Every finding on record at Liberty Commons Nursing and Rehabilitation Center

Based on observations, record reviews, and interviews with staff, the facility failed to follow the approved menu for 2 of 4 residents on a pureed diet (Residents #18 and #38). The findings included: The Week 1 dietitian approved menu indicated residents on a pureed diet were to receive a #6 scoop (equal to 5.3 ounces) of pureed vegetable chili and a #10 scoop (equal to 3.25-4 ounces) of pureed cornbread. The Diet Report dated 11/24/25 documented 4 residents had orders for a pureed diet. a. Resident #18 was admitted to the facility on [DATE] with diagnoses including dysphagia (trouble swallowing), hospice care, and weight loss. Resident # 18's current physician orders reviewed 11/24/25 documented she was to receive a pureed no added salt diet. b. Resident #38 was admitted to the facility on [DATE] with diagnoses including dysphagia. Resident #38's physician orders dated 1/10/25 documented she was to receive a pureed cardiac diet. Observation on 11/24/25 at 12:05 PM revealed [NAME] #1 served one 4-ounce scoop of chili and one 4-ounce scoop of pureed greens to 2 residents on a pureed diet. There was no pureed cornbread or bread served on the trays. The pureed chili was a brown and gray color, and the regular chili was a bright red color. In an interview on 11/24/25 at 12: 07 PM, [NAME] #1 said the pureed chili contained only beef and beans and she did not put the vegetables in while preparing the pureed chili, which was why the two dishes were different colors. She stated not adding the vegetables would make the pureed chili taste better. She stated she used a 4-ounce scoop because she thought that was what the menu had indicated to use. She stated she forgot to make pureed cornbread or a bread item to serve. In an interview on 11/24/25 at 12:09 PM, the Certified Dietary Manager (DM) confirmed [NAME] #1 did not serve a pureed bread option and after surveyor intervention, asked her to make some for service. She stated normally she ordered premade pureed bread which meant the cooks did not routinely have to make it. She stated she was unable to order premade pureed bread on the last order due to a cost increase. The DM was unable to find a #6 scoop for the pureed chili and, after surveyor intervention, she gave [NAME] #1 a 6-ounce ladle to serve the chili. The DM was not aware the vegetables were not added to the pureed chili and stated they should have been as per the recipe. In a phone interview on 11/24/25 at 12:14 PM, the Registered Dietitian stated a pureed bread option should have been served, and the scoop size should have been followed per the menu. The recipe, which called for vegetables to be put into the pureed chili the same as the regular chili, should have been followed so residents on a pureed diet received the same menu item. She stated the menu should have been followed to ensure residents received enough calories in their meals.

Based on lunch meal tray line observation, and staff interviews, the facility failed to maintain the plate warmer, essential equipment to the dietary department, in good operating condition, as evidenced by the plate warmer being inoperable. The findings included: An observation of the lunch meal tray line occurred on 10/09/24 at 11:50 AM. The two cylinder plate warmer was not plugged in or warm to the touch. In an interview on 10/09/24 at 12:04 PM Dietary Staff #1 stated the plate warmer had not worked for over 2 months. In an interview on 10/09/24 at 12:20 PM the Maintenance Assistant revealed he had worked at the facility for 2 months and was not aware the plate warmer was not working or had attempted to repair it. In an interview on 10/09/24 at 1:04 PM the Dietary Manager revealed she had been at the facility for over 2 months and the plate warmer had not worked since she arrived. She revealed the prior maintenance director had been unable to repair the plate warmer and she told the Administrator it was not working. In an interview on 10/09/24 at 12:17 PM the Administrator revealed that the prior Maintenance Director had been unable to repair the plate warmer. She indicated the dietary staff utilized insulated plates and staff served food immediately after it reached the halls.

