Every finding on record at Legacy Nursing and Rehabilitation Winnsboro

Resident #74 On 07/07/2025 at 10:39 a.m. observation of Resident #74's room revealed the room was excessively dirty with debris and clutter and the room had a strong smell of urine. Further observation revealed a liquid that appeared to be urine all over bathroom floor. Further observation revealed that Resident #74's wheelchair had an excess of dirt and debris with both arm rests damaged. Interview with S2Director of Nursing (DON) on 07/09/2025 at 2:25 p.m. confirmed that staff had problems with keeping Resident #74's room clean and had to move all items out of room recently. S2DON confirmed that the wheelchair was damaged. Resident #76 On 07/07/2025 at 11:00 a.m. an observation of Resident #76's room revealed no linen/covers on her bed. Further observation revealed that her oxygen concentrator was dirty and there was a pair of shoes that were not the resident's lying on floor in her space. On 07/09/2025 at 2:25 p.m. an interview with S2DON confirmed linen/sheets should be available to all residents and that she was unaware why Resident #76 did not have bed linen. Resident #1 On 07/07/2025 at 1:47 p.m., observation of Resident #1's room revealed dirt and grime on the suction machine, unlabeled creams and substance on bed side table, and overall dirty. Further observation revealed the oxygen concentrator had dirt and debris on all days of survey. On 07/09/2025 at 2:30 p.m. an interview with S2DON confirmed that the equipment and bedside table were dirty and in need of cleaning. Based on record reviews, observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 5 (#1, #25, #71, #74, and #76) of 7 (#1, #5, #25, #70, #71, #74, and #76) sampled residents reviewed for environmental issues and the facility failed to maintain a safe, clean, and sanitary environment in the laundry area. The facility failed to ensure: 1. Resident #25 and #71's wheelchairs were free from dirt and debris; 2. Resident #71 and 74's padding on their wheelchair arm rests were intact and free of cracking; 3. Resident #1, #74, and #76's rooms were properly cleaned and free of odor; and 4. Resident #76's bed had linens in place. Findings: Resident #25 Review of records for Resident #25 revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, chronic kidney disease, and osteoarthritis. Observations on 07/07/2025 at 11:00 a.m. and on 07/08/2025 at 8:40 a.m. revealed Resident #25 had an excess of dirt and debris on her wheelchair frame. Observation with S1Administrator on 07/08/2025 at 2:30 p.m. confirmed that Resident #25's wheelchair had an excess of dirt and debris and needed to be cleaned. Resident #71 Review of records for Resident #71 revealed the resident was admitted on [DATE] with diagnoses including systemic lupus erythematous, chronic obstructive disease, depression, and polyosteoarthritis. Observations on 07/07/2025 at 10:00 a.m. and 07/08/2025 at 8:37 a.m. revealed resident #71's wheelchair arm padding was cracked with exposed foam underneath. Observation on 07/08/2025 at 8:37 a.m. revealed Resident #71 had dirt and debris on his wheelchair frame. Observation with S1Administrator on 07/08/2025 at 2:30 p.m. confirmed the wheelchair's arm padding for Resident #71 was damaged and needed to be replaced. S1Administrator also confirmed Resident #71's wheelchair had dirt and debris and needed to be cleaned. Laundry Area Observation of the laundry area on 07/09/2025 at 10:30 a.m. revealed the following: -disinfectant supplies stored in the sink upon entry into the laundry room; -clothing/shoes stacked on top of 2 of 2 washing machines; -the filter on the washing machine with thick build-up of dust/lint; the label specified that the filter is to be changed daily; -lint buildup between washers, behind washers, and on walls; -laundry detergents that were actively in use were stored directly on the floor; -3 empty chemical containers on the floor; -the corner of room with washers had random piles of linen, clothing, shoes, etc. on the floor; some items were in plastic laundry baskets/some were not; -Shelving in room with the washers had random water resistant resident care supplies (wedge, bolster, etc) covered in a thick layer of dust; -empty laundry basket on the floor; and -heel protectors on the floor. On 07/09/2025 at 10:45 a.m. an interview with S16Housekeeping Supervisor revealed there is a daily laundry list completed by the staff, but was unable to produce a completed daily checklist. On 07/09/2025 at 10:48 a.m., S10Licensed Practical Nurse confirmed all of the above findings in the laundry area.

Based on record reviews and interviews, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted timely for 4 (#34, #35, #55, and #59) of 4 sampled residents reviewed for resident assessment. Findings: Review of the records for Resident #34, #35, and #55 revealed each of these residents had a Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/27/2025. Further review of the record revealed these 3 MDS Assessments were not transmitted to state until 07/07/2025 for each of these residents. Review of the record for Resident #59 revealed an Annual MDS Assessment with an ARD date of 05/27/2025 was not transmitted to the state until 07/07/2025. An interview on 07/08/2025 at 2:50 p.m. with S13MDS Coordinator and S14MDS Coordinator confirmed the facility failed to complete and transmit MDS Assessments timely for Resident #34, #35, #55, and #59.

Based on observations, policy review and interviews, the facility failed to store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect the 63 residents that received meals prepared in the facility's kitchen. Findings: Review of the facility's Dietary Service policy and procedures dated 07/21/2016 revealed, in part, sanitary conditions are maintained in the storage, preparation, and distribution of food. On 07/07/2025 at 8:15 a.m. during an initial tour of the kitchen, observations revealed the following: -dust/grime build up on air vent near entrance to the kitchen; -grime/old food build up on base of large can opener; -large amount of old grease buildup in lower compartment of deep fryer and on the floor underneath the fryer; -2 commercial ovens have dark stains/old food buildup on inside of the oven doors and interior of both ovens; and -microwave had a large amount of old food splatters on inside top and sides of the microwave; -walk-in refrigerator had a large bin that had packages of cheese stored in it that had a lid with dirt/grime; and -walk-in freezer had multiple broken pieces of ice that was scattered on the floor and a large box of hashbrowns was open to air and had ice buildup noted on the hashbrowns. Further observation during the initial tour of the kitchen dry storage room revealed the following: -old foil and food particles were underneath the oatmeal and grits containers, and the 2 small plastic storage containers for the oatmeal and grits were not dated; -2 rolling carts (had 3 shelves each) had old food/grime build-up on all the shelves; -large bin with packages of noodles had a lid that had dirt/grime and was broken; -large bin with individual packets of salt and pepper had a lid that had dirt/grime and was broken; -large bin with individual packages of lemonade drink mixes had a lid that had dirt/grime; -multiple large cans were dented (2 marinara sauces, 1 mandarin orange, 2 apple, 1 tropical fruit, and 1 cream of chicken soup); -large round plastic container that had rice stored in it was not labeled with a date; and -large plastic container that had flour stored in it was not labeled with a date. On 07/07/2025 at 8:40 a.m., an observation with S14Dietary Manager of the above findings was conducted. S14Dietary Manager confirmed food was not stored and labeled properly and kitchen was not cleaned properly.

Based on record reviews, observations, and interviews the facility failed to maintain electrical equipment in safe operating condition for 1 (#70) of 7 (#1, #5, #25, #70, #71, #74, #76) residents reviewed for environment. The facility failed to ensure that Resident #70's bed control was properly maintained and in safe working order. Findings: Review of the medical record for Resident #70 revealed an admission date of 06/17/2024 with diagnoses that included Alzheimer's disease, cerebrovascular disease, aphasia, dysphagia, repeated falls, and transient ischemic attack. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 6 which indicated Resident #70 had severe cognitive impairment. On 07/08/2025 at 9:28 a.m., an observation of Resident #70's room revealed a bed remote with exposed wires. On 07/09/2025 at 10:02 a.m., an observation with S15Maintenance Supervisor of Resident #70's bed control confirmed exposed wires.

Based on record review and interview, the facility failed to complete a discharge summary for 1 (#89) of 1 closed records reviewed. Findings: Review of the facility's undated Discharge Transfer of a Resident Policy and Procedure revealed the following in part: Procedure- discharge: 6. Complete a discharge summary and post discharge plan of care form Review of Resident #89's record revealed an admission date of 03/31/2025 and discharge date of 04/30/2025. Further review of the record revealed no documentation of a discharge summary completed for Resident #89. An interview on 07/09/2025 at 8:45 a.m. with S2Director of Nursing (DON) confirmed Resident #89 was discharged from the facility on 04/30/2025. S2DON further confirmed there was no documentation of a discharge summary for Resident #89.

Based on observations of the medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 5.41 % medication error rate with 2 medication errors out of 37 opportunities. Findings: Resident #72 Observation of the medication pass for Resident #72 on 07/08/2025 at 8:06 a.m. revealed S4Licensed Practical Nurse (LPN) administered 10 oral medications to resident #72. Further observation of the medication pass revealed S4LPN administered the phosphate binder medication Sevelamer Carbonate (Renvela), 800 milligrams, 2 tablets. Interview with Resident #72 on 07/08/2025 at 8:06 a.m. confirmed that he had already eaten his breakfast meal. Review of the pharmacy label and the current physician orders revealed the following: Sevelamer Carbonate tablet, 800mg, take 2 tablets (1600mg) by mouth three times daily before meals and take one tablet before snacks. Review of the current physician orders for Resident #72 revealed an order for the medication Ondansetron HCl Oral Tablet 8 mg, take 1 tablet by mouth one time a day every Tuesday, Thursday, and Saturday on dialysis days related to nausea and vomiting. This medication was not observed to be administered during the medication pass. Interview with S4LPN on 07/09/2025 at 12:10 p.m. confirmed that she administered the medication Sevelamer Carbonate 800mg, 2 tablets, after resident #72 had completed his breakfast. Further interview with S4LPN revealed that she administered the medication Ondansetron 8mg after medication pass observation was completed. She confirmed that she did not attempt to notify the Director of Nursing (DON) or this surveyor prior to administering medication. On 07/09/2025 at 2:25 p.m., S2DON was made aware of 2 medication errors for resident #72. Surveyor explained to S2DON that 2 medication errors were made during the medication pass resulted in a medication error rate greater than 5%.

Resident #1 Review of the record for Resident #1 revealed an admit date of 05/01/2005 with diagnoses of hemiplegia, unspecified affecting unspecified side, and traumatic hemorrhage of cerebrum. Review of the current physician orders for Resident #1 revealed an order for oxygen therapy as follows: oxygen saturation level each shift, apply oxygen if saturation less than 92% at 2 liters per nasal cannula. Review of the care plan revealed a plan for at risk for respiratory infection related to Covid with interventions to administer oxygen as ordered. Observation of Resident #1 on 07/07/2025 at 8:23 a.m. revealed the oxygen concentrator flow set to three liters. Further observation revealed that the oxygen nasal cannula was lying on the floor. Further observation revealed that the concentrator was filthy with white debris splattered on it. Observation of Resident #1 on 07/07/2025 at 1:30 p.m. revealed the oxygen concentrator on and the flow set for three liters. Further observation revealed that the oxygen nasal cannula was lying on side of the bed. Observation of Resident #1 on 07/07/2025 at 4:15 p.m. revealed that the oxygen concentrator was on and set for 3 liters. Further observation revealed that the oxygen nasal cannula was lying on the bed. Observation of Resident #1 on 07/08/2025 at 9:44 a.m. revealed that the oxygen concentrator was set on 3 liters. Further observation revealed that the oxygen nasal cannula was on side of Resident #1's face and was not in her nostrils. Further observation revealed that the concentrator was filthy with food splatters on it. Interview with S3Licensed Practical Nurse (LPN) on 07/08/2025 at 1:30 p.m. revealed that Resident #1 had recently returned from the hospital on [DATE] with an order for continuous oxygen therapy at 3 liters a minute. S3LPN confirmed that Resident #1 is sometimes non-compliant and removes her nasal cannula. Interview with S6Certified Nursing Assistant (CNA) on 07/09/2025 at 7:52 a.m. confirmed that Resident #1 was supposed to have oxygen on at all times. Further interview with S6CNA confirmed that the oxygen concentrator was filthy and was in need of cleaning. Observation on 07/09/2025 at 2:25 p.m. with S2DON present, S2DON confirmed that the oxygen concentrator was not clean. S2DON was notified at this time that Resident #1 not receiving oxygen as ordered. Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#1, #5, #22) of 4 (#1, #5, #22, and #76) residents reviewed for respiratory care. The facility failed to ensure: 1.) the residents' oxygen concentrators and filters on the back of the concentrators were free from dust and grime build up (#1, #22), 2.) a resident had the correct oxygen flow rate (#1), and 3.) a resident's nebulizer tubing was changed timely (#5). Review of the facility's undated oxygen policy and procedures, revealed in part the following: Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Procedure: 1. Check physician's order for liter flow and method of administration. 5. Prefilled, sealed, disposable humidifiers may be changed per facility procedure. e. Set the flow meter to the rate ordered by the physician. g. Change tubing per facility procedure. 9. At regular intervals, check and clean oxygen equipment, masks, tubing, and cannula. Review of the facility's undated nebulizer/continuous positive airway pressure (CPAP) cleaning policy and procedure revealed, in part: Purpose: To keep Nebulizer or CPAP machine and equipment clean. Policy: Resident's Nebulizer or CPAP will be kept clean when in resident room. 3. Tubing, mouthpiece and mask to be changed out weekly and as needed. Findings: Resident #22 Review of the record for Resident #22 revealed diagnoses of chronic obstructive pulmonary disease (COPD), congestive heart failure, and cerebral infarction. Review of the Resident #22's current physician's orders revealed an order dated 02/04/2025 to administer oxygen at 2 liters per nasal cannula. Further review revealed an order dated 06/09/2025 to clean filter and concentrator (free from dust) as needed for oxygen therapy. Review of Resident #22's active care plan revealed she had COPD and chronic lung disease and needed oxygen when she had a respiratory crisis. On 07/07/2025 at 9:23 a.m., 07/08/2025 at 9:30 a.m., and 07/08/2025 at 2:14 p.m., observations revealed Resident #22 was observed in bed in her room with oxygen at 2 liters per nasal cannula. Further observation revealed there was dust and grime build up on the outside of her oxygen concentrator and on the filter on the back of the concentrator. On 07/09/2025 at 2:05 p.m., observation of resident #22's oxygen concentrator with S2Director of Nursing (DON) revealed there was a buildup of dust on the resident's oxygen concentrator and the filter on the back of the oxygen concentrator. S2DON confirmed resident #22's oxygen concentrator was in need of cleaning. Resident #5 Review of the medical record for Resident #5 revealed an admission date of 09/23/2019 with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, dementia, and hyperlipidemia. Review of the physician's orders revealed ipratropium-albuterol solution 0.5-2.5 (3) milligrams/3 milliliters 1 vial inhale orally four times a day for productive cough. Review of the current plan of care addressed Resident #5's chronic obstructive pulmonary disease with interventions that included administration of medications as ordered by the physician. Review of the July 2025 Medication Administration Record (MAR) revealed Resident #5 last received ipratropium-albuterol solution 0.5-2.5 (3) milligrams/3 milliliters inhaled orally on 07/03/2025 at 4:00 p.m. On 07/07/2025 at 9:15 a.m., the nebulizer mask tubing at Resident #5's bedside was dated 06/09/2025. On 07/08/2025 at 9:16 a.m., the nebulizer mask tubing at Resident #5's bedside was dated 06/09/2025. On 07/08/2025 at 9:16 a.m., S4LPN confirmed the nebulizer mask tubing at Resident #5's bedside was dated 06/09/2025.

