- Aide B exited room [ROOM NUMBER] at 7:46 am.Interview on 05/07/2026 at 7:46 am Med-Aide B stated she forgot to lock the medication cart. She stated the door was closed to room [ROOM NUMBER] and she was unable to view the medication cart. She stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. Med Aide B stated if a resident did ingest medications the resident was allergic to there was a possibility the resident may have a reaction and possibly die. She stated a resident also had a potential of overdosing on medications or giving the medications to another resident. Med Aide B stated she had been in-serviced on locking medication carts; however, she did not recall the date of the in-service. She stated there were all types of medications prescribed by the physician in Medication Cart #1 except for narcotics.In an interview on 05/07/2026 at 9:30 a.m. LVN D stated the medication cart was to always be locked except when he was dispensing medications from the medication cart. He stated anytime a nurse or med-aide walked away from the medication cart it was to be locked. LVN D stated there was a possibility a resident may take medications from the cart. He stated if a resident ingested medications there was a possibility for an allergic reaction and possibly may need to go to the hospital for further evaluation. He stated he had been in-serviced on locking medication carts, however, he did not remember the date.In an interview on 05/07/2026 at 10:30 a.m. the Director of Nurses stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated she did not know the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse or medication aide's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated she was expected to monitor the nursing staff.Record review of the facility Medications, Labeling, and Storage Policy, revised on 11/2024, reflected Storage requirements: Locked med carts/ rooms; temperature monitored (68-77 degrees F, 36-46 degrees F fridge/freezer) with logs. Med Carts: locked when unattended; cleaned weekly; emergency kit stocked.

Based on observation, interviews, and record review, the facility failed to ensure residents were given the appropriate services to maintain activities of daily living (ADLs) for three of six (Resident #1, Resident #2, and Resident #3) residents. 1. Resident #1 had a soiled and stained top. 2. Resident #2 had soiled pants and unwanted facial hairs. 3. Resident # 3 had crumbs on the top of her blanket, unwanted facial hair, and had a brown substance under her fingernails. These deficient practices could place residents at risk of embarrassment and placing them at risk for social isolation, loss of dignity and self-worth. Findings included: 1. Record review of Resident #1's Face sheet dated 06/03/2025 revealed Resident #1 admitted on [DATE] was a [AGE] year-old female with diagnosis of Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), Epilepsy (is a brain disease that causes repeated seizures), Unspecified Atrial Fibrillation (is an irregular and often very rapid heart rhythm). Record review of Resident #1's MDS assessment revealed Resident #1 had a BIMS score of 06 which suggested she had severe cognitive impairment. The MDS reflected Resident #1 needed extensive assistance with toileting, shower/ bath, personal Hygiene, and partial to moderate assistance with upper and lower body dressing. Record review of Resident #1's care plan revealed Resident #1 was At risk for complications with deficits with ADLs. Interventions: The resident is dependent for Personal Hygiene. The resident requires partial to moderate assistance with upper body dressing, and she requires substantial/ maximal assistance with both lower body dressing. 2. Record review of Resident #2's Face sheet dated 06/03/2025 revealed Resident #1 admitted on [DATE] was a [AGE] year-old female with diagnosis to included Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), Obstructive and Reflux Uropathy (is when your urine can't flow through your ureter, bladder, or urethra due to some obstruction), Insomnia (having a hard time falling asleep at night). Record review of Resident #2's MDS revealed Resident #2 BIMS score was not available as the resident was unable to complete the interview. The MDS reflected resident #2 has impairment on both sides of the lower body and she uses a wheelchair. Resident # 2 is dependent for: oral care, toileting, shower, putting on and taking off footwear. Resident # 2 needs partial to moderate assistance for personal hygiene such as combing hair, applying makeup, washing, or drying her face and hands. Resident # 2 needs substantial assistance regarding upper and lower body dressing. Record review of Resident #2's care plan revealed Resident #2 was at risk and or has potential for complications with deficits with ADL's. The care plan stated Resident #2 required dependent assistance with dressing. 3. Record review of Resident #3's Face sheet dated 06/03/2025 revealed Resident #1 admitted on [DATE] was a 92 -year-old female with diagnosis of Unspecified Dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), Obstructive and Reflux Uropathy (When urine can't flow through your ureter, bladder, or urethra due to some type of obstruction), Insomnia (having a hard time falling asleep at night). Record review of Resident #3's MDS revealed Resident #3 had a BIMS score of 07 which indicated severe cognitive impairment. Residents Functional Abilities indicate that Resident # 3 requires substantial/ maximal assistance for oral hygiene, toileting, and personal hygiene, as well as bathing, upper body, and lower body dressing. Record review of Resident #3's care plan revealed Resident #3 was at risk and/or has potential for complications with deficits with ADLs. Interventions: Resident # 3 required dependent assistance with dressing and other grooming. During an attempted interview on 6/3/25 at 9:05 AM with Resident#1 revealed she was not able to converse with the Investigator. She was wearing a top that was disheveled and had a dried brown substance stain on it. During an interview and observation on 06/03/2025 at 9:24 AM revealed Resident # 2 was located at the nursing station, she was sitting in her wheelchair holding a stuffed animal to her chest. Resident was not conversant. Resident # 2's hair was slightly disheveled. There were some unkept facial hairs and crumbs were on her slacks. During an interview and observation on 06/03/25 at 8:58 AM revealed Resident # 3 was not conversant. Resident # 3 was sitting in a wheelchair by the nursing station. There were crumbs on her blue top and on a blue blanket that was situated on her lap. Her fingernails were painted but a brown substance was visible under and around her fingernails. Resident # 3's face was soiled and appeared unclean. During an interview with CNA A on 06/03/2025 at 2:50pm revealed that she was trained on ADLS. She said the training covered proper training includes, transfers, greetings, body care, feeding, bathing, clothing. She said the last time she had the training was recently in a mandatory meeting. She said the ADL policy was to change the resident right away, she said to do a check and change which meant staff were to check the resident and if needed change the resident. She said the CNAs were responsible for ensuring that the residents were clean and well groomed. She said it was important to provide ADL care to the residents to ensure that they do not have skin breakdown and it makes the resident feel good when they are clean and groomed. She said the charge nurse monitors to ensure that ADL care is being done. She said the nurse monitors it by doing a skin assessment, and checking the shower sheets, she said she did not know why Resident #1, Resident #2, and Resident #3 all had dirty clothing on. During an interview with CNA B on 06/03/2025 at 3:11pm revealed that she was trained on ADLS. She said the training covered, bathing, helping the resident with grooming cutting the resident's nails, clothing, and bathing the resident. She said the last time she had the training was in May. She said the ADL policy was to change the resident every two hours. She said they do a check and change which meant staff were to check the resident and if needed change the resident. She said the CNAs were responsible for ensuring that the residents were clean and well groomed. She also said that nail care was done on Sunday since there were no shower on Sundays. She said it was important to provide ADL care to the residents to prevent infection and skin She said the charge nurse monitors to ensure that ADL care is being done. She said the nurse monitored it by checking PCC charting. She said Resident #1, Resident #2 and Resident #3 may have gotten dirty at breakfast. During an interview with MA C on 06/03/2025 3:23pm revealed that she had been trained on ADLS. She said the training covered gate belt, transfers, changed every 2 hrs. She said she had the training during her 4 days of orientation. She said that the policy for ADLS was to do the check off list and greet the resident. She said staff should be providing care every two hours or PRN. She said that if a resident needed clothing changed or grooming that staff were supposed to get it done. She said everyone was responsible to ensure ADL care was done. She said it was important to do the ADL care because the residents could not do it themselves. She said by not doing ADL care for the resident could make them feel bad. She said that the Charge Nurse, and DON were responsible for monitoring that all staff did ADL care. She said that the nurse checks documentation in PCC. She said she did not know why Resident #1, Resident #2 and Resident #3 were in dirty clothing. During an interview with the DON on 06/03/2025 at 3:50 PM revealed that she had been trained on ADLS. She said the training covered grooming, teeth, nails, shampooing, bathing, dressing undressing, transfer lift. she said the facility had a 2-day ADL skills training March 2025 on Resident Rights. She said the policy for ADL care was provide whatever level of assistance they may need. Modified independence. She said ADL care should be provided when needed. She said grooming was an as needed thing, and it should be done on a regular basis. She said on Sundays the staff did extra care, like nail polish if it was wanted. she said the CNA, Charge nurse, ADON, DON were responsible for ensuring ADLS were done. She said it was important to make the resident feel better if they are clean and dry, they have a sense of well being and they have less skin breakdown. She said the resident would have dignity and feel good about themselves. she said if a resident was not groomed, or their clothing was dirty it might make the resident feel bad about themselves. She said the charge nurse was responsible for monitoring to ensure staff were doing ADL care. She said the charge nurse would look at POC every morning-to see docs, did they miss some documentation. She said she did not know why Resident #1, Resident #2 and Resident #3 were in dirty clothes. She said her expectation was that the residents would have been taken down to their rooms for cleanup. During an interview with the Admin on 06/03/2025 at 5:32 PM revealed that she and staff have been trained on ADL care. She said the training covered bathing, feeding, transferring, dressing. She said the last time she had the training was in February of 2025. She said the policy was to make sure residents received the amount. of ADL care they need. She said that staff should provide ADL care as needed daily. She said staff were to make sure all residents were looking presentable, looking nice. Oral care, hair is combed. She said that nursing assistants and charge nurse, and CNAs were responsible for providing ADL care. She said it was important for the residents overall grooming, everyone deserves dignity. She said that she assumed the resident would not like being dirty and that the residents wanted to be well presented. She said the charge nurses were responsible for monitoring to ensure staff did ADL care. She said the charge nurse monitored the ADL documentation is on PCC. Check on morning rounds also called Ambassador rounds. She said if something was noticed the staff should say something to the Admin. She said she did not know why Resident #1, Resident #2 and Resident #3 were left in dirty clothing. Record review of the facility's policy dated November 2023, revealed: A resident who is unable to carry out the activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene.

Based on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for residents residing on four of four halls. The facility failed to provide activities on the weekends for the months of February and March of 2025. This failure placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life. Findings include: Review of activity participation binder on 03/10/2025 reflected group activities did not occur in the facility on the weekends for the month of February 2025 and two weekends in March 2025 (03/01/2025 to 03/02/2025 and 03/08/2025 to 03/09/2025). Review of the Activity Director Personnel Record on 03/11/2025 reflected the Activity's Director's date of hire was 11/04/2024 and she did have her Activity Professional License (does not expire). Record review of Activity Calendar month of February and March 2025 reflected Activity Pact was the activity for Saturdays. Church Service and activty pact were the activities for Sundays. Observation on 03/09/2025 at 9:10 AM upon entering the rehabilitation unit revealed four residents sitting in a common area before entering the dining room. Two of the four residents' heads were leaning to the right side and they were asleep. One resident stated to another resident I wished we had something to do there is nothing to do on weekends and I get so tired of not having anything to do. Observation on 03/09/2025 at 9:40 AM on the rehabilitation unit revealed three residents sitting in the common area near the dining tables. There was one resident unable to sit still. He was wandering around the common area and attempted to go into other residents' rooms. The staff was re-directing him to his room. In an observation and interview on 03/09/2025 at 9:43 AM Resident # 52 was in his room sitting in his wheelchair. He was staring toward the floor of Resident #52 had a facial expression of sadness/depression slanting inner eyebrows and looking downward (signs of feeling sad). There was no stimulation in his room such as tv being on, radio, magazines, no activity items, etc. Resident #52 stated he wished he had something to do. He stated, I always had something to do. Resident #52 stated his [family member] would tell all the kids to always stay busy and not be a lazy person. He stated, I feel like I am being lazy just sitting here looking at my hands and this floor. Resident #52 stated he did feel sad and was thinking about how his life used to be. He stated this was why he wanted to be busy doing something. In an interview on 03/09/2025 at 10:35 AM Resident #165 was in the common area sitting in her wheelchair. She stated, I am here for therapy and have a lot of therapy during the week but on weekends we don't have anything to do. Resident #165 stated no one had spoken to her about the activity programs at this facility or what she enjoyed doing when she was at home and her hobbies. Resident #165 stated it would be nice if they could have a group of people to do something together. She stated no one had offered her any activity items. Resident #165 stated she never heard of activity pact( this was a folder the Activity Director placed coloring pictures , colors, and circle word puzzles) She stated if that is the activity for today no one had talked to her about it. She stated she thought someone would ask her what she liked to do and help her get something to do if no one was going to do anything with them in a group. In an interview on 03/10/2025 at 9:40 AM the Activity Director stated activity pact on the calendar was for residents to receive activity pact with coloring pictures in it for them to do in their rooms. She stated this was not considered a group activity. The Activity Director stated all activities were to be documented on the participation records. She stated she had only been working there for the past four months and she was still getting to know the residents. The Activity Director stated when a new resident comes in she was expected to explain the activity programs with them but she is the only activity person in the facility and it was difficult for her to do activities for 50 residents. She stated she worked as Activity Director at other facilities and knew how to do activities in a nursing home. The Activity Director stated it was her responsibility to ensure the residents had the activity items they needed and knew about the activity programs. She did not respond to any more questions about the importance of activities for residents in the facility and if there was a possibility a resident may have a negative outcome with their cognition, psychosocial and physical needs or who was responsible for activities on the weekends. In an interview on 03/10/2025 at 1:15 PM Resident #12 stated he was a preacher and did not have a bible in his room. He stated no one had been to his room and interviewed him about his activity preferences. Resident #12 stated he did not know the Activity Director and he had not been interviewed by anyone if he needed any more books and especially he wanted a bible. He stated no one explained to him what activity pact was, however, he did not attend group activities. Resident #12 stated he had been residing at this facility for several years. He stated he heard there was a new Activity Director but he did not know her and she had not been to his room to speak to him about his interests. Resident #12 stated he would enjoy for someone to come by and talk to him about what is going on in the facility and talk to him for a few minutes. He stated he would not want this every day but once or twice a week would be helpful to him. In an interview on 03/10/2025 at 2:05 PM during the confidential Resident Group meeting six out of six residents attending the group meeting agreed there was not any group activities on the weekends. The residents in the meeting stated on weekends has activity pack for the activity. All residents in attendance stated they had never heard of activity pact and it was never explained to them what type of activity this was and where the activity met. One of the six residents stated she thought it may be something to do in the room. Another resident stated if it was for them to do in the room it did not need to be listed as a group activity on the calendar. The residents in the group agreed they were bored on weekends and wanted to be more involved in the decisions of what type of activities they did in a group and in their room. In an interview on 03/11/2025 at 8:57 AM the Administrator stated she expected activities be provided to the residents seven days a week in a group setting. She stated if a resident was not receiving any activities on weekends there was a potential a resident may become bored or depressed. The Administrator stated activities have an important role in the overall quality of life in the residents' lives. She stated the Activity Director was responsible to ensure all residents' activity preferences were documented and residents were provided with any activity item they may want to enhance their lives at the facility. She stated she was responsible to monitor the Activity Director. She stated she expected all activities to be documented on the participation records. The Administrator did not respond to the question of who was responsible for activities on the weekends. She stated Activity Pact was when the Activity Director left coloring pictures or puzzles on paper in a folder for residents to do on weekends. In an interview on 03/11/2025 at 9:52 AM the Social Worker stated if the residents were not receiving activities on the weekends there was a possibility a resident may become depressed, lonely and/or bored. She stated if a resident is bored there is a potential the resident may attempt to get out of their chair to do something and may fall. The Social Worker stated activities were very important to the residents and if they are not getting activities on weekends there was a possibility their cognition may decline and depression increase. She stated she did not know what an Activity Pact was and it had not been explained to her. The Social Worker stated if she was manager of the day on weekends and saw activity pact on the calendar when she came to work on a Saturday she would not know what it was if a resident asked her. In an interview on 03/11/2025 at 10:14 AM RN B stated she did not know what Activity Pact meant on the activity She stated this was the only activity listed on the calendar. She stated no one discussed with her about his activity or any activities on the weekends. RN B stated she worked a lot of weekends and she did work on 03/09/2025 and there were not any activities for the residents to do on the rehabilitation unit. She stated they were not interested in the few activity items stored on the unit. RN B stated she was not informed of what the residents' interests were on the rehabilitation unit or where to find the activity interests of the residents. She stated the Activity staff was responsible for activities on the weekends or they can give the staff activity items the residents would be interested in doing and inform the staff what activities they could do with the residents. She stated the Activity Director did not discuss of what type of activities she thought the residents may enjoy with her. In an interview on 03/11/2025 at 10:30 AM CNA G stated the Activity Director did not discuss the resident's activity preferences with her or what was activity pact. She stated she assumed it was something in a bag for residents to do in their rooms but they do not have any on the rehabilitation unit. CNA G stated there was some activity items on the rehabilitation unit but sometimes the residents became tired of doing the same thing. She stated no group activities occurred on weekends on the rehabilitation unit. CNA G stated it would be helpful if the Activity Director would discuss with the residents on what they prefer to do in group activities and the staff would attempt to do these activities if they had the supplies. She stated if a resident did not have any activities to do there was a possibility a resident may become bored and become depressed about being in the facility especially a newly admitted resident to the facility. She stated they do become bored and sad on the weekends and especially when they are new to the facility. Review of the facility's Activity Policy, dated 10/2022, reflected the community must provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident, encouraging both independence and interaction in the community. An individualized activity program for each resident will be developed. Review of the facility's Policy on Dignity- Quality of Life, dated 10/2022, reflected In full recognition of his or her individuality, the facility promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. This includes staff assisting the resident to attendance of activities of their choice. Review of the facility's Policy on Resident Rights, dated January 2023, reflected Residents have the right to dignity, self-determined and person-centered care. The community must protect and promote the rights of all residents and ensure that they are receiving the care and services they need. The community must provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. Activities: o Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices; having control over their daily lives. o Participate in social, religious, and community activities that do not interfere with the rights of other residents in the community. o Participate in activities of his/her choice that do not interfere with the rights of other residents; o Participate in community activities.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biological) to meet the needs of each resident for 2 of 4 residents (Resident #14 and Resident #29) reviewed for medications and pharmacy services, in that: 1. The facility failed to ensure Resident #14's physician ordered medication Calcium and Gabapentin were available for administration. 2. The facility failed to ensure Resident #29's physician ordered medication Saccharomyces Baulardii (probiotic) was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include: 1.) Review of Resident #14's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses lumbar vertebra fracture (fracture of the spine), vitamin D deficiency and low back pain. Review of Resident #14's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 13 indicating she was cognitively intact. Resident #14 was further assessed to have occasional pain. Review of Resident #14's comprehensive care plan reflected a problem dated 10/01/2024 At risk for potential complications with pain related to pain to shoulder .low back pain and history of fracture to first lumbar vertebra Interventions included Meds/Labs/ treatments as ordered; Resident has schedule pain meds . Review of Resident #14's consolidated physician orders dated 03/10/2025 reflected orders for calcium 500 mg with D 5mg by mouth daily for supplement related to fracture of lumbar vertebra and an order for gabapentin 300 mg by mouth three times a day for back pain. Review of Resident #14's March 2025 MAR reflected entries for calcium 500 mg with D 5mg by mouth daily and an entry for Gabapentin give 300 mg by mouth three times daily. Review of the documentation on the MAR for the calcium and gabapentin reflected a 9 was documented indicating from the facility's chart code other/ see nurses notes. Review of nurses notes reflected no entry regarding the administration of the medication. Observation on 03/10/2025 at 8:16 AM, revealed MA E prepared Resident #14's medication for administration. MA E prepared 8 medications for administration which did not include her physician ordered calcium or gabapentin. In an interview on 03/10/2025 at 10:30 AM, MA E stated she did not give Resident #14's calcium or gabapentin during morning medication pass because the calcium medication was not in stock, and she was not sure why the gabapentin was not available because it was ordered but she did not see it on the cart, so she did not give it. When she was asked if she reported the missing medication to her nurse she stated she had not but would. Observation and interview on 03/10/2025 at 1:26 PM, Resident #14 stated she was ok and did not have pain at this time. She stated they gave her Tylenol and that always helps. Resident #14 stated she was not really sure what medications she took and did not know she did not get all of her morning medications. In an interview on 03/10/2025 at 4:25 PM, the DON stated Resident #14's physician was notified that her calcium and gabapentin were missed, and he stated to not give her the missing dose of gabapentin to wait until the next dose. She stated the facility did not have the right calcium for Resident #14 but was able to get it from the pharmacy right away. She stated Resident #14's gabapentin was in the medication room all the med aide had to do was go get it. The DON stated it was the MA's and nurses' responsibility to make sure all medications are available for administration, and she expected the medication aides to let their nurse know if a medication is not available for administration right away. She stated the medication aide should have stopped the medication pass and looked for the medications. She stated she had re-in-serviced the MA to make sure she knew the facility's procedure to make sure the residents get the right medications at the right time. 2.) Review of Resident #29's face sheet dated 03/10/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses enterocolitis due to clostridium difficile (It is a highly contagious bacterium that causes diarrhea and colitis.) and constipation (is a condition in which you have hard, dry, or lumpy stools that are difficult or painful to pass, or fewer than three bowel movements a week.). Review of Resident #29's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #29 was further assessed to always be incontinent of bowel. Review of Resident #29's comprehensive care plan reflected a focus area dated 05/14/2024 Bowel/ Bladder .Resident #29 has meds/ dx that can/may affect his bowel and bladder status. Interventions included medications and creams as ordered. Review of Resident #29's consolidated physician orders dated 03/10/2025 reflected an order for saccharomyces boulardii (probiotic) oral capsule give one by mouth daily. Review of Resident #29's March 2025 MAR, reflected an entry for saccharomyces boulardii. Review of the documentation on the MAR for the saccharomyces boulardii reflected a 9 was documented indicating from the facility's chart code other/ see nurses notes. Review of the nurses' notes reflected no entry regarding the administration of the medication. Observation on 03/10/2025 at 8:16 AM, revealed MA E prepared Resident #29's medication for administration. MA E prepared 8 medications for administration which did not include his physician ordered saccharomyces boulardii (probiotic) capsule. In an interview on 03/10/2025 at 10:30 AM, MA E stated she did not give Resident #29's saccharomyces boulardii during morning medication pass because she just missed it. After she reviewed his orders she stated she should have given him the medication during the morning medication pass. In an interview on 03/10/2025 at 4:25 PM, the DON stated Resident #29's probiotic was not in stock and had to be obtained from the pharmacy. She stated it was the MA's and nurses' responsibility to make sure all medications are available for administration, and she expected the medication aides to let their nurse know if a medication is not available for administration right away she stated the medication aide should have stopped the med pass and looked for the medications. She stated she had re-in-serviced the MA to make sure she knew the facility's procedure to make sure the residents get the right medications at the right time. Review of the facility's policy medication administration dated 11/2024 reflected This community supervises or administers all medications a resident receives as ordered by their physician. The community provides appropriate methods and procedures for obtaining, dispensing, and administering drugs approved by the resident's physician and consulting pharmacist. Orders are obtained from the resident's physician either to the community or from the pharmacy, if using pharmacy-initiated orders. Medication orders initiated by the pharmacy are verified by the director of nursing (DON), executive director, or designee. Staff members responsible for administering medications review the physician's order prior to administering medications . 8. Medication is ordered on a timely basis by an approved staff member. All the information on the medication label is faxed to the preferred pharmacy. The preferred pharmacy delivers the medications the next working day; however, in an emergency, will deliver when needed .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11.54% based on 3 out of 26 opportunities, which involved 2 of 4 residents (Resident #14 and Resident #29) and 1 of 1 MA's (MA E) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #14's physician ordered medication Calcium and Gabapentin was available for administration. 2. The facility failed to ensure Resident #29's physician orders medication Saccharomyces Baulardii (probiotic) was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include: 1.) Review of Resident #14's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses lumbar vertebra fracture (fracture of the spine), vitamin D deficiency and low back pain. Review of Resident #14's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 13 indicating she was cognitively intact. Resident #14 was further assessed to have occasional pain. Review of Resident #14's comprehensive care plan reflected a problem dated 10/01/2024 At risk for potential complications with pain related to pain to shoulder .low back pain and history of fracture to first lumbar vertebra Interventions included Meds/Labs/ treatments as ordered; Resident has schedule pain meds . Review of Resident #14's consolidated physician orders dated 03/10/2025 reflected orders for calcium 500 mg with D 5mg by mouth daily for supplement related to fracture of lumbar vertebra and an order for gabapentin 300 mg by mouth three times a day for back pain. Review of Resident #14's March 2025 MAR, reflected entries for calcium 500 mg with D 5mg by mouth daily and an entry for Gabapentin give 300 mg by mouth three times daily. Review of the documentation on the MAR for the calcium and gabapentin reflected a 9 was documented indicating from the facility's chart code other/ see nurses notes. Review of the nurses' notes reflected no entry regarding the administration of the medication. Observation on 03/10/2025 at 8:16 AM, revealed MA E prepared Resident #14's medication for administration. MA E prepared 8 medications for administration which did not include her physician ordered calcium or gabapentin. In an interview on 03/10/2025 at 10:30 AM, MA E stated she did not give Resident #14's calcium or gabapentin during morning medication pass because the calcium medication was not in stock, and she was not sure why the gabapentin was not available because it was ordered but she did not see it on the cart, so she did not give it. When she was asked if she reported the missing medication to her nurse she stated she had not but would. Observation and interview on 03/10/2025 at 1:26 PM, Resident #14 stated she was ok and did not have pain at this time. She stated they gave her Tylenol and that always helps. Resident #14 stated she was not really sure what medications she took and did not know she did not get all of her morning medications. In an interview on 03/10/2025 at 4:25 PM, the DON stated Resident #14's physician was notified that her calcium and gabapentin were missed, and he stated to not give her the missing dose of gabapentin to wait until the next dose. She stated the facility did not have the right calcium for Resident #14 but was able to get it from the pharmacy right away. She stated Resident #14's gabapentin was in the medication room all the med aide had to do was go get it. The DON stated it was the MA's and nurses' responsibility to make sure all medications are available for administration, and she expected the medication aides to let their nurse know if a medication is not available for administration right away. She stated the medication aide should have stopped the medication pass and looked for the medications. She stated she had re-in-serviced the MA to make sure she knew the facility's procedure to make sure the residents get the right medications at the right time. 2.) Review of Resident #29's face sheet dated 03/10/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses enterocolitis due to clostridium difficile (It is a highly contagious bacterium that causes diarrhea and colitis.) and constipation (is a condition in which you have hard, dry, or lumpy stools that are difficult or painful to pass, or fewer than three bowel movements a week.). Review of Resident #29's quarterly MDS dated [DATE] reflected he was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #29 was further assessed to always be incontinent of bowel. Review of Resident #29's comprehensive care plan reflected a focus area dated 05/14/2024 Bowel/ Bladder .Resident #29 has meds/ dx that can/may affect his bowel and bladder status. Interventions included medications and creams as ordered. Review of Resident #29's consolidated physician orders dated 03/10/2025 reflected an order for saccharomyces boulardii (probiotic) oral capsule give one by mouth daily. Review of Resident #29's March 2025 reflected an entry for saccharomyces boulardii. Review of the documentation on the MAR for the saccharomyces boulardii reflected a 9 was documented indicating from the facility's chart code other/ see nurses notes. Review of the nurses' notes reflected no entry regarding the administration of the medication. Observation on 03/10/2025 at 8:16 AM, revealed MA E preparing Resident #29's medication for administration. MA E prepared 8 medications for administration which did not include his physician ordered saccharomyces boulardii (probiotic) capsule. In an interview on 03/10/2025 at 10:30 AM, MA E stated she did not give Resident #29's saccharomyces boulardii during morning medication pass because she just missed it. After she reviewed his orders she stated she should have given him the medication during the morning medication pass. In an interview on 03/10/2025 at 4:25 PM, the DON stated Resident #29's probiotic was not in stock and had to be obtained from the pharmacy. She stated it was the MA's and nurses' responsibility to make sure all medications are available for administration, and she expected the medication aides to let their nurse know if a medication is not available for administration right away she stated the medication aide should have stopped the med pass and looked for the medications. She stated she had re-in-serviced the MA to make sure she knew the facility's procedure to make sure the residents get the right medications at the right time. Review of the facility's policy medication administration dated 11/2024 reflected This community supervises or administers all medications a resident receives as ordered by their physician. The community provides appropriate methods and procedures for obtaining, dispensing, and administering drugs approved by the resident's physician and consulting pharmacist. Orders are obtained from the resident's physician either to the community or from the pharmacy, if using pharmacy-initiated orders. Medication orders initiated by the pharmacy are verified by the director of nursing (DON), executive director, or designee. Staff members responsible for administering medications review the physician's order prior to administering medications . 8. Medication is ordered on a timely basis by an approved staff member. All the information on the medication label is faxed to the preferred pharmacy. The preferred pharmacy delivers the medications the next working day; however, in an emergency, will deliver when needed .