Based on record review, and resident and staff interviews, the facility failed to conduct care plan meetings for 2 of 3 residents reviewed for care planning (Resident #10, and Resident #24), and failed to update a care plan for Resident 1of 3 residents reviewed for care planning (Resident #24). The findings included: 1. Resident #10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. During an interview with Resident #10 on 10/7/2024 at 10:23 A.M. he disclosed he could not remember the last time he participated in a care plan meeting. Calls to the Representative of Person for Resident #10 on 10/8/2024 at 3:47 P.M., and on 10/9/2024 at 8:47 A.M. went unanswered. A review of Resident #10's care plan revealed it had been updated on 6/12/2024 and on 6/19/2024. In an interview with the Social Worker (SW) on 10/8/2024 at 3:35 P.M. she revealed it was her responsibility to schedule care plan meetings, and to send out invites to participants. She stated it was an error on her part not to schedule a care plan meeting for Resident #10. The SW revealed the last care plan meeting for Resident #10 was held on 2/17/2024. During an interview with the Director of Nursing (DON) on 10/8/2024 at 3:40 P.M she revealed care plans were reviewed every 3 months and was not aware Resident #10's last care plan meeting was held on 2/17/2024. She further stated Resident #10's care plan was reviewed on 6/12/2024 and 6/19/2024. In an interview with the Administrator on 10/09/24 at 9:50 A.M. she revealed she was not aware Resident #10 had not had a care plan meeting since 2/17/2024. She further revealed it was the responsibility of SW to schedule the meetings and the responsibility of the DON to ensure the care plan was updated accordingly. 2. Resident #24 was admitted to the facility on [DATE]. Resident #24's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and her own responsible party. In an interview with Resident #24 on 10/7/2024 at 10:58 A.M. she revealed she had not participated in any care plan meetings since arrival at the facility on 4/11/2024. Review of Resident #24's care plan initiated on 4/11/2024 revealed the care plan had not been updated. The Social Worker (SW) was interviewed on 10/8/2024 at 3:35 P.M. SW revealed that Resident #24 was supposed to have had a care plan meeting in July 2024. She further stated it was her responsibility to schedule the meeting and it was an error on her part for not scheduling a meeting. An interview with the MDS Nurse on 10/8/2024 at 10:12 A.M. revealed she was responsible for ensuring the care plan was updated. She stated it was an error that Resident #24's care plan had not been updated. The MDS Nurse revealed it was the responsibility of the SW to schedule care plan meetings. During an interview with the Director of Nursing (DON) on 10/8/2024 at 3:40 P.M she revealed the care plan is reviewed every 3 months and was not aware Resident #24's care plan meeting had not been held. She revealed it was the responsibility of the SW to schedule and call for the care plan meetings for residents. During an interview with the Administrator on 10/9/2024 at 9:50 A.M. she revealed it was the responsibility of the Social Worker and the DON to ensure care plan meetings for Resident #24 were held quarterly or as needed.

Based on observation and staff interviews, the facility failed to maintain a medication storage refrigerator within the recommended temperature range for 1 of 1 medication refrigerator reviewed (100 Hall medication storage refrigerator). Findings included: An observation of the medication storage refrigerator located in the 100 hall medication storage room was made on 6/14/23 at 11:59 AM with Nurse #1. The refrigerator thermometer was observed at 30 degrees Fahrenheit ( F). Nurse #1 viewed the refrigerator thermometer and stated it appeared to read between 30 and 32 degrees. The June 2023 temperature monitoring log for the medication storage refrigerator had been noted daily with temperatures between 38 F and 40 F. The instructions at the bottom of the monitoring log indicated refrigerator temps must be between 36 and 46 degrees. If temps are not between these ranges all medications must be moved to a different refrigerator. The refrigerator contained: 8 Insulin aspart 100 unit pens. Insulin package instructions note to store unopened insulin in a refrigerator at 36 F to 46 F and do not freeze. 7 Insulin glargine 100 unit pens. Insulin package instructions note to store unopened insulin in a refrigerator at 36 F to 46 F and do not freeze. 6 Acetaminophen 650 milligram suppositories. The package instructions note to store at 68 F -77 F or in a cool place. 4 Tuberculin purified protein 1 milliliter vials. The package instructions note to store at 35 F -46 F and do not freeze. 8 Pneumococcal 20-valent Conjugate vaccines. The package instructions note to store refrigerated at 36 F -46 F, do not freeze and discard if the vaccine has been frozen. An interview with the Administrator was conducted on 6/14/23 at 12:22 PM was conducted. The Administrator stated the refrigerator temperatures should be in the recommended range.