Based on record reviews, observations, and interviews, the facility failed to ensure the resident's environment remained free of accident hazards by failing to ensure bed rails were properly secured for 1 (#5) of 2 (#5, #11) residents reviewed for accident hazards. Findings: Review of the medical record for Resident #5 revealed an admission date of 09/23/2019 with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, dementia, and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8 which indicated the resident had moderately impaired cognitive skills for daily decision making. Further review revealed Resident #5 was dependent with bed mobility. Review of the current plan of care addressed Resident #5's need for staff assistance with all activities of daily living. The resident required half side rails for turning and repositioning. Observations on 07/07/2025 at 9:15 a.m. and 07/08/2025 at 9:16 a.m. revealed the half side rail on Resident #5's left side of the bed was loose. On 07/09/2025 at 9:56 a.m., an observation of Resident #5's left side rail with S15Maintenance Supervisor confirmed the side rail was loose.

Based on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#1) of 1 residents reviewed for position/mobility. The facility failed to ensure hand rolls and an elbow splint were provided for Resident #1's hand and arm contractures. Findings: Review of the record for Resident #1 revealed diagnoses of traumatic hemorrhage of cerebrum, hemiplegia, aphasia, and bilateral hand contractures. Review of the quarterly Minimal Data Set assessment dated [DATE] for Resident #1 revealed functional limitation in range of motion on both sides for upper extremity and impairment on both sides of lower extremity. Resident's cognitive skills for daily decision making were severely impaired. Observations on 07/07/2025 at 8:30 a.m. revealed Resident #1 had bilateral contractures with no splints in place. On 07/07/2025 at 1:30 p.m. and 07/07/2025 at 4:00 p.m., observations revealed no hand splints were in place. Further observation revealed no elbow splint in place. All observations on 07/08/2025 revealed no splints in place for Resident #1. Review of the current physician orders for Resident #1 revealed an order for an elbow splint for right elbow due to diagnosis of contracture of right elbow. Review of the care plan for Resident #1 revealed the following focus: assistance for all activities of daily living (ADLs), (total care due to traumatic hemorrhage, hemiplegia). I have impaired physical mobility related to contractures of right arm, bilateral hands, bilateral lower extremities and left wrist. I have history of traumatic hemorrhage. I have a right elbow splint and bilateral hand rolls. Interview with S3Licensed Practical Nurse (LPN) on 07/08/2025 at 1:30 p.m. confirmed Resident #1 did not have hand rolls or elbow splint in place. Interview with S6Certified Nursing Assistant (CNA) on 07/09/2025 at 7:52 a.m. confirmed Resident #1 did not have splints in place. S6CNA stated she last worked on the weekend and the splints were not present. On 07/09/2025 at 2:25 p.m, S2Director of Nursing (DON) was notified of the above findings.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 2 (#11, #22) of 6 (#11, #14, #22, #56, #70, #74) residents reviewed for ADL care. Findings: Resident #22 Review of Resident #22's record revealed an admission date of 01/23/2025 with diagnoses that included cerebral infarction with hemiplegia and hemiparesis, chronic obstructive pulmonary disease, and congestive heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #22 had no cognitive impairment. Further review revealed Resident #22 required partial/moderate assistance with personal hygiene. Review of Resident #22's active care plan revealed she required assistance for all ADLs and needed assistance with hygiene and grooming tasks. On 07/07/2025 at 9:23 a.m., 07/08/2025 at 9:30 a.m., and 07/08/2025 at 2:14 p.m., observations revealed Resident #22 was observed in bed in her room and she had long facial hair on her chin. On 07/09/2025 at 8:58 a.m., observation of Resident #22 with S9Certified Nursing Aide (CNA) revealed Resident #22 had long facial hair on her chin. An interview with S9CNA revealed Resident #22 allows them to shave her without any problem. S9CNA confirmed the resident's face was not groomed and the facial hair needed to be shaved. On 07/09/2025 at 2:05 p.m., S2Director of Nursing (DON) was notified of the above findings and she confirmed Resident #22 was dependent on staff for ADL care. Resident #11 Review of Resident #11's record revealed an admission date of 03/18/2024 with diagnoses including type 2 diabetes mellitus with ketoacidosis without coma, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic combined systolic (congestive) and diastolic heart failure, hypertension, functional dyspepsia, polyosteoarthritis, hyperlipidemia, morbid obesity, and chronic kidney disease. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating no cognitive impairment. Further review of the MDS revealed Resident #11 required assistance with ADLs and has functional limitation in range of motion on one side of upper extremities. An observation on 07/07/2025 at 8:50 a.m. and 07/08/2025 at 9:25 a.m. of Resident #11 revealed her fingernails were long and needed to be trimmed. Further observation revelaed Resident #1 had limited in range of motion to her right hand. An interview on 07/08/2025 at 9:25 a.m. with Resident #11 revealed she's unable to trim her own fingernails and she asked a staff member to cut her fingernails on 07/07/2025. An interview on 07/09/2025 at 1:00 p.m. with S11Licensed Practical Nurse (LPN) revealed that Resident #11 required extensive assistance with ADLs including nail care. S11LPN confirmed Resident #11's fingernails were trimmed by the nurse on the hall or the treatment nurse due to the resident having diabetes. Interview on 07/09/2025 at 1:05 p.m. with S2DON was notified of the above findings and confirmed Resident #11 required assistance from staff for nail care.

Based on record review, observation, and interview the facility failed to treat the resident with respect and dignity and care in a manner and in an environment that promotes or enhances his or her quality of life for 1 (#76) of 1 residents reviewed for dignity. The facility failed to ensure that Resident #76's privacy was maintained. Findings: Review of the record for Resident #76 revealed diagnoses of congestive heart failure, metabolic encephalopathy, and drug-induced subacute dyskinesia and aphasia. Review of Resident #76's Minimal Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment for daily decision making. Further review of the MDS revealed the resident was dependent on staff for Activities of Daily Living (ADL) and had limited range of motion on both sides other upper and lower extremities. Observations of Resident #76 on 07/07/2025 at 9:00 a.m., 11:30 a.m., 1:30 p.m., and 4:00 p.m. revealed the resident was lying in bed in the fetal position on her right side with her brief exposed and no linens on the resident's bed. On 07/07/2025 at 11:30 a.m., an interview with S7Certified Nursing Assistant (CNA) revealed she was not aware of a reason that Resident #76 did not have bed linens. On 07/07/2025 at 11:45 a.m., an interview with S5CNA revealed she was not aware of a reason that Resident #76 did not have bed linens. S5CNA made no attempt to find linen for the resident. On 07/08/2025 at 10:00 a.m., an interview with S3Licensed Practical Nurse (LPN) confirmed she was unaware of a reason that Resident #76 did not have bed linens. Observation on 07/09/2025 at 11:32 a.m. revealed Resident #76 lying in bed with no bed linen and no sheets on the resident. On 07/09/2025 at 2:20 p.m., an interview was conducted with S2Director of Nursing (DON). S2DON confirmed residents are to be provided linen/covers and S2DON was informed of the findings related to dignity.