Based on observations, interviews, and record reviews the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen and food sanitation. The facility failed to ensure [NAME] J wore gloves and used proper hand hygiene while preparing purée food for residents on 03/10/2025. The facility failed to ensure Culinary Aide I wore gloves while preparing a cake on 03/11/2025. These failures could have placed residents at risk for food contamination and foodborne illness. Findings included: Observation on 03/10/2025 at 11:11 AM revealed [NAME] J had just finished checking temperatures of the baked chicken, rice, and beans that she pulled out of the oven wearing an oven mitt, and then proceeded to purée beans in the grinder. [NAME] J did not wash her hands and did not put on gloves before starting the purée process. [NAME] J touched the inside of the grinder blade as she adjusted the grinder prior to putting the beans in the grinder. She stood with the palms of her hands touching the countertop and then touched the inside of the grinder lid during the puréed process. She did not wash her hands and was not wearing gloves. Observation and interview on 03/10/2025 at 11:19 AM revealed [NAME] J washed her hands and then did the chicken purée. During the chicken purée process, [NAME] J touched her shirt, her pants, put her hand in her pants pocket and then inside an oven mitt, touched the inside of the chicken pan, the kitchen counter, a meal cart by the stove that had dirty dishes sitting on top, and did not wash her hands nor put on gloves after she touched multiple surfaces in the kitchen. [NAME] J rested her hands on the kitchen counter while preparing the purée chicken. [NAME] J stated that she received training in hand hygiene and knew that she needed to wash her hands when she arrived in the kitchen and before touching food to avoid cross contamination, otherwise residents get sick. She did not think she had done anything wrong and stated she did not directly touch any of the food she was pureeing. In an interview on 03/10/2025 at 11:45 AM, the Registered Dietitian stated that kitchen staff were to always wear gloves when preparing food, which included the purée food process to avoid bare hands encountering food. This was to avoid cross contamination and sanitation issues. She stated that if a kitchen staff were to touch their face or other surfaces in the kitchen while preparing food, they must change gloves, wash their hands, and put on new gloves. Also, staff needed to wash their hands in between tasks such as after checking temperatures and before starting to prepare food. She stated that [NAME] J not wearing gloves during the purée process and touching multiple surfaces in the kitchen would not meet her expectations and stated they needed in-service training about hand hygiene and glove usage. In an interview on 03/10/2025 at 11:51 AM, the Culinary Director stated that kitchen staff should wash hands when they arrived in the kitchen and in between different tasks. She stated she would expect staff to wear gloves while preparing food to avoid cross-contamination and to maintain proper sanitation. She stated lack of proper hand hygiene could make residents ill. Observation and interview on 03/11/2025 at 08:58 AM, revealed Culinary Aide I was preparing food in the kitchen. She was opening dry ingredients (batter) and pouring it in a large bowl. She was not wearing gloves. She stated that she was baking a cake and made all the desserts for the facility. She stated she had been trained on hand hygiene and the use of gloves. Culinary Aide I stated she knew to wash hands before and after tasks, after touching surfaces in the kitchen, and before and after putting on gloves. She stated she must wear gloves when she had direct contact with food to avoid bacteria and germs getting into the food, which could make the residents sick. In an interview on 03/11/2025 at 10:24 AM, the DON stated kitchen staff must wear gloves when handling food. Her expectation would be that staff wore gloves during food preparation, including food purée process, and washed their hands before putting on gloves, and after touching multiple surfaces in the kitchen. The DON stated that the best prevention against infection was proper hand washing and the use of gloves to prevent food borne illnesses to residents, which could cause nausea, diarrhea, and dehydration, especially in the elderly population. The DON stated that [NAME] J not wearing gloves while puréeing food for residents and not washing her hands after touching multiple surfaces in the kitchen and her clothes, would not meet her expectations. The DON stated the kitchen staff needed training on proper hand hygiene and glove usage. In an interview on 03/11/2025 at 01:14 PM, the Administrator stated it was the facility's policy to wash hands before prepping meals and to wear gloves during food preparation process. She stated that if staff did not have gloves on and they touched any part of their body or other surfaces in the kitchen, she would expect them to wash their hands and put on new gloves to prevent food borne illness and protect residents from getting sick. The Administrator stated that [NAME] J not wearing gloves while puréeing food for residents and not washing her hands after touching the inside of the grinder, multiple surfaces in the kitchen and her clothes, and putting her hand inside an oven mitt, would not meet her expectations. Review of the kitchen's in-service trainings from September 2024 to March 1, 2025 revealed kitchen staff had not been trained on hand hygiene and glove usage prior to the survey. Review of the facility's undated Policy & Procedure Manual titled Food Safety and Sanitation reflected, Policy: All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Procedure: 2. Employees d. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. Review of the facility's undated Policy & Procedure Manual titled Employee Sanitary Practices reflected, Policy: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Procedure: All employees will: 2. Wash hands before handling food, using posted hand-washing procedures. 4. Use a single use glove to cover bandages on cuts or sores located on the fingers, hands, or wrists when working with exposed food. Review of the facility's undated Policy & Procedure Manual titled Hand Washing reflected, Policy: Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures (and surrogate prosthetic device washing procedures as appropriate). Hand washing facilities will be readily accessible and equipped with hot and cold running water, paper towels, and/or automatic hand dryer, soap, trash cans and signage outlining hand washing procedures . Procedure: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands: g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. j. After engaging in other activities that contaminate the hands. Review of the facility's undated Policy & Procedure Manual titled Bare Hand Contact with Food and Use of Plastic Gloves reflected, Policy: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Procedure: 1. Staff will use good hygienic practices and techniques with access to proper hand washing facilities (available soap, hot water, and disposable towels and/or heat/air drying methods). Antimicrobial or antiseptic gel will not be used in place of proper hand washing techniques. 2. Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food. 3. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single use gloves. 5. Clean barriers such as single-use gloves are to be used when: a. Handling ready-to-eat foods. b. Handling raw meat, poultry, raw eggs, fish, and shellfish. c. Preparing foods such as meatloaf or meat salads. d. Hand tossing salad, mixing coleslaw, potato or macaroni salad. e. Bagging bread or cookies. f. Anytime hands would otherwise touch food DIRECTLY. 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: c. After handling soiled trays or dishes. d. After handling anything soiled. g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. l. Any time a contaminated surface is touched.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #15) reviewed for infection control practices. The facility failed to ensure LVN D followed standard precautions during wound care on 03/10/2025 for Resident #15's Stage III pressure ulcer to her sacrum, when she failed to set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure placed resident at risk for developing wound infections, and at risk for healthcare associated cross-contamination and infection. Findings included: Review of Resident #15's face sheet dated 03/10/2025 reflected a [AGE] year-old female admitted the facility on 10/28/2020 with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) transient cerebral ischemic attack (brief blockage of blood flow to the brain.)and malignant neoplasm of the colon (colon cancer). Review of Resident #15's significant change MDS dated [DATE] reflected she was assessed to have a BIMS score of three indicating severe cognitive impairment. Resident #15 was assessed to be at risk for pressure ulcers and was assessed to have a stage III pressure ulcer. Review of Resident #15's comprehensive care plan reflected a focus area dated 03/06/2025 Actual Potential for complications with impaired skin integrity . pressure related to incontinence, immobility and cognitive impairment. Interventions included wound care physician evaluation and treatment as needed. Review of Resident #15's weekly wound round documentation dated 03/06/2025 reflected Resident #15 had a Stage 3 Pressure ulcer to her sacrum measuring 1 cm long by 0.5 cm wide with 0.2 cm depth. Observation on 03/10/2025 at 11:06 AM, revealed LVN D prepared her clean field for Resident #15's wound care. LVN D placed a whole (newly opened) package of 4x4's, a bottle of wound cleanser and a box of gloves along with her dressings. LVN D then stated she was going down the hall to wash her hands and left her clean field while she went down the hall to wash her hands. LVN D then returned and entered Resident #15's room to preform wound care. During wound care LVN D cleansed Resident #15's pressure ulcer to her coccyx with her left hand she was holding Resident #15's left buttock to expose the coccyx pressure ulcer once she cleansed the wound she allowed the skin folds to fall back over the pressure ulcer (contaminating the wound) and without re-cleaning applied the dressing. After the treatment LVN D then took the package of 4x4, wound cleanser and gloves used during care and placed them back on her treatment cart. In an interview on 03/10/2025 at 11:42 AM, LVN D stated she did go down the hall to wash her hands and should not have left her clean field because anyone could have walked by and contaminated her field. She stated she should not have taken the package of 4x4's, wound cleanser, and gloves back to her cart because once she brought them into the room they were contaminated and should not be used on other residents. LVN D further stated she should not have let Resident #15's skin fall back over her wound because it caused the wound to be contaminated and it needed to be recleaned prior to putting the dressing on. She stated that she should have had a second person in there to help her to prevent that from happening, but they were all busy and she did not find anyone to help. In an interview on 03/10/2024 at 4:20 PM, the DON stated staff are not supposed to take items into room then bring them back to their cart she stated that was cross contamination and could lead to infections. she stated it was her expectation that staff use wound cleansing tech that do not re contaminate the wound. She stated if the skin folds fall back over the wound the wound would need to be recleaned. Review of the facility's policy Infection Prevention and Control Program dated 02/2024 reflected The community will maintain an organized, effective community-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents. visitors and team members. This program involves the collaboration of many programs and services within the community and is designed to meet the intent of regulatory and accrediting agencies . Review of the facility's policy Clean Dressing Change Technique (not dated) reflected What is a clean dressing change? By definition a clean dressing change involves techniques to reduce the overall number of microorganisms during a dressing change. This helps to prevent or reduce the risk of transmission of microorganisms from person to person and/or surface. This technique utilizes handwashing, maintaining a clean surface, and using gloves and sterile instruments to prevent direct contamination of supplies and materials. Clean technique is considered most appropriate for long term care, chronic wounds, and wounds not at high risk for infection .As a rule, anything that enters the room must be cleaned with an antibacterial when leaving the resident's room, this includes spray bottles, tubes/bottles of ointments, scissors, etc.No open dressings should be on the cart. Dispose of unused supplies .

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #160) of 6 residents reviewed for resident rights. The facility failed to cover Resident #160's catheter bag during therapy in the rehabilitation unit. This failure placed residents at risk of loss of dignity, embarrassment, and diminished quality of life. Findings include: Review of Resident #160's face sheet, dated, 03/05/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #160 had diagnoses which included retention of urine, unspecified (the condition where the bladder does not empty or cannot completely empty, leaving some urine behind), and neuromuscular dysfunction of bladder, unspecified (a medical condition where the bladder's muscles or the nerves controlling them are not functioning as they should, causing urination problems). Review of Resident #160's admission MDS reflected it was in process on 03/11/2025. Review of Resident #160's Baseline Care Plan, dated 03/05/2025, reflected Resident #160 had a catheter (a tube used to drain urine from the bladder). Goal: will be /remain free from device-related trauma. Resident #160 was at risk for pain. She was not cognitively (the mental processes of thinking, knowing, understanding, and learning) impaired. She communicated without difficulty. Resident #160 required assistance with bathing, dressing, bed mobility, hygiene, locomotion, toileting, and transfers. Resident #160 required physical therapy and occupational therapy. Review of Resident #160's Physician Orders, dated 03/05/2025, reflected maintain drainage bag (a bag connected to a urinary catheter to collect urine that drains from the bladder) below level of bladder; keep tubing free of kinks. Monitor urinary output every shift. Perform catheter care every shift and as needed. Maintain catheter size 16 FR/ 10 cc balloon for diagnosis of urinary retention and change as needed for obstruction. In an observation on 03/09/2025 from 9:55 AM to 10:20 AM Resident #160 was sitting in her wheelchair when the Physical Therapist Assistant assisted Resident #160 from her room to the rehabilitation area (approximately 300 feet). Resident #160's catheter bag was uncovered. After Resident #160 finished her therapy session, the Physical Therapy Assistant assisted Resident #160 from the therapy area to Resident #160's room with the uncovered catheter bag. She did not report any issues of Resident #160's catheter bag to nursing staff or attempt to find a cover for the catheter bag. In an interview on 03/09/2025 at 10:21 AM the Physical Therapy Assistant stated she did not know if a catheter bag was expected to be covered. The Physical Therapy Assistant stated she did not check the catheter bag to ensure it was covered prior to assisting Resident #160 from her room to the area of the rehabilitation unit where other residents would be around Resident #160. The Physical Therapy Assistant stated, I see how it is with the catheter. She stated she did not report anything to the nurses about Resident #160's catheter bag. (The Physical Therapy Assistant did not elaborate on her response I see how it is or answer any other questions about catheters such as dignity issues). In an interview on 03/09/2025 at 10:45 AM Resident # 165 stated she did not enjoy looking at someone's urine and it made her sick at her stomach. She stated someone needed to cover it so no one else had to look at urine. In an interview on 03/09/2025 at 11:20 AM RN A stated all catheter bags were expected to be covered. RN A stated if a catheter bag was not covered a resident may be embarrassed to be around other people and this was a dignity issue for other residents looking at the catheter bag and not wanting to see urine. She stated any staff was expected to report to the nurse anytime there was an issue with catheters including the therapy staff. In an interview on 03/11/2025 at 9:16 AM the Administrator/RN stated if a catheter bag was not covered and a resident was sitting around other residents, there was a possibility a resident may become embarrassed/humiliated if other residents can view their urine in the catheter bag and this was a dignity issue. She stated if a therapist assisted a resident out of their room to a common area it was the therapist's responsibility to ensure the catheter bag was covered. In an interview on 03/11/2025 at 09:50 AM the Director of Therapy stated all the therapy staff were expected to report any medical concerns including catheters to the nursing staff. She stated the Physical Therapist Assistant was expected to check and make sure the catheter bag was covered prior to assisting a resident anywhere in the facility. She stated this was a dignity issue for the resident and for other residents viewing the urine in the catheter bag. In an interview on 03/11/2025 at 10:14 AM RN B stated all catheter bags were expected to be covered. RN B stated if Resident #160's catheter bag was not covered and she was sitting around other residents there was a possibility she may be embarrassed and it was a dignity issue for Resident #160 and other residents. She stated other residents may not want to see urine and it was a possibility other residents may not want to eat if they have a weak stomach when they see urine. RN B stated all staff including therapy was expected to report any type of medical concerns to the nurse including any issues with catheters. She stated if a resident had a catheter all staff were expected to inspect the catheter bag prior to transferring a resident from their room to a public area. In an interview on 03/11/2025 at 10:30 AM CNA G stated all catheter bags needed to be covered. CNA G stated if the catheter bag was not covered a resident may feel bad about themselves if other residents or staff saw urine in their catheter bag. CNA G stated this was against a resident right of not becoming embarrassed when around others if their catheter bag was not coved. She stated also other residents may become upset viewing the urine in someone's catheter bag. Review of the Facility's Policy on Dignity-Quality of Life , dated 10/2022, reflected In full recognition of his or her individuality, the facility promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Review of the facility's Policy on Resident Rights, dated January 2023, reflected Residents have the right to dignity, self-determined and person-centered care. The community must protect and promote the rights of all residents and ensure that they are receiving the care and services they need. The community must provide equal access to quality care regardless of diagnosis, severity, condition, or payment source.

Based on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of three residents (Resident #15) reviewed for pressure ulcers. The facility failed to ensure LVN D followed standard precautions during wound care on 03/10/2025 for Resident #15's Stage III pressure ulcer to her sacrum, when she failed to set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #15's face sheet dated 03/10/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) transient cerebral ischemic attack (brief blockage of blood flow to the brain.)and malignant neoplasm of the colon (colon cancer). Review of Resident #15's significant change MDS dated [DATE] reflected she was assessed to have a BIMS score of three indicating severe cognitive impairment. Resident #15 was assessed to be at risk for pressure ulcers and was assessed to have a stage III pressure ulcer. Review of Resident #15's comprehensive care plan reflected a focus area dated 03/06/2025 Actual Potential for complications with impaired skin integrity . pressure related to incontinence, immobility and cognitive impairment. Interventions included wound care physician evaluation and treatment as needed. Review of Resident #15's weekly wound round documentation dated 03/06/2025 reflected Resident #15 had a Stage 3 Pressure ulcer to her sacrum measuring 1 cm long by 0.5 cm wide with 0.2 cm depth. Observation on 03/10/2025 at 11:06 AM, revealed LVN D preparing her clean field for Resident #15's wound care. LVN D placed a whole (newly opened) package of 4x4's, a bottle of wound cleanser and a box of gloves along with her dressings. LVN D then stated she was going down the hall to wash her hands and left her clean field while she went down the hall to wash her hands. LVN D then returned and entered Resident #15's room to preform wound care. During wound care LVN D cleansed Resident #15's pressure ulcer to her coccyx with her left hand she was holding Resident #15's left buttock to expose the coccyx pressure ulcer once she cleansed the wound she allowed the skin folds to fall back over the pressure ulcer (contaminating the wound) and without re-cleaning applied the dressing. After the treatment LVN D then took the package of 4x4's, wound cleanser, and gloves used during care and placed them back on her treatment cart. In an interview on 03/10/2025 at 11:42 AM, LVN D stated she did go down the hall to wash her hands and should not have left her clean field because anyone could have walked by and contaminated her field. She stated she should not have taken the package of 4x4's, wound cleanser, and gloves back to her cart because once she brought them into the room they were contaminated and should not be used on other residents. LVN D further stated she should not have let Resident #15's skin fall back over her wound because it caused the wound to be contaminated and it needed to be recleaned prior to putting the dressing on. She stated that she should have had a second person in there to help her to prevent that from happening, but they were all busy and she did not find anyone to help. In an interview on 03/10/2024 at 4:20 PM, the DON stated staff are not supposed to take items into room then bring them back to their cart she stated that was cross contamination and could lead to infections. she stated it was her expectation that staff use wound cleansing tech that do not re contaminate the wound. She stated if the skin folds fall back over the wound the wound would need to be recleaned. Review of the facility's policy Clean Dressing Change Technique (not dated) reflected What is a clean dressing change? By definition a clean dressing change involves techniques to reduce the overall number of microorganisms during a dressing change. This helps to prevent or reduce the risk of transmission of microorganisms from person to person and/or surface. This technique utilizes handwashing, maintaining a clean surface, and using gloves and sterile instruments to prevent direct contamination of supplies and materials. Clean technique is considered most appropriate for long term care, chronic wounds, and wounds not at high risk for infection .As a rule, anything that enters the room must be cleaned with an antibacterial when leaving the resident's room, this includes spray bottles, tubes/bottles of ointments, scissors, etc. No open dressings should be on the cart. Dispose of unused supplies .