Based on staff interviews and record reviews, the facility failed to accurately code an admission Minimum Data Set (MDS) in the area of anticoagulants for 1 of 16 (Resident #17) residents reviewed for MDS accuracy. Findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an irregular heartbeat). Resident #17's admission MDS dated [DATE] indicated she received 7 of 7 days of an anticoagulant (a blood thinner that prevents blood clots). Review of Resident #17's physician's orders included an order for Clopidogrel (an anti-platelet medication that prevents blood clots) by mouth one time daily. During an interview on 6/14/23 at 1:40 PM, the MDS nurse revealed Resident #17 was on Clopidogrel. She was not aware an anti-platelet medication should not be coded as an anti-coagulant. During an interview on 6/15/23 at 11:30 AM, the Director of Nursing (DON) revealed Clopidogrel should not be coded as an anticoagulant. During an interview on 6/15/23 at 12:50 PM, the Administrator revealed that Clopidogrel should not be coded as an anticoagulant. The MDS nurse had been made aware of the issue.

Based on observations and staff interviews the facility failed to date potential hazardous food items stored for use in 1 of 1 walk-in cooler and 1 of 1 reach-in cooler. This practice had the potential to affect food served to residents. The findings included: 1. a. Initial observation of the kitchen walk-in cooler on 02/28/2022 at 11:24 AM revealed the following foods were unlabeled and undated: 1 opened container of thickened liquid 1 opened package of cheese b. Initial observation of the kitchen reach-in refrigerator on 02/28/2022 at 11:26 AM revealed the following food was unlabeled and undated: 1 bag of opened shredded cheese c. Observation of the kitchen reach-in refrigerator on 03/03/2022 at 11:32 AM revealed the following food was unlabeled and undated: 1 opened container of pimiento cheese An interview with the Dietary Manager (DM) on 02/28/2022 at 11:26 AM revealed that all opened food in the kitchen walk-in refrigerator, the reach-in refrigerator should be labeled and dated at the time it was opened. She further revealed that any unlabeled and undated food should be discarded. The DM stated staff who opened a container was responsible for labeling and dating that container at the time it was opened. She further stated she was responsible for checking the units for proper storage of opened food. An interview with the Administrator on 03/03/2022 at 11:48 AM revealed it was her expectation that kitchen staff make sure all food was labeled and dated upon opening the packaging. She also stated if food was not labeled and dated it should be discarded.

Based on record review and staff interviews the facility failed to develop a baseline care plan within 48 hours of admission and failed to develop a resident centered baseline care plan to address wound care on admission and readmission for 1 of 13 residents reviewed for baseline care plans (Resident #184). The findings included: 1.a. Resident #184 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #184 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #184 ' s base line care plan dated 2/14/22 revealed there was no baseline care plan developed within 48 hours of admission on 2/10/22 and that it failed to address pressure ulcers. b. Resident #184 ' s Minimum Data Set indicated a discharge assessment was completed on 2/14/22 and a reentry was completed on 2/22/22. Review of Resident #184 ' s medical record revealed resident was readmitted on [DATE] with an unstageable pressure ulcer to the left buttock and shear wound to right buttock. Review of Resident #184 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #184 ' s base line care plan dated 2/23/22 revealed there was no baseline care plan developed to address pressure ulcers. An interview on 3/3/22 at 1:44 PM with MDS nurse revealed that wounds should be included in the baseline care plan which is developed 48 hours after admission. She further stated the baseline care plans generated the information to the Kardex which informed the staff how to care for the resident. An interview at 2:16 PM on 3/3/22 with the Administrator revealed that the baseline care plans should be developed within 48 hours, should be person centered and include areas such as wounds that are significant to each resident ' s care.