Based on record review and interview, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 2 (#1,#2) of 3 (#1,#2,#3) residents records reviewed. The facility did not have documentation of wound care being provided daily as ordered. Findings: Review of resident #1's medial record revealed an admitted [DATE] with diagnosis of hypertension, dislocation of internal right hip prosthesis, macular degeneration, malnutrition, Stage 4 pressure ulcer sacral region, history of falls, dementia, depression, and osteoporosis without pathological fractures. Review of resident #1's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicates the resident is cognitively impaired. Further review of the MDS revealed the resident needs moderate assistance with activities of daily living. Review of resident #1's November 2024 physician's orders revealed an order dated 08/06/2024 for wound care ordered as follows: Stage IV pressure ulcer to left sacral area, cleanse with wound cleanser, pat dry, skin prep peri-wound, apply collagen to the wound bed, pack lightly with calcium alginate, and cover with dry absorbent dressing. Change daily and as needed. Review of the October 2024 and November 2024 Treatment Administration Records (TAR) for resident #1 revealed no documented evidence of wound care on 10/25/2024, 10/27/2024, and 11/04/2024. Review of the nurse notes revealed no documentation of wound care on 10/25/2024, 10/27/2024, and 11/04/2024. Interview on 11/14/2024 at 12:55 p.m. with S2Director of Nurses (DON) confirmed the nurses did not document the wound care on resident #1 on 10/25/2024, 10/27/2024, and 11/04/2024. Resident #2 Review of resident #2's medical record revealed an admitted [DATE] with diagnosis of hemiplegia, hemiparesis, and acute respiratory failure with hypoxia, chronic kidney disease, dysphagia, atrial fibrillation, and hypertension. Review of resident #2's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed resident was dependent on staff for assistance with activities of daily living. Review of resident #2's November 2024 physician's orders revealed an order dated 10/08/2024 for wound care: pressure ulcer stage 3 to sacrococcygeal, cleanse with wound cleanser, pat dry, skin prep peri-wound, apply collagen to the wound bed, and cover with dry absorbent dressing, changed daily and as needed for soilage/dislodgement until resolved. Review of the October 2024 TAR revealed wound care on resident #2 was not documented on 10/31/2024. Interview on 11/14/2024 at 12:55 p.m. with S2DON confirmed the nurses did not document the wound care for resident #2 on 10/31/2024.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#9) of 3 (#9, #40, and #231) sampled residents reviewed for urinary catheters. This failed practice resulted in actual harm for resident #9 on 04/16/2024 due to the facility failing to: 1. Ensure resident #9 was free of urinary tract infections as evidenced by resident #9 having a urinary tract infection on 04/16/2024 and again on 05/13/2024, and was treated with antibiotic therapy on both occasions for 5 days, beginning respectively on 04/17/2024 and 05/13/2024. 2. Assess the medical justification for the indication for use of a urinary catheter for resident #9 upon admission on 03/18/2024. 3. Ensure the facility documented the color, clarity and character of resident #9's urine as per resident #9's current care plan. Findings: Review of the facility's current policy and procedure for Catheter Indwelling, Insertion and Removal (updated 06/30/2021) and Catheter Care, Indwelling Competency (02/22/2024) revealed no pertinent guidance on documentation of the appearance of urine when a catheter is used nor the need for medical justification of urinary catheters being assessed upon admission to the facility. Review of the record for resident #9 revealed an admitted to the facility of 03/18/2024 from a hospitalization . Diagnoses included chronic kidney disease stage 3, dehydration, diabetic ulcer of right foot, hypertension, type 2 diabetes mellitus with ketoacidosis without coma, and non-pressure chronic ulcer of other part of right foot with unspecified severity. Review of the Nursing Admission/Readmission Form dated 03/18/2024 revealed resident #9 required 2 person physical assist with toileting, urinary incontinence - always continent, bowel continence- always continent, and indwelling catheter was marked. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Further review of the MDS revealed the resident required substantial/maximal assistance with toileting hygiene. Further review of the MDS revealed resident #9 had an indwelling urinary catheter on admission. Review of the May 2024 Physician's Orders for resident #9 revealed an order dated 03/19/2024 to maintain urinary catheter 16 French (10) cubic centimeters (cc) balloon, monitor catheter care every shift and as needed. The medical record had no other orders for the care of the urinary catheter. Review of the current care plan dated 03/18/2024 revealed resident #9 had a 16 French catheter. Interventions included to assess for symptoms of urinary tract infection as needed, change catheter tubing/bag as appropriate, evaluate for removal of catheter as appropriate, ongoing assessment of color, clarity, and character of urine, provide catheter care every shift, and watch for acute behavioral changes that may indicate a urinary tract infection. An observation and interview with resident #9 on 05/13/2024 at 10:45 a.m. revealed the resident was up in her gerichair and was noted to have a urinary catheter bag with dark amber urine, and catheter tubing that was very cloudy. Resident #9 reported at this time she should have had her catheter changed already. An observation on 05/14/2024 at 3:15 p.m. of resident #9 revealed amber urine still noted in catheter bag, but catheter tubing was clear. An interview on 05/14/2024 at 3:15 p.m. with resident #9 revealed that a nurse changed her catheter on 05/13/2024 and the nurse got a urine sample due to cloudy urine and her complaint of lower back pain. Review of the March 2024, April 2024, and May 2024 Medication Administration Record (MAR) revealed no documentation of color, clarity, and character of urine since resident #9 was admitted on [DATE]. Review of the April 2024 and May 2024 nurses' progress notes revealed there were only 6 entries (04/21/2024, 04/22/2024, 04/29/2024, 05/03/2024, 05/13/2024, and 05/14/2024) that documented color and clarity of the urine, but had no character of the urine noted. An interview on 05/14/2024 at 3:20 p.m. with S11Licensed Practical Nurse (LPN) revealed S11LPN reported resident #9 was crying and complaining of lower back pain on 05/13/2024, noted that resident's catheter was cloudy with dark urine in the catheter bag. S11LPN notified S13Nurse Practitioner (NP) and received an order to obtain a urinalysis on resident #9. S11LPN reported that she changed the resident's catheter bag and catheter tubing before she obtained a urine sample for urinalysis. S11LPN reported that resident #9 had 4+ bacteria noted on urinalysis, and was started on Macrobid (antibiotic) 100 milligrams (mg) 1 capsule by mouth twice a day beginning on 05/13/2024. S11LPN reported that urinary catheters are changed as needed for obstruction. S11LPN confirmed that March, April, and May 2024 MARs for resident #9 did not have documentation of color, consistency, and character of urine documented. S11LPN confirmed that resident #9 had a urinary catheter upon admission to the facility on [DATE]. Review of resident #9's urinalysis results dated 05/13/2024 revealed the following results: cloudy urine, 3+ blood in urine, 1+ protein, white blood cells too numerous to count, and 4+ bacteria. An interview on 05/14/2024 at 3:30 p.m. with S2Director of Nursing (DON) revealed that resident #9 has had a catheter since she was admitted to the facility on [DATE]. S2DON confirmed resident #9 had a urinary tract infection (UTI) currently and was started on Macrobid 100 mg 1 capsule by mouth twice a day for 5 days beginning 05/13/2024. S2DON confirmed there was no documentation of color, clarity, and character of the urine for resident #9 on March, April, and May 2024 MARs. Review of the April MAR for resident #9 revealed a urinalysis was obtained on 04/16/2024. Further review of the MAR revealed resident #9 was administered Macrobid 100 mg 1 capsule by mouth twice a day for 5 days beginning on 04/17/2024. Review of resident #9's urinalysis results dated 04/16/2024 revealed the following: 3+ bacteria, 2+ blood, cloudy urine, and white blood cells 20-30. Review of the urine culture results dated 04/16/2024 for resident #9 revealed Escherichia coli identified. An interview on 05/15/2024 at 8:05 a.m. with S2DON confirmed resident #9 did not have orders related to changing the resident's urinary catheter. S2DON confirmed that resident #9 had a urinary tract infection on 04/16/2024 and was started on Macrobid 100 mg 1 capsule by mouth twice a day on 04/17/2024. Review of resident #9's hospital discharge summary dated 03/18/2024 revealed resident #9 will be continued on ciprofloxacin for 10-14 days for Proteus infection of her foot wound. No diagnoses in hospital discharge record revealed a diagnosis that would medically justify the need for resident #9 to have a urinary catheter. An interview on 05/15/2024 at 8:45 a.m. with S12LPN/Minimum Data Set (MDS) Coordinator revealed the facility did not have a catheter use justification for resident #9, and was not aware that a justification was needed. She further reported resident was admitted with the urinary catheter, and the resident was unable to walk due to the wound to her right heel, so they left the catheter in place. An interview on 05/15/2024 at 8:55 a.m. with S2DON confirmed the facility did not have (indication for use of urinary catheter) a catheter justification, and that resident #9 did not have a diagnosis that would justify having a urinary catheter. An interview on 05/15/2024 at 1:48 p.m. with S13Nurse Practitioner (NP) revealed she was aware that resident #9 was admitted with a urinary catheter and confirmed there was no medical justification to indicate that resident #9 should have had a urinary catheter. S13NP confirmed resident #9 has had 2 urinary tract infections since she was admitted to the facility. S13NP confirmed that she spoke with S11LPN on 05/15/2024 and gave an order to discontinue resident #9's urinary catheter. S13NP confirmed resident #9 should not have been admitted to the facility with a urinary catheter without having a medical diagnosis to justify the use of a urinary catheter. An interview on 05/15/2024 at 2:30 p.m. with resident #9 revealed that staff removed her catheter today. Resident #9 reported she was able to urinate on her own before the catheter was put into place while in the hospital. An interview on 05/15/2024 at 2:35 p.m. with S12LPN/MDS Coordinator confirmed she should have identified resident #9 was admitted to the facility with a urinary catheter and did not have a medical diagnosis to justify use of the catheter. S12LPN/MDS Coordinator reported she should have made sure resident #9 had a medical justification for the indication of a urinary catheter. S12LPN/MDS Coordinator confirmed resident #9 has had 2 UTIs since she was admitted to the facility on [DATE]. S12LPN/MDS Coordinator confirmed the discharge documentation from the hospital for resident #9 did not include a medical justification for the use of a urinary catheter. An interview on 05/15/2024 at 2:45 p.m. with S2DON confirmed the following: -resident #9 had a urinary catheter on admission on 03/18/2024 but was not assessed for medical justification for indication of use of a urinary catheter, -resident #9 did not have a diagnoses that justified the need for use of a urinary catheter, -no documentation of color, clarity, and character of resident #9's urine on March, April, and May 2024 MAR, and -resident #9 had a UTI on 04/16/2024 and 05/13/2024 and was ordered Macrobid 100 mg 1 capsule by mouth twice a day for 5 days.

Based on record reviews and interviews, the facility failed to assure that nursing staff possessed the competency to provide nursing related services as evidenced by S2Director of Nursing (DON), S12Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator, and S13Nurse Practitioner (NP) failing to ensure a resident admitted with a urinary catheter had a medical justification for the indication/use of a urinary catheter for 1 (#9) of 3 (#9, #40 and #231) sampled residents reviewed for urinary catheters. Findings: Review of the facility's current policy and procedure for Catheter Indwelling, Insertion and Removal (updated 06/30/2021) and Catheter Care, Indwelling Competency (02/22/2024) revealed no guidance for the need of an admission assessment to determine a medical justification for the use of a urinary catheter. Review of the record for resident #9 revealed an admitted [DATE] with diagnoses including chronic kidney disease stage 3, dehydration, diabetic ulcer of right foot, diabetic ketoacidosis, hypertension, and non-pressure chronic ulcer of other part of right foot with unspecified severity. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating mild cognitive impairment. Further review of the MDS revealed resident #9 had an indwelling urinary catheter. Review of the current care plan dated 03/18/2024 revealed resident #9 had a 16 French catheter. Interventions included to assess for symptoms of urinary tract infection as needed, change catheter tubing/bag as appropriate, evaluate for removal of catheter as appropriate, ongoing assessment of color, clarity, and character of urine, provide catheter care every shift, and watch for acute behavioral changes that may indicate a urinary tract infection. Review of resident #9's hospital Discharge Summary dated 03/18/2024 revealed resident #9 did not have a diagnosis that would medically justify the need for resident #9 to have a urinary catheter. An interview on 05/15/2024 at 8:05 a.m. with S2Director of Nursing (DON) confirmed resident #9 had a urinary catheter since she was admitted to the facility on [DATE]. S2DON further confirmed resident #9 had 2 urinary tract infections since she was admitted on [DATE]. An interview on 05/15/2024 at 8:45 a.m. with S12LPN/Minimum Data Set (MDS) Coordinator revealed the facility did not have a catheter justification for resident #9 and S12LPN/MDS Coordinator was not aware that a justification was needed. An interview on 05/15/2024 at 1:48 p.m. with S13Nurse Practitioner (NP) revealed she was aware that resident #9 was admitted with a urinary catheter on 03/18/2024 and confirmed there was no medical justification to indicate that resident #9 should have had a urinary catheter. S13NP confirmed that she spoke with S11LPN on 05/15/2024 and ordered to discontinue resident #9's urinary catheter. An interview on 05/15/2024 at 2:45 p.m. with S2DON confirmed she was aware that resident #9 had a urinary catheter upon admission. Further interview with S2DON confirmed resident #9 was not assessed for a medical justification for the urinary catheter.

Based on record reviews, observations and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 3 (#51, #55, & #57) of 5 (#4, #38, #51, #55, & #57) sampled residents reviewed for activities of daily living (ADLs). Findings: Resident #51 Review of the record for resident #51 revealed diagnoses of weight loss, dehydration, recent falls and vascular dementia and urinary tract infection. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed the resident scored a 1 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognitive skills for daily decision making. Further review revealed resident #51 required total assistance with activities of daily living (ADLs). Review of the plan of care for resident #51 revealed the resident required assistance for all ADLs with the following interventions: assist resident with hygiene and grooming and assist me with my clothing. Observation on 05/13/2024 at 8:20 a.m. of resident #51 revealed the resident was in the dining room of the locked unit eating breakfast. Further observation revealed food debris and liquid on her blouse and pants after her meal was consumed. Observation of resident #51 revealed she was barefooted. Observation on 05/13/2024 at 12:29 p.m. of resident #51 revealed resident #51 was eating her lunch meal. Resident #51 was observed with food debris and liquid debris on her clothing after the meal and was wearing the same clothing from the morning meal. Observation on 05/13/2024 at 3:10 p.m. revealed resident #51 had the same blouse on and was observed to have food debris and liquid spilled on blouse after eating snack food. Observation on 05/14/2024 at 8:18 a.m. revealed resident #51 in the dining room eating breakfast. Resident was observed to have same blouse on from the previous day. Further observation revealed that resident spilled orange juice on self and S8Certified Nursing Assistant (CNA) was observed to wipe off access juice with paper towel and did not change the resident. Resident #51 was observed to be barefooted. Observation on 05/15/2024 at 7:46 a.m. revealed resident #51 was observed to have emesis on her clothing. An interview with S10CNA confirmed that resident #51 vomited during breakfast meal. An interview on 05/15/2024 at 3:00 p.m. with S2Director of Nursing (DON) confirmed that staff are to assist residents with all meals and beverages and are to change the residents' clothes when needed. Further interview with S2DON revealed that staff are to ensure residents have on proper footwear/non-slip socks. 19256 Resident #55 Review of the medical record for resident #55 revealed the resident was admitted on [DATE] with diagnoses including bilateral osteoarthritis of knee, anxiety disorder, agoraphobia with panic disorder, severe obesity, bipolar disorder with psychotic features, hypertension, depression, and malignant neoplasm of left breast. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated her cognition was intact. The resident required set up assistance with personal hygiene. Review of the record revealed the following care plan: I require staff assistance for all activities of daily living (ADLs). Further review of the care plan revealed the following intervention: assist me with hygiene and grooming tasks. An interview on 05/13/2024 at 12:00 p.m. revealed resident #55 stated, My toenails need to be trimmed. Observation of the resident's toenails at this time revealed they were long and needed to be trimmed. An interview on 05/14/2024 at 9:00 a.m. with resident #55 revealed her toenails were still in need of trimming. During an observation of resident #55's toenails with S2Director of Nursing (DON) on 05/15/2024 at 9:30 a.m., S2DON confirmed that resident #55's toenails were in need of trimming and staff should assist resident #55 with personal hygiene. Resident #57 Review of the medical record for resident #57 revealed the resident was admitted on [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery, Alzheimer's, schizoaffective disorder, bipolar type, hemiplegia and hemiparesis following cerebral infarction, dysarthria following cerebral infarction, chronic pain, peripheral vascular disease, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 6 on the Brief Interview of Mental Status (BIMS) which indicated the resident had severely impaired cognitive skills for daily decision making skills. The resident had range of motion impairment on both side of the upper extremities and lower extremities. The resident required substantial/maximal assistance with toileting/hygiene and shower/bathe self. The resident required partial/moderate assistance with personal hygiene. Review of the record revealed the following care plan: I require staff assistance for all activities of daily living. Further review of the care plan revealed the following intervention: assist me with hygiene and grooming. Observations on 05/13/2024 at 10:15 a.m. and on 05/14/2024 at 9:40 a.m. revealed resident #57 had long, jagged fingernails. During an observation of resident #57's fingernails with S3Wound Care Nurse on 05/15/2024 at 8:50 a.m., S3Wound Care Nurse confirmed resident #57's fingernails were long and needed to be trimmed.