Based on observations, interviews, and record reviews the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for two ( Resident #7 and Resident #160) of seven residents reviewed for catheters. The facility failed to prevent Resident #7's and Resident #160's catheter bag/tubing from touching the floor on 03/09/2025. These failures could place residents at risk for cross contamination and urinary tract infections. Findings included: Resident #7 Review of Resident #7's face sheet, dated, 03/09/2025, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #7 had diagnoses which included end stage congestive heart failure and renal (kidney) insufficiency. Review of Resident #7's MDS dated [DATE] reflected a BIMS score of 8, which suggested a moderate cognitive impairment. He had an indwelling catheter. Review of Resident #7's Baseline Care Plan, dated 02/20/2025, reflected Resident #7 had an indwelling catheter (a tube used to drain urine from the bladder) related to obstructive uropathy (a condition where a blockage hinders urine flow). Goal: will be/remain free from catheter-related trauma through the review date. Observation and interview on 03/09/2025 from 01:38 PM to 01:54 PM revealed Resident #7 was lying in bed eating lunch. The catheter bag and tubing were lying flat on the floor beside the bedside table and the tubing crossed over the bottom of the bedside table wheels. Resident #7 complained about wanting to move his leg and when he pushed the bedside table away from the bed, it rolled on top of the catheter bag full of dark yellow color urine and the bag started leaking. Resident #7 stated he was aware of the bag being on the floor but was in pain and unable to answer questions about how long the bag had been on the floor. At 01:45 PM, CNA K came into the room, picked up the catheter bag up off the floor, and hooked it on the bed frame. The bag was leaking, and CNA K responded, it's a mess and left the room. A nurse responded to assess the resident's complaint of pain, noted the bag was leaking, and requested help emptying the bag. At 01:54 PM, CNA H put the catheter bag on the floor, emptied the urine, wiped the floor and the outside of the catheter bag with a towel, and hooked the catheter bag back on the bed frame. In an interview on 03/10/2025 at 09:23 AM, Resident #7 stated that he had no pain from his foley catheter when the bag and tubing were on the floor on 03/09/2025 and the bedside table rolled on top of the bag. He did not care that the bag was leaking urine, but he expected staff to clean it up. In an interview on 03/11/2025 at 09:13 AM, CNA H stated he had received training on emptying catheter bags. He stated he must ensure the catheter bag was hung below the bladder and did not touch the floor because that could cause an infection. CNA H stated the bag was usually hooked onto the bed frame. He stated the catheter bag and tubing should not have been on the floor next to the bedside table, because the line (tube) could have been pulled out when Resident #7 moved the bedside table, which could have caused damage or pain to the resident. He stated it was everyone's responsibility for checking placement of the catheter bag and tubing when they entered a resident's room. In an interview on 03/11/2025 at 09:32 AM, RN C stated he had received training on catheter care. RN C stated the catheter bag must be hung below the bladder and must not touch the floor. He stated it was the CNA's responsibility to empty the bags and notify the nurse if there was concern or problem. The CNAs should pick the catheter bag up off the floor and put it back on the bed when they notice it. RN C stated that if the bag touched the floor, there was an increased risk of infection because bacteria could go up the tube. There was also an increased risk of the tube being tugged or pulled out, which could cause damage to the urethra and pain to the resident. RN C stated everyone (CNAs, nurses, and the director of nursing) should check the placement of the bag during incontinent care and when entering/exiting the residents' rooms. He stated that he did rounds in the morning to ensure placement of the catheter bags. In an interview on 03/11/2025 at 10:11 AM, the DON stated staff were trained on catheter care. The training covered placement of the bag, which included using a securement device to avoid pulling and injury to urethra. The bag must be hung below the bladder, attached to the frame of the bed if the resident was in bed, and should not be on the floor. If the bag touched the floor, that would be an infection control issue and the bag would need to be changed to avoid the risk of infection. The DON stated it was everyone's responsibility to ensure the bag was off the floor (CNAs, RNs, and the DON) and if a CNA observed it on the floor, her expectation would be to let the charge nurse know so that the bag could be changed. The bag on the floor and the bedside table on top of it would not meet her expectation and had the potential of the tubing being kinked, pulled out, or causing the resident an injury or discomfort. Resident #160 Review of Resident #160's face sheet, dated, 03/05/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #160 had diagnoses which included retention of urine, unspecified (the condition where the bladder does not empty or cannot completely empty, leaving some urine behind), neuromuscular dysfunction of bladder, unspecified (a medical condition where the bladder's muscles or the nerves controlling themre are not functioning as they should, causing urination problems), and cerebral infarction, unspecified (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of Resident #160's admission MDS reflected it was in process on 03/11/2025. Review of Resident #160's Baseline Care Plan, dated 03/05/2025, reflected Resident #160 had a catheter (a tube used to drain urine from the bladder). Goal: will be /remain free from device-related trauma. Resident #160 was at risk for pain. She was not cognitively (the mental processes of thinking, knowing, understanding, and learning) impaired. She communicated without difficulty. Resident #160 required assistance with bathing, dressing, bed mobility, hygiene, locomotion, toileting, and transfers. Resident #160 required physical therapy and occupational therapy. Review of Resident #160's Physician Orders, dated 03/05/2025, reflected maintain drainage bag (a bag connected to a urinary catheter to collect urine that drains from the bladder) below level of bladder; keep tubing free of kinks. Monitor urinary output every shift. Perform catheter care every shift and as needed. Maintain catheter size 16 FR ( French gauge, a measurement system that indicates the outer diameter of the catheter) / 10 cc ( cubic centimeters a volume unit for substance) balloon for diagnosis of urinary retention and change as needed for obstruction. In an observation on 03/09/2025 from 9:55 AM to 10:20 AM Resident #160 was sitting in her wheelchair when the Physical Therapist Assistant assisted Resident #160 from her room to the rehabilitation area (approximately 300 feet). Resident #160's uncovered catheter bag and tubing dragged on the floor when she was assisted from her room to the rehabilitation area. The color of urine was yellow. The Physical Therapist Assistant placed Resident #160 in the area for the physical therapy session. There was a kink in Resident #160's tubing. Over half of Resident #160's uncovered catheter bag was lying on the floor. After Resident #160 finished her therapy session, the Physical Therapy Assistant assisted Resident #160 from the therapy area to Resident #160's room. During this transfer the uncovered catheter bag and kinked tubing dragged on the floor (approximately 300 feet). In an interview on 03/09/2025 at 10:21 AM the Physical Therapy Assistant stated she was not aware the uncovered catheter bag was partially on the floor or the tubing from the catheter had a kink and was lying on the floor when she transferred Resident #160 to and from the rehabilitation area. She stated she did not know if a catheter was expected to be covered. The Physical Therapy Assistant stated she did not check the catheter or the tubing before, during or after the therapy session. She stated she worked PRN and was not a full-time staff at the facility. The Physical Therapy Assistant stated, I see how it is with catheter. She stated she did not report anything to the nurses about the catheter bag or tubing. (The Physical Therapy Assistant did not elaborate on her response or answer any other questions about catheters such as possible negative outcome with Resident #160 if the catheter bag and tubing was lying on the floor and the tubing had a kink). In an interview on 03/09/2025 at 11:20 AM RN A stated if half of a catheter was on the floor and tubing was on the floor there was a possibility bacterium from the floor may enter the tubing or catheter. She stated if this occurred there was a potential where Resident #160 may develop an infection. RN A stated if a tubing had a kink, this may prevent urine from draining properly and may cause urinary retention and other complications. She stated all catheters and tubing was to be off the floor and hanging on a hook or on the wheelchair. She stated all catheter bags were expected to be covered. She stated any staff was expected to report to the nurse anytime there was an issue with catheters including the therapy staff. In an interview on 03/11/2025 at 9:16 AM the Administrator/RN stated catheter bags and tubing was expected to remain off the floor. She stated if a catheter and tubing was on the floor when a resident was being assisted from one area to another area in a wheelchair, there was a possibility a wheel may run over the tubing or bag and the catheter may dislodge. The Administrator stated if a catheter dislodges there was a potential for infection. She stated it was therapy's responsibility to report any medical issues including catheter bags to a nurse. In an interview on 03/11/2025 at 09:50 AM the Director of Therapy stated all the therapy staff was expected to report any medical concerns including catheters to the nursing staff. She stated the Physical Therapy Assistant was expected to place the catheter in its proper position and ensure the catheter bag and tubing was not on the floor during transfers or anytime during therapy. The Director of Therapy stated she expected all the therapists to report any changes of resident medical condition to the nurse. She stated there was a possibility the tubing may contract some type of bacteria from the floor. She stated Resident #160 may develop an infection. She stated if the tubing was kinked all types of medical issues may develop (when asked what type of medical issues, she did not elaborate on what type of medical issues). The Director of Therapy stated there was a potential the catheter may come out of Resident #160 and develop an infection. She stated there was only one therapist in the facility on 03/09/2025 and it was the Physical Therapy Assistant. She stated staff did receive training to report any medical issues to the nursing staff. Requested the training and it was not provided at time of exit. In an interview on 03/11/2025 at 10:14 AM RN B stated if a catheter was not properly placed and was located on the floor there was a possibility bacteria can enter the catheter tubing even if the tubing was kinked. She stated there was all types of bacteria on the floor. RN B stated Resident #160 had a potential to develop an infection if her catheter bag was on the floor, tubing on the floor with a kink in the tubing. RN B stated if staff was pushing a resident in their wheelchair and the catheter and tubing was on the floor there was a possibility the wheel on the wheelchair may run over the catheter bag or tubing. She stated if this incident occurred the catheter may dislodge, and potential problems may occur such as blood in urine, infection, and difficulty with bladder emptying. She stated all catheters were expected to be covered. RN B stated all staff including therapy was expected to report any type of medical concerns to the nurse including any issues with catheters. She stated if a resident had a catheter all staff was expected to inspect the catheter prior to transferring a resident from their room to a public area. RN B stated the correct positioning of the catheter is placed below the level of the bladder and off the floor for proper drainage. In an interview on 03/11/2025 at 10:30 AM CNA G stated she had been in-serviced to report any issues with catheters including if the tube was twisted. She stated all catheters were expected to be covered. She stated if a catheter bag or tube was on the floor it was a possibility germs may enter the tubing and cause a resident to become sick with an infection. CNA G stated she had been in-serviced on catheter bags but did not recall the date. Review of the facility's policy on Catheter-Management dated 03/01/2014 reflected The facility will have a system for the management of urinary catheters. All catheter bags are covered with privacy bags at all times. Correct positioning of catheter will be maintained. Review of the facility's policy titled Foley Catheter - Care revised 03/01/2014 reflected: Policy Proper care will be provided for the management of a Foley catheter to drain urine from the bladder and to prevent reflux of urine back into the bladder. Procedure 3. The Foley bag should be hooked to the metal bed frame when resident is in bed and covered with a privacy bag. 5. The Foley bag should not be touching the floor. 6. Foley tubing should be free from kinks.

Based on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for 5 of 6 Resident' beds (Residents # 1, #2, #3, #4, and #5) observed for bed linens and failed to have clean towels and top sheets available in one of one rehabilitation units. The facility failed to ensure Residents #1, #2, #3, #4, and #5's beds had a top sheet. The facility failed to ensure there were clean towels and top sheets available in the Rehabilitation unit. These failures could place residents at risk of living in an un-homelike environment. Findings included: Record review of the undated Face Sheet for Resident # 1 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) without complications. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 12 indicating moderate cognitive status. Observation on 03/26/2024 at 9:15 AM of Resident #1's bed revealed she had a bottom sheet and no top sheet under her bedspread. Observation on 03/26/2024 at 9:17 AM revealed there was one top sheet on the 200 Hall clean linen cart. Record review of the undated Face Sheet for Resident #2 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Anxiety and Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy.). Record review of Resident #2's Comprehensive MDS dated [DATE] reflected she had a BIMS score of 7 indicating severe cognitive impairment. Observation on 03/26/2024 at 9:18 AM of Resident #2's bed revealed she had a bottom sheet and no top sheet under her bedspread. In an interview on 03/26/2024 at 9:20 AM the ADON stated the housekeeping department was operated by a third party and he was unaware the facility was low on top sheets. Record review of the undated Face Sheet for Resident #3 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning) without behavioral disturbance and Cognitive Communication Deficit (difficulty with thinking and how someone uses language). Record review of Resident #3's Comprehensive MDS dated [DATE] reflected she had a BIMS score of 14 indicating intact cognitive status. Observation on 03/26/2024 at 9:30 AM of Resident #3's bed revealed she had a bottom sheet and no top sheet under her bedspread. Record review of the undated Face Sheet for Resident #4 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning) Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and End Stage Renal Disease (condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #4's Quarterly MDS dated [DATE] reflected he had a BIMS score of 14 indicating intact cognitive status. Observation on 03/26/2024 at 9:52 AM of Resident #4's bed revealed he had a bottom sheet and no top sheet under his bedspread. Record review of the undated Face Sheet for Resident #5 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease late onset (common form of Dementia that begins after age 65), Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning) and Epilepsy (neurobiological disorder marked by sudden episodes of sensory disturbance, loss of consciousness or convulsions, associate with abnormal electrical activity in the brain). Record review of Resident #5's Comprehensive MDS dated [DATE] reflected she had a BIMS score of 8 indicating moderate cognitive impairment. Observation on 03/26/2024 at 10:08 AM of Resident #5's bed revealed she had a bottom sheet and no top sheet under her bedspread. Observation on 03/29/2024 at 9:00 AM in the facility laundry room revealed there were no towels and no top sheets in the clean linen closet. In an interview on 03/26/2024 at 9:05 AM the Laundry Room Attendant stated there were five towels in the dirty laundry. Observation on 03/29/2024 at 9:58 AM in the rehabilitation unit revealed there were no top sheets or towels on the clean linen cart. Observation on 03/29/2024 at 10:02 AM in the rehabilitation unit shower room revealed there were two bath towels, a purple one and a pink one. In an interview on 03/29/2024 at 10:05 AM CNA A stated she had worked at the facility for [AGE] years and they had recently had a shortage in the past month or two with a lack of top sheets and towels. She stated the pink and purple towel did not belong to the facility as the facility towels were all white. In a confidential interview on 03/29/2024 at 10:10 AM a staff member stated the facility had a shortage of bed sheets. In an interview on 03/26/2024 at 10:15 AM CNA B stated he made up the residents' beds without top sheets due to some family members coming to the facility early and he wanted the beds to look nice. In an interview on 03/26/2024 at 10:45 AM the ADON stated the housekeeping department was responsible for stocking the linen carts in the evening. In a confidential interview on 03/26/2024 at 11:00 AM a staff member stated it was amazing how things like linens showed up when surveyors arrived in the building. In an interview on 03/26/2024 at 11:53 AM the Housekeeping Supervisor stated she had been in that position for 8 months. She stated she did not know how many sheets or towels the facility needed, however, when she placed an order, it was for a dozen flat sheets and a dozen bath towels. She stated that's what her previous supervisor did. She stated she arrived at the facility at 7:00 AM and the laundry attendant arrived 6:30 AM. She stated the laundry attendant stocked the linen carts before she left the facility at 2:30 in the afternoon but there was no one to stock them in the evenings. She stated she thought some aides were throwing sheets and towels away, but she did not know that for a fact. She further stated that when she did the laundry, she never received enough flat sheets and towels back in the dirty laundry barrels. She stated she would put 15 towels out daily for the residents but agreed there were more than 15 residents in the facility. She stated they were going to put out more towels based on the census and not going to do what her previous supervisor did. In an interview on 03/26/2024 at 1:15 PM the Wound Care Nurse stated she had worked at the facility for 7 years. She said there had been shortages of mostly flat sheets and draw sheets on the 2-10 shifts and that problem had been worse in the past month. In an interview on 03/26/2024 at 2:29 PM the DON stated she had worked at the facility since October 2023. She stated the CNAs should be turning in their linen barrels before the laundry attendant leaves so the linens could be washed. She stated she, the ADON and the floor nurses were responsible for supervising the CNAs and ensuring they turned completed that task. In an interview on 03/26/2024 at 2;39 PM the laundry attendant stated she had worked at the facility for 9 years. She stated she arrived at the facility at 6:00 AM in the mornings and the washer took one hour and the dryer took 40 minutes to complete a load of laundry. She stated she had trouble getting the aides to bring her the dirty laundry. She stated they were not returning towels and flat sheets. She further stated she had only received one flat sheet back that morning. In an interview on 03/26/2024 at 2:55 Pm the Assistant Executive Director stated she had not received any complaints regarding laundry. She stated the Housekeeping Supervisor checked the laundry carts twice a day and the laundry lady stocked the carts. She stated the staff should know how to tell any supervisor if they were having issues with a shortage of linens. In an interview on 03/26/2024 at 3:40 PM the Executive Director stated his expectation was for residents to have top sheets, drawsheets and towels available. He stated the facility should have par levels of linens to meet the resident's needs. He stated he was the Interim Executive Director, and he was unaware there was an issue with the laundry, however, it would be addressed. Record review of a facility Policy and Procedure titled Resident Rights and dated 04/01/20208 and revised in January 2023 reflected Residents have the right to dignity, self-determined and person-centered care. The community must protect and promote the rights of all residents and ensure they are receiving the care and services they need. Safe Environment: A safe, clean, comfortable, and homelike environment.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs 3 of 7 residents (Residents #39, #44, and #47) reviewed for unnecessary medications. The facility did not have appropriate indications for medications based on Resident #39's diagnoses. The facility did not have parameters to hold blood pressure medication for Resident #39. The facility did not hold blood pressure medications for Residents #44 and #47 when the residents' blood pressure or pulse was outside parameters set by their physician. These failures could place residents at risk of complications related to receiving unnecessary medications. Findings included: 1. Record review of a face sheet dated 01/31/24 indicated Resident #39 was an [AGE] year-old male admitted on [DATE]. His diagnoses included atrial fibrillation (a type of irregular heartbeat), benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), personal history of other diseases of the blood system, nontraumatic chronic subdural hemorrhage (an old clot of blood on the surface of the brain beneath its outer covering), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), vascular dementia (stroke related memory loss), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), zoster (reactivation of the chickenpox virus in the body), personal history of other diseases of urinary system, anemia (lower than normal healthy blood cells), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs), acute kidney failure (kidneys suddenly become unable to filter waste products from the blood), and obstructive and reflux uropathy (when urine cannot drain through the urine tubes). Record review of the MDS dated [DATE] indicated Resident #39 had active diagnoses of anemia, heart failure, renal insufficiency, obstructive uropathy, cerebral vascular accident, non-Alzheimer's dementia, hemiplegia or hemiparesis, malnutrition, zoster, insomnia, metabolic encephalopathy, and atrial fibrillation. Record review of the January 2024 physician orders indicated Resident #39 had: * the same diagnoses as the face sheet, * an order dated 09/26/23 he was to receive atorvastatin for high cholesterol, * an order dated 01/12/24 he was to receive potassium for elevated potassium, and * an order dated 09/27/23 he was to receive levothyroxine for hypothyroidism. During an interview on 01/30/24 at 03:21 p.m., RN D said when a resident was admitted the medications were to be given appropriate diagnoses based on the diagnoses the resident had. She said if there was not a diagnosis for a medication the admitting nurse should check the hospital record for a diagnosis or contact the physician and clarify. During an interview on 01/31/24 at 12:01 p.m., RN E said when a resident was admitted the medications were to be given appropriate diagnoses based on the diagnoses the resident had. She said if there was not a diagnosis for a medication the admitting nurse should contact the physician and clarify. During an interview on 01/31/24 at 12:12 p.m., the Administrator said medications should be given appropriate diagnoses based on the diagnoses the resident had. She said if there was not a diagnosis for a medication the nurse should check the clinical record from the hospital for a diagnosis. She said she was the nurse who transcribed Resident #39's orders and did not realize she had not inputted the appropriate diagnoses or clarified with physician/NP. During an interview on 01/31/24 at 12:45 p.m. the ADON said medications should be given appropriate diagnoses based on the diagnoses the resident had. He said if there was not a diagnosis for a medication the admitting nurse should check the hospital record for a diagnosis or contact the physician and clarify. 2. Record review of a face sheet dated 01/31/24 indicated Resident #39 was an [AGE] year-old male admitted on [DATE]. His diagnoses included atrial fibrillation (a type of irregular heartbeat), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). Record review of a physician order dated 09/26/23 indicated Resident #39 was to receive nifedipine ER Oral Tablet Extended Release 24 Hour 30 mg (Nifedipine) 1 tablet by mouth one time a day for hypertension with no indications for parameters to hold the medication. Record review of the January 2024 MAR indicated Resident #39's nifedipine was not administered on 01/15 and 01/17 with a code number 5 marked indicating Hold/See Nurse Notes. Record review of Nursing Progress Notes for Resident #39 indicated: *on 01/15/24 an eMAR-Administration Note indicating nifedipine ER Oral Tablet Extended Release 24 Hour 30 mg give 1 tablet by mouth one time a day for hypertension. Medication not given at this time due to BP outside parameters. BP was 99/43. Nurse in charge notified. *on 01/17/24 an eMAR-Administration Note indicating nifedipine ER Oral Tablet Extended Release 24 Hour 30 mg give 1 tablet by mouth one time a day for hypertension. Medication not given at this time due to BP outside parameters. BP was 100/50. Nurse in charge notified. 3. Record review of a face sheet dated 01/30/24 indicated Resident #44 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included hypertension (condition in which the force of the blood against the artery walls is too high). Record review of the physician orders for January 2024 indicated Resident #44 had an order dated 01/11/24 to receive amlodipine 2.5 mg twice daily with indications to hold the medications if SBP was <110; DBP was <60; or P was <60. Record review of the January 2024 eMAR indicated Resident #44 received amlodipine on 01/28 for the morning dose when her SBP was 108 and she received the medication on 01/28 for the evening dose with code 9. Code 9 was indicated on the eMAR as See Nurse Notes. Record review of the Nursing Progress Note dated 01/28/24 for Resident #44 had no indication the evening dose of the amlodipine was held. During an interview on 01/31/24 at 12:01 p.m., RN E said they checked the vital signs if there was parameters ordered and if the VS were in the parameters to be held then the medications were held. She said she did not realize she checked on the eMAR for Resident # 44's Metoprolol the code 9. She said she did not document in the nursing notes that the medication was held. Record review of the physician orders for January 2024 indicated Resident #44 had an order dated 01/24/24 to receive Metoprolol 25 mg twice daily with indications to hold the medications if SBP was <110, DBP was <60, or P was <60. Record review of the January 2024 eMAR indicated Resident # 44 received Metoprolol on: * 01/15 when her SBP was 101 and DBP was 53; * 01/18 when her DBP was 59; * 01/19 when her SBP was 100; and * 01/28 when her SBP was 108. Record review of a face sheet dated 01/31/24 indicated Resident #47 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump). Record review of the physician orders for January 2024 indicated Resident # 47 had an order dated 01/19/24 for her to receive Toprol XL mg daily and indications to hold the medications if SBP was <110; DBP was <60; or P was <60. Record review of the January 2024 eMAR indicated Resident # 47 received Toprol XL on: *01/09 when her DBP was 51; *01/15 when her DBP was 58 and P was 58. During an interview on 01/30/24 at 04:25 p.m., RN D said they checked the vital signs prior to medication administration. She said if there were parameters ordered and the VS were in the parameters to be held, then they were held. During an interview on 01/31/24 at 01:35 p.m., the ADON said BP medications should be held if they have parameters to hold them. He said if they the medication was held there should be a nursing note also. He said residents given BP medications when they should be held could cause the resident BP to drop and them being sent to the hospital. Record review of an Unnecessary Drugs Policy revised 09/22/17 indicated Policy: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: .without adequate indications for its use Record review of an Unnecessary Drugs Policy revised 09/22/17 indicated Policy: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: .In the presence of adverse consequences which indicate the dose should be reduced or discontinued;

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Supervisor indicated no documentation that she had completed the certified Dietary Manager course. She had a date of hire of 12/02/16. During an interview on 01/30/24 at 8:00 a.m., the Dietary Supervisor said she had not completed or started the dietary manager classes. She said she was working as dietary supervisor until the facility could hire a certified dietary manager. During an interview on 01/31/24 at 10:45 a.m., the HR staff said the Dietary Supervisor was not a certified dietary manager and had assumed the position on 01/17/24. He said the facility had tried to hire a certified dietary manager or hire staff and have them become a certified dietary manager since February 2023. During an interview on 01/31/24 at 12:00 p.m., the Administrator said her expectation was for the DM to be certified to over see the dietary services. She said the DM would monitor staff's dietary certifications and ensure diets were followed. Reference obtained from the Texas Food Establishment Rules dated 2015 indicated .Certified Food Protection Manager and Food Handler Requirements. (a) At least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program. Record review of the Food Service policy dated January 2023 indicated . In addition, a minimum of one person directly responsible food preparation must successfully complete a state approved food protection program by a. Obtaining a certification as a dietary manager; or b. Obtaining a certification as a food protection professional .