Based on record review, observation and staff interview, the facility failed to revise the comprehensive care plan based on current interventions including physical and occupational therapy recommendations for 1 of 13 residents (Resident # 7) reviewed for care plans. The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #7 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident required extensive assistance with bed mobility, transfers, eating and toileting. Review of the Care Planning Process policy dated 12/2021 indicated that care plans are to include information from a variety of documentation sources, are to include pertinent areas of care, assign relevant items to the Kardex for nursing assistant (NA) communication and are updated with changes by the MDS and Nurse Management Team. Review of Resident #7 ' s physical therapy discharge summary dated 1/23/22 indicated resident was discharged from skilled therapy services on a functional maintenance program which included daily ambulation with a front wheeled walker and cueing with a goal of 50 feet at a time. Review of Resident #7 ' s occupational therapy functional therapy maintenance program for feeding dated 2/19/22 indicated staff were to set up each meal by cutting and slicing items and placing drink in plastic cup with lid and straw and utilize plastic utensils. Plastic utensils were to be kept in resident ' s room on bedside table. The goal of this plan was that resident would continue to self-feed with set up assistance. Review of Resident #7 ' s care plan dated 2/25/22 indicated resident had an ADL (Activities of Daily Living) self-care problem related to [CONDITION(S)] (stroke) with [CONDITION(S)]. Interventions included in part, able to feed herself independently with set up, limited assist with eating as needed, set up and supervision for meals. Ambulation was not included in the care plan. On 3/3/22 at 8:30 AM Nursing Assistant (NA)#1 was observed standing beside Resident #7 ' s bed feeding her using standard silverware, not plastic. Interview on 3/3/22 at 8:30 AM with NA#1 revealed she was not aware of self-feeding interventions for Resident #7. She further stated, I think she is walked sometimes but I am not sure who does it. Interview with the Social Worker (SW) on 3/3/22 at 9:08 AM indicated that care plan meetings are not held unless there is a grievance and there was no way to know what was discussed or revisions to be made to the care plan. Interview on 3/3/22 at 9:15 AM with Occupational Therapy Assistant revealed Resident #7 received occupational therapy services for strengthening and improving fine motor skills. Resident #7 was able to feed herself with interventions in place upon discharge from occupational therapy. Interview with Nurse #1 on 3/3/22at 10:30 AM indicated she assisted with some administrative duties and updated the MDS nurse about the residents as needed. Nurse #1 indicated that interventions from the functional maintenance program should be added to the care plan to generate information to the Kardex for the NA ' s. Interview via phone at 1:44 PM on 3/3/22 with MDS nurse revealed she completed MDS and care plans remotely for the facility. She indicated she reviewed nurse notes, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated she did not attend care plan meetings for the residents. She indicated that she called the facility or sent an e mail if she needed further information or clarification. She stated that Resident #7 ' s care plan should have been revised to include the functional maintenance program interventions from physical and occupational therapy. Interview at 2:16 PM on 3/3/22 with the administrator revealed that she expected care plans were revised to include current interventions including physical and occupational therapy recommendations. The administrator indicated that care plans were to be up to date, individualized and contain goals that were appropriate for each resident