Based on record reviews and interview, the pharmacist failed to report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#30) of 1 sampled resident who received an anticoagulant medication. The pharmacist failed to identify that the facility had not monitored resident #30 for bleeding while the resident was receiving an anticoagulant medication. Findings: Review of the medical record for resident #30 revealed the resident was admitted on [DATE] with diagnoses of hypertensive heart disease with heart failure, edema, Alzheimer's, anxiety disorder, hyperlipidemia, and cervical disc degeneration. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately impaired cognitive skills for daily decision making skills. The resident required supervision for toileting/hygiene and partial/moderate assistance for shower/bathe self and dressing. Review of the physician orders revealed an order dated 02/27/2024 for Eliquis (anticoagulant or blood thinner) 5 milligrams (mg) give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure. Review of the record revealed the following care plan: I have been prescribed multiple medications. Further review revealed the following intervention: I need monitoring for adverse reactions. Review of the Medication Administration Record and Treatment Administration Record for May 2024 revealed there was no documented evidence that the staff were monitoring the resident for bleeding. Review of the Drug Regimen Review for 03/01/2024, 04/03/2024, and 05/01/2024 revealed there was no documented evidence the pharmacist identified that the staff were not monitoring the resident for bleeding while receiving Eliquis. An interview on 05/15/2024 at 2:50 p.m. with S2Director of Nursing (DON) confirmed there was no documented evidence the pharmacist identified that the staff were not monitoring the resident for bleeding while receiving Eliquis.

Based on record review, observations, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 (#10) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure the oxygen tubing and cannula were stored properly when not in use for resident #10. Findings: Review of the Oxygen Concentrator Cleaning Policy and Procedure dated 04/08/2022 revealed in part: Procedure: 2. Store oxygen tubing, cannula, and mask in plastic bag when not in use. Review of the medical record for resident #10 revealed the resident was admitted on [DATE] with diagnoses including: chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, severe obesity, schizoaffective disorder/depressive type, insomnia, depression, peripheral venous insufficiency, hypertension, edema, and heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 10 on the Brief Interview of Mental Status (BIMS) which indicated the resident had moderately impaired cognitive skills for daily decision making skills. Review of the physician orders revealed an order dated 03/26/2024 - oxygen to run at 2-3 Liters per minute (LPM) via nasal cannula as needed to keep oxygen saturations > 90% with shortness of breath (SOB), SOB when lying flat. Review of the Medication Administration Record for May 2024 revealed: oxygen at 2 LPM per nasal cannula at bedtime (hs) due to SOB while lying flat at bedtime related to COPD. Review of the record revealed the following care plan: I require oxygen therapy at hs and as needed due to SOB r/t COPD and congestive heart failure (CHF). Further review revealed an intervention to administer my oxygen as ordered. Observation on 05/13/2024 at 11:51 a.m. revealed the resident's nasal cannula was not in use and it was observed directly on the mattress. Interview with resident #10 at this time revealed he wears the nasal cannula at night. Observation on 05/14/2024 at 9:43 a.m. and 3:15 p.m. revealed the resident's nasal cannula was not in use and it was observed uncovered and hanging on the side rail on the bed. Observation on 05/15/2024 at 9:15 a.m. revealed the resident's nasal cannula was not in use and it was observed uncovered and hanging on the side rail on the bed. An interview with S14Licensed Practical Nurse (LPN) on 05/15/2024 at 9:15 a.m. confirmed resident #10's nasal cannula should be stored in a bag when not in use. During an observation with S2Director of Nursing (DON) on 05/15/2024 at 9:25 a.m., S2DON confirmed resident #10 required oxygen per nasal cannula at night and the nasal cannula should be stored in a bag while not in use.

Based on record review, observations, and interviews, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for 1 (#51) of 1 (#51) resident reviewed for nutrition. The facility failed to provide the required assistance with meals to prevent significant weight loss. Findings: Review of the record for resident #51 revealed diagnoses including weight loss, dehydration, recent falls, vascular dementia and urinary tract infection. Review of the weights for resident #51 revealed 124 pounds recorded on 05/09/2024. Resident #51 admit weight was 141 pounds recorded on 01/25/2024 which was an 11.66% weight loss since admit. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed the resident scored a 1 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognitive skills for daily decision making. Further review of MDS revealed that meals are to be supervised and set up with assistance. Review of the May 2024 physician orders revealed the following diet order for resident #51: No added salt, pureed texture, nectar thick fluid consistency, house supplement three times a day, and pudding twice daily. No straws, no ice related to dysphagia, oropharyngeal phase. Observation on 05/13/2024 at 8:20 a.m. of resident #51 revealed she was on the locked unit dining room eating breakfast which consisted of thickened dairy beverage, glass of thickened orange juice, thickened water, and pureed eggs and sausage. Resident #51 was observed to eat less than 20% of this meal. Further observation revealed staff set up tray only for resident #51 and did not prompt resident to consume meal. Observation on 05/13/2024 at 12:29 p.m. resident #51 was observed eating lunch meal. The meal consisted of pureed red beans and rice, mashed potatoes and gravy, pureed green beans, pudding and a glass of thickened tea. Resident #51 was observed to eat less than 20% of this meal. Further observation revealed staff set up meal tray only for resident #51. Observation on 05/14/2024 at 8:18 a.m. revealed resident #51 in locked unit day room eating breakfast. The meal consisted of thickened dairy beverage, thickened orange juice, thickened water, pureed sausage and eggs. Further observation revealed that S8Certified Nursing Assistant (CNA) was standing over resident #51 and prompting resident #51 to eat meal. Further observation revealed S8CNA left the day room and went outside leaving 6 residents including resident #51 unattended. During this time, resident #51 spilled the glass of orange juice on self and did not eat any of the meal. Observation on 05/14/2024 at 3:30 p.m. revealed resident #51 was eating a bag of BBQ potato chips without staff monitoring. Observation on 05/15/2024 at 7:46 a.m. revealed resident #51 was observed to have emesis on clothing. S10CNA confirmed that she vomited during the breakfast meal this morning. Further interview with S10CNA revealed resident #51 did not eat any breakfast. S10CNA stated that resident #51 had a decline and that staff have to feed her all meals. Interview on 05/15/2024 at 9:45 a.m. with S7CNA Supervisor confirmed that resident #51 required total assistance with meals and set up. Further interview with S7CNA Supervisor confirmed that staff should never leave residents unattended during the meal process. Interview with S4Assistant Director of Nursing (ADON) on 05/15/2024 at 11:06 a.m. confirmed that staff are to be present to assist residents with meals and beverages at all times. S4ADON confirmed weight loss for resident #51. S4ADON stated that CNAs are to notify floor nurses of any change of status and when residents are not eating. S4ADON further stated that resident#51 should not have been given BBQ chips.

Based on record review, observations, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure that each resident received adequate supervision to prevent accidents for 1 (#51) of 3 (#51, #61 & #62) sampled residents reviewed for falls. Findings: Review of the record for resident #51 revealed diagnoses of closed head injury, dehydration, falls and urinary tract infection. Resident #51 was admitted to the local hospital on 05/09/2024 and discharged back to facility on 05/11/2024 after sustaining a fall on the secured unit. Review of the Fall Risk assessment dated [DATE] revealed resident #51 scored a 65, high risk for falling. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed the resident scored a 1 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognitive skills for daily decision making. Review of the plan of care for resident #51 revealed the resident was at risk for falls related to weakness and balance - fall with injury - hematoma to scalp/forehead. Interventions include Certified Nursing Assistant (CNA) to stand by assist when resident #51 is ambulating, nonskid socks and supervision at all times. Review of the record for resident #51 revealed the following incident (no date and time noted): while administering medication in the dementia unit, resident #51 was sitting in a chair in the day room with other residents. CNA on duty called for me stating that resident #51 had fallen face first onto the floor. Resident #51 was examined for injuries. Resident#51 had a hematoma to her forehead that had blood present. Resident #51 was sent to local emergency department for evaluation - mental status is impairment with medical diagnoses, injury type: hematoma to top of scalp. Observation on 05/13/2024 at 8:15 a.m. of the lock unit day room revealed resident #51 attempting to ambulate without assistance with an unsteady gait. Resident #51 was also observed to be barefooted. Observation on 05/14/2024 at 8:14 a.m. of the locked unit day room revealed S8CNA stepped out of the room away from 6 residents in the day room. No staff were present to assist and monitor resident #51 or the other 5 residents in the locked unit day room. Resident #51 was sedated in appearance and was again barefooted. Observation on 05/14/2024 at 3:30 p.m. revealed resident #51 was ambulating with an unsteady gait and walking behind her walker. Staff were not observed to be in close proximity of resident #51. Interview on 05/15/2024 at 9:45 a.m. with S7CNASupervisor confirmed that resident #51 required assistance with ambulation at all times and that staff must be present with resident #51 while ambulating or attempting to ambulate. Interview on 05/15/2024 at 11:06 a.m. with S4Assistant Director of Nurses (ADON) confirmed that staff are to assist resident #51 with ambulation. Further interview with S4ADON confirmed that staff are not to ever leave residents unattended. S4ADON confirmed that staff are responsible to ensure that each resident has proper foot wear in place.

Based on record reviews and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#30) of 1 sampled resident who received an anticoagulant medication. The facility failed to monitor resident #30 for bleeding when administered an anticoagulant medication. Findings: Review of the medical record for resident #30 revealed the resident was admitted on [DATE] with diagnoses of hypertensive heart disease with heart failure, edema, Alzheimer's, anxiety disorder, hyperlipidemia, and cervical disc degeneration. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately impaired cognitive skills for daily decision making skills. The resident required supervision for toileting/hygiene and partial/moderate assistance for shower/bathe self and dressing. Review of the physician orders revealed an order dated 02/27/2024 for Eliquis (anticoagulant or blood thinner) 5 milligrams (mg) give 1 tablet by mouth two times a day related to hypertensive heart disease with heart failure. Review of the record revealed the following care plan: I have been prescribed multiple medications. Further review revealed the following intervention: I need monitoring for adverse reactions. Review of the Medication Administration Record and Treatment Administration Record for May 2024 revealed there was no documentation that the staff were monitoring the resident for bleeding. An interview on 05/15/2024 at 2:50 p.m. with S2Director of Nursing (DON) confirmed there was no documented evidence that the facility was monitoring resident #30 for bleeding while she was receiving Eliquis.