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 10 dietary staff (Dietary Aide B) reviewed for food and nutrition services. The facility failed to ensure Dietary Aide B had a current Food Handler's Certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Findings included: Record review of 10 dietary staff food handlers' certificates indicated Dietary Aide B's certificate expired on [DATE]. During an interview on [DATE] at 11:47 a.m., Dietary Aide B said he did not know his food handler's certification had expired last year. He stated, I completed the food handler training and tested last night. During an interview on [DATE] at 12:00 p.m., the Administrator said the Dietary Manager was responsible for monitoring the dietary staff and the food handler certificates. She said the facility did not have a certified dietary manager. She said her expectation was for the dietary staff to have current food handler's certification to prevent food borne illness and the food handler certification was required. Reference obtained from the Texas Food Establishment Rules' dated 2015 indicated .Certified Food Protection Manager and Food Handler Requirements. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee. The requirement to complete a food handler training course shall be effective [DATE]

Based on observation, interview, and record review, the facility failed to provide liquids consistent to meet the residents' needs, for one (Resident #43) of 16 residents reviewed for food and nutrition services. The facility did not serve Resident #43 nectar thickened coffee or juice during his breakfast meal on 01/29/24. This failure could place residents who have dysphagia at risk for aspiration. Findings included: Record review of Resident #43's admission record dated 01/29/24 indicated he was [AGE] years old and admitted on [DATE] with aphasia (language disorder) and dysphagia (difficulty swallowing). Record review Resident #43's of the MDS quarterly assessment dated [DATE], indicated Resident #43's BIMS score was 09 indicating moderate impairment with cognition. He was dependent on staff for eating. Resident #43 required mechanically altered diet - required change in texture of food or liquids (thickened liquids) while a resident of this facility and within the last 7 days. Record review of the care plan dated 11/10/2023 indicated Resident #43 was at risk for potential complications with nutrition/hydration. The interventions included diet as ordered, mechanical soft with thickened liquids. Record review of physician orders dated 01/29/24 indicated Resident #43's orders included NAS (No Added Salt) diet mechanical soft texture, mildly thick/nectar thick consistency. During an observation on 01/29/24 at 8:35 a.m., Resident #43 was eating his mechanical soft diet breakfast and drinking his coffee. The coffee and juice on his tray were not thickened. During an observation and interview on 01/29/24 at 8:40 a.m., MA C said Resident #43's coffee and juice were thin consistency, but the liquids should have been thickened. CNA A said Resident #43 drank thin liquids. MA C picked up Resident #43's dietary card on his tray and said the card indicated nectar thickened liquids. During an interview 01/29/24 at 9:05 a.m., the ADON said Resident #43's physician's orders indicated he was to receive a mechanical soft diet with his liquids thickened to nectar consistency. The ADON said the consistency of the resident's liquid was to prevent choking or aspiration. Record review of the policy titled Consistency Altered Diet dated February 2021 indicated Policy To assist in meeting a tenant's/ resident's dietary needs. Consistency altered diets (texture changes and or thickened liquids) are provided as long as these altered diets are adhered to by the tenant /resident, do not jeopardize the tenant's/ resident's health, and are within the capability of the community.

Based on observation, interview and record review, the facility failed to ensure residents were provided the therapeutic diets as prescribed by the attending physician for 2 of 16 residents (Residents #18 and #40) reviewed for therapeutic dietsfood and nutrition services. The facility failed to ensure Residents #18 and #40 did not received their health shake with the lunch meal on 01/29/24 as ordered by physician. This failure could place residents with diet needs at risk for a decrease in calories and potential weight loss. The findings included: 1. Record review of Resident #18's admission record dated 01/31/24 indicated she was [AGE] years old and admitted on [DATE] with vitamin deficiency and heart disease. Record review of the MDS quarterly assessment dated [DATE], indicated Resident #18's BIMS score was 08 indicating moderate impairment with cognition. She required supervision for eating. No weight loss or gain of 5% or more in the last month or loss of 10% or more in the last 6 months was noted. Record review of the care plan dated 12/08/23 indicated Resident #18 had actual weight loss related to varied intake. The approaches included health shakes with meals. Record review of physician orders dated 01/31/24 indicated Resident #18's orders included orders for health shakes with meals with a start date of 11/11/22 and mechanical soft diet. During an observation on 01/29/24 at 12:15 p.m., Resident #18 was eating her mechanical soft lunch meal, and no health shake was on the tray. During an interview on 01/29/24 at 1:15 p.m., Resident #18 stated I did not get my milk shake at lunch. 2. Record review of admission record dated 01/29/24 indicated Resident #40 was admitted on [DATE] with a stroke, dysphagia (difficulty swallowing) and protein calorie malnutrition (insufficient consumption of protein). Record review of the MDS significant change assessment dated [DATE] indicated Resident #40's BIMS was 14 indicating her cognition was intact. She required supervision or touching assistance as resident completed the activity of eating and assistance could be provided throughout the activity or intermittently. She had a weight gain of 5% or more in the last month or gain of 10% or more in the last 6 months. Record review of the care plan dated 01/18/24 for Resident #40 included she was at risk for complications with nutrition / hydration related to acceptance of supplements, appetite, and meal Intake. The interventions included diet: regular pureed diet, nectar thick liquids and health shakes. Record review of physician's orders dated 01/29/24 indicated Resident #40 diet was on a pureed diet with nectar thick liquids and health shake with meals for weight loss with start date of 01/16/2024 During an observation on 01/29/24 at 12:40 p.m., Resident #40 was sitting in the dining room, and staff was assisting her back to her room. Her plate was empty, and no health shake was on the tray. There was a glass of thickened water half full and thickened juice was almost emptied. During an interview on 01/29/24 at 2:00 p.m., Resident #40 said she did not remember if she had her milk shake at lunch. During an interview on 01/29/24 at 12:45 p.m., CNA A said Residents #18 and #40 did not receive their health shakes with the lunch meal. She said the kitchen did not send them out with lunch trays . She said the nurse in the dining room was responsible for checking the trays and pointed to the DON. During an interview on 01/29/24 at 1:30 p.m., the DON said after surveyor intervention, the staff in the dining room brought Residents #18 and #40 the health shakes. She said the dietary staff had not put them out in the dining room. She said the health shakes were in addition to their meals to prevent weight loss.

Based on interview, record review and policy review, the facility failed to ensure one of three residents reviewed for hydration/nutrition (Resident (R)12) received adequate fluids. R12 experienced a change in condition which included a refusal to eat and drink. The resident was not assessed for dehydration and fluid intake was not monitored even though R12 refused most meals for a period of approximately two weeks resulting in harm with an elevated sodium level on 09/25/20. R12 was sent to the hospital emergency room (ER) on 10/06/20 and was diagnosed with dehydration and a critically elevated sodium level; intravenous (IV) fluids were administered. Findings include: R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/20, located in the EMR under MDS, revealed R12 had a Brief Interview for Mental Status (BIMs) score of 13 of out a total of 15, indicating he was intact in cognition (score of 13 - 15). Under Mood, he was documented with feeling down, depressed or hopeless and feeling tired or having little energy. R12 was not identified as exhibiting any behaviors. R12 required limited assistance with transfers, locomotion on the unit, and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The resident was independent with meals and required setup help only. R12's height was 67 and he weighed 166 pounds. He had experienced no significant weight loss or gain prior to admission. Active discharge planning was in place. Review of Section V, Care Area Assessment (CAA) Summary, of the Admission MDS with an ARD of 09/18/20, located in the EMR under MDS, revealed the problem area of Nutrition triggered for further review and the problem would be care planned. The CAA Worksheet dated 9/21/20, a paper copy printed for the surveyor, indicated R12's body mass index (BMI - measure of adequacy of weight for height) revealed the resident's BMI was 25.99, indicating he was overweight (overweight is a BMI of 25 or higher). R12 was identified at mild nutritional risk, having a history of [CONDITION(S)]. R12 was identified with [CONDITION(S)], cardiovascular disease, pain, gastrointestinal problem, and respiratory disease. Hydration did not trigger for further review. Review of the Physician's Notes in the EMR revealed no Physician's visits in person during the resident's stay. However, an initial History and Physical (H & P) dated 09/08/20, was printed for the surveyor and was from the resident's admission to the hospital prior to his admission to the facility on [DATE]. The H & P revealed the resident was noted with mumbling, sweating, vomiting blood, with bilateral flank pain and [CONDITION(S)]. Review of the Care Plan, dated 09/28/20, in the EMR under the Care Plan tab, revealed the problem of at risk for nutritional problem r/t [related to] history of [CONDITION(S)], recent hospitalization and acute illness. The goal was for R12 to maintain adequate nutritional status by maintaining weight and exhibiting no signs and symptoms of malnutrition. Interventions in full were: Provide and serve diet as ordered .RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed). Review of the Look Back Report, printed meal intake records, dated 09/15/20 - 10/06/20 revealed R12, from admission on 09/15/20 - 09/23/20 breakfast, R12 refused five out of 15 total meals (33% of the time) for breakfast and lunch. From 9/23/20 lunch through discharge on 10/06/20, R12 refused breakfast and lunch 24 times out of 27 meals (88% of the time). Dinner intake was sporadic throughout the resident's stay; however, starting on 09/29/20 - 10/06/20, he refused dinner once, consumed between 0-25% four times, and consumed 25-50% twice. There were no fluid intake records for R12. R12's Weight Record in the electronic medical record (EMR) under the heading of Vital Signs revealed R12 experienced weight loss from 166.2 pounds (lbs) to 152.2 lbs during his stay as follows: 09/16/20 - 166.2 lbs 09/23/20 - 158 lbs 09/23/20 - 149 lbs 09/30/20 - 152.2 lbs 10/04/20 - 152.2 lbs Record review revealed a change in the resident's condition occurred during his stay with poor nutritional and fluid intake occurring; there was no evidence R12 was assessed for dehydration. Notes were as follows: -Review of a Registered Dietitian (RD) Note dated 09/15/20, in the EMR under Progress Notes revealed the resident was 67 tall, weighed 166.2 lbs and his ideal body weight was 148 lbs. The resident's estimated needs were 1890 calories, 76 grams of protein and 2260 ml of fluid daily. The resident received a regular diet, regular texture and thin liquids. The goals were no wound formation and no significant weight changes of 5% of more in one moth. Recommendations were to continue with the current plan of care. -Review of the Basic Metabolic Panel dated 09/25/20 (paper copy printed by the facility), revealed a high sodium level of 146 (normal range for the lab 136 - 145). Review of the Merck Manual, revised April 2020, online version under Hormonal and Metabolic Disorders/ Electrolyte Balance/ [CONDITION(S)], (https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/[CONDITION(S)]-high-level-of-sodium-in-the-blood#:~:text=[CONDITION(S)]%20typically%20causes%20thirst.,seizures%2C%20coma%2C%20and%20death.) [CONDITION(S)] is a high level of sodium in the blood. [CONDITION(S)] involves dehydration, which can have many causes, including not drinking enough fluids, diarrhea, kidney dysfunction, and diuretics. Mainly people are thirsty, and if [CONDITION(S)] worsens, they may become confused or have muscle twitches and seizures. Blood test are done to measure the sodium level. Usually, fluids are given intravenously to slowly reduce the sodium level in the blood. -Review of a Nurse's Note dated 09/29/20 at 8:50 AM, in the EMR under Progress Notes, documented R12's appetite being poor. The nurse discussed with R12's family his meal refusal and poor appetite. The family member had been delivering home cooked meals, but R12 still did not eat. -Review of a Nurse's Note dated 9/29/20 at 11:05 AM, in the EMR under Progress Notes, revealed the resident's Physician was notified of his condition including responding poorly with ADLs, expression of pain, yelling out, refusing care and poor appetite. A request was made to the Physician to review medications. [MEDICATION(S)] (pain medication) was given. -Review of an Activity Progress Note dated 9/30/20 at 3:12 PM, in the EMR under Progress Notes, revealed R12's Physician was notified of changes to resident such as declining therapy, requiring to be fed, and mumbled speech. The note indicated the resident was not displaying these symptoms on admission. -Review of a Dietary Progress Note dated 9/30/20, in the EMR under Progress Notes, revealed the resident experienced a significant weight loss of 17.2 lbs (10.3%) in two weeks. The note indicated the resident was not eating. He was on a regular diet with poor intake noted. A Communication between the Dietitian and Attending Physician form, dated 9/30/20, paper copy revealed the Dietitian recommended Health Shakes BID and Med Pass 60 ml BID on this date (which were implemented on 10/01/20 per review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Review of a note dated 09/30/20 at 11:25 PM, in the EMR under Progress Notes, revealed the nurse was unable to wake R12 to make sure he swallowed his medications even though they were crushed. -Review of a Nurse's Note dated 10/03/20 at 6:49 PM, in the EMR under Progress Notes, revealed the resident ate poorly on this date, but drank Health Shakes and Med Pass supplements. -Review of a Nurse's Note on 10/04/20 at 5:25 AM, in the EMR under Progress Notes, revealed the resident was nonverbal, uncooperative with care, yelling out and grabbing at staff. R12 had poor fluid intake this shift and appeared to forget how to drink at times. Medications were crushed due to safety concerns. -Review of an Activity Progress Note dated 10/06/20 at 2:29 PM, in the EMR under Progress Notes, revealed the resident had a major decline in status. He wouldn't respond to speech or touch, was moaning and exhibited constant facial grimacing. R12 had an increased respiratory rate, [CONDITION(S)] heart rate, and felt warm to touch. The Resident's Physician was notified. R12 was sent to the ER and left via Emergency Medical Services at 1:36 PM. Hospital records revealed R12 was dehydrated when he arrived at the hospital. Review of the ER Report dated 10/06/20 at 1:58 PM, paper copy, revealed the resident had emesis in his mouth and possible aspiration. He was admitted with dry membranes. R12 was treated with IV fluids and antibiotics. R12's sodium level was critically high at 166 and he was diagnosed with severe [CONDITION(S)] (elevated sodium) hemoconcentration and volume depletion. Review of the Hospital Discharge Summary dated 10/15/20, paper copy, revealed R12 was admitted with lethargy/confusion/poor oral intake, severe [CONDITION(S)], and dehydration. The resident's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resolved problems included: [CONDITION(S)], [CONDITION(S)], acute kidney injury, [CONDITION(S)], and acute hypoxemic respiratory failure. During an interview 05/17/21 at 3:33 PM, the resident's family (F)12 stated R12 was originally admitted to the facility on [DATE], after being hospitalized , and the goal was for him to return home after 21 days of rehab. F12 stated when the resident was admitted , he was able to eat a regular diet and he had no history of a swallowing problem. F12 stated R12 was originally admitted to the quarantine unit where he stayed for 14 days as a precaution for coronavirus (COVID)-19. F12 stated she was not able to visit the resident during this period; however, once his quarantine was over, she visited him outdoors. F12 stated she visited R12 on 9/29/20 and he was very thirsty. F12 asked the staff to bring him some water and he readily drank it like he had not been given fluids in a long time. F12 stated, when she saw him, she noticed R12 had lost a considerable amount of weight and was not eating. F12 stated she was cooking his meals and taking them over for lunch and supper for the staff to feed to him. F12 stated on 10/06/20, a nurse called her and said R12 needed to go to the emergency room (ER) because he needed blood work. F12 stated she met R12 in the emergency room (ER) and she knew when she saw him, that staff had not been taking care of him. She stated when she got to the ER, R12's mouth was very dry, he had not been given adequate fluids and the doctor informed her there was dried vomit in his mouth. F12 stated R12 had aspirated; he was intubated and placed on a respirator. R12 was discharged home from the hospital; he was placed on hospice care and passed away on 10/24/20. During an interview on 05/19/21 1:44 PM Certified Nursing Assistant (CNA)26 stated R12 stayed in bed during most of his stay. She indicated R12 talked a little at first, but went down-hill quickly. She stated R12 wouldn't eat even though F12 brought him food every day. She stated R12 did not drink either. She stated R12 mainly stayed in bed and refused care. She stated R12 needed total assistance with care. She indicated CNAs documented both meal and fluid intake in the computer. During an interview on 05/19/21 at 2:12 PM, CNA 20 stated R12 was communicative, was getting up at first and going to therapy, then he gave up. CNA 20 stated R12 stayed in bed and gave up on eating and did not want to drink. CNA 20 stated after he gave up, needed total assistance with activities of daily living (ADLs). CNA 20 verified F12 brought R12 foods from home often. During an interview on 05/19/21 at 3:31 PM, CNA 10 stated within days of R12's admission, he stopped eating and drinking. CNA 10 said R12 declined rapidly. He was alert and oriented at first and able to stand, and then could not stand. CNA 10 stated she tried to encourage the resident, but he did not want to be messed with. CNA 10 stated R12 would not allow her to assist him with meals. CNA 10 stated R12's teeth were sheared at the gum line and he ended up being served soft and pureed foods. During an interview on 05/20/21 at 9:55 AM, Registered Nurse (RN) 33 stated she worked day shift and had cared for R12 during his stay. She stated R12 came in for rehab to gain strength. She indicated R12 was verbal and communicative the first few days and was able to transfer himself into the bed, but declined rapidly thereafter. RN 33 stated R12 would not eat, so F12 made him home cooked meals. RN 33 stated he might eat a quarter of the meal at best. She stated the resident's teeth were broken and he had missing teeth. She stated it was hard to tell initially if he had a swallowing problem or if his teeth were the problem. RN 33 indicated the last week R12 was in the facility, his swallowing was a concern. RN 33 stated she ended up crushing medications at the end and it was hard to administer medications because he had a dry pasty mouth. RN 33 stated she could not remember if IV fluid were ever suggested or administered. RN 33 indicated she had frequent contact with R12's physician during the resident's stay and R12's medications were changed several times. RN 33 stated the CNAs documented fluid intake in the computer, adding, We knew he had minimal intake. RN 33 did not indicate an assessment for hydration was conducted. RN 33 stated she did not remember the resident vomiting prior to going to theER on [DATE] and stated there was not much (food or fluid consumed) to vomit. RN 33 stated she did not like the look about R12 for a couple days prior to sending him to the ER. RN 33 stated she was the nurse on duty the day R12 went to theER on [DATE]. She stated breathing was the main issue and R12's oxygen level was not good so she sent him out. A call was placed to the facility Dietician by the surveyor on 05/20/21 at 10:30 AM and a message left to please return the call for additional information. No call was returned and the Dietician was not in the building for an opportunity to conduct an additional interview and review documentation. During an interview on 05/20/21 at 9:02 AM, the Director of Nursing and Administrator stated they did not know if R12's Physician came into the facility during R12's stay to see him in person. They stated, at that time, they were doing telehealth visits due to COVID-19. The DON stated the RD and Speech Therapist saw the resident during his stay and health shakes were implemented. The DON stated CNAs should document meal and fluid intake. The DON stated although they found meal intake records, they could not find any fluid intake records for R12. The DON stated R12's fluid intake should have been documented but it was not. During an interview on 05/21/20 at 9:44 AM, R12's Physician stated R12 was acutely ill when admitted to the facility and deteriorated during his rehab stay. He stated he did not go to the facility to see the resident, but was informed by nursing of medical concerns. The Physician stated he did not remember any conversations about IV fluids or potential dehydration with facility staff. He stated R12 was difficult, declined treatment, and could be aggressive. The Physician stated the facility should maintain fluid intake records and should keep him notified of the resident refusing fluids. Review of the Hydration policy dated November 2016, paper copy revealed, The facility assesses all residents for their risk of hydration problems at admission and annually, as well as with a significant change of condition .Sufficient fluid intake is offered to all resident in order to maintain proper hydration and health .Individual risk factors for hydration problems include: .functional impairments, cognitive impairments (e.g., forgetting to drink), refusal of fluids . overall health status . Additional attention to hydration may be required during periods of acute conditions such as: . nausea/vomiting . presence of signs/symptoms of dehydration such as: dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, and abnormal laboratory values (i.e., elevated sodium .).