Based on record review and staff and physician ' s interviews the facility failed to transfer a resident in a manner that prevented an injury that resulted in a toe fracture during a transfer by an outside transport company for 1 of 3 residents reviewed for accidents (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] and had a diagnosis of [CONDITION(S)], diabetes and diabetic [CONDITION(S)]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was not ambulatory and required total assistance with transfers. The MDS noted the resident had impaired range of motion of the upper and lower extremities on one side. A progress note dated 9/22/21 at 4:30 PM revealed a phone call was received from a family member indicating the resident had suffered an injury to her left foot and had been transported to the hospital for treatment. The nurse called and spoke with the [CONDITION(S)] nurse who confirmed the resident had arrived with blood in her left sock and stated something happened during transport. Spoke with the transport service who also confirmed the resident complained of pain during transport. A progress note dated 9/23/21 at 1:12 PM noted on 9/22/21 at approximately 2:30 PM [CONDITION(S)] called to report an incident that happened on the wheelchair ramp while transferring the resident. The [CONDITION(S)] Nurse stated she saw a trail of blood on the floor and it was coming from the resident ' s foot. The [CONDITION(S)] Nurse stated she applied direct pressure to it and that [CONDITION(S)] would send the resident to the Emergency Department (ED) after her [CONDITION(S)] treatment. A progress note dated 9/23/21 at 2:35 (Late Entry) noted the transportation Driver called to inform them an incident happened with the resident ' s left foot getting hit with the wheelchair ramp on the van. Review of the Emergency Department Record revealed Resident #3 arrived at the ED on 9/22/21 at 4:24 PM. The physician note revealed a [CONDITION(S)] patient had gone for [CONDITION(S)] and the left big toe was injured during transport and the nail got partially avulsed. Brought to the ED for evaluation of the toe injury. The patient otherwise had no symptoms. The ED treatment included a procedure to remove the left big toenail and an X-ray of the left toes. The X-ray report revealed a fracture of the distal phalanx of the left great toe. The resident was discharged back to the facility and was to follow-up with an orthopedist. An avulsed nail is when part or all of the nail is torn away from the nail bed on a finger or toe. A progress note dated 9/23/21 at 2:30 AM revealed the resident had returned from the ED and had an avulsion of the toe and the nail was removed in the ED and no new orders. The note revealed dark bruising across the top and bottom of the foot and the second, third, fourth and fifth toenails were dark in color with no swelling noted. The note revealed the resident stated her foot was sore but no pain at present. The Director of Nursing (DON) was notified and a call was placed to the Responsible Party (RP) and a message left for the RP to call the facility. A message was left for the oncoming shift to call the physician for treatment orders in the morning. There was a physician ' s order dated 9/23/21 for an antibiotic medication to be given twice a day for 7 days for the left great toe prophylactically. Clean with normal saline and apply a clean non adherent dressing to the left great toe and wrap the foot with a gauze dressing. On 10/12/21 at 9:40 AM, Resident #3 stated in an interview that when going to [CONDITION(S)] her foot got caught on the ramp and she broke her foot. The Resident further stated she yelled out when it happened but after that she did not feel any pain. On 10/12/21 at 12:43 PM an interview was conducted with the resident ' s physician in the facility. The Physician stated the resident was in a transport van and a bar fell on her foot and she was bleeding and she was sent to the ED from [CONDITION(S)]. The Physician stated the resident ' s foot was healing and there had been no further problems with the resident ' s foot. On 10/12/21 an interview was conducted with the DON and the Administrator. The DON stated the person that transported the resident on 9/22/21 put the resident in the van and the resident said ouch and the transport person asked her if she was okay and the resident stated she was and was taken to [CONDITION(S)]. The DON stated there was no staff from the facility present during the transfer to the van. The DON further stated when she arrived at [CONDITION(S)] the nurse went to the waiting room to get her and saw blood near the wheelchair and when the nurse pulled off the resident ' s sock the nail was hanging and the resident told the [CONDITION(S)] nurse that something happened on the van on the way to [CONDITION(S)] and she felt a sharp pain and then nothing else. The DON stated the [CONDITION(S)] nurse called the facility around 2:30 PM and said something happened to her left toe and if she still had bleeding after [CONDITION(S)] she was going to send her to the hospital. The DON further stated when [CONDITION(S)] was complete the resident still had some bleeding so the nurse at [CONDITION(S)] sent her to the hospital. The DON stated they tried to get the transport company to do a re-enactment of the incident but the company declined. On 10/21/21 at 1:56 PM an attempt was made to interview [CONDITION(S)] Nurse #1, but the nurse was not available for an interview. On 10/13/21 at 9:08 AM an interview was conducted with the employee that transported the resident to [CONDITION(S)] on 9/22/21. The Employee stated the resident had on thick socks but no