Based on observation, record review, and interviews, the facility failed to protect the residents' right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#7) of 4 (#1, #4, #5, and #7) sampled residents. The actual harm resulted for resident #7, who was cognitively impaired, on 02/13/2024 at approximately 1:12 p.m. when S3Certified Nursing Assistant (CNA) was witnessed being physically and verbally abusive to resident #7. S3CNA was witnessed by two Licensed Practical Nurses (LPNs) aggressively pull resident #7 up from her geri-chair and then popped her on the behind. S3CNA also was witnessed telling resident #7 to stop f______ pulling that sh__ down, I'm tired of the f______ sh__. Because this type of inappropriate, unwanted physical and verbal abuse would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm-dehumanization, and humiliation- as a result of the physical and verbal abuse. Findings: Review of the facility's current Abuse Prevention and Prohibition Policy revealed: Purpose: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Review of the medical record for resident #7 revealed an admitted [DATE] with diagnoses including cerebral palsy, profound intellectual disabilities, depression, psychosis, and impulse disorder. Review of the care plan revealed resident #7 had cognitive loss related to mental disorder, resident was nonverbal and required assistance from staff with activities of daily living. The resident had difficulty communicating related to impaired cognition. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #7 had severe cognitive skills for daily decision making, and required extensive assistance with activities of daily living. Resident #7 had a diagnosis of cerebral palsy and had physical impairment on both sides of the upper and lower extremities. Review of the facility's investigation documentation of the 02/13/2024 incident revealed a summary of events that included: on 02/13/2024 at approximately 1:12 p.m. resident #7 was in the front lobby sitting in a geri-chair, resident was scratching herself and the LPN gave resident a dose of Hydroxyzine for itching. Resident #7's CNA was told that resident was pulling her brief down, Resident #7's CNA went over to the resident and aggressively snatched her up, popped her behind and cursed her. The CNA was witnessed telling the resident stop f_____ pulling that sh__ down, I'm tired of the f______ sh__. LPN stopped CNA and informed her she had just given her something for itching. On 02/14/2024 at 3:45 p.m. observation of resident #7 revealed she was in the lobby area sitting in a geri-chair with staff in close proximity. Resident #7 was unable to communicate with the surveyor. On 02/15/2024 at 12:45 p.m., an interview with S5Licensed Practical Nurse (LPN) revealed S3CNA was aggressive and verbally and physically abusive to resident #7. S5LPN revealed on 02/13/2024 1:12 p.m. Resident #7 was sitting in a geri-chair close to the nurses' station and was scratching her right hip area. S5LPN was at her medication cart in close proximity and witnessed S3CNA roughly handle the resident, pop her on her right hip area and tell resident #7 I am sick of this f_____ sh__. She revealed she told S3CNA to get away from resident #7 and S2Director of Nursing (DON) and S1Administrator were notified immediately. Resident #7 was assessed for injuries and none were noted. On 02/15/2024 at 1:30 p.m., an interview with S6LPN revealed she was at the nurses' station when the incident occurred. Resident #7 was sitting in a geri-chair close to the nurses' station and S6LPN revealed she witnessed S3CNA handle resident #7 very aggressively, S3CNA popped her on the right hip area and tell resident #7 I am sick of this f_____ sh___. S5LPN notified S2DON and S1Administrator and S3CNA was terminated immediately. On 02/15/2024 at 2:45 p.m., an interview with S2DON revealed on 02/13/2024, S5LPN came to her and told her that S3CNA had aggressively grabbed and cursed resident #7. S3CNA was called to S2DON's office along with S1Administrator and S4Family Nurse Practitioner (FNP). S3CNA was informed to clock out, and S3CNA was terminated immediately. S2DON revealed the resident was assessed for injuries and none noted. On 02/15/2024 at 3:10 p.m., an interview with S1Administrator confirmed the abuse to resident #7 did occur and when he was notified of the abuse incident S3CNA was immediately terminated and S1Administrator escorted S3CNA out of the building.

Based on record reviews and interviews, the facility failed to ensure that the resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #1 on 07/14/2023 when S4Certified Nursing Assistant (CNA) failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's wheelchair to bed. Resident #1 complained of pain and was sent to the local hospital. An x-ray of Resident #1's left hip showed comminuted displaced and angulated left hip and intertrochanteric fracture. Resident #1 was admitted to the hospital for management of her acute left hip fracture. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the current Hoyer Lift - Proper Use Policy and Procedure revealed, in part: Policy: 1. Residents who are unable to transfer themselves independently or with minimum assistance shall be transferred safely with the Hoyer lift. Review of the medical record revealed the resident was admitted on [DATE] and readmitted on [DATE]. Review of the resident's diagnoses revealed, in part: hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, end stage renal disease, cardiomegaly, dementia with behavioral disturbance, osteoarthritis, edema, hypertension, anemia, diabetes, and neurogenic bladder. Review of Resident #1's Quarterly Minimum Data Set, dated dated dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 13 out of 15 indicating the resident had independent cognitive skills for daily decision making. The resident required 2 person extensive assistance with bed mobility, transfers, and toilet use. The resident had range on motion impairment on one side of the upper and lower extremities. Review of the care plan revealed the following: I require staff assistance for all activities of daily living related to left sided hemiplegia, I require a mechanical lift for transfers, and I require assistance with bed mobility. An interview with S4CNA on 08/16/2023 at 9:55 a.m. revealed the following: on 07/14/2023, the CNA was attempting to transfer Resident #1 from her wheelchair to the bed. S4CNA reported she picked Resident #1 up from the wheelchair, went to turn her, and she thought she was slipping so she asked the housekeeper to lower the bed. S4CNA reported she laid her across the foot of the bed and she asked the other staff to get help. S4CNA reported that the resident complained of leg pain when she was on the bed. S4CNA reported that she didn't know if her leg twisted or what. S4CNA reported she usually used the lift with 2 people to transfer Resident #1. When asked why she didn't use the lift with Resident #1, she reported that she thought she could get her into the bed. An interview with S3Licensed Practical Nurse (LPN)/CNA supervisor 08/16/2023 at 12:55PM revealed she worked on 07/15/2023. S3LPN/CNA supervisor revealed when she assessed the resident, the resident complained of pain from the knee down. S3LPN/CNA supervisor reported the left leg didn't look right and the left hip looked rolled out. S3LPN/CNA supervisor reported the resident had limited ROM to that left leg. S3LPN/CNA supervisor notified the physician and sent the resident to the emergency room . S3LPN/CNA supervisor reported she interviewed S4CNA and the CNA reported to her that she transferred the resident from the wheelchair to the bed by herself and she might have gotten her feet tangled. S4CNA reported to S3LPN/CNA supervisor that the resident did not fall on the floor and the resident complained about her leg hurting at some point. S3LPN/CNA supervisor reported S4CNA knew Resident #1 was a 2 person transfer before the incident. S3LPN/CNA supervisor reported that the CNA did not ask for assistance and did the transfer own her own. Review of the hospital's History and Physical dated 07/16/2023 revealed the x-ray of her left hip showed comminuted displaced and angulated left hip and intertrochanteric fracture. Resident was admitted for management of her acute left hip fracture. An interview with S2Director of Nursing on 08/16/2023 at 3:00PM confirmed Resident #1 required 2 person assistance with transfers and the CNA should have asked for assistance to transfer the resident from the wheelchair to the bed and should have used the Hoyer lift. Review of the facility's Quality Assurance (QA) Plan for the improper transfer on 07/14/2023 revealed: An incident occurred when an employee attempted to transfer a resident without assistance and the use of a lift. This oversight caused the resident to fall. The resident is short in stature but large, she is incapable of assisting in transferring. It is the facility's rule to call for assistance when a resident requires total assistance or uses a mechanical lift. The policy states that if a resident is unable to transfer independently, they should be transferred with the Hoyer lift or 2-person manual transferring. The policy also states that at least two nursing staff must be needed to transfer a resident with the lift. We have a policy and procedure guideline for this activity. The policy will accompany this QA along with the Hoyer lift competency. An investigation was initiated by the DON and a Statewide Incident Management System Report was submitted to the state agency. It is the facility's finding that the incident could have been averted if 2 people had been present with the transfer. The safety of residents is our number one priority. Policy and procedures are used to comply with the standard rules and regulations for competency in the care and health of our resident. The following plan of correction was implemented. 1. Corrective action: The resident involved was sent to emergency room for medical evaluation. The CNA involved was given a disciplinary warning for not following the facility's policy regarding transfers. The CNA involved was in-serviced on the proper communication techniques in notifying the LPN and ensuring the LPN acknowledged the report. The CNA involved was in-serviced on the importance of getting assistance with transfers whether it be with the lift or a 2 person manual assist. The CNA was trained by Therapy on the proper transfer techniques and CNA demonstrated to the therapist the transfer technique. Any deviations from the training were corrected and explained to the CNA by the therapist. 2. Affecting other residents: All residents that require assistance with transfers have the potential to be affected. CNAs were in-serviced on the importance of following the facility's policy and procedures regarding transfers. CNAs also received transfer training by the Therapy Director on the proper procedures for transfers. New hire CNAs will be trained by the therapy department on how to properly transfer a resident. 3. Measures to prevent reoccurrence: Monitors were developed to monitor transfers to ensure CNAs are properly transferring residents. These monitors will be completed once a week x 4 weeks then randomly thereafter. CNA Coordinator or designee will in-service CNAs on proper transfers using gait belt, two persons assist and lifts quarterly. CNA coordinator developed a list of residents' transfer requirements and abilities posted to CNA communication board. New hire CNAs will be trained by Therapy on the proper transfer techniques. 4. Monitoring CNA Coordinator will monitor transfer techniques randomly by observing transfers and completing skills checkoffs. If CNA does not show proficiency in transfers, he/she will be retrained by therapy. Review of the facility's above actions revealed the facility had implemented the training, monitoring, and quality control aspects by 08/11/2023.

Based on observations, record review, and interviews, the facility failed to protect the resident's right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted when resident #1 had increased anxiety and nightmares, along with feeling ashamed after the 12/03/2022 sexual abuse incident. Resident #1 received a 12/08/2022 physician's order for a dosage increase to her antidepressant medication; and an order for an anti-anxiety medication was also added to her drug regime after the 12/03/2022 sexual abuse incident. The resident also had a 12/08/2022 physician's order for therapy and has been receiving individualized therapy every two weeks since the 12/03/2022 sexual abuse incident. Findings: Review of the facility Abuse Prevention and Prohibition Policy revealed in part each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy included the touching of intimate body parts or the clothing covering intimate body parts as an example of sexual abuse. Review of the medical record for resident #1 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, diabetes mellitus, hypertensive heart disease, chronic kidney disease, cervical disc degeneration, major depressive disorder, polyosteoarthritis, and anxiety disorder. Review of resident #1's 12/27/2022 Quarterly Minimum Data Set revealed her Brief Interview for Mental Status (BIMS) score was assessed to be 15, which indicated she was cognitively intact. Further review revealed she was independent or required supervision with setup help only for most activities of daily living (ADLs). Review of the medical record for resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to multiple myeloma, chronic kidney Disease (stage 3), type 2 diabetes mellitus, congestive heart disease, hemiplegia and hemiparesis following cerebral infarction, generalized anxiety disorder, other specified depressive episodes and mild cognitive impairment. Further review revealed on 12/16/2022, he was discharged from the facility and transferred to another facility. Review of resident #2's 11/02/2022 Quarterly MDS revealed his BIMS score was assessed to be 14, which indicated he was cognitively intact. Review of resident #1's 12/03/2022 at 12:31 a.m. Nurses' Note, revealed summoned to room per resident #1. She said that a male resident came to her room and put his hand under her blanket and touched her vagina. Resident #1 told him she was married and did not do stuff like that and for him to leave the room. S5LPN (licensed practical nurse) spoke with resident #2's nurse (S6LPN), then she went to speak with resident #2. Resident #2 said that he did not go to her room at first, then he changed his story and said that he was just visiting her. On 01/10/2023 at 11:02 a.m. during a phone interview with S5LPN, she confirmed the 12/03/2022 at 12:31 a.m. Nurses' Note documentation of the incident with resident #1 and resident #2 was accurate. S5LPN reported that resident #1 informed her she was not hurt in the incident so she did not feel she needed to assess her after the incident. Review of the medical record revealed after the 12/03/2022 incident involving resident #1 and resident #2, there was no documentation that a physical exam for resident #1 was offered or completed after she reported the sexual abuse allegation on 12/03/2022 at 12:31 a.m. On 01/09/2023 at 4:10 p.m., an interview with resident #1 revealed resident #2 came in her room on 2 different occasions (she was unsure of exact dates). The first time, he told her that he really wanted her. Resident #1 told him that she was married and did not do that. Resident #1 reported that resident #2 touched her breast. She told him to stop and she asked him to leave, which he did. Resident #1 revealed she did not report this to anyone, she only told her nurse that she did not want him in her room. Resident #1 also revealed that resident #2 came back in her room at night time a couple of days after the first above incident (unsure of date). Resident #1 realized it was resident #2 and she pulled the covers up so he would not touch her. She reported that resident #2 told her again that he really wanted her, she told him she was married and did not do that kind of stuff. Resident #2 pulled covers up, and reached his hand inside her pull up and touched the outside of her vagina. Resident #1 confirmed he did not touch the inside of her vagina. Resident #1 pushed his arm away and asked him to leave, which he did. She stated the incident scared her to death. She confirmed she immediately reported it to her nurse. Resident #1 revealed she was not hurt in the above incident but it bothered her. She also stated she had some nightmares after it occurred. Resident #1 also reported she felt ashamed that it happened. Resident #1 also confirmed she has received additional medications to help after the 12/03/2022 incident and has been receiving individual therapy every 2 weeks. On 01/10/2023 at 5:44 p.m., a phone interview was conducted with S7CNA (certified nursing assistant), she revealed that resident #1 used her call light late on the night of 12/02/2022 (unsure of time). S7CNA reported she saw resident #2 going to the vending machine near the hall that resident #1 resided on around the same time resident #1 used her call light. When S7CNA went in to check on her, resident #1 seemed upset, but did not want to tell her what happened. Resident #1 told her she wanted to see her nurse and she would not tell her what was wrong. When S5LPN came out of resident #1's room she did not tell S7CNA what was reported to her by resident #1. However, she informed S7CNA to monitor resident #1 more closely the rest of her shift. Review of the Offense Report (completed by local police department) dated 12/03/2022 at 2:30 p.m., revealed the complaint was filed by S3LPN/ADON (Assistant Director of Nursing). S3LPN/ADON reported that at approximately 12:31 a.m. on 12/03/2022, resident #2 was in resident #1's room and he put his hand under her sheet and touched her vagina. Further review revealed there was no documentation of the police's response to the above filed complaint. The surveyor phoned the local police department to see if there was any further documentation available regarding the 12/03/2022 incident, but was informed the only information available was the above Offense Report. On 01/11/2023 at 11:00 a.m., an interview with S3LPN/ADON revealed the above incident did occur on 12/03/2022 with resident #1 and resident #2. S3LPN/ADON confirmed she went to the local police station on 12/03/2022 and filed a complaint with the local police department regarding resident #1's allegation of sexual abuse against resident #2. She revealed the police follow up has been limited and the results of the case are still pending. Review of resident #1's current care plan revealed on 12/03/2022, the facility had identified she was at risk for sad mood, scared, traumatized related to a personal incident involving a male resident. Further review revealed resident #1 did not want family notified, however, the police were notified of the incident. Review of 12/08/2022 Physician Orders for resident #1 revealed orders for Ativan 0.5mg (milligrams) by mouth twice daily (bid) as needed (prn), increase Paxil to 30mg by mouth daily, and schedule therapy appointment. Review of resident #1's December 2022 and January 2023 Medication Administration Records (MARs) revealed documentation she received Ativan 0.5mg by bid daily prn, and Paxil 30mg by mouth daily as ordered. On 01/11/2023 at 1:50 p.m., an interview with S4 Social Services revealed resident #1 talked to her about the 12/03/2022 incident involving resident #2. Resident #1 reported to her that she was embarrassed and blamed herself for what had happened. On 01/11/2023 at 2:30 p.m., an interview with S2DON revealed resident #1 was upset and initially had increased anxiety after the above incident occurred on 12/03/2022. S2DON confirmed that Ativan prn and the resident's Paxil dose was increased after the above incident. On 01/11/2023 at 1:10 p.m., an interview with S1Administrator revealed on 12/03/2022 resident #1 reported an allegation of sexual abuse against resident #2. S1Administrator confirmed the facility investigated the incident and substantiated the sexual abuse allegation reported by resident #1. On 01/11/2023 at 2:30 p.m., an interview with S2DON revealed on 12/03/2022 resident #1 reported an allegation of sexual abuse against resident #2. S2DON reported she completed a SIMS (Statewide Incident Management System) Report regarding the incident. S2DON reported she viewed video footage that showed resident #2 entering resident #1's room on 11/30/2022 (date of incident that resident #1 failed to report to staff) and resident #2 entering her room again on 12/03/2022. S2DON confirmed the facility investigated the incident and substantiated the sexual abuse allegation reported by resident #1.