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect for one (1) of five (5) residents. (Resident #1) The facility failed to adequately train CNA H in the proper procedures for the use of a Hoyer lift. Resident # 1 fell from a Hoyer Lift sling while being transferred from her bed to her wheelchair when CNA H turned away to retrieve the wheelchair. This fall resulted in the resident's emergency transportation to the local hospital followed by surgery for [REDACTED]. This deficient practice effected Resident #1 and placed 12 other residents identified as requiring Hoyer Lift transfers at risk for falls resulting in injury or death. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included Intertrochanteric, closed (Hip Surgery), Acute [MEDICAL CONDITION] Disease, [MEDICAL CONDITION], and Hypertension. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. The MDS further reflected a transfer functional status of Total dependence with two (2) person physical assistance. Review of Resident #1's Care Plan dated 10/10/14 reflected a problem of "I am at risk for falls secondary to weakness, cognitive loss and [MEDICAL CONDITION] medication use. Fall risk=15." Approaches included "I will transfer with Hoyer Lift and assistance x 2 staff assist at all times." Observation of Resident #1 on 02/09/15 at 3:28 PM reflected the resident in bed. The bed was set in the low position. The resident was moaning. Review of the facility's Investigation Report dated 01/29/15 reflected an incident date of 01/22/15 at 11:33 AM. The investigation summary reflected "During the investigation it was determined that (CNA H) was getting a wheelchair in place. CNA H was also the one that put the sling on (Resident #1). During the pumping action of lifting the Hoyer performed by (CNA F) (Resident #1's) shoe begins to fall off. (Resident #1) lunges for her shoe and slides out of the sling. Found out during the investigation that one of the sides of the sling had come undone." Provider action taken post-investigation included: "(CNA H) will be terminated once corporate termination process has been completed. CNA F will be disciplined and will be put on weekly transfer monitoring for the next 4 weeks. Staff were in-serviced on 01/22/15 on how to use a Hoyer Lift. Care Plan and MDS will be updated. Police were notified. Family and physician notified of findings. Will present at next QA (Quality Assurance) meeting." In an interview on 02/09/15 at 4:05 PM CNA H stated "I don't know how she fell . I was guiding her from the bed and reached around for a wheelchair. When I turned back around the strap had come loose and (Resident #1) was on the floor." The CNA further stated she had, in fact, taken her eyes off of the resident while she searched for a wheelchair and could not recall if she monitored the sling's straps to be sure they stayed on the lift's arm. CNA H further stated she had never received Hoyer lift training other than by watching and assisting with Hoyer transfers while on the job. In an interview on 02/09/15 at 11:38 AM CNA F stated she had assisted CNA H in performing a bed to wheelchair Hoyer Lift transfer with Resident #1 on 01/22/15. During the transfer, CNA F was responsible for connecting the upper sling straps to the Hoyer Lift's arm as well responsible for operating the lift's controls. CNA H was responsible for connecting the lower sling straps and guiding Resident #1 from the bed to the wheelchair. CNA F further stated the resident had just been lifted from the bed and was being swung away from the bed when CNA H turned away from the resident to get a wheelchair. CNA F stated CNA H's eyes were not on the resident when the resident lunged for a shoe that had fallen off of her foot. At that time the resident slid out of the sling and fell on the floor. The lower left sling connection was observed at that time to be disconnected from the Hoyer Lift's arm. CNA F provided a visual demonstration of the incident with the use of a Hoyer lift and sling to show exactly how the sling was supposed to be attached and to present an opinion that the sling's strap became disconnected when the sling was sitting loosely on the lift's arm and the lift was being jacked up but before tension had been established on the strap. CNA F further stated that staff members should "never" take their eyes off of a Hoyer's sling until it had attained tension on the lifts arm and should never take their eyes off of the resident while conducting a Hoyer transfer. In an interview on 02/09/15 at 9:31 AM Resident #1's husband stated he had been present in the resident's room on 01/22/15 at the time of her fall. "She just slipped right out of the sling and hit the floor. She slipped while they (the CNAs) were getting her in the air." In an interview on 02/09/15 at 3:28 PM Resident #1 stated she felt pain "all over." The resident further stated she felt the greatest pain along her right leg. The resident could not recall the events of 01/22/15 when she fell from a Hoyer lift. The resident further stated she could not recall being sent to the hospital or having hip surgery. Review of Resident #1's Hospital Progress Notes dated 01/26/15 reflected Resident #1 was admitted to the hospital with [REDACTED]." The notes further stated the resident had "Orthopedic surgery repair on 01/25/15." Review of Resident #1's Medication Administration Record [REDACTED]." The MAR further reflected the medication was administered on 02/13/15 and 02/09/15. In an interview on 02/09/15 at 8:00 AM the Administrator stated on 01/22/15 CNA F and CNA H were conducting a bed to wheelchair Hoyer Lift transfer. While CNA F was cranking the Hoyer Lift arm up CNA H was guiding the resident's body away from the bed. At some point during that process CNA H took her hands off of the resident and turned away to get a wheelchair. A lower corner of the sling had disconnected from the Hoyer Lift's arm and the resident fell from the sling as she reached for a fallen shoe. CNA F notified her charge nurse RN K of the incident. RN K and the ADON assessed the resident and agreed that Resident #1's hip "looked bad". 911 was called and the resident was sent to the local hospital for evaluation and treatment. The resident's primary care physician and family were immediately notified of the incident. The Administrator further stated CNA F and CNA H were both "fairly new employees" that had been trained in Hoyer Lift procedures as part of their orientation to the facility. The Administrator further stated "I might as well tell you now, I don't have documentation." The training documentation had been handled by a nurse who had since resigned from the facility (LVN L). The Administrator had been unable to contact the LVN as she would not return telephone calls. The Administrator's investigation of the incident consisted of interviewing all staff members that had been in the room at the time of the fall and in response to the fall. Inspection of the Hoyer Lift used at the time of the fall revealed the Hoyer Lift sling's lower right strap was hanging away from the Hoyer Lift's arm. CNA's F and H were suspended pending results of the investigation. CNA F was allowed to return to work with the understanding that she would receive weekly Hoyer lift training from a nurse until further notice. The Administrator stated CNA H was terminated from employment because she had broken facility policy by turning her back on the resident during the transfer. CNA H also had a history of [REDACTED]. CNA H used a Hoyer Lift to lift a resident from a recliner and left the resident, hanging in the lift's sling alone, while she left the room to request assistance. Review of CNA H's Employee Performance Improvement Plan dated 11/24/14 reflected CNA H had left a resident "hanging from a Hoyer Lift over his recliner. (CNA H), who was assigned to resident's care, was not in the room." The CNA received a one (1) day suspension for "Violation of Hoyer lift device procedure policy." Training to be provided included: "CNA will be trained by staff member on Hoyer transfers. CNA and trainer will sign off that training has been completed before CNA is allowed back on the floor." Review of the facility's policy and procedure titled "On The Job Training" reflected "All training programs and classes attended by an employee shall be entered on his/her "Employee Training Attendance Record." Review of CNA F and CNA H's personnel files reflected no documentation of Hoyer Lift training other than a signed copy of the facility's policy and procedure titled "Hoyer Lift Device" (undated). Further review of both CNA's personnel file reflected no copy of the CNA's " Employee Training Attendance Record." In an interview on 02/09/15 at 2:21 PM LVN M stated she had been responsible for annual mandatory in-service on fall prevention dated 12/23/14. CNA H failed to attend the training and refused to attend make-up training on several occasions when approached to schedule the needed training. Review of a written statement dated 01/27/15 and signed by LVN M reflected: "(CNA H) was aware of mandatory annual in-services training on 12/23/14 and did not attend. (CNA H) was asked several times to make up training on one to one basis but did not make an effort to do training." Review of a written statement dated 02/03/15 and signed by LVN M reflected: "Fall Prevention in-service was given on 12/23/14. This in-service was part of the mandatory annual in-service training. Hoyer lifts were a part of the fall prevention in-service. (CNA H) was aware of the in-service but failed to attend." In an interview on 02/09/15 at 3:05 PM the Administrator stated any employee that failed to attend mandatory in-service training would be subject to disciplinary action ranging from coaching and counseling to termination of employment. The Administrator further stated she had not been aware that CNA H had failed to attend make-up training in the 30 days that passed from the date in which CNA H missed the fall prevention in-service to the date of Resident #1's fall with injury. Review of the facility's policy and procedure titled "Hoyer Lift Device" (undated) reflected: "Check to make sure that the sling is properly connected to the cradle. If the sling attachments are not properly connected, lower the resident back onto the bed to correct the problem." Review of the facility's abuse and neglect policy and procedure titled: "Abuse/Neglect/Misappropriation Policy and Procedures" (undated) reflected "It is the goal of this policy to ensure the safety of our residents and consumers against abuse, neglect, exploitation, or misappropriation." The policy further reflected "Initial training of employees will begin on the employee's date of hire during new employee orientation by Human Resources or his/her designee. Training will continue during orientation in the department. Mandatory in-service training will be conducted annually." The facility Director of Nursing provided a list of 13 residents who relied on Hoyer Lifts for transfers.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for one (1) of five (5) residents reviewed for neglect.(Resident #1) The facility failed to properly train CNA H in the proper use of Hoyer Lifts. One (1) of five (5) residents (Resident #1) reviewed for neglect; fell from a Hoyer Lift sling while being transferred from her bed to her wheelchair when CNA H turned away to retrieve the wheelchair. This fall resulted in the resident's emergency transportation to the local hospital followed by surgery for [REDACTED]. This deficient practice effected Resident #1 and placed 12 other residents identified as requiring Hoyer Lift transfers at risk for falls resulting in injury or death. Findings included: Review of the facility's abuse and neglect policy and procedure titled: "Abuse/Neglect/Misappropriation Policy and Procedures" (undated) reflected "It is the goal of this policy to ensure the safety of our residents and consumers against abuse, neglect, exploitation, or misappropriation." The policy further reflected "Initial training of employees will begin on the employee's date of hire during new employee orientation by Human Resources or his/her designee. Training will continue during orientation in the department. Mandatory in-service training will be conducted annually." Review of the facility's policy and procedure titled "Hoyer Lift Device" (undated) reflected: "Check to make sure that the sling is properly connected to the cradle. If the sling attachments are not properly connected, lower the resident back onto the bed to correct the problem." Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included Intertrochanteric, closed (Hip Surgery), Acute [MEDICAL CONDITION] Disease, [MEDICAL CONDITION], and Hypertension. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. The MDS further reflected a transfer functional status of Total dependence with two (2) person physical assistance. Review of Resident #1's Care Plan dated 10/10/14 reflected a problem of "I am at risk for falls secondary to weakness, cognitive loss and [MEDICAL CONDITION] medication use. Fall risk=15." Approaches included "I will transfer with Hoyer Lift and assistance x 2 staff assist at all times." Observation of Resident #1 on 02/09/15 at 3:28 PM reflected the resident in bed. The bed was set in the low position. The resident was moaning. Review of the facility's Investigation Report dated 01/29/15 reflected an incident date of 01/22/15 at 11:33 AM. The investigation summary reflected "During the investigation it was determined that (CNA H) was getting a wheelchair in place. CNA H was also the one that put the sling on (Resident #1). During the pumping action of lifting the Hoyer performed by (CNA F) (Resident #1's) shoe begins to fall off. (Resident #1) lunges for her shoe and slides out of the sling. Found out during the investigation that one of the sides of the sling had come undone." Provider action taken post-investigation included: "(CNA H) will be terminated once corporate termination process has been completed. CNA F will be disciplined and will be put on weekly transfer monitoring for the next 4 weeks. Staff were in-serviced on 01/22/15 on how to use a Hoyer Lift. Care Plan and MDS will be updated. Police were notified. Family and physician notified of findings. Will present at next QA (Quality Assurance) meeting." In an interview on 02/09/15 at 4:05 PM CNA H stated "I don't know how she fell . I was guiding her from the bed and reached around for a wheelchair. When I turned back around the strap had come loose and (Resident #1) was on the floor." The CNA further stated she had, in fact, taken her eyes off of the resident while she searched for a wheelchair and could not recall if she monitored the sling's straps to be sure they stayed on the lift's arm. CNA H further stated she had never received Hoyer lift training other than by watching and assisting with Hoyer transfers while on the job. In an interview on 02/09/15 at 11:38 AM CNA F stated she had assisted CNA H in performing a bed to wheelchair Hoyer Lift transfer with Resident #1 on 01/22/15. During the transfer, CNA F was responsible for connecting the upper sling straps to the Hoyer Lift's arm as well responsible for operating the lift's controls. CNA H was responsible for connecting the lower sling straps and guiding Resident #1 from the bed to the wheelchair. CNA F further stated the resident had just been lifted from the bed and was being swung away from the bed when CNA H turned away from the resident to get a wheelchair. CNA F stated CNA H's eyes were not on the resident when the resident lunged for a shoe that had fallen off of her foot. At that time the resident slid out of the sling and fell on the floor. The lower left sling connection was observed at that time to be disconnected from the Hoyer Lift's arm. CNA F provided a visual demonstration of the incident with the use of a Hoyer lift and sling to show exactly how the sling was supposed to be attached and to present an opinion that the sling's strap became disconnected when the sling was sitting loosely on the lift's arm and the lift was being jacked up but before tension had been established on the strap. CNA F further stated that staff members should "never" take their eyes off of a Hoyer's sling until it had attained tension on the lifts arm and should never take their eyes off of the resident while conducting a Hoyer transfer. In an interview on 02/09/15 at 9:31 AM Resident #1's husband stated he had been present in the resident's room on 01/22/15 at the time of her fall. "She just slipped right out of the sling and hit the floor. She slipped while they (the CNAs) were getting her in the air." In an interview on 02/09/15 at 3:28 PM Resident #1 stated she felt pain "all over." The resident further stated she felt the greatest pain along her right leg. The resident could not recall the events of 01/22/15 when she fell from a Hoyer lift. The resident further stated she could not recall being sent to the hospital or having hip surgery. Review of Resident #1's Hospital Progress Notes dated 01/26/15 reflected Resident #1 was admitted to the hospital with [REDACTED]." The notes further stated the resident had "Orthopedic surgery repair on 01/25/15." Review of Resident #1's Medication Administration Record [REDACTED]." The MAR further reflected the medication was administered on 02/13/15 and 02/09/15. In an interview on 02/09/15 at 8:00 AM the Administrator stated on 01/22/15 CNA F and CNA H were conducting a bed to wheelchair Hoyer Lift transfer. While CNA F was cranking the Hoyer Lift arm up CNA H was guiding the resident's body away from the bed. At some point during that process CNA H took her hands off of the resident and turned away to get a wheelchair. A lower corner of the sling had disconnected from the Hoyer Lift's arm and the resident fell from the sling as she reached for a fallen shoe. CNA F notified her charge nurse RN K of the incident. RN K and the ADON assessed the resident and agreed that Resident #1's hip "looked bad". 911 was called and the resident was sent to the local hospital for evaluation and treatment. The resident's primary care physician and family were immediately notified of the incident. The Administrator further stated CNA F and CNA H were both "fairly new employees" that had been trained in Hoyer Lift procedures as part of their orientation to the facility. The Administrator further stated "I might as well tell you now, I don't have documentation." The training documentation had been handled by a nurse who had since resigned from the facility (LVN L). The Administrator had been unable to contact the LVN as she would not return telephone calls. The Administrator's investigation of the incident consisted of interviewing all staff members that had been in the room at the time of the fall and in response to the fall. Inspection of the Hoyer Lift used at the time of the fall revealed the Hoyer Lift sling's lower right strap was hanging away from the Hoyer Lift's arm. CNA's F and H were suspended pending results of the investigation. CNA F was allowed to return to work with the understanding that she would receive weekly Hoyer lift training from a nurse until further notice. The Administrator stated CNA H was terminated from employment because she had broken facility policy by turning her back on the resident during the transfer. CNA H also had a history of [REDACTED]. CNA H used a Hoyer Lift to lift a resident from a recliner and left the resident, hanging in the lift's sling alone, while she left the room to request assistance. Review of CNA H's Employee Performance Improvement Plan dated 11/24/14 reflected CNA H had left a resident "hanging from a Hoyer Lift over his recliner. (CNA H), who was assigned to resident's care, was not in the room." The CNA received a one (1) day suspension for "Violation of Hoyer lift device procedure policy." Training to be provided included: "CNA will be trained by staff member on Hoyer transfers. CNA and trainer will sign off that training has been completed before CNA is allowed back on the floor." Review of the facility's policy and procedure titled "On The Job Training" reflected "All training programs and classes attended by an employee shall be entered on his/her "Employee Training Attendance Record." Review of CNA F and CNA H's personnel files reflected no documentation of Hoyer Lift training other than a signed copy of the facility's policy and procedure titled "Hoyer Lift Device" (undated). Further review of both CNA's personnel file reflected no copy of the CNA's " Employee Training Attendance Record." In an interview on 02/09/15 at 2:21 PM LVN M stated she had been responsible for annual mandatory in-service on fall prevention dated 12/23/14. CNA H failed to attend the training and refused to attend make-up training on several occasions when approached to schedule the needed training. Review of a written statement dated 01/27/15 and signed by LVN M reflected: "(CNA H) was aware of mandatory annual in-services training on 12/23/14 and did not attend. (CNA H) was asked several times to make up training on one to one basis but did not make an effort to do training." Review of a written statement dated 02/03/15 and signed by LVN M reflected: "Fall Prevention in-service was given on 12/23/14. This in-service was part of the mandatory annual in-service training. Hoyer lifts were a part of the fall prevention in-service. (CNA H) was aware of the in-service but failed to attend." In an interview on 02/09/15 at 3:05 PM the Administrator stated any employee that failed to attend mandatory in-service training would be subject to disciplinary action ranging from coaching and counseling to termination of employment. The Administrator further stated she had not been aware that CNA H had failed to attend make-up training in the 30 days that passed from the date in which CNA H missed the fall prevention in-service to the date of Resident #1's fall with injury. Review of the facility's policy and procedure titled "Hoyer Lift Device" (undated) reflected: "Check to make sure that the sling is properly connected to the cradle. If the sling attachments are not properly connected, lower the resident back onto the bed to correct the problem." The facility Director of Nursing provided a list of 13 residents who relied on Hoyer Lifts for transfers.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (1) of five (5) residents. (Resident #1) The facility failed to adequately train CNA H in the proper procedures for the use of a Hoyer lift. Resident # 1 fell from a Hoyer Lift sling while being transferred from her bed to her wheelchair when CNA H turned away to retrieve the wheelchair. This fall resulted in the resident's emergency transportation to the local hospital followed by surgery for [REDACTED]. This deficient practice effected Resident #1 and placed 12 other residents identified as requiring Hoyer Lift transfers at risk for falls resulting in injury or death. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included Intertrochanteric, closed (Hip Surgery), Acute Cerebrovascular Disease, Peripheral Vascular Disease, and Hypertension. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. The MDS further reflected a transfer functional status of Total dependence with two (2) person physical assistance. Review of Resident #1's Care Plan dated 10/10/14 reflected a problem of "I am at risk for falls secondary to weakness, cognitive loss and psychotropic medication use. Fall risk=15." Approaches included "I will transfer with Hoyer Lift and assistance x 2 staff assist at all times." Observation of Resident #1 on 02/09/15 at 3:28 PM reflected the resident in bed. The bed was set in the low position. The resident was moaning. Review of the facility's Investigation Report dated 01/29/15 reflected an incident date of 01/22/15 at 11:33 AM. The investigation summary reflected "During the investigation it was determined that (CNA H) was getting a wheelchair in place. CNA H was also the one that put the sling on (Resident #1). During the pumping action of lifting the Hoyer performed by (CNA F) (Resident #1's) shoe begins to fall off. (Resident #1) lunges for her shoe and slides out of the sling. Found out during the investigation that one of the sides of the sling had come undone." Provider action taken post-investigation included: "(CNA H) will be terminated once corporate termination process has been completed. CNA F will be disciplined and will be put on weekly transfer monitoring for the next 4 weeks. Staff were in-serviced on 01/22/15 on how to use a Hoyer Lift. Care Plan and MDS will be updated. Police were notified. Family and physician notified of findings. Will present at next QA (Quality Assurance) meeting." In an interview on 02/09/15 at 4:05 PM CNA H stated "I don't know how she fell . I was guiding her from the bed and reached around for a wheelchair. When I turned back around the strap had come loose and (Resident #1) was on the floor." The CNA further stated she had, in fact, taken her eyes off of the resident while she searched for a wheelchair and could not recall if she monitored the sling's straps to be sure they stayed on the lift's arm. CNA H further stated she had never received Hoyer lift training other than by watching and assisting with Hoyer transfers while on the job. In an interview on 02/09/15 at 11:38 AM CNA F stated she had assisted CNA H in performing a bed to wheelchair Hoyer Lift transfer with Resident #1 on 01/22/15. During the transfer, CNA F was responsible for connecting the upper sling straps to the Hoyer Lift's arm as well responsible for operating the lift's controls. CNA H was responsible for connecting the lower sling straps and guiding Resident #1 from the bed to the wheelchair. CNA F further stated the resident had just been lifted from the bed and was being swung away from the bed when CNA H turned away from the resident to get a wheelchair. CNA F stated CNA H's eyes were not on the resident when the resident lunged for a shoe that had fallen off of her foot. At that time the resident slid out of the sling and fell on the floor. The lower left sling connection was observed at that time to be disconnected from the Hoyer Lift's arm. CNA F provided a visual demonstration of the incident with the use of a Hoyer lift and sling to show exactly how the sling was supposed to be attached and to present an opinion that the sling's strap became disconnected when the sling was sitting loosely on the lift's arm and the lift was being jacked up but before tension had been established on the strap. CNA F further stated that staff members should "never" take their eyes off of a Hoyer's sling until it had attained tension on the lifts arm and should never take their eyes off of the resident while conducting a Hoyer transfer. In an interview on 02/09/15 at 9:31 AM Resident #1's husband stated he had been present in the resident's room on 01/22/15 at the time of her fall. "She just slipped right out of the sling and hit the floor. She slipped while they (the CNAs) were getting her in the air." In an interview on 02/09/15 at 3:28 PM Resident #1 stated she felt pain "all over." The resident further stated she felt the greatest pain along her right leg. The resident could not recall the events of 01/22/15 when she fell from a Hoyer lift. The resident further stated she could not recall being sent to the hospital or having hip surgery. Review of Resident #1's Hospital Progress Notes dated 01/26/15 reflected Resident #1 was admitted to the hospital with [REDACTED]." The notes further stated the resident had "Orthopedic surgery repair on 01/25/15." Review of Resident #1's Medication Administration Record (MAR dated 02/01/15 to 02/28/15 reflected "Norco 5/325mg (milligrams) 1 tablet PO (By Mouth) Q (every) 6 hours PRN (as needed) pain." The MAR further reflected the medication was administered on 02/13/15 and 02/09/15. In an interview on 02/09/15 at 8:00 AM the Administrator stated on 01/22/15 CNA F and CNA H were conducting a bed to wheelchair Hoyer Lift transfer. While CNA F was cranking the Hoyer Lift arm up CNA H was guiding the resident's body away from the bed. At some point during that process CNA H took her hands off of the resident and turned away to get a wheelchair. A lower corner of the sling had disconnected from the Hoyer Lift's arm and the resident fell from the sling as she reached for a fallen shoe. CNA F notified her charge nurse RN K of the incident. RN K and the ADON assessed the resident and agreed that Resident #1's hip "looked bad". 911 was called and the resident was sent to the local hospital for evaluation and treatment. The resident's primary care physician and family were immediately notified of the incident. The Administrator further stated CNA F and CNA H were both "fairly new employees" that had been trained in Hoyer Lift procedures as part of their orientation to the facility. The Administrator further stated "I might as well tell you now, I don't have documentation." The training documentation had been handled by a nurse who had since resigned from the facility (LVN L). The Administrator had been unable to contact the LVN as she would not return telephone calls. The Administrator's investigation of the incident consisted of interviewing all staff members that had been in the room at the time of the fall and in response to the fall. Inspection of the Hoyer Lift used at the time of the fall revealed the Hoyer Lift sling's lower right strap was hanging away from the Hoyer Lift's arm. CNA's F and H were suspended pending results of the investigation. CNA F was allowed to return to work with the understanding that she would receive weekly Hoyer lift training from a nurse until further notice. The Administrator stated CNA H was terminated from employment because she had broken facility policy by turning her back on the resident during the transfer. CNA H also had a history of [REDACTED]. CNA H used a Hoyer Lift to lift a resident from a recliner and left the resident, hanging in the lift's sling alone, while she left the room to request assistance. Review of CNA H's Employee Performance Improvement Plan dated 11/24/14 reflected CNA H had left a resident "hanging from a Hoyer Lift over his recliner. (CNA H), who was assigned to resident's care, was not in the room." The CNA received a one (1) day suspension for "Violation of Hoyer lift device procedure policy." Training to be provided included: "CNA will be trained by staff member on Hoyer transfers. CNA and trainer will sign off that training has been completed before CNA is allowed back on the floor." Review of the facility's policy and procedure titled "On The Job Training" reflected "All training programs and classes attended by an employee shall be entered on his/her "Employee Training Attendance Record." Review of CNA F and CNA H's personnel files reflected no documentation of Hoyer Lift training other than a signed copy of the facility's policy and procedure titled "Hoyer Lift Device" (undated). Further review of both CNA's personnel file reflected no copy of the CNA's " Employee Training Attendance Record." In an interview on 02/09/15 at 2:21 PM LVN M stated she had been responsible for annual mandatory in-service on fall prevention dated 12/23/14. CNA H failed to attend the training and refused to attend make-up training on several occasions when approached to schedule the needed training. Review of a written statement dated 01/27/15 and signed by LVN M reflected: "(CNA H) was aware of mandatory annual in-services training on 12/23/14 and did not attend. (CNA H) was asked several times to make up training on one to one basis but did not make an effort to do training." Review of a written statement dated 02/03/15 and signed by LVN M reflected: "Fall Prevention in-service was given on 12/23/14. This in-service was part of the mandatory annual in-service training. Hoyer lifts were a part of the fall prevention in-service. (CNA H) was aware of the in-service but failed to attend." In an interview on 02/09/15 at 3:05 PM the Administrator stated any employee that failed to attend mandatory in-service training would be subject to disciplinary action ranging from coaching and counseling to termination of employment. The Administrator further stated she had not been aware that CNA H had failed to attend make-up training in the 30 days that passed from the date in which CNA H missed the fall prevention in-service to the date of Resident #1's fall with injury. Review of the facility's policy and procedure titled "Hoyer Lift Device" (undated) reflected: "Check to make sure that the sling is properly connected to the cradle. If the sling attachments are not properly connected, lower the resident back onto the bed to correct the problem." The facility Director of Nursing provided a list of 13 residents who relied on Hoyer Lifts for transfers.

Based on observation, interview, and record review the facility failed to ensure that a Certified Nurse Aide (CNA H) demonstrated competency in skills and techniques necessary to care for one (1) of five (5) residents reviewed for neglect. (Resident #1) CNA H failed to properly secure a Hoyer Lift sling and additionally failed to visually monitor a resident (Resident #1) during a Hoyer Lift transfer. Resident #1 fell from a Hoyer Lift sling while being transferred from her bed to her wheelchair when CNA H turned away to retrieve the wheelchair. This fall resulted in the resident's emergency transportation to the local hospital followed by surgery for [REDACTED]. This deficient practice effected Resident #1 and placed 12 other residents identified as requiring Hoyer Lift transfers at risk for falls resulting in injury or death. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted [DATE] and readmitted [DATE]. Diagnoses' included Intertrochanteric, closed (Hip Surgery), Acute [MEDICAL CONDITION] Disease, [MEDICAL CONDITION], and Hypertension. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of three (3) indicating severe cognitive impairment. The MDS further reflected a transfer functional status of Total dependence with two (2) person physical assistance. Review of Resident #1's Care Plan dated 10/10/14 reflected a problem of "I am at risk for falls secondary to weakness, cognitive loss and [MEDICAL CONDITION] medication use. Fall risk=15." Approaches included "I will transfer with Hoyer Lift and assistance x 2 staff assist at all times." Observation of Resident #1 on 02/09/15 at 3:28 PM reflected the resident in bed. The bed was set in the low position. The resident was moaning. Review of the facility's Investigation Report dated 01/29/15 reflected an incident date of 01/22/15 at 11:33 AM. The investigation summary reflected "During the investigation it was determined that (CNA H) was getting a wheelchair in place. CNA H was also the one that put the sling on (Resident #1). During the pumping action of lifting the Hoyer performed by (CNA F) (Resident #1's) shoe begins to fall off. (Resident #1) lunges for her shoe and slides out of the sling. Found out during the investigation that one of the sides of the sling had come undone." Provider action taken post-investigation included: "(CNA H) will be terminated once corporate termination process has been completed. CNA F will be disciplined and will be put on weekly transfer monitoring for the next 4 weeks. Staff were in-serviced on 01/22/15 on how to use a Hoyer Lift. Care Plan and MDS will be updated. Police were notified. Family and physician notified of findings. Will present at next QA (Quality Assurance) meeting." In an interview on 02/09/15 at 4:05 PM CNA H stated "I don't know how she fell . I was guiding her from the bed and reached around for a wheelchair. When I turned back around the strap had come loose and (Resident #1) was on the floor." The CNA further stated she had, in fact, taken her eyes off of the resident while she searched for a wheelchair and could not recall if she monitored the sling's straps to be sure they stayed on the lift's arm. CNA H further stated she had never received Hoyer lift training other than by watching and assisting with Hoyer transfers while on the job. In an interview on 02/09/15 at 11:38 AM CNA F stated she had assisted CNA H in performing a bed to wheelchair Hoyer Lift transfer with Resident #1 on 01/22/15. During the transfer, CNA F was responsible for connecting the upper sling straps to the Hoyer Lift's arm as well responsible for operating the lift's controls. CNA H was responsible for connecting the lower sling straps and guiding Resident #1 from the bed to the wheelchair. CNA F further stated the resident had just been lifted from the bed and was being swung away from the bed when CNA H turned away from the resident to get a wheelchair. CNA F stated CNA H's eyes were not on the resident when the resident lunged for a shoe that had fallen off of her foot. At that time the resident slid out of the sling and fell on the floor. The lower left sling connection was observed at that time to be disconnected from the Hoyer Lift's arm. CNA F provided a visual demonstration of the incident with the use of a Hoyer lift and sling to show exactly how the sling was supposed to be attached and to present an opinion that the sling's strap became disconnected when the sling was sitting loosely on the lift's arm and the lift was being jacked up but before tension had been established on the strap. CNA F further stated that staff members should "never" take their eyes off of a Hoyer's sling until it had attained tension on the lifts arm and should never take their eyes off of the resident while conducting a Hoyer transfer. In an interview on 02/09/15 at 9:31 AM Resident #1's husband stated he had been present in the resident's room on 01/22/15 at the time of her fall. "She just slipped right out of the sling and hit the floor. She slipped while they (the CNAs) were getting her in the air." In an interview on 02/09/15 at 3:28 PM Resident #1 stated she felt pain "all over." The resident further stated she felt the greatest pain along her right leg. The resident could not recall the events of 01/22/15 when she fell from a Hoyer lift. The resident further stated she could not recall being sent to the hospital or having hip surgery. Review of Resident #1's Hospital Progress Notes dated 01/26/15 reflected Resident #1 was admitted to the hospital with [REDACTED]." The notes further stated the resident had "Orthopedic surgery repair on 01/25/15." Review of Resident #1's Medication Administration Record [REDACTED]." The MAR further reflected the medication was administered on 02/13/15 and 02/09/15. In an interview on 02/09/15 at 8:00 AM the Administrator stated on 01/22/15 CNA F and CNA H were conducting a bed to wheelchair Hoyer Lift transfer. While CNA F was cranking the Hoyer Lift arm up CNA H was guiding the resident's body away from the bed. At some point during that process CNA H took her hands off of the resident and turned away to get a wheelchair. A lower corner of the sling had disconnected from the Hoyer Lift's arm and the resident fell from the sling as she reached for a fallen shoe. CNA F notified her charge nurse RN K of the incident. RN K and the ADON assessed the resident and agreed that Resident #1's hip "looked bad". 911 was called and the resident was sent to the local hospital for evaluation and treatment. The resident's primary care physician and family were immediately notified of the incident. The Administrator further stated CNA F and CNA H were both "fairly new employees" that had been trained in Hoyer Lift procedures as part of their orientation to the facility. The Administrator further stated "I might as well tell you now, I don't have documentation." The training documentation had been handled by a nurse who had since resigned from the facility (LVN L). The Administrator had been unable to contact the LVN as she would not return telephone calls. The Administrator's investigation of the incident consisted of interviewing all staff members that had been in the room at the time of the fall and in response to the fall. Inspection of the Hoyer Lift used at the time of the fall revealed the Hoyer Lift sling's lower right strap was hanging away from the Hoyer Lift's arm. CNA's F and H were suspended pending results of the investigation. CNA F was allowed to return to work with the understanding that she would receive weekly Hoyer lift training from a nurse until further notice. The Administrator stated CNA H was terminated from employment because she had broken facility policy by turning her back on the resident during the transfer. CNA H also had a history of [REDACTED]. CNA H used a Hoyer Lift to lift a resident from a recliner and left the resident, hanging in the lift's sling alone, while she left the room to request assistance. Review of CNA H's Employee Performance Improvement Plan dated 11/24/14 reflected CNA H had left a resident "hanging from a Hoyer Lift over his recliner. (CNA H), who was assigned to resident's care, was not in the room." The CNA received a one (1) day suspension for "Violation of Hoyer lift device procedure policy." Training to be provided included: "CNA will be trained by staff member on Hoyer transfers. CNA and trainer will sign off that training has been completed before CNA is allowed back on the floor." Review of the facility's policy and procedure titled "On The Job Training" reflected "All training programs and classes attended by an employee shall be entered on his/her "Employee Training Attendance Record." Review of CNA F and CNA H's personnel files reflected no documentation of Hoyer Lift training other than a signed copy of the facility's policy and procedure titled "Hoyer Lift Device" (undated). Further review of both CNA's personnel file reflected no copy of the CNA's " Employee Training Attendance Record." In an interview on 02/09/15 at 2:21 PM LVN M stated she had been responsible for annual mandatory in-service on fall prevention dated 12/23/14. CNA H failed to attend the training and refused to attend make-up training on several occasions when approached to schedule the needed training. Review of a written statement dated 01/27/15 and signed by LVN M reflected: "(CNA H) was aware of mandatory annual in-services training on 12/23/14 and did not attend. (CNA H) was asked several times to make up training on one to one basis but did not make an effort to do training." Review of a written statement dated 02/03/15 and signed by LVN M reflected: "Fall Prevention in-service was given on 12/23/14. This in-service was part of the mandatory annual in-service training. Hoyer lifts were a part of the fall prevention in-service. (CNA H) was aware of the in-service but failed to attend." In an interview on 02/09/15 at 3:05 PM the Administrator stated any employee that failed to attend mandatory in-service training would be subject to disciplinary action ranging from coaching and counseling to termination of employment. The Administrator further stated she had not been aware that CNA H had failed to attend make-up training in the 30 days that passed from the date in which CNA H missed the fall prevention in-service to the date of Resident #1's fall with injury. Review of the facility's policy and procedure titled "Hoyer Lift Device" (undated) reflected: "Check to make sure that the sling is properly connected to the cradle. If the sling attachments are not properly connected, lower the resident back onto the bed to correct the problem." The facility Director of Nursing provided a list of 13 residents who relied on Hoyer Lifts for transfers.

Based on observations, interviews and record reviews the facility failed to provide adequate supervision to prevent accidents and assistance devices to prevent accidents for one (1) of nine (9) residents reviewed for appropriate transfers. Resident #6 was not assessed, referred or evaluated by Physical Therapy to ensure the Sit-to-Stand lift was appropriate. The Physical Therapy Director and The Physical Therapy Assistant who are responsible for training staff were unaware of the proper procedure for the Sit-to-Stand lift or criteria for the use of the Sit-to-Stand lift. Resident #6 was unable to bear weight or hold on to the Sit-to-Stand lift causing Resident #6's shoulders and arms to to be a chicken wing formation (an improper body formation in which the shoulders are up and elbows out, which caused the majority of his weight (248 lbs.) to be supported by his shoulder joints) and abducted (Abduction is a term that refers to a body part moving laterally away from the body. In the case of the shoulder, this refers to the arm swinging out from the side of the body, in an arm-flapping motion.) during transfers. This caused Resident #6 experienced numbness in the limbs and discomfort while being transferred with the Sit-to-Stand lift, placing him at risk of injury. An Immediate Jeopardy (IJ) was identified on 12/19/2013. While the IJ was removed on 12/20/2013 at exit, the facility remained out of compliance at a Severity level of Potential for More Than Minimal Harm with a Scope of isolated that is not IJ. This deficient practice placed 46 residents that required assistance with transfer at risk of injury, pain, fractures, dislocation of joints, falls from slipping out of the sit-to-stand lift or death. Non Immediate Jeopardy Based on observation, interviews, and record review, the facility failed to ensure the environment remained free of accidents and hazards as is possible in shared bathrooms in three(3) of four (4) halls (Hall 100, 200 and 400). Hazardous chemicals were found in a shared bathroom between Rooms 202 and 204, Rooms 210 and 212 and between Rooms 402 and 404. In addition, an electric razor was plugged in and sitting on the edge of the bathroom sink in the shared bathroom between Rooms 106 and 108. This deficient practice placed 35 cognitively impaired at risk for ingesting dangerous chemicals and electrocution that could result in illness and injury including cuts, abrasions, nausea, vomiting, gastrointestinal issues and death. Findings Include: Review of Resident #6's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #6's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Resident #6 was not coded to have behaviors. Resident #6 was coded to require extensive one person physical assist for bed mobility, dressing and personal hygiene. Resident #6 was coded to be totally dependent with one person physical assist for transfers and toilet use. Resident #6 was coded to have an indwelling catheter. Review of Resident #6's Comprehensive Care Plan dated 03/15/2013 reflected Problem: "I need assistance with my ADL's (Activities of daily living) secondary to weakness." Handwritten on the Care plan with a date of 05/31/2013: "I am very weak s/p (status [REDACTED]. I need more assist with ADL's." Approach: "I will be transferred with sit to stand lift, 5/31/2013 change to Hoyer lift status [REDACTED]." Review of Resident #6's History and Physical dated 03/02/2013 reflected "CVA (Cerebral Vascular Accident) in 2009 with left-side weakness ... " "Significant joint pain, mostly in the lower back and knees reported. The patient has difficulty moving any of his extremities through the full range of motion. He is able to feed himself with his right hand but is not able to do things like brush his teeth or comb his hair. He cannot transfer independently in the nursing home and is confined to a wheelchair." Review of Resident #6's History and Physical dated 12/25/2010 reflected "He does have some difficulty with grip strength in his right hand due to mild contractors." Review of the facilities Weight Review report for 2013 reflected Resident #6 weights was 248 lbs. (pounds) for December 2013. Observation on 12/18/2013 at 9:50 AM revealed Certified Nurse Aide (CNA) R in Resident #6's room to perform a sit to stand mechanical lift transfer on Resident #6. CNA R assisted Resident #6 to the side of the bed. CNA R placed the standing sling around Resident #6's upper back and under his arms then hooked the sling to the lift. CNA R then began to lift Resident #6 with the sit to stand lift. Resident #6's shoulders began to rise in a chicken wing formation. Resident #6 was suspended in the sling with his arms out. Resident #6 was not holding on to the lift or bearing weight. Resident #6's knees were bent which caused the majority of his weight to be supported by his shoulder joints. In an interview on 12/19/2013 at 9:00 AM the Director of Nursing (DON) stated for a resident to be appropriate for a sit to stand lift the resident needs to be able to bear weight and would need to be able to hold on to the lift. The DON stated Resident #6 was a Hoyer lift transfer but was changed to a sit to stand. The DON stated the therapy department screens residents to see what type of transfer is appropriate for each resident. The DON stated she had not seen a transfer on Resident #6 lately. In an interview on 12/19/2013 at 10:40 CNA R stated Resident #6's shoulders and arms always go up like that when he is on the sit-to-stand lift. In an interview on 12/19/2013 at 11:45 AM Resident #6 stated the sit to stand lift sling hurt him under his arms. Resident #6 stated the facility needed to get a new. Resident #6 further stated the sling they use hurts and cuts off circulation to his arms. In an interview on 12/19/2013 at 2:15 PM the Physical Therapy Assistant (PTA) stated he had not screened Resident #6 for the sit to stand lift. The PTA stated he was not sure how a resident was screened for sit to stand lift. The PTA further stated residents were not screened on admit for transfers that he knew of. Observation on 12/19/2013 at 2:30 PM revealed CNA H (to perform transfer) and the PTA (to observe transfer) in Resident #6's room to transfer Resident #6 to bed with the sit to stand lift. Resident #6 was in his wheelchair. CNA H placed the sit to stand standing sling around Resident #6's back and under his arms and attached the sling to the sit to stand lift. CNA H did not lock Resident #6's wheelchair. CNA H lifted Resident #6 with the sit to stand lift. Resident #6's shoulders rose in a chicken wing formation, his legs were bent and he was not bearing weight. Resident #6's right hand came off the grab bar and was hanging off to the side. CNA H moved Resident #6 to the bed and lowered the Resident to the bed. CNA H placed Resident #6's legs in the bed. Resident #6's legs remained bent and did not extend out. In an interview on 12/19/2013 at 2:45 PM outside of Resident #6's room after the transfer the PTA stated the transfer was good. The PTA stated he would have like to see the wheelchair wheels locked but stated Resident #6 was appropriate for the sit to stand lift. When asked by surveyor if Resident #6 needed to be able to bear weight and hold on to lift to be appropriate for the sit to stand lift the PTA stated "It is suggested they be able to hold on." The PTA further stated Resident #6 might be more appropriate for a Hoyer lift. Observation on 12/19/2013 at 3:00 PM revealed the PTA in Resident #6's room to look at Resident #6's knee contractures. Resident #6 was in bed with his legs bent. The PTA grabbed Resident #6's right ankle and pulled down. Resident #6's leg did not fully extend. In an interview on 12/19/2013 at 3:30 PM the Physical Therapy (PT) Director stated the therapy department screened all residents in the facility on admission and Quarterly. The PT Director stated a resident would be appropriate for the sit to stand lift if they could not bear weight and did not have any behaviors. The PT Director stated they did not have a tool or assessment for the screening of sit to stand lift. The PT Director stated the sling should not place the residents' arms in a chicken wing formation that the sling needed to be placed under the hips. Observation on 12/19/2013 at 3:45 PM the PT Director performed a demonstration of how to apply a standing sling to a resident. The PT Director took a Standing sling and placed the sling on the surveyor placing the sling under the surveyor's hips. Review of the Manufacture recommendations for the Sit to stand lift dated 04/2011 reflected "Stand assist slings: Before lifting the patient, make sure the bottom edge of the stand assist sling is positioned on the lower back of the patient and the patient's arms are outside the stand assist sling." "Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur." Review of the Website: <http://www.invacare.com/cgi-bin/imhqprd/inv_micro/index.jsp?org=ICC&site=Resident%20Transfer%20Information&page=Stand-Up%20Lifts%20FAQs> reflected " The standing sling is proper to use for transferring residents who are partially dependent, have at least 60% weight-bearing capacity, have head and neck control, are cooperative, can sit up on the edge of the bed (with or without assistance), and are able to bend at the hips, knees and ankles." In an interview on 12/20/2013 at 9:00 AM the PT Director stated that a resident changing from one form of transfer to another would trigger an evaluation to be performed by therapy. The PT Director further stated there was no evaluation completed on Resident #6 at any point that she could find. Review of the facilities Policy and Procedure for Sit-to-Stand Transfer (no dated) reflected: " Purpose: ...to ensure safe transfers with residents that require the Sit-to-Stand." "The stand assist sling belt must be snug, but comfortable on the resident, otherwise the resident can slide out of the sling during transfer." The facility policy did not describe criteria of resident abilities or how a residents body should be aligned during a sit-to-stand transfer. Review of the facilities Decision criteria for use of mechanical lift devices for transfers developed on 12/20/2013 reflected: " Resident can: 1.) sit up on the side of the bed with or without assistance. 2.) Bear some weight on their own. 3.) Bend at the hips, knees and ankles. 4.) Follow verbal commands ... " " Resident has to meet all of the above criteria to be appropriate for a sit-to-stand transfer. If resident does not meet the above requirements resident ' s transfer status will be a Hoyer lift until further evaluation by therapy department. " In an interview on 12/20/2013 at 6:45 PM the Administrator stated she had been having problems with the therapy department stating there was no communication. The Administrator stated the therapy department was not part of the Quality Assurance team and that could be part of the problem. The Administrator further stated the new therapy team will be part of the team. The facility Administrator was notified on 12/19/2013 at 4:00 PM that an IJ situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 12/19/2013 at 5:09 PM. The final Plan of Removal was accepted by the survey team on 12/20/2013 at 5:16 PM PLAN OF REMOVAL Problem to be addressed: Immediate Jeopardy was called at 4 PM on December 19, 2013. Problem identified- screening and assessment for proper resident transfer and in-service for mechanical lifting devices. The problem will be addressed by: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Treatment Nurse, and Therapy Staff. What has been done: 1. December 19, 2013 at 4:20 PM the Executive Director of the facility and the Chief Operating Officer of Social Services were informed of the immediate jeopardy. 4:45 PM the Executive Director called the Therapy Department Regional Manager to inform her of the immediate jeopardy. Medical Director was called a t 8:15 PM December 19, 2013. 2. Nursing identified five (5) residents who were previously screened to be sit to stand appropriate. 3. Per nursing judgment residents previously screened as sit to stand appropriate will be changed to Hoyer lift transfer. 4. 5:45 PM December 19, 2013, the Administrative staff, ADON, Treatment nurse: and the MDS Coordinator utilizing the step by step procedures for safe Hoyer transfer from the manufacturer began developing a in-service for safe Hoyer lift transfers. Resident mode of transfer will be re-addressed following resident screening and implementation of training program. 5. 6:10 PM December 19, 2013, The Regional Manager for the Therapy Company called to report the Therapy Company will have an interim Program Director in the building by 9:00 AM on 12/20/2013. The staff member who trained current staff will not be coming on December 20, 2013. 6. 7:00 PM December 19, 2013, immediate action taken to provide for resident care: administrative nursing staff (ADON, Treatment nurse; and the MDS Coordinator) began in-service training on: a. 2-10 PM sift LVN's and CNA's b. the LVN's will then train the 10- 6 AM CNA's and oncoming 6 AM to 6 PM LVN's c. 6 AM to 6 PM LVN's will then train the 6 to 2 PM CNA's On the proper use of the Hoyer lift. Trainers will demonstrate proper procedure and verify by return demonstration. 7. When the interim Program Director of Therapy along with the Therapy Company Regional Manager arrive, they will produce a screening tool for therapy staff and will perform a screen on all residents for appropriate mode of mechanical lift transfer to be completed by December 20, 2013. 8. The Interim Program Director will establish criteria and implement screening protocols for appropriate modes of transfer (See Below). Referral to Therapy/ Screening ? Admission or Re-admission: The admission referral/ screen must be completed timely, as soon as possible, post admission unless a therapy evaluation order is present. ? Change of Condition: This referral/ screen are coordinated with the other disciplines and / or nursing's referral for therapy upon notice of a significant change in the patient's condition possible warranting a therapy evaluation. ? Annual: The annual referral/ screen must be completed timely, unless a therapy evaluation order is present or the patient is currently receiving rehab services. Upon review, the appropriate therapy discipline will make the determination if a comprehensive evaluation is indicated. This will be documented in the " Results " section of the " Referral/ Screen to Rehab Services " form. The clinician may gather information to answer questions on the referral form from nursing. CNA's, other interdisciplinary team members, family, physician, etc., and / or therapist's observation, history and physical. This process is a brief hand off procedure that should not exceed 15 minutes in duration. If it is determined that the patient can benefit from a comprehensive evaluation, the clinician will proceed with the evaluation request per facility procedures. The original referral/ screen forms will be filed in the medical record upon completion. 9. Facility developed a decision criteria tool for the use of mechanical lift devices for transfers screening form (see attached). 10. Facility developed a decision criteria tool for CNA's to alert their charge nurse of changes in resident ' s ability to transfer (see attached). 11. DON will train administrative staff (ADON, treatment nurse; and the MDS Coordinator) and therapy staff on screening tool. They in turn will train staff nurses by December 21, 2013. In addition to this DON will develop an in-service for the CNA's on what to look for and how to report change in a resident's ability to transfer. 12. Facility will be in substantial compliance with in-service training of staff on the screening tool following the acceptance of the "Plan of Removal" by December 21, 2013. 13. 4:30 PM December 20, 2013, the Administrative Staff, the MDS Coordinator utilizing the step-by-step procedures for sit-to-stand transfer from the manufacturer began developing an in-service for safe Hoyer lift transfers. Residents mode of transfer will be re-addressed following resident screening and implementation of training program (see attached). Starting 5:20 PM 12/20/2013. 14. Nursing Staff are responsible for initial screening process and when appropriate, referrals will be completed and communicated to the therapy department. The therapy department is responsible for assessment and treatment as appropriate. 15. Once interventions are in place administrative staff DON; ADON; Treatment Nurse; and the MDS Coordinator; will monitor program implementation by auditing all new admissions weekly x three months and quarterly and PRN and report to QA committee. The survey team monitored the current plan of removal as follows: Reviewed Resident #6 clinical record: Resident #6 was changed to Hoyer lift transfer 12/20/2013. Reviewed referral/ screen forms, and decision criteria tools for mechanical lift devices and CNA's notification to charge nurse form no problems noted. All in-service documentation was reviewed and attendance checked to ensure all licensed nurses were in-serviced. No further problems identified. Interviews with licensed nursing staff reflected the nurses knew the screening process and when appropriate, referrals need to be communicated to therapy department and the procedure for mechanical lift transfers and whether or not a resident is appropriate. Interviews with certified nursing aides reflected the CNA's knew how to report changes in resident transfer status and the procedure for mechanical lift transfers Mechanical lift transfers were observed on multiple residents. No further problems were identified. 100% of residents in the facility were screened to ensure they were being transferred appropriately. This was completed on 12/20/2013 prior to exit. On 12/20/2013 at 10:15 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list 46 residents that required assist with transfers. Non Immediate Jeopardy Findings: Observation made on 12/17/2013 at 7:30 AM revealed an electric razor plugged in and sitting on the edge of the bathroom sink in the shared bathroom between Resident Rooms 106 and 108. Observation on 12/19/2013 at 2:30 PM revealed a full bottle of 7.5 fluid ounces (fl. oz.) perineal cleanser, a 1.5 oz. tube of toothpaste and a 6.4 oz. tube of toothpaste located in the shared bathroom between Rooms 202 and 204, The bottle of perineal cleanser was labeled "Keep out of Reach of Children" and the toothpaste was labeled "Do not swallow." Observation on 12/19/2013 at 2:35 PM revealed a full 4 fl. oz. bottle of mouthwash, a half-full 7.5 fl. oz. perineal cleanser and an open 1.4 oz. stick of deodorant located in shared bathroom between Resident Rooms 210 and 212. All items were labeled "Keep out of Reach of Children" and "For External Use Only ". Observation on 12/19/2013 at 2:45 PM revealed A half full 1Liter bottle of mouthwash, a 3.8 fl. oz. spray deodorant, a 1/3 full bottle of 7.5 fl. oz. perineal cleanser, a 1.5 oz. can of shaving cream, two (2) 1.5 oz. tubes of toothpaste and one (1) 6.4 oz. tube of toothpaste located in shared bathroom between Resident Rooms 402 and 404. All were labeled "Keep out of Reach of Children" and "For External Use Only ". All the toothpaste was labeled "Do not swallow". In an interview on 12/19/2013 at 1:45 PM the Director of Nursing (DON) stated she was unaware these items had been left out by staff and they should be stored in the residents ' night stands or in their closets. Record review of an undated list provided by Administrator revealed it to be titled "Items prohibited in Residents rooms" reflected "For safety and regulatory reasons, the following items that are not allowed in residents ' rooms. This list is not all inclusive. Safety Hazards: aerosol cans, razors, electric appliances. For infection control purposes: personal care items should be kept in the resident ' s bedside table." CMS form 672 listed 35 cognitively impaired residents.