Based on observation, interview, and record review, the facility failed to ensure that certified nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through resident assessments as described in the plan of care. The facilty further failed to have an orientation program in place that ensured certified nurse aides had the skill sets required to safely provide services to residents for 2 (#1, #2) of 10 (#1-#10) residents reviewed. This deficient practice resulted in an Immediate Jeopardy to Resident #1 on 01/28/19 at 3:45PM when Resident #1 was being transferred by two CNAs (certified nursing assistant) with a lift where the straps were not securely in place on the bar. This resulted in Resident #1 falling to the floor. The resident was transferred to a local hospital and found to have a cervical fracture at the C2 level and a lumbar fracture at the L2 level. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on 12/14/18 at 8:05PM when Resident #2 was transferred from the wheelchair to the bed by S1CNA. At that time, Resident #2 began complaining of left arm and shoulder pain. The resident was sent to a local hospital where she was admitted and diagnosed with [REDACTED]. S11Administrator and S3DON (Director of Nurses) were notified of the Immediate Jeopardy on 02/21/19 at 4:00PM. The Immediate Jeopardy was removed on 02/22/19 at 12:55PM when the facility submitted the following Plan of Removal which included: 1. New CNAs will be required to view the following videos prior to working the floor: a. Preventing Blood Borne Infections b. Infection Control c. Bathing with a Battle d. Infection Control e. DVD on the Lumex sling lift and Lumex sit to stand lift f. Website training on Hoyer Lift 2. New CNA will be required to read and sign the facility's Transfer and/or Use of Lift Policy which states A CNA is never to transfer a resident without assistance from another CNA when that resident is a two person assist or a lift transfer. It further states if I transfer a resident without assistance from another CNA, I will be dismissed from employment. 3. Competency skill check off on all lifts before orientation on floor. 4. Competency skill check off on transfer/gait belt use. 5. Orientation of New CNA: a. New CNA will begin orientation on the floor with CNA Floor Supervisor or an experienced CNA after performing successful skills check off on all lifts and transfer/gait belt use. b. New CNA will perform return demonstration with CNA Floor Supervisor observing. c. CNA Floor Supervisor will document new CNA's performance using skill check off list for lifts and transfer/gait belt use. d. At the end of orientation the CNA Floor Supervisor will determine (with the assistance of the DON/ADON) if the new CNA is competent to work alone. e. New CNA will work a minimum of one day on each hall with the supervision of the ADON, (CNA Floor Supervisor), or experienced CNA. f. New CNA will have a minimum of 5 days of orientation before being assigned residents. 6. During the first 30 days new CNA will be required to perform CNA skills check off for competency. a. If CNA is not able to show competency with a skill the CNA Floor Supervisor along with ADON (CNA Supervisor) will conduct additional training until aide is competent with skill. Monitoring of CNA: 1. CNA will be monitored on their skills to ensure staff is competent to care for residents once a week x 4 weeks, then monthly thereafter. 2. Monitoring will occur randomly during the week on random shifts by CNA Floor Supervisor or DON/ADON (CNA Supervisor). 3. DON/ADON/CNA Floor Supervisor will monitor CNA monthly indefinitely to ensure CNA is competent with skills. a. 5% of population will be monitored monthly. 4. DON/ADON/CNA Floor Supervisor will focus on skills randomly during each monitoring period. 5. DON/ADON/CNA Floor Supervisor will watch CNA perform chosen skill during the CNA AM/PM care of resident. a. A monitoring tool will be used to check off skills to ensure CNA is performing skill correctly. b. If the CNA is found to perform skill incorrectly, it will be noted on monitoring form. i. If problems with skill performance noted, CNA will be re-educated on the skill and monitored again. 6. If CNA continues to have problems understanding how to perform required skills, DON/ADON/CNA Floor Supervisor will determine if CNA needs to be re-oriented or terminated. Educating CNAs on Staff Assisted ADLs: CNA will be educated on reviewing the care plan on the Kiosk regarding resident's ADLs. a. New CNA will be in-serviced on where to locate resident's ADLs/mode of transfer and assistance level with transfers on the kiosk. b. Current CNAs will be re-in serviced quarterly on where to locate resident's adls/mode of transfer on the Kiosk. Orientation/Monitoring of CNA Floor Supervisor: 1. DON/ADON will orientate new CNA Floor Supervisor. 2. CNA Floor Supervisor will be required to show competency in all skills to ensure proper training of other CNAs. 3. CNA Floor Supervisor will be monitored monthly by DON/ADON to ensure job requirements are being met. This deficient practice continued at a potential for harm for the 72 residents in the facility who required assistance with care and services. Findings: Resident #1: Review of the record for Resident #1 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's MDS (Minimum Data Set) dated 11/05/18 revealed a BIMS (Brief Interview for Mental Status) score of 12, which indicates moderately impaired cognition. A further review revealed Resident #1 was coded as total dependence with two person assist for bed mobility, transferring, and toileting. On 02/11/2019 at 10:15AM, Resident #1 was interviewed. She was sitting up in a geri chair at the bedside. She was wearing a hospital gown and a large neck brace. She appeared neat and clean with a lift pad beneath her. She stated she was dropped while being transferred with the lift. She stated two CNAs were lifting her and let go of her and she fell . She said she broke her head, neck, and back and her right shoulder is messed up. She stated they took her to the emergency room but she came back the same day without spending the night in the hospital. She said they haven't dropped her since that incident. An interview was conducted on 02/12/19 at 3:10PM with S2CNA who stated she was assisting S1CNA when Resident #1 fell out of the lift. She said when Resident #1 was in the air, the sling made a pop sound and the resident fell to the ground before they could catch her. She stated the sling came out of the lift's arm hook on S1CNA's side. She further stated S1CNA was a newer CNA and needed more experience. A review of the facility's investigative report dated 01/28/19 revealed at 3:45PM, Resident #1 was heard calling out. When entering resident's room, Resident #1 was found on the floor under the lift with S1CNA and S2CNA beside resident with the call light pressed. The report further stated Resident #1 was sent to the hospital. The 24 hour follow up stated Resident #1 was sent to the emergency room and returned with a neck collar brace and [DIAGNOSES REDACTED]. A review of Resident #1's record revealed a CT (computerized tomography) of the cervical spine dated 01/28/19 at 4:22PM with an impression of Nondisplaced longitudinal fracture through the posterior aspect of the C2 vertebral body. A further review of Resident #1's record revealed a CT of the lumbar spine dated 01/28/19 at 4:23PM with an impression of Nondisplaced corner [MEDICAL CONDITION] anterior superior L2 vertebral body. Resident #2: A review of Resident #2's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 5, which indicates severely impaired cognition. A further review revealed Resident #2 requires limited assistance with transferring by one person assist. A review of Resident #2's nurse's notes revealed an entry dated 12/14/18 that stated nurse was called to room at 8:05PM. Upon entry, S1CNA stated she had transferred resident to the bed unassisted and resident is complaining of left arm and shoulder pain. Resident was sent to the emergency room . She was admitted to the hospital for a dislocated shoulder. A nurse's note dated 12/15/18 revealed Resident #2 was readmitted to the nursing facility with a [DIAGNOSES REDACTED]. In an interview on 02/13/19 at approximately 10:30AM, S3DON stated when a CNA is hired, they are oriented by working the floor with other CNAs, on different halls and on different shifts. At the end of the orientation, S4CNA Floor Supervisor goes around and asks the CNAs how the new CNA is doing. Also, S4CNA Floor Supervisor makes observations and monitors them, too. However, there is no orientation packet, etc. There is nothing he signs off when they are done. There is no skills check off system in place at this time. In an interview with S4CNA Floor Supervisor at 10:55AM on 02/13/19, he confirmed when someone is hired as a CNA they orient on the floor by working four days with another CNA. Then, after four days, he decides if they are done with orientation, need more orientation, or are not going to work out. He verified he does not sign off on anything at the end of orientation. He confirmed he does not have any documentation of S1CNA's orientation. In an interview on 02/13/19 at 1:55PM, S3DON confirmed there is no orientation system in place to check off new CNAs on their skills/competencies before completing orientation. She stated newly hired CNAs orient by working the floors with other CNAs and S4CNA Floor Supervisor walks the floors and monitors them, too. She further stated after four days of working with other CNAs, S4CNA Floor Supervisor asks the other CNAs how the newly hired CNA is doing before signing off on their orientation. Again, S3DON confirmed there is no paperwork completed during orientation or when a CNA finishes orientation to validate skills were checked off. A review of the personnel charts for S1CNA and S2CNA revealed no documented evidence of orientation or skills check offs at the time of hire. A review of a 01/29/2019 Nursing Counseling Form revealed S3DON counseled S1CNA regarding putting residents in danger due to unsafe work practices. It stated this was S1CNA's third counseling. She had been involved in 1. Transferring a resident with no assistance and resident slid to the floor, 2. CNA was involved in transferring a resident with no assistance and resident had a shoulder dislocation, and 3. CNA was involved with lifting a resident up in lift and sling was not attached properly and resident fell to the floor with a C2 and L2 fracture.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 2 (#1, #2) of 10 (#1-#10) residents reviewed for accidents by failing to supervise and monitor staff when transferring residents. This deficient practice resulted in an Immediate Jeopardy to Resident #1 on 01/28/19 at 3:45PM when Resident #1 was being transferred by two CNAs with a lift where the straps were not securely in place on the bar. This resulted in Resident #1 falling to the floor. The resident was transferred to a local hospital and found to have a cervical fracture at the C2 level and a lumbar fracture at the L2 level. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on 12/14/18 at 8:05PM when Resident #2 was transferred from the wheelchair to the bed by S1CNA. At that time, Resident #2 began complaining of left arm and shoulder pain. The resident was sent to a local hospital where she was admitted and diagnosed with [REDACTED]. S11Administrator and S3DON (Director of Nurses) were notified of the Immediate Jeopardy on 02/21/19 at 4:00PM. The Immediate Jeopardy was removed on 02/22/19 at 12:55PM when the facility submitted the following Plan of Removal which included: 1. New CNAs will be required to view the following videos prior to working the floor: a. Preventing Blood Borne Infections b. Infection Control c. Bathing with a Battle d. Infection Control e. DVD on the Lumex sling lift and Lumex sit to stand lift f. Website training on Hoyer Lift 2. New CNA will be required to read and sign the facility's Transfer and/or Use of Lift Policy which states A CNA is never to transfer a resident without assistance from another CNA when that resident is a two person assist or a lift transfer. It further states if I transfer a resident without assistance from another CNA, I will be dismissed from employment. 3. Competency skill check off on all lifts before orientation on floor. 4. Competency skill check off on transfer/gait belt use. 5. Orientation of New CNA: a. New CNA will begin orientation on the floor with CNA Floor Supervisor or an experienced CNA after performing successful skills check off on all lifts and transfer/gait belt use. b. New CNA will perform return demonstration with CNA Floor Supervisor observing. c. CNA Floor Supervisor will document new CNA's performance using skill check off list for lifts and transfer/gait belt use. d. At the end of orientation the CNA Floor Supervisor will determine (with the assistance of the DON/ADON) if the new CNA is competent to work alone. e. New CNA will work a minimum of one day on each hall with the supervision of the ADON, (CNA Floor Supervisor), or experienced CNA. f. New CNA will have a minimum of 5 days of orientation before being assigned residents. 6. During the first 30 days new CNA will be required to perform CNA skills check off for competency. a. If CNA is not able to show competency with a skill the CNA Floor Supervisor along with ADON (CNA Supervisor) will conduct additional training until aide is competent with skill. Monitoring of CNA: 1. CNA will be monitored on their skills to ensure staff is competent to care for residents once a week x 4 weeks, then monthly thereafter. 2. Monitoring will occur randomly during the week on random shifts by CNA Floor Supervisor or DON/ADON (CNA Supervisor). 3. DON/ADON/CNA Floor Supervisor will monitor CNA monthly indefinitely to ensure CNA is competent with skills. a. 5% of population will be monitored monthly. 4. DON/ADON/CNA Floor Supervisor will focus on skills randomly during each monitoring period. 5. DON/ADON/CNA Floor Supervisor will watch CNA perform chosen skill during the CNA AM/PM care of resident. a. A monitoring tool will be used to check off skills to ensure CNA is performing skill correctly. b. If the CNA is found to perform skill incorrectly, it will be noted on monitoring form. i. If problems with skill performance noted, CNA will be re-educated on the skill and monitored again. 6. If CNA continues to have problems understanding how to perform required skills, DON/ADON/CNA Floor Supervisor will determine if CNA needs to be re-oriented or terminated. Educating CNAs on Staff Assisted ADLs: CNA will be educated on reviewing the care plan on the Kiosk regarding resident's ADLs. a. New CNA will be in-serviced on where to locate resident's ADLs/mode of transfer and assistance level with transfers on the kiosk. b. Current CNAs will be re-in serviced quarterly on where to locate resident's adls/mode of transfer on the Kiosk. Orientation/Monitoring of CNA Floor Supervisor: 1. DON/ADON will orientate new CNA Floor Supervisor. 