Based on observations, interviews and record reviews the facility failed to provide proper assistive devices to prevent accidents for three (3) of 12 residents reviewed for appropriate transfers (Residents #36, #37 and #14). A) Resident #36 was not correctly assessed to ensure the Sit-to-Stand lift was an appropriate method of transfer. Resident #36 was unable to bear weight causing the Resident's shoulders and arms to be a chicken wing formation (an improper body formation in which the shoulders are up and elbows out), which caused the majority of her weight to be supported by her shoulder joints and abducted (Abduction is a term that refers to a body part moving laterally away from the body. In the case of the shoulder, this refers to the arm swinging out from the side of the body, in an arm-flapping motion) during transfers. B) Resident #37 was not correctly assessed to ensure the stand and pivot mode of transfer was appropriate. Resident #37 was unable to bear weight, her feet were not firmly on the ground and her knees were bent during transfer. C) Resident #14 was not correctly assessed to ensure the Sit-to-Stand lift was appropriate. Resident #14 was unable to bear weight causing Resident #14's shoulders and arms to be a chicken wing formation, which caused the majority of her weight to be supported by her shoulder joints and abducted during transfers. An Immediate Jeopardy (IJ) was identified on 03/06/2014. While the IJ was removed on 03/07/2014 at exit, the facility remained out of compliance at a Severity level of Potential for More Than Minimal Harm with a Scope of Pattern that is not IJ. This deficient practice placed 38 residents that required assistance with transfer at risk of injury, pain, fractures, and dislocation of joints, falls or death. Findings included: A) Review of Resident #36's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected the resident had moderately impaired cognition and required extensive assistance of one person for transfers. The resident was also coded as only being able to stabilize with staff assistance for seated to standing position and surface-to-surface transfers. Review of Resident #36's Care Plan for transfers dated 05/15/2013 and updated on 08/05/2013, 11/05/2013 and 02/04/2014 reflected "I will be transferred with Sit-to-Stand lift." Review of Resident #36's Decision Criteria for Mechanical Transfer dated 12/20/2013 reflected "Pt. (patient) candidate for Sit-to-Stand". Review of the facility's Decision Criteria for use of mechanical lift devices for transfers developed on 12/20/2013 reflected: "Resident can: 1) sit up on the side of the bed with or without assistance. 2) Bear some weight on their own. 3) Bend at the hips, knees and ankles. 4) Follow verbal commands ... " " Resident has to meet all of the above criteria to be appropriate for a Sit-to-Stand transfer. If resident does not meet the above requirements resident ' s transfer status will be a Hoyer lift until further evaluation by therapy department." Observation on 03/06/2014 at 9:15 AM revealed CNAs A and B transferring Resident #36. The Sit-to-Stand lift was positioned in front of the resident and wheels were locked on her wheelchair. CNA A placed the Sit-to-Stand sling around the resident as she was sitting in the wheelchair and fastened it loosely in front of her at the waist. CNA A and CNA B each attached their respective sides of the sling to the Sit-to-Stand lift and then began lifting the resident. The sling moved up under the resident's armpits causing Resident # 1's arms to go out and up in a chicken wing formation and her shoulder joints abducted. The surveyor asked the CNAs if the sling needed to be readjusted. CNA B stated " yes " , and lowered the resident back into the wheelchair. CNA A moved the sling back down to the resident ' s waist but did not properly tighten it again. CNA B lifted the Resident for the second time, the sling moved up under Resident #36 ' s armpits and again caused Resident #36 to be in the "chicken-winged" position with her shoulder joints abducted as they proceeded to move her to the bed. In an interview on 03/06/2014 at 10:55 AM CNA B stated that she had only been working at the facility since 02/07/2014 and she was uncertain if Resident #36 was able to bear weight. CNA B stated " They (facility staff) told me to use the Sit-to-Stand so that ' s what I have been using. " CNA B also stated " the latch on the sling could have been adjusted and the sling could have been tighter." CNA B stated she had been trained and felt comfortable using the Sit-to-Stand lift. In an interview on 03/06/2014 at 11:00 AM CNA A stated Resident #36 "stands good on most days". CNA A stated she had noticed a few days ago that Resident #36 was having more difficulty with transfers and needed more eating assistance. CNA A stated she had notified a nurse of her observations. In an interview on 03/06/2014 at 11:05 AM the Director of Nursing (DON) stated she was unaware Resident #36 was experiencing good and bad days with transfers. She stated that she would check with her Administrative Assistant (CNA C) who is an experienced CNA and performs transfer monitoring. Review of the Plan of Correction from the Annual Survey conducted 12/20/2013 reflected the Therapy Department had been relieved of the duty of assessing Residents for proper transfer modes. In an interview on 03/06/2014 at 11:15 AM CNA C stated her past observations of transfers for Resident #36 were done correctly and that she was unaware that staff was having difficulty with Resident #36 bearing weight. In an interview on 03/06/2014 at 3:30 PM the DON stated she would expect Resident # 1 to be transferred via Sit-to-Stand lift. B) Review of Resident #37's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's Quarterly MDS dated [DATE] reflected the Resident had moderately impaired cognition and was coded as needing total assistance by one person for transfers. The resident was also coded as only being able to stabilize with staff assistance for seated to standing position and surface-to-surface transfers. Review of Resident #37's Care Plan for transfers dated 09/27/2013 and updated on 12/21/2013 reflected transferred with one staff assistance using gait belt. Review of Resident #37's Decision Criteria for Mechanical Transfer dated 12/20/2013 reflected "stand and pivot transfer with the assist of one person, Hoyer or Sit-to-Stand not needed." The use of a gait belt was not documented. Observation on 03/06/2014 at 6:25 PM revealed CNAs D and E, Resident #37 and the ADON in the room for the transfer. The ADON told the CNAs before the transfer, if the Resident was unable to bear weight, to place her back in the wheelchair instead of attempting to transfer her. Resident #37 had the gait belt around her waist and the wheelchair was locked. The CNAs attempted to lift her but she was unable to bear weight. Resident # 6's knees were bent and her feet were not firmly on the floor. The CNAs placed Resident #37 back in the wheelchair and the ADON left to get the Hoyer lift and a sling and transferred the Resident to bed. The ADON told the CNAs that Resident # 6 would use the Hoyer lift until she could be referred to therapy. In an interview on 03/06 2014 at 5:45 PM the DON stated either the transfer assessment or the MDS was incorrect. The DON stated Resident #37 would be reassessed when being transferred to bed after dinner. The DON stated staff had been using the gait belt when transferring the resident. In an interview on 03/07/2014 at 8:20 AM the DON stated Resident #37 used to be able to bear weight during the transfers. The DON stated she spoke with Licensed Vocational Nurse (LVN) G regarding the resident and LVN G stated the CNAs had not told her Resident # 6 was not able to bear weight. In an interview on 03/07/2014 at 9:00 AM LVN G stated she was unaware Resident #37 was unable to bear weight during transfers. LVN G stated she expected the CNAs to notify her if a Resident was unable to transfer at their current level. LVN G stated if the CNAs felt a Resident was unsafe to transfer with the current technique, they were to stop the transfer and notify a nurse for reassessment. LVN G stated when reassessing a Resident, the Resident had to be able to bear weight and be cooperative with staff. LVN G stated a Resident was able to bear weight and be cooperative with staff; they could use a gait belt for transfers. LVN G stated if the resident could not bear weight and/or was uncooperative with staff, they would use a Hoyer lift for transfers. C) Review of Resident #14's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly MDS dated [DATE] reflected the resident had moderately impaired cognition and was coded as extensive assistance of one person for transfers. The resident was also coded as only being able to stabilize with staff assistance for seated to standing position and surface-to-surface transfers. Review of Resident #14's Care Plan for transfers dated 09/03/2013 and updated on 11/07/2013 and 02/14/2014 reflected "I will be transferred with Sit-to-Stand lift." Review of Resident #14's Decision Criteria for Mechanical Transfer dated 12/20/2013 reflected "Appropriate for Sit-to-Stand device". Observation on 03/06/2014 at 9:30 AM revealed CNAs A and B transferring Resident #14. CNA A placed the Sit-to-Stand sling around the resident ' s waist and fastened it. CNA B attached the sling to the Sit-to-Stand lift and began lifting the resident. The sling was not properly positioned. CNA B asked CNA A if the sling was correctly positioned and CNA A stated that " Yes, it ' s fine. " When the Resident was lifted, the sling moved up under the resident's armpits and caused the resident's arms to start abducting or "chicken-winging". This Surveyor requested that they lower and reposition the sling. CNA B lowered the resident and CNA A attempted to readjust the sling. The sling was not properly readjusted and tightened so it again slid up on Resident #14 ' s body and under her armpits. The CNAs moved the Resident over to the bed with her arms " chicken-winged " and before releasing the Resident from the sling the CNAs noticed they had gotten the call light cord caught under the lift's wheels. CNA A & B allowed Resident #14 to hang over the bed with her arms " chicken-winged " while they removed the call light cord from under the lift. The sling had been improperly placed and it was folded back onto itself, resting tightly across her upper-back and shoulder area and under Resident # 14's armpits. In an interview on 03/06/2014 at 11:03 AM CNA A stated Resident #14 had a "bad day" today. CNA A stated some days Resident #14 will stand and bear weight when being lifted with the Sit-to-Stand lift. CNA A did not state whether or not she had informed the nursing department of Resident #14's decreased and limited ability to bear weight during transfers. In an interview on 03/06/2014 at 11:05 AM CNA B stated that she had only been working at the facility since 02/07/2014 and stated she was uncertain if Resident #14 was able to bear weight. CNA B stated " I don ' t know, they just told me to use the lift so that is what I do. " CNA B stated she noticed "the way she (Resident #14) was just hanging there when we lifted her up." In an interview on 03/06/2014 at 11:07 AM the DON stated she was unaware Resident #14 was experiencing good and bad days with transfers. The DON stated she would check with her Administrative Assistant (CNA C) who is an experienced CNA and performs transfer monitoring. In an interview on 03/06/2014 at 11:15 AM CNA C stated her past observations of transfers for Resident #14 were done correctly and that she was unaware that staff had difficulty with Resident # 14's weight bearing skills. In an interview on 03/06/2014 at 11:17 AM the DON stated " we will take Resident #14 off of the Sit-to-Stand lift and put her on the Hoyer lift until therapy can reassess. " In an interview on 03/06/2014at 11:20 AM the DON and ADON stated due to Resident # 14's change in transfer and weight bearing status we " will reassess for transfer mode and refer to therapy " . In an interview on 03/06/2014 at 1:30 PM the Administrator stated she expected the CNAs to know how to perform proper transfers and to notify the nurses if they noticed a problem when transferring a resident. The Administrator stated she expected the nurses to properly assess a resident when notified there was difficulty during transfers. In an interview on 03/07/2014 at 8:20 AM the DON stated she felt the failure was in the fact that the CNAs were witnessing changes in the resident ' s ability to transfer but they were not relaying the information to the nurses. The DON stated the reassessments may have been done correctly in December, but the CNAs had not relayed new information to the nurses since then and the assessments had not been updated. In an interview on 03/07/2014 at 8:10 AM the Administrator stated she felt when the previous Administrator developed the Plan of Correction for the previous Immediate Jeopardy, she did not inform her nursing staff of the changes she made in their procedures for transfers. Review of the Manufacture recommendations for the Sit to stand lift dated 04/2011 reflected "Stand assist slings: Before lifting the patient, make sure the bottom edge of the stand assist sling is positioned on the lower back of the patient and the patient's arms are outside the stand assist sling." "Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur." Review of the Website for the facility's Sit-to-Stand Life Instructions reflected: <http://www.invacare.com/cgi-bin/imhqprd/inv_micro/index.jsp?org=ICC&site=Resident%20Transfer%20Information&page=Stand-Up%20Lifts%20FAQs> reflected "The standing sling is proper to use for transferring residents who are partially dependent, have at least 60% weight-bearing capacity, have head and neck control, are cooperative, can sit up on the edge of the bed (with or without assistance), and are able to bend at the hips, knees and ankles." Review of the facilities Policy and Procedure for Sit-to-Stand Transfer (no date) reflected: "Purpose...to ensure safe transfers with residents that require the Sit-to-Stand." "The stand assist sling belt must be snug, but comfortable on the resident, otherwise the resident can slide out of the sling during transfer." The facility policy did not describe criteria of resident abilities or how a resident ' s body should be aligned during a Sit-to-Stand transfer. The facility Administrator was notified on 03/06/2014 at 1:53 PM that an IJ situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 03/07/2014 at 10:00 AM. The final Plan of Removal was accepted by the survey team on 03/07/2014 at 10:02 AM and reflected: PLAN FOR REMOVAL Problem to be addressed: Immediate Jeopardy was called at 2:00 pm on March 6, 2014. Screening and Assessment for proper resident transfer and in-service for mechanical lifting devices. The problem will be addressed by: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, and Treatment Nurse. What has been done: 1. March 6, 2014 at 11:30 am - Resident #36, Resident #37 and Resident #14 were referred to therapy for transfer training. At this time Resident #36 and Resident #14 were changed from the Sit-to-Stand lift to the Hoyer lift, all ADL (/Activities of Daily Living) and section sheets were updated with new transfer technique. Resident #37 was changed from a stand and pivot to a Hoyer lift, all ADL and section sheets were updated with new transfer technique. CNAs were informed. Care plans were updated by MDS Coordinator to reflect change in transfers and the MDSs will be updated with change of condition as of 03/07/14. 2. March 6, 2014 at 2:10 pm - The Executive Director of Kruse Village, Medical Director, and executive nursing staff were informed of the Immediate Jeopardy. 3. March 6, 2014 at 2:15pm - An in-service was developed for all nursing staff on following facility policy and procedures for transfers using mechanical lifting devices and demonstrating proper return demonstration on using the Hoyer lift. The CNAs are to understand that during any 1 or 2 person transfer with a gait belt, if resident is unable to bear weight, the CNA will immediately stop the transfer, sit the resident back down and alert the nurse. 4. March 6, 2014 - The DON was in-serviced by the ADON regarding proper resident transfer screening and transfers. The nurses will be in-serviced by the ADON and/or DON by 03/07/2014 on how to properly assess resident transfers using the Decision Criteria. All residents will be reassessed for proper transfer technique by 03/07/2014. 5. March 6, 2014 at 2:15pm - the Sit-to-Stand lifts were permanently removed from operations. 6. March 6, 2014 at 2:15pm - Immediate action to provide resident care: CNAs A and B involved in the transfers of Resident #36 and Resident #14 resulting in the Immediate Jeopardy were removed from the unit until in-servicing could occur at 2:30pm. 7. March 6, 2014 at 2:30pm - CNA A received disciplinary actions for her failure to follow proper policy and procedure in transfers using mechanical lifting devices. 8. March 6, 2014 at 2:30pm - The executive nursing team began in-servicing nursing staff on proper transfer procedures and following facility policy and procedure for transfers using only the Hoyer lift because the Sit-to-Stand lifts have been removed from the facility and placed in maintenance storage. 9. March 6, 2014 at 2:50pm - For the next two weeks, all modes of transfer will be observed at least daily by a nurse. If no further issues or concerns arise, the schedule will change to once a week monitoring for the next three months by a nurse. 10. March 6, 2014 - A communication form, CNA Reporting Tool for Changes in Resident's Ability to Transfer, will be implemented that tracks when a CNA notifies a nurse regarding changes in the resident ' s ability to transfer and tracks the nurse ' s response and referral to therapy for transfer training. The DON and/or ADON will monitor the tool for proper utilization. Nursing staff will be in-serviced by 03/07/2014. The survey team monitored the current plan of removal as follows: Reviewed changes made to Resident #36 ' s care: Review Resident #36 ' s Care Plan for Transfers updated 03/06/2014 reflected "I am having difficulty using a Sit-to-Stand lift, so I was switched to a Hoyer and a referral was sent to therapy. Changed to Hoyer lift. " Review of Resident #36's Decision Criteria for Transfers dated 03/07/2014 reflected the Resident did not meet the above criteria of being able to bear weight and being cooperative with staff. Resident #36's transfer status was changed to Hoyer lift and received a referral to rehab services. Review of Resident #36's Nursing to Therapy Referral Form dated 03/06/2014 reflected "Physical Therapy: decreased lower body ROM (Range of Motion), decreased lower body strength, limited lower body ROM, needs assistance with transfers, and weakness. Occupational Therapy: decreased upper body ROM and decreased upper body strength. Not appropriate for Sit-to-Stand lift; changed to Hoyer lift". Review of Resident #36's Telephone physician's order [REDACTED]. Reviewed changes made to Resident #37 ' s care: Review of Resident #37 ' s Care Plan for Transfers updated 03/06/2014 reflected "I am no longer able to bear weight and am not safe to transfer with only gait belt - changed to Hoyer lift". Review of Resident #37's Physician's Telephone Order dated 03/06/2014 reflected an order to use Hoyer lifts only. Review of Resident #37's Decision Criteria for Transfer dated 03/07/2014 reflected the Resident did not meet the above criteria of being able to bear weight and being cooperative with staff. Resident #37's transfer status was changed to Hoyer lift and received a referral to rehab services. Review of Resident #37's Nursing to Therapy Referral Form dated 03/07/2014 reflected "Physical Therapy: decreased lower body ROM, decreased lower body strength, limited lower body ROM, needs assistance with transfers and weakness. Resident unable to bear weight - changed to Hoyer lift". Reviewed changes made to Resident #14 ' s care: Review of Resident #14 ' s Care Plan for Transfers updated 03/06/2014 reflected "I am having some difficulty using the Sit-to-Stand lift and was changed to a Hoyer and a referral was sent to therapy. Changed to Hoyer lift". Review of Resident #14's Nursing to Therapy Referral Form dated 03/06/2014 reflected "Physical Therapy: decreased lower body ROM (Range of Motion), decreased lower body strength, limited lower body ROM, needs assistance with transfers, and weakness. Occupational Therapy: decreased upper body ROM, decreased upper body strength and limited upper body ROM. Not appropriate for Sit-to-Stand lift; changed to Hoyer". Review of Resident #14's Decision Criteria for Transfer dated 03/07/2014 reflected the resident did not meet the above criteria of being able to bear weight and being cooperative with staff. Resident #14's transfer status was changed to Hoyer lift and received a referral to rehab services. Review of Resident #14's Telephone physician's orders [REDACTED]. Review of the CNA Reporting Tool for Changes in Residents Ability to Transfer form developed on 03/06/2014 reflected "Stop: do you notice a change in your resident, Think: how are they different (harder to transfer, a decline in ADLs), Act: alert your charge nurse". At the bottom are blanks for the resident's name, CNA's name, nurse's name and whether a referral to therapy was made. Review of the Decision Criteria for Transfers developed on 03/06/2014 reflected "Is the resident able to bear weight and cooperative with staff. Resident has met above criteria to be appropriate for transfer utilizing x1-2 staff and gait belt. If resident does not meet above requirements, resident's transfer status will be a Hoyer lift. Was referral/screen made to rehab services: yes or no." All in-service documentation was reviewed and attendance checked to ensure all licensed nurses and CNAs were in-serviced. Interviews with licensed nursing staff on 03/07/2014 betweeen 11:30 AM through 2:30 PM revealed the nurses knew the screening process and when appropriate, referrals need to be communicated to therapy department and the procedure for mechanical lift transfers and whether or not a resident is appropriate. Interviews with CNAs on 03/07/2014 from 11:45 AM through 2:15 PM reflected they knew how to report changes in resident transfer status and the procedure for mechanical lift transfers Observations were made on 03/07/2014 from 11:35 AM through 2:35 PM of one (1) and two (2) person transfers with a gait belt and mechanical lift transfers on multiple residents. No further problems were identified. 100% of Residents in the facility were screened to ensure they were being transferred appropriately. This was completed on 03/07/2014 prior to exit. On 03/07/2014 at 2:52PM the facility Administrator was informed the IJ was removed; However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 38 residents that required assist with transfers.

Based on observation, interview and record review the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one (1) of nine (9) residents reviewed for transfers. The Administrator failed to ensure residents were being assessed, referred or evaluated by the Physical Therapy Department to ensure the transfer method being used was appropriate. The Administrator failed to ensure effective communication between the therapy department and nursing to ensure the transfer method being used for each resident was appropriate The Administrator also failed to supervise, monitor and consult with the DON to ensure residents received the care and services to meet their individual needs. The DON failed to monitor resident care and nursing staff responsible for providing quality care for residents reviewed for transfers. Resident #6 was not assessed, referred or evaluated by Physical Therapy to ensure the Sit-to-Stand lift was appropriate. The Physical Therapy Director and The Physical Therapy Assistant who are responsible for training staff were unaware of the proper procedure for the Sit-to-Stand lift or criteria for the use of the Sit-to-Stand lift. Resident #6 was unable to bear weight or hold on to the Sit-to-Stand lift causing Resident #6's shoulders to be abducted (Abduction is a term that refers to a body part moving laterally away from the body. In the case of the shoulder, this refers to the arm swinging out from the side of the body, in an arm-flapping motion.) In a chicken winged formation (an improper body formation in which the shoulders are up and elbows out, which caused the majority of his weight (248 lbs.) to be supported by his shoulder joints) during transfers and Resident #6 experiencing discomfort while being transferred with the Sit-to-Stand lift and placing him at risk of injury. An Immediate Jeopardy (IJ) was identified on 12/19/2013. While the IJ was removed on 12/20/2013 at exit, the facility remained out of compliance at a Severity level of Potential for More Than Minimal Harm with a Scope of isolated that is not IJ. This deficient practice placed 46 residents that required assistance with transfer at risk of injury, pain, fractures, dislocation of joints, falls from slipping out of the sit-to-stand lift or death. Findings Include: Review of Resident #6's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #6's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. Resident #6 was not coded to have behaviors. Resident #6 was coded to require extensive one person physical assist for bed mobility, dressing and personal hygiene. Resident #6 was coded to be totally dependent with one person physical assist for transfers and toilet use. Resident #6 was coded to have an indwelling catheter. Review of Resident #6's Comprehensive Care Plan dated 03/15/2013 reflected Problem: "I need assistance with my ADL's (Activities of daily living) secondary to weakness." Handwritten on the Care plan with a date of 05/31/2013: "I am very weak s/p (status [REDACTED]. I need more assist with ADL's." Approach: "I will be transferred with sit to stand lift, 5/31/2013 change to Hoyer lift status [REDACTED]." Review of Resident #6's History and Physical dated 03/02/2013 reflected "[MEDICAL CONDITIONS] in 2009 with left-side weakness ... " "Significant joint pain, mostly in the lower back and knees reported. The patient has difficulty moving any of his extremities through the full range of motion. He is able to feed himself with his right hand but is not able to do things like brush his teeth or comb his hair. He cannot transfer independently in the nursing home and is confined to a wheelchair." Review of Resident #6's History and Physical dated 12/25/2010 reflected "He does have some difficulty with grip strength in his right hand due to mild contractors." Review of the facilities Weight Review report for 2013 reflected Resident #6 weights was 248 lbs. (pounds) for December 2013. Observation on 12/18/2013 at 9:50 AM revealed Certified Nurse Aide (CNA) R in Resident #6's room to perform a sit to stand mechanical lift transfer on Resident #6. CNA R assisted Resident #6 to the side of the bed. CNA R placed the standing sling around Resident #6's upper back and under his arms then hooked the sling to the lift. CNA R then began to lift Resident #6 with the sit to stand lift. Resident #6's shoulders began to rise in a chicken wing formation. Resident #6 was suspended in the sling with his arms out. Resident #6 was not holding on to the lift or bearing weight. Resident #6's knees were bent which caused the majority of his weight to be supported by his shoulder joints. In an interview on 12/19/2013 at 9:00 AM the Director of Nursing (DON) stated for a resident to be appropriate for a sit to stand lift the resident needs to be able to bear weight and would need to be able to hold on to the lift. The DON stated Resident #6 was a Hoyer lift transfer but was changed to a sit to stand. The DON stated the therapy department screens residents to see what type of transfer is appropriate for each resident. The DON stated she had not seen a transfer on Resident #6 lately. In an interview on 12/19/2013 at 10:40 CNA R stated Resident #6's shoulders and arms always go up like that when he is on the sit-to-stand lift. In an interview on 12/19/2013 at 11:45 AM Resident #6 stated the sit to stand lift sling hurt him under his arms. Resident #6 stated the facility needed to get a new. Resident #6 further stated the sling they use hurts and cuts off circulation to his arms. In an interview on 12/19/2013 at 2:15 PM the Physical Therapy Assistant (PTA) stated he had not screened Resident #6 for the sit to stand lift. The PTA stated he was not sure how a resident was screened for sit to stand lift. The PTA further stated residents were not screened on admit for transfers that he knew of. Observation on 12/19/2013 at 2:30 PM revealed CNA H (to perform transfer) and the PTA (to observe transfer) in Resident #6's room to transfer Resident #6 to bed with the sit to stand lift. Resident #6 was in his wheelchair. CNA H placed the sit to stand standing sling around Resident #6's back and under his arms and attached the sling to the sit to stand lift. CNA H did not lock Resident #6's wheelchair. CNA H lifted Resident #6 with the sit to stand lift. Resident #6's shoulders rose in a chicken wing formation, his legs were bent and he was not bearing weight. Resident #6's right hand came off the grab bar and was hanging off to the side. CNA H moved Resident #6 to the bed and lowered the Resident to the bed. CNA H placed Resident #6's legs in the bed. Resident #6's legs remained bent and did not extend out. In an interview on 12/19/2013 at 2:45 PM outside of Resident #6's room after the transfer the PTA stated the transfer was good. The PTA stated he would have like to see the wheelchair wheels locked but stated Resident #6 was appropriate for the sit to stand lift. When asked by surveyor if Resident #6 needed to be able to bear weight and hold on to lift to be appropriate for the sit to stand lift the PTA stated "It is suggested they be able to hold on." The PTA further stated Resident #6 might be more appropriate for a Hoyer lift. Observation on 12/19/2013 at 3:00 PM revealed the PTA in Resident #6's room to look at Resident #6's knee contractures. Resident #6 was in bed with his legs bent. The PTA grabbed Resident #6's right ankle and pulled down. Resident #6's leg did not fully extend. In an interview on 12/19/2013 at 3:30 PM the Physical Therapy (PT) Director stated the therapy department screened all residents in the facility on admission and Quarterly. The PT Director stated a resident would be appropriate for the sit to stand lift if they could not bear weight and did not have any behaviors. The PT Director stated they did not have a tool or assessment for the screening of sit to stand lift. The PT Director stated the sling should not place the residents' arms in a chicken wing formation that the sling needed to be placed under the hips. Observation on 12/19/2013 at 3:45 PM the PT Director performed a demonstration of how to apply a standing sling to a resident. The PT Director took a Standing sling and placed the sling on the surveyor placing the sling under the surveyor's hips. Review of the Manufacture recommendations for the Sit to stand lift dated 04/2011 reflected "Stand assist slings: Before lifting the patient, make sure the bottom edge of the stand assist sling is positioned on the lower back of the patient and the patient's arms are outside the stand assist sling." "Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur." Review of the Website: <http://www.invacare.com/cgi-bin/imhqprd/inv_micro/index.jsp?org=ICC&site=Resident%20Transfer%20Information&page=Stand-Up%20Lifts%20FAQs> reflected " The standing sling is proper to use for transferring residents who are partially dependent, have at least 60% weight-bearing capacity, have head and neck control, are cooperative, can sit up on the edge of the bed (with or without assistance), and are able to bend at the hips, knees and ankles." In an interview on 12/20/2013 at 9:00 AM the PT Director stated that a resident changing from one form of transfer to another would trigger an evaluation to be performed by therapy. The PT Director further stated there was no evaluation completed on Resident #6 at any point that she could find. Review of the facilities Policy and Procedure for Sit-to-Stand Transfer (no dated) reflected: " Purpose: ...to ensure safe transfers with residents that require the Sit-to-Stand." "The stand assist sling belt must be snug, but comfortable on the resident, otherwise the resident can slide out of the sling during transfer." The facility policy did not describe criteria of resident abilities or how a residents body should be aligned during a sit-to-stand transfer. Review of the facilities Decision criteria for use of mechanical lift devices for transfers developed on 12/20/2013 reflected: " Resident can: 1.) sit up on the side of the bed with or without assistance. 2.) Bear some weight on their own. 3.) Bend at the hips, knees and ankles. 4.) Follow verbal commands ... " " Resident has to meet all of the above criteria to be appropriate for a sit-to-stand transfer. If resident does not meet the above requirements resident ' s transfer status will be a Hoyer lift until further evaluation by therapy department. " In an interview on 12/20/2013 at 6:45 PM the Administrator stated she had been having problems with the therapy department stating there was no communication. The Administrator stated the therapy department was not part of the Quality Assurance team and that could be part of the problem. The Administrator further stated the new therapy team will be part of the team. The facility Administrator was notified on 12/19/2013 at 4:00 PM that an IJ situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 12/19/2013 at 5:09 PM. The final Plan of Removal was accepted by the survey team on 12/20/2013 at 5:16 PM PLAN OF REMOVAL Problem to be addressed: Immediate Jeopardy was called at 4 PM on December 19, 2013. Problem identified- screening and assessment for proper resident transfer and in-service for mechanical lifting devices. The problem will be addressed by: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Treatment Nurse, and Therapy Staff. What has been done: 1. December 19, 2013 at 4:20 PM the Executive Director of the facility and the Chief Operating Officer of Social Services were informed of the immediate jeopardy . 4:45 PM the Executive Director called the Therapy Department Regional Manager to inform her of the immediate jeopardy. Medical Director was called a t 8:15 PM December 19, 2013. 2. Nursing identified five (5) residents who were previously screened to be sit to stand appropriate. 3. Per nursing judgment residents previously screened as sit to stand appropriate will be changed to Hoyer lift transfer. 4. 5:45 PM December 19, 2013, the Administrative staff, ADON, Treatment nurse: and the MDS Coordinator utilizing the step by step procedures for safe Hoyer transfer from the manufacturer began developing a in-service for safe Hoyer lift transfers. Resident mode of transfer will be re-addressed following resident screening and implementation of training program. 5. 6:10 PM December 19, 2013, The Regional Manager for the Therapy Company called to report the Therapy Company will have an interim Program Director in the building by 9:00 AM on 12/20/2013. The staff member who trained current staff will not be coming on December 20, 2013. 6. 7:00 PM December 19, 2013, immediate action taken to provide for resident care: administrative nursing staff (ADON, Treatment nurse; and the MDS Coordinator) began in-service training on: a. 2-10 PM sift LVN ' s and CNA's b. the LVN's will then train the 10- 6 AM CNA's and oncoming 6 AM to 6 PM LVN's c. 6 AM to 6 PM LVN ' s will then train the 6 to 2 PM CNA's On the proper use of the Hoyer lift. Trainers will demonstrate proper procedure and verify by return demonstration. 7. When the interim Program Director of Therapy along with the Therapy Company Regional Manager arrive, they will produce a screening tool for therapy staff and will perform a screen on all residents for appropriate mode of mechanical lift transfer to be completed by December 20, 2013. 8. The Interim Program Director will establish criteria and implement screening protocols for appropriate modes of transfer (See Below). Referral to Therapy/ Screening ? Admission or Re-admission: The admission referral/ screen must be completed timely, as soon as possible, post admission unless a therapy evaluation order is present. ? Change of Condition: This referral/ screen are coordinated with the other disciplines and / or nursing ' s referral for therapy upon notice of a significant change in the patient ' s condition possible warranting a therapy evaluation. ? Annual: The annual referral/ screen must be completed timely, unless a therapy evaluation order is present or the patient is currently receiving rehab services. Upon review, the appropriate therapy discipline will make the determination if a comprehensive evaluation is indicated. This will be documented in the " Results " section of the " Referral/ Screen to Rehab Services " form. The clinician may gather information to answer questions on the referral form from nursing. CNA ' s, other interdisciplinary team members, family, physician, etc., and / or therapist ' s observation, history and physical. This process is a brief hand off procedure that should not exceed 15 minutes in duration. If it is determined that the patient can benefit from a comprehensive evaluation, the clinician will proceed with the evaluation request per facility procedures. The original referral/ screen forms will be filed in the medical record upon completion. 9. Facility developed a decision criteria tool for the use of mechanical lift devices for transfers screening form (see attached). 10. Facility developed a decision criteria tool for CNA's to alert their charge nurse of changes in resident ' s ability to transfer (see attached). 11. DON will train administrative staff (ADON, treatment nurse; and the MDS Coordinator) and therapy staff on screening tool. They in turn will train staff nurses by December 21, 2013. In addition to this DON will develop an in-service for the CNA ' s on what to look for and how to report change in a resident's ability to transfer. 12. Facility will be in substantial compliance with in-service training of staff on the screening tool following the acceptance of the " Plan of Removal " by December 21, 2013. 13. 4:30 PM December 20, 2013, the Administrative Staff, the MDS Coordinator utilizing the step-by-step procedures for sit-to-stand transfer from the manufacturer began developing an in-service for safe Hoyer lift transfers. Residents mode of transfer will be re-addressed following resident screening and implementation of training program (see attached). Starting 5:20 PM 12/20/2013. 14. Nursing Staff are responsible for initial screening process and when appropriate, referrals will be completed and communicated to the therapy department. The therapy department is responsible for assessment and treatment as appropriate. 15. Once interventions are in place administrative staff DON; ADON; Treatment Nurse; and the MDS Coordinator; will monitor program implementation by auditing all new admissions weekly x three months and quarterly and PRN and report to QA committee. The survey team monitored the current plan of removal as follows: Reviewed Resident #6 clinical record: Resident #6 was changed to Hoyer lift transfer 12/20/2013. Reviewed referral/ screen forms, and decision criteria tools for mechanical lift devices and CNA ' s notification to charge nurse form no problems noted. All in-service documentation was reviewed and attendance checked to ensure all licensed nurses were in-serviced. No further problems identified. Interviews with licensed nursing staff reflected the nurses knew the screening process and when appropriate, referrals need to be communicated to therapy department and the procedure for mechanical lift transfers and whether or not a resident is appropriate. Interviews with certified nursing aides reflected the CNA's knew how to report changes in resident transfer status and the procedure for mechanical lift transfers Mechanical lift transfers were observed on multiple residents. No further problems were identified. 100% of residents in the facility were screened to ensure they were being transferred appropriately. This was completed on 12/20/2013 prior to exit. On 12/20/2013 at 10:15 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list 46 residents that required assist with transfers.

Based on interview and record review the facility failed to ensure that 1 of 11 sampled residents reviewed for Narrow Therapeutic Index medications (Resident #1) was free of a significant medication error when Licensed Vocational Nurse (LVN) B incorrectly transcribed an order for [REDACTED]. This facility deficient practice has the potential to affect all 54 facility residents. This failure could result in residents experiencing side/adverse effects from receiving too much medication or reduced effects from receiving too little medication. Findings: Review of a Progress Note written by Resident #1's Nurse Practitioner (NP) dated [DATE] lists the following [DIAGNOSES REDACTED]. Review of a Fax dated [DATE] sent from the facility to Resident #1's NP: Resident #1 had a [MEDICAL CONDITION] starting with a loud scream/facial grimacing and then one minute of stiffening of body with whole body jerking. Resident remains lethargic after the [MEDICAL CONDITION]. [MEDICATION NAME] level was drawn at 10:00 AM, the results 4.4 (therapeutic range of [MEDICATION NAME] is 10 to 20). Receives [MEDICATION NAME] 300 mg at bedtime. Review of physician's orders [REDACTED]. Review of Nurses Notes for Resident #1 revealed: [DATE] at 11:30 PM, Resident #1 sent to the emergency room for evaluation. [DATE] at 2:40 AM, Resident #1 returned from emergency room . Orders: Resume other nursing home orders, rinse mouth with water after meals, increase [MEDICATION NAME] to 300 milligrams twice a day. Re-check [MEDICATION NAME] level in one week. Review of physician's orders [REDACTED]. Re-check [MEDICATION NAME] level in one week. Notify Primary Care Physician of changes. [MEDICAL CONDITION] Precautions. Review of a Fax sent from the facility to the NP dated [DATE] regarding Resident #1: Resident #1 returned from the emergency room with orders to increase [MEDICATION NAME] to 300 mg twice a day; recheck [MEDICATION NAME] level in one week, rinse mouth with water after meals, resume other nursing home orders and [MEDICAL CONDITION] precautions. Review of a Fax sent from the NP to the facility dated [DATE] at 7:17 AM: Discontinue [MEDICATION NAME] 300 mg twice a day and change current 300 mg at bedtime to 400 mg at bedtime. Recheck [MEDICATION NAME] level in 2 weeks and 4 weeks. Review of physician's orders [REDACTED]. The order was signed by LVN B, indicating LVN transcribed the order from the fax sent from the NP on [DATE] at 7:17 AM. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Nurses Notes for Resident #1 dated [DATE] at 10:00 AM: Resident lying in bed. Eyes open. When name called resident turns eyes toward voice,eyes opening very wide, staring. Skin warm and dry, color pale. Vital signs: Temperature: 97, pulse: 46, respirations: 18, Blood Pressure: ,[DATE]. 2:00 PM: Call placed to the emergency room . Report given. Resident #1 transferred to the emergency room . Resident without any noted distress at time of transport. Review of a hospital History and Physical dated [DATE] revealed Resident #1 had a [MEDICATION NAME] level of 27.8 on admission to the hospital on [DATE]. The [DIAGNOSES REDACTED]. In the section entitled Plan: the patient is a [AGE] year old lady who is a resident of a nursing home who has been steadily deteriorating over the last year. She is on a [MEDICATION NAME] drip for blood pressure support and she is putting out not very much urine at all. IV [MEDICATION NAME] drops her blood pressure down into the 70s so will have to be used cautiously. Although she has rales and rhonci throughout the lungs, x-ray is not showing [MEDICAL CONDITION]. I think she is just not able to handle her secretions at this time. We will continue the [MEDICATION NAME], give the [MEDICATION NAME] as tolerated as she is having problems with renal shutdown at this time. Review of a Facility Report entitled Medication Error Report dated [DATE] revealed: A medication error occurred for Resident #1. In the section "Description of the error": [DATE] [MEDICATION NAME] 300 mg twice a day. On [DATE] the NP faxed over new orders, her orders read to discontinue [MEDICATION NAME] 300 mg twice a day and change to [MEDICATION NAME] 400 mg at bedtime. Nurse on duty who transcribed orders wrote orders as [MEDICATION NAME] 300 mg by mouth every morning and [MEDICATION NAME] 400 mg by mouth at bedtime. Review of Progress Notes from the hospital reveal Resident # 1 expired on [DATE]. In an interview on [DATE] at 1:00 PM the Director of Nurses (DON) acknowledged the Medication Order had occurred. The DON further stated the facility was in the process of changing their policy/procedure for taking orders from physicians. The DON stated the change is with faxed orders. The nurse who takes a faxed order will write the order on the order sheet. The nurse will then hand over the written order and the fax to the next shift for the next nurse on duty to review. The DON stated in the past the facility had not handed over the faxes with the written order to the next shift for review. The DON stated the faxes are now going to be passed on to the night shift along with the telephone order. The DON stated the night shift is responsible for Quality Assurance for new orders. The DON further stated the facility is in the process of checking all charts to make sure all orders received either via fax or telephone are transcribed correctly. The DON also stated the facility is in the process of in-servicing all nurses about the new procedure but has not yet finished in-servicing. Review of facility Employee In-Service Sign in Sheet dated [DATE] revealed 9 nurses attended the inservice. A sheet entitled agenda was attached to the sign-in sheet: Medication Transcription Errors: DON review the medication error that occurred with Resident #1's [MEDICATION NAME] on [DATE] - the order was transcribed incorrectly from the fax to the telephone order. Nurses will keep any order received via fax and attach it with a paper clip to the telephone order written in the chart and review this in change of shift report with the oncoming nurse. this will give the oncoming nurse the opportunity to look at the order on the fax and the transcribed telephone order to see if it is correct. The fax and telephone order will remain clipped together until the 10:00 PM to 6:00 AM nurse has checked the order for correct completion. The 10:00 PM to 6:00 AM nurse will check the faxed order against the telephone order to be sure it was transcribed correctly and will then check the telephone order against the MAR, Treatment and or Activities of Daily Living sheet. Discussed always double checking yourself when you write an order, re-read it to assure it is correct. If unsure, get another nurse to review it with you. If you feel it needs clarification it is your RIGHT to call the physician for clarification. In an interview on [DATE] at 2:50 PM, Resident #1's Physician in the Nursing Facility stated Resident #1 received a dose after the transcription error that was 100 mg more than what the Emergency Department physician had prescribed. When asked if the additional [MEDICATION NAME] administered to Resident #1 had contributed to her death the Nursing Facility Physician stated he did not think the medication error was a major contributing factor in Resident #1's death. In an interview on [DATE] at 3:20 PM, LVN B stated she was told about the transcription error on [DATE]. LVN stated in retrospect she found the way the order was written was confusing, but at the time the order came into the facility she did not have any doubts about the way the order was written; she interpreted the order to be 300 mg of [MEDICATION NAME] in the morning and 400 mg of [MEDICATION NAME] in the evening. LVN B stated she transcribed the order from the fax to the order sheet and called it into the pharmacy. LVN B stated she told the 2:00 PM to 10:00 PM nurse about the new order. LVN B further stated the night shift is responsible for checking all orders from the previous day. In an interview on [DATE] at 4:50 PM, the Assistant Director of Nurses (ADON) stated she had spoken to the NP on [DATE]. The ADON stated the NP had told her on [DATE] that Resident #1's order for 300 mg [MEDICATION NAME] twice a day was too much and would be faxing a new order. The ADON stated she did not check the new order and did not know when it came in to the facility. In an interview on [DATE] at 12:40 PM, Resident #1's NP stated she had spoken with Resident #1's nursing facility physician earlier in the day on [DATE]. The NP stated they both agreed Resident #1's [MEDICATION NAME] was elevated upon admission to the hospital, but not at a toxic level. In an interview on [DATE] at 1:00 PM, LVN D stated she worked the 10:00 PM to 6:00 AM shift on [DATE]. LVN D stated she remembered hearing about the order in change of shift report. LVN D stated she only looked at the telephone order and did not think about looking at the fax order. LVN D stated she did not know at that time the order was a fax order originally. In an interview on [DATE] at 1:15 PM, the Physician who cared for Resident #1 in the hospital from [DATE] to [DATE] stated the additional [MEDICATION NAME] was a contributing factor in Resident #1's death, but not the only cause, multiple issues caused her death. The Hospital Physician (HP) stated Resident #1 had kidney failure which caused [MEDICAL CONDITIONS]. In an interview on [DATE] at 2:30 PM, LVN C stated she worked 2:00 PM to 10:00 PM on [DATE] and she remembered seeing the order for Resident #1's [MEDICATION NAME]. LVN C stated she did not question the order. LVN C stated LVN B did not mention the new order to her. The Administrator and DON were notified on [DATE] at 12:00 PM that Substandard Quality of Care had been identified. The facility provided document identified the census at 54 and 10 residents currently receiving Narrow Therapeutic Index Medications.

Based on interview and record review the facility failed to provide pharmaceutical services to meet the needs of 1 of 11 sampled residents (Resident #1) reviewed for Narrow Therapeutic Index Medications. When 1 of 17 Licensed Vocational Nurses (LVN B) employed at the facility incorrectly transcribed an order for [REDACTED]. This deficient practice could affect 10 residents in the facility. Failure to correctly transcribe medication orders could result in adverse/side effects of the medication or a lower than therapeutic dose of the medication. Findings Include: Review of a Progress Note written by Resident #1's Nurse Practitioner (NP) dated 08/12/10 lists the following [DIAGNOSES REDACTED]. Review of a Fax dated 09/05/10 sent from the facility to Resident #1's NP: Resident #1 had a seizure starting with a loud scream/facial grimacing and then one minute of stiffening of body with whole body jerking. Resident remains lethargic after the seizure. Dilantin level was drawn at 10:00 AM, the results 4.4 (therapeutic range of Dilantin is 10 to 20). Receives Dilantin 300 mg at bedtime. Review of physician's orders [REDACTED]. Review of Nurses Notes for Resident #1 revealed: 09/05/10 at 11:30 PM, Resident #1 sent to the emergency room for evaluation. 09/06/10 at 2:40 AM, Resident #1 returned from emergency room . Orders: Resume other nursing home orders, rinse mouth with water after meals, increase Dilantin to 300 milligrams twice a day. Re-check Dilantin level in one week. Review of physician's orders [REDACTED]. Re-check Dilantin level in one week. Notify Primary Care Physician of changes. Seizure Precautions. Review of a Fax sent from the facility to the NP dated 09/06/10 regarding Resident #1: Resident #1 returned from the emergency room with orders to increase Dilantin to 300 mg twice a day; recheck Dilantin level in one week, rinse mouth with water after meals, resume other nursing home orders and seizure precautions. Review of a Fax sent from the NP to the facility dated 09/07/10 at 7:17 AM: Discontinue Dilantin 300 mg twice a day and change current 300 mg at bedtime to 400 mg at bedtime. Recheck Dilantin level in 2 weeks and 4 weeks. Review of physician's orders [REDACTED]. The order was signed by LVN B, indicating LVN transcribed the order from the fax sent from the NP on 09/07/10 at 7:17 AM.. Review of the September 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Nurses Notes for Resident #1 dated 09/10/10 at 10:00 AM: Resident lying in bed. Eyes open. When name called resident turns eyes toward voice,eyes opening very wide, staring. Skin warm and dry, color pale. Vital signs: Temperature: 97, pulse: 46, respirations: 18, Blood Pressure: 98/62. 2:00 PM: Call placed to the emergency room . Report given. Resident #1 transferred to the emergency room . Resident without any noted distress at time of transport. Review of a hospital History and Physical dated 09/11/10 revealed Resident #1 had a Dilantin level of 27.8 on admission to the hospital on [DATE]. The [DIAGNOSES REDACTED]. In the section entitled Plan: the patient is a [AGE] year old lady who is a resident of a nursing home who has been steadily deteriorating over the last year. She is on a dopamine drip for blood pressure support and she is putting out not very much urine at all. IV Lasix drops her blood pressure down into the 70s so will have to be used cautiously. Although she has rales and rhonci throughout the lungs, x-ray is not showing congestive heart failure. I think she is just not able to handle her secretions at this time. We will continue the dopamine, give the Lasix as tolerated as she is having problems with renal shutdown at this time. Review of a Facility Report entitled Medication Error Report dated 09/11/10 revealed: A medication error occurred for Resident #1. In the section "Description of the error": 09/06/10 Dilantin 300 mg twice a day. On 09/07/10 the NP faxed over new orders, her orders read to discontinue Dilantin 300 mg twice a day and change to Dilantin 400 mg at bedtime. Nurse on duty who transcribed orders wrote orders as Dilantin 300 mg by mouth every morning and Dilantin 400 mg by mouth at bedtime. Review of Progress Notes from the hospital reveal Resident # 1 expired on 09/13/10. In an interview on 09/14/10 at 1:00 PM the Director of Nurses (DON) acknowledged the Medication Order had occurred. The DON further stated the facility was in the process of changing their policy/procedure for taking orders from physicians. The DON stated the change is with faxed orders. The nurse who takes a faxed order will write the order on the order sheet. The nurse will then hand over the written order and the fax to the next shift for the next nurse on duty to review. The DON stated in the past the facility had not handed over the faxes with the written order to the next shift for review. The DON stated the faxes are now going to be passed on to the night shift along with the telephone order. The DON stated the night shift is responsible for Quality Assurance for new orders. The DON further stated the facility is in the process of checking all charts to make sure all orders received either via fax or telephone are transcribed correctly. The DON also stated the facility is in the process of in-servicing all nurses about the new procedure but has not yet finished in-servicing. Review of facility Employee In-Service Sign in Sheet dated 09/13/10 revealed 9 nurses attended the inservice. A sheet entitled agenda was attached to the sign-in sheet: Medication Transcription Errors: DON review the medication error that occurred with Resident #1's Dilantin on 09/07/10 - the order was transcribed incorrectly from the fax to the telephone order. Nurses will keep any order received via fax and attach it with a paper clip to the telephone order written in the chart and review this in change of shift report with the oncoming nurse. this will give the oncoming nurse the opportunity to look at the order on the fax and the transcribed telephone order to see if it is correct. The fax and telephone order will remain clipped together until the 10:00 PM to 6:00 AM nurse has checked the order for correct completion. The 10:00 PM to 6:00 AM nurse will check the faxed order against the telephone order to be sure it was transcribed correctly and will then check the telephone order against the MAR, Treatment and or Activities of Daily Living sheet. Discussed always double checking yourself when you write an order, re-read it to assure it is correct. If unsure, get another nurse to review it with you. If you feel it needs clarification it is your RIGHT to call the physician for clarification. In an interview on 09/14/10 at 2:50 PM, Resident #1's Physician in the Nursing Facility stated Resident #1 received a dose after the transcription error that was 100 mg more than what the Emergency Department physician had prescribed. When asked if the additional Dilantin administered to Resident #1 had contributed to her death the Nursing Facility Physician stated he did not think the medication error was a major contributing factor in Resident #1's death. In an interview on 09/14/10 at 3:20 PM, LVN B stated she was told about the transcription error on 09/13/10. LVN stated in retrospect she found the way the order was written was confusing, but at the time the order came into the facility she did not have any doubts about the way the order was written; she interpreted the order to be 300 mg of Dilantin in the morning and 400 mg of Dilantin in the evening. LVN B stated she transcribed the order from the fax to the order sheet and called it into the pharmacy. LVN B stated she told the 2:00 PM to 10:00 PM nurse about the new order. LVN B further stated the night shift is responsible for checking all orders from the previous day. In an interview on 09/14/10 at 4:50 PM, the Assistant Director of Nurses (ADON) stated she had spoken to the NP on 09/07/10. The ADON stated the NP had told her on 09/07/10 that Resident #1's order for 300 mg Dilantin twice a day was too much and would be faxing a new order. The ADON stated she did not check the new order and did not know when it came in to the facility. In an interview on 09/15/10 at 12:40 PM, Resident #1's NP stated she had spoken with Resident #1's nursing facility physician earlier in the day on 09/15/10. The NP stated they both agreed Resident #1's Dilantin was elevated upon admission to the hospital, but not at a toxic level. In an interview on 09/15/10 at 1:00 PM, LVN D stated she worked the 10:00 PM to 6:00 AM shift on 09/07/10. LVN D stated she remembered hearing about the order in change of shift report. LVN D stated she only looked at the telephone order and did not think about looking at the fax order. LVN D stated she did not know at that time the order was a fax order originally. In an interview on 09/15/10 at 1:15 PM, the Physician who cared for Resident #1 in the hospital from 09/10/10 to 09/13/10 stated the additional Dilantin was a contributing factor in Resident #1's death, but not the only cause, multiple issues caused her death. The Hospital Physician (HP) stated Resident #1 had kidney failure which caused Pulmonary edema. In an interview on 09/15/10 at 2:30 PM, LVN C stated she worked 2:00 PM to 10:00 PM on 09/07/10 and she remembered seeing the order for Resident #1's Dilantin. LVN C stated she did not question the order. LVN C stated LVN B did not mention the new order to her. Review of the Texas Administrative Code; Examining Boards, Board of Nurse Examiners, Licensure, Peer Assistance and Practice Texas Board of Nursing under Standards for Nursing Practice, at Title 22; Part II; chapter 217; Rule 217.11, confirmed the following: (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall (D) Accurately and completely report and document: (iii) physician, dentist or podiatrist orders The facility provided document identified the census at 54 and 10 residents currently receiving Narrow Therapeutic Index Medications.