2. CNA Floor Supervisor will be required to show competency in all skills to ensure proper training of other CNAs. 3. CNA Floor Supervisor will be monitored monthly by DON/ADON to ensure job requirements are being met. This deficient practice continued at a potential for harm for the 43 residents that required assistance with transfers. Findings: Resident #1 Review of the record for Resident #1 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's MDS (Minimum Data Set) dated 11/05/18 revealed a BIMS (Brief Interview for Mental Status) score of 12, which indicates moderately impaired cognition. A further review revealed resident #1 was coded as total dependence with 2 person assist for bed mobility, transferring, and toileting. On 02/11/2019 at 10:15AM, Resident #1 was interviewed. She was sitting up in a geri chair at the bedside. She was wearing a hospital gown and a large neck brace. She appeared neat and clean with a lift pad beneath her. She stated she was dropped while being transferred with the lift. She stated two CNAs were lifting her and let go of her and she fell . She said she broke her head, neck, and back and her right shoulder is messed up. She stated they took her to the emergency room but she came back the same day without spending the night in the hospital. She said they haven't dropped her since that incident. She denied any pain at present. A review of the facility's investigative report dated 01/28/19 revealed at 3:45PM, Resident #1 was heard calling out. When entering resident's room, Resident #1 was found on the floor under the lift with S1CNA and S2CNA beside resident with the call light pressed. The report further stated Resident #1 was sent to the hospital. The 24 hour follow up stated Resident #1 was sent to the emergency room and returned with a neck collar brace and [DIAGNOSES REDACTED]. A review of Resident #1's record revealed a CT (computerized tomography) of the cervical spine dated 01/28/19 at 4:22PM with an impression of Nondisplaced longitudinal fracture through the posterior aspect of the C2 vertebral body. A further review of Resident #1's record revealed a CT of the lumbar spine dated 01/28/19 at 4:23PM with an impression of Nondisplaced corner [MEDICAL CONDITION] anterior superior L2 vertebral body. In an interview on 02/12/19 at 1:30PM, S3DON stated she went in Resident #1's room as soon as the 01/28/19 incident happened and stated the sling was not hooked on one corner of the lift. She said she inspected the sling to see if it was torn or ripped and it was not. She stated after investigating the incident, it is believed the sling strap must not have been placed completely on the lift arm hook and it slipped off. She confirmed it was one of the hooks attached by S1CNA. She stated S1CNA was discharged from employment the following day because they felt she was unsafe. S3DON stated when CNAs are hired at the facility, they are oriented on the floor but there is no skills check off or paperwork proving competency for each skill, such as using the lift or transferring residents. An interview was conducted at 1:43PM on 02/12/19 with S4CNA Floor Supervisor. He stated he trained S1CNA when she was hired. There was no additional training provided to S1CNA or other CNAs. An interview was conducted on 02/12/19 at 3:10PM with S2CNA who stated she was assisting S1CNA when Resident #1 fell out of the lift. She said when Resident #1 was in the air, the sling made a pop sound and the resident fell to the ground before they could catch her. She stated the sling came out of the lift's arm hook on S1CNA's side. She further stated S1CNA was a newer CNA and needed more experience. A review of an alleged incident/accident report revealed that on 09/24/18, S1CNA had been involved in an incident in which the CNA attempted to transfer Resident #1 without any other assistance. In this incident, S1CNA assisted the resident to the floor and the resident did not receive any apparent injuries. At that time, S1CNA received verbal counseling, but there was no evidence of increased monitoring/supervision of S1CNA assisting residents with transfers after this incident. Resident #2: A review of Resident #2's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 5, which indicates severely impaired cognition. It further revealed Resident #2 requires limited assistance with transferring by one person assist. At 12:50PM on 02/11/19, Resident #2 was observed sitting near the lobby and nurse's station area. She was sitting in her wheelchair and was softly saying help me but was in no distress. A CNA pushed her to the dining room where other residents were sitting. Resident #2 was obviously confused. She was very alert and sitting upright in her wheelchair. A review of Resident #2's nurse's notes revealed an entry dated 12/14/18 that stated nurse was called to room at 8:05PM. Upon entry, S1CNA stated she had transferred resident to the bed unassisted and resident is complaining of left arm and shoulder pain. Resident was sent to the emergency room . She was admitted to the hospital for a dislocated shoulder. A nurse's note dated 12/15/18 revealed Resident #2 was readmitted with a [DIAGNOSES REDACTED]. Review of the facility's investigative report dated 12/14/18 revealed S1CNA told the nurse she transferred Resident #2 to the bed unassisted. Resident #2 was complaining of pain in left arm and shoulder and was sent to the emergency room . The 24 hour follow up report revealed Resident was admitted to the hospital for anterior dislocation of left shoulder, was put under conscious sedation to have put back in place the following morning then returned to the nursing facility with her arm in a sling. A review of a written note by S3DON dated 12/15/18 at 11:00AM stated: Spoke with S2CNA regarding the incident with Resident #2. S2CNA asked S1CNA what happened and S1CNA stated I picked her up under her arms and put her on the bed. They then reported it to the LPN (licensed practical nurse). A review of Resident #2's record revealed a progress note dated 12/17/18 that stated resident developed acute left shoulder and arm pain after being positioned in bed by nursing home staff. She was sent to the ER and found to have a closed inferior dislocation of the left shoulder. She was admitted to the hospital for a planned closed reduction under conscious sedation in the operating room. She did have a reduction and is wearing a splint at this time on left shoulder/left arm. In an interview on 02/13/19 at approximately 10:30AM, S3DON stated when a CNA is hired, they are oriented by working the floor with other CNAs, on different halls and on different shifts. At the end of the orientation, S4CNA Floor Supervisor goes around and asks the CNAs how the new CNA is doing. Also, S4CNA Floor Supervisor makes observations and monitors them, too. However, there is no orientation packet, etc. There is nothing he signs off when they are done. There is no skills check off system in place at this time. In an interview with S4CNA Floor Supervisor at 10:55AM on 02/13/19, he confirmed when someone is hired as a CNA they orient on the floor by working four days with another CNA. Then, after four days, he decides if they are done with orientation, need more orientation, or are not going to work out. He verified he does not sign off on anything at the end of orientation. He confirmed he does not have any documentation of S1CNA's orientation. In an interview on 02/21/19 at approximately 10AM, S3DON confirmed there was no documentation on monitoring staff after an incident along with no skills check offs for newly hired nurse aides, nor for more seasoned aides.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (#1, #2) of 10 (#1-#10) residents reviewed. The facility failed to have an effective system in place to ensure: 1. the monitoring and supervision of services being provided by the CNAs when they are delivering care to residents, and 2. Competency is measurable to assure that CNAs have the knowledge, skills and abilities to perform their duties in meeting residents' needs including the proper transferring of residents who required assistance with transfers. This deficient practice resulted in an Immediate Jeopardy to Resident #1 on 01/28/19 at 3:45PM, when Resident #1 was being transferred by two CNAs with a lift where the straps were not securely in place on the bar. This resulted in Resident #1 falling to the floor. The resident was transferred to the hospital and found to have a cervical fracture at the C2 level and a lumbar fracture at the L2 level. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on 12/14/18 at 8:05PM when Resident #2 was transferred from the wheelchair to the bed by S1CNA. At that time, Resident #2 began complaining of left arm and shoulder pain. She was sent to the hospital where she was admitted and diagnosed with [REDACTED]. S11Administrator and S3DON (Director of Nurses) were notified of the Immediate Jeopardy on 02/21/19 at 4:00PM. The Immediate Jeopardy was removed on 02/22/19 at 12:55PM when the facility submitted the following Plan of Removal which included: 1. New CNAs will be required to view the following videos prior to working the floor: a. Preventing Blood Borne Infections b. Infection Control c. Bathing with a Battle d. Infection Control e. DVD on the Lumex sling lift and Lumex sit to stand lift f. Website training on Hoyer Lift 2. New CNA will be required to read and sign the facility's Transfer and/or Use of Lift Policy which states A CNA is never to transfer a resident without assistance from another CNA when that resident is a two person assist or a lift transfer. It further states if I transfer a resident without assistance from another CNA, I will be dismissed from employment. 3. Competency skill check off on all lifts before orientation on floor. 4. Competency skill check off on transfer/gait belt use. 5. Orientation of New CNA: a. New CNA will begin orientation on the floor with CNA Floor Supervisor or an experienced CNA after performing successful skills check off on all lifts and transfer/gait belt use. b. New CNA will perform return demonstration with CNA Floor Supervisor observing. c. CNA Floor Supervisor will document new CNA's performance using skill check off list for lifts and transfer/gait belt use. d. At the end of orientation the CNA Floor Supervisor will determine (with the assistance of the DON/ADON) if the new CNA is competent to work alone. e. New CNA will work a minimum of one day on each hall with the supervision of the ADON, (CNA Floor Supervisor), or experienced CNA. f. New CNA will have a minimum of 5 days of orientation before being assigned residents. 6. During the first 30 days new CNA will be required to perform CNA skills check off for competency. a. If CNA is not able to show competency with a skill the CNA Floor Supervisor along with ADON (CNA Supervisor) will conduct additional training until aide is competent with skill. Monitoring of CNA: 1. CNA will be monitored on their skills to ensure staff is competent to care for residents once a week x 4 weeks, then monthly thereafter. 2. Monitoring will occur randomly during the week on random shifts by CNA Floor Supervisor or DON/ADON (CNA Supervisor). 3. DON/ADON/CNA Floor Supervisor will monitor CNA monthly indefinitely to ensure CNA is competent with skills. a. 5% of population will be monitored monthly. 4. DON/ADON/CNA Floor Supervisor will focus on skills randomly during each monitoring period. 5. DON/ADON/CNA Floor Supervisor will watch CNA perform chosen skill during the CNA AM/PM care of resident. a. A monitoring tool will be used to check off skills to ensure CNA is performing skill correctly. b. If the CNA is found to perform skill incorrectly, it will be noted on monitoring form. i. If problems with skill performance noted, CNA will be re-educated on the skill and monitored again. 6. If CNA continues to have problems understanding how to perform required skills, DON/ADON/CNA Floor Supervisor will determine if CNA needs to be re-oriented or terminated. Educating CNAs on Staff Assisted ADLs: CNA will be educated on reviewing the care plan on the Kiosk regarding resident's ADLs. a. New CNA will be in-serviced on where to locate resident's ADLs/mode of transfer and assistance level with transfers on the kiosk. b. Current CNAs will be re-in serviced quarterly on where to locate resident's adls/mode of transfer on the Kiosk. Orientation/Monitoring of CNA Floor Supervisor: 1. DON/ADON will orientate new CNA Floor Supervisor. 2. CNA Floor Supervisor will be required to show competency in all skills to ensure proper training of other CNAs. 3. CNA Floor Supervisor will be monitored monthly by DON/ADON to ensure job requirements are being met. This deficient practice continued at a potential harm for the 43 residents in the facility who required assistance with transfers. Findings: 1. Cross refer to findings at F689. 2. Cross refer to findings at F726. The Orientation for Nurse Aides policy was provided by S3DON. It included the following: 1. All newly hired nurse aides must attend an orientation program within their first 5 days of employment. 2. The orientation program includes, but is not limited to: a. A tour of the facility, which includes; (1) A description of the resident population; (2) An overview of the resident's daily routine; and (3) A demonstration of the use of the resident's call light, intercom system, and the use of the facility's telephone system. b. Instructions in procedures to be followed in an emergency situation, which include: (1) Unusual occurrences with residents (i.e. choking, wandering, missing, etc.); (2) Fire safety; (3) Disaster preparedness; and (4) Accident prevention. c. An introduction to resident care procedures, which includes; (1) A review of the facility's policies and procedures; (2) A review of the facility's in-service training program; (3) A review of the facility's infection control practices; (4) A review of the facility's philosophy of care; and (5) A discussion of the legal and ethical considerations in the care of the residents. d. An introduction to the administrative structure, which includes: (1) A review of the facility's quality assurance and performance improvement program; (2) A review of the organized staff including an introduction to each department supervisor; (3) An overview of each department's services; (4) A review of the employee's job description; (5) A review of the residents' rights and responsibilities; and (6) A review of the personnel policies. 3. The orientation program is not part of the 75 hour training program and must be completed before the nurse aide begins the training course. A review of the above Orientation for Nurse Aides policy revealed the policy did not address orientation, training, or monitoring of certified nurse aides upon hire and on an on-going basis. In an interview on 02/13/19 at approximately 10:30AM, S3DON stated when a CNA is hired, they are oriented by working the floor with other CNAs, on different halls and on different shifts. At the end of orientation, S4CNA Floor Supervisor goes around and asks the CNAs how the new CNA is doing. Also, S4CNA Floor Supervisor makes observations and monitors them, too. However, there is no orientation packet, etc. There is nothing he signs off when they are done. There is no skills check off system in place at this time. In an interview with S4CNA Floor Supervisor at 10:55AM on 02/13/19, he confirmed when someone is hired as a CNA they orient on the floor by working four days with another CNA. Then, after four days, he decides if they are done with orientation, need more orientation, or are not going to work out. He verified he does not sign off on anything at the end of orientation. He confirmed he does not have any documentation of S1CNA's orientation. In an interview on 02/21/19 at approximately 10AM, S3DON (Director of Nurses) confirmed there is no documentation on monitoring staff after an incident along with no skills check offs for newly hired nurse aides, nor for more seasoned nurse aides. A review of the personnel charts for S1CNA and S2CNA revealed no documented evidence of orientation or skills check offs at the time of hire. In an interview on 02/21/19 at 1:15PM, S3DON confirmed the facility did not have a policy for transferring residents per different methods or devices. S3DON verified the above policy is the only policy regarding orientation of CNAs and there is currently no orientation system in place requiring the CNAs to be checked off on their skills during orientation or prior to being assigned residents. She confirmed the orientation at present consists of newly hired CNAs working the floors with other CNAs. S3DON stated S4CNA Floor Supervisor walks the floors and monitors them, too, but has no documentation of the monitoring. She further stated after four days of working with other CNAs, S4CNA Floor Supervisor asks the other CNAs how the newly hired CNA is doing before signing off on their orientation. Again, S3DON confirmed there is no paperwork completed during orientation or when a CNA finishes orientation to validate skills were checked off. S3DON confirmed there is currently no documentation of ongoing monitoring or supervision of CNAs.

I. Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained free of accident hazards by failing to ensure that resident #47 was compliant with the facility's smoking policy. The facility failed to: 1.) Reassess resident #47's ability to understand the risk of smoking in the facility with Oxygen in progress as well as the danger of starting a fire from sparks from the cigarette or cigarette butt, 2.) Add new interventions when current interventions did not work, 3.) Have a care plan meeting that involved the IDT and family in order to identify possible barriers for the resident's noncompliance in following the facility's smoking policy, and 4.) Increase supervision and monitoring of the resident after failed attempts at getting the resident to comply with the facility's policy on smoking. The facility identified 8 residents (#7, #12, #40, #47, #51, #63, #65, #80) as being smokers. Resident #47 was the only resident with continuous oxygen. Two residents (#63, #7) had Oxygen in the room for use as needed. This failed practice had the potential to affect 68 residents in the facility. An Immediate Jeopardy situation began on 10/28/14 when resident #47 had a "smoke-like smell coming from room and ashes on the floor ". Documentation revealed that resident #47 had Oxygen per nasal cannula at 2 Liters in progress at the time. The resident in an interview said, she does not think that it is that dangerous to smoke in her room with her Oxygen. S1Administrator was notified of the Immediate Jeopardy situation on 12/10/14 at 3:22PM. The Immediate Jeopardy ended on 12/11/14 at 9:00AM when the facility's Administrator provided an acceptable plan of removal labeled "Charlyn Rehabilitation & Nursing Center Plan of action for Correcting the Smoking Deficiency" which included the following: 1. We assigned an employee one on one until the conference with the family, staff, and Ombudsman was held. 2. A conference has been held with the responsible party and the Ombudsman for this area concerning the resident with unsafe smoking issues. The conference stated the deficient practice and out plan with the family. All parties present signed the documentation including the resident. 3. We are now conducting hourly searches of the resident's room for smoking materials. 4. We are reviewing and revising the smoking assessment sheet. All smokers will be reviewed by the new sheet. The Physician will be involved as indicated by the review. 5. A care plan will be developed for the issues identified. The staff will be in-serviced on the issues and their responsibilities. 6. We are revising our smoking policy and procedures. All smokers will be given a copy along with an explanation/reason for the policy. 7. All new admits along with the responsible party will be required to sign agreeing to the policy and consequences of not following it. 8. An in-service will be held with the staff on the new policy and their responsibilities. 9. A QA procedure will be developed for monitoring smokers along with documentation for same. 10. All smoking issues will be reviewed/discussed in our Quarterly QA meeting. The deficient practice remains at a level 2. Findings: A review of the chart revealed that resident #47 was admitted [DATE]. Her [DIAGNOSES REDACTED]. A review of the safe smoking assessment dated [DATE] and 10/13/14 revealed that the resident was assessed to be a safe smoker. This smoking assessment tool assesses the residents mental clarity to smoke by themselves, whether their hands have the physical ability to hold smoking material, if they can light their own cigarette safely, if they burn their fingers/clothing, if they are likely to drop smoking materials, and whether or not they dispose of cigarettes in the ashtray. This assessment tool does not address if the resident is compliant with the smoking policy. A review of the Annual Minimum Data Set (MDS) with an assessment date of 10/13/14 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). A review of the re-entry MDS dated [DATE] the resident scored 12 (moderately impaired). A review of the December 2014 physician orders [REDACTED]. The resident had oxygen orders dating back to admit on 10/22/13. A review of the Nurse notes revealed the following documentation: 07/04/14 - CNA entered room, resident smoking, did not have on Oxygen at this time, counseled resident, removed cigarettes and lighter, instructed to call for assistance if wanted to smoke. 07/07/14 - Upon entering the room to give the resident medications, the resident was lying in bed on left side smoking in the room. Oxygen per nasal canal in place. Explained that resident could not smoke while wearing oxygen and in the room. The resident attempted to put out the cigarette on a lid that covered a coffee cup, the cigarette burned through the plastic lid and fell on to the blanket that she was covered with causing a hole in the blanket. 07/12/14 - Upon entering the room the resident was sitting on side of bed with oxygen in place. Resident had labored breathing. Smoke could be smelled strongly in the room. A pack of Marlboro cigarettes was lying on the bedside tray with a lighter. 10/07/14 - Resident mobile around facility, in wheelchair propelling self to go outside to smoke. 10/28/14 - Aide states that resident has smoke-like smell coming from room and ashes on the floor. Oxygen per nasal cannula at 2 liters on. Encouraged resident not to smoke in room. 11/24/14 - Propelled to smoke area, resident asked CNA if she could keep oxygen on while smoking. A review of the careplan with a next revision due date of 01/13/15 and goal that the resident will comply with facility policies for smoking revealed the following interventions: orientate to designated smoking areas, make sure ashtrays are provided in all designated smoking areas, remind resident never to smoke in room, smoking safety assessment quarterly and prn, and make MD aware of any problems immediately. A review of the policy and procedure provided by the facility on 12/09/14 revealed in part "No smoking is permitted inside the facility. This policy applies to employees, visitors, and residents. Also no smoking will be allowed in an area when oxygen is in use". During an interview with resident #47 on 12/09/14 at 2:10pm the resident stated that she does not think that it is that dangerous to smoke in her room with her Oxygen. She stated that someone told her that she would have to have an open flame on for her Oxygen to start a fire. An interview with S2DON on 12/09/14 at 2:45PM revealed that the facility has a smoking policy and they usually have the smoking residents sign a copy. She was unable to produce a copy signed by the resident #47 or her responsible party. During an interview with S6CNA on 12/10/14 at 10:05AM, this CNA was asked where the resident keeps her cigarettes. She stated that the resident has a pack of cigarettes on her night stand and pointed in the direction of the nightstand. Observation at this time revealed a pack of Marlboro cigarettes sitting on the night stand. The pack was missing a couple of cigarettes. An interview was held with S1ADM, S3ADON, S4MDS, S2DON on 12/10/14 at 11:30AM. At this time S3DON, S1ADM, S4MDS, and S3ADON confirmed that they have had problems with resident #47 smoking in her room with her oxygen on. It was stated that the resident had previously been in a room down the hall for about a year and that room really smelled like smoke. The ADON stated that they were monitoring the resident for smoking with her oxygen on in her room, even when the resident was further down the hall. S2DON stated that the resident would hide cigarettes all in her room, such as in her drawers and clock. S1ADM stated that they moved the resident to a room closer to the smoking area in hopes that that would encourage the resident not to smoke in the room. S2DON confirmed that the careplan was not updated to reflect the resident's noncompliance or the interventions that they have reported. She also confirmed that the resident was assessed to be a safe smoker per their current smoking assessment tool. She further confirmed that there smoking tool did not address wether or not the resident was compliant with the facilities smoking policy. She agree that this information was important in deciding whether or not the resident is a safe smoker. When informed of the resident's statements that she did not think that it was dangerous to smoke with her oxygen on and that someone had told her that it would need an open flame for the oxygen to catch fire, S3ADON stated that she (the resident) had told her the same thing and she was not sure who would have told her that. S1ADM stated that they had counseled the resident and the resident's family concerning this matter. S1ADM also stated that the employees know to keep resident #47's smoking materials at the nursing station. When asked if the resident's physician had been notified of the issues with her smoking with her Oxygen on, S1ADM and S2DON confirmed that the resident's physician had not been notified. Interview with S10CNA on 12/10/14 at 2:10PM revealed that she stated that the resident had a cigarette last night and was asking her for a match. Interview with resident #47 on 12/10/14 at 2:40PM revealed that the resident stated she now understands that smoking with her Oxygen on is a safety issue for herself and the other residents. When asked if she had a cigarette and lighter at that moment would she choose to smoke in her room with Oxygen she stated "I hope not, but I just can't say for sure". II. Based on observation and interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, by 1) failing to ensure that sampled resident #28's electrical outlet was covered and the air conditioning unit wiring was not exposed and 2) by having an unsecured portable oxygen cylinder in sampled resident #87's room. Findings: On 11:05AM an observation of sampled resident #28's room revealed an electric outlet that did have a cover. Further observation of the room revealed the wiring to air conditioning unit was not completely covered and approximately 1/2 of the insulation was exposed. On 12/11/14 at 9:44AM, an observation of resident #87's room revealed one portable oxygen cylinder that had 2000 psi (pounds per square inch) of oxygen observed in the portable cylinder. The tank was unsecured and free standing next to the resident's dresser. On 12/11/14 at 11:20AM, an observation and interview of the resident's room was conducted with S1Administrator. He confirmed the psi of oxygen remaining in the cylinder and then confirmed that the oxygen cylinder should not have been left unsecured in sampled resident #87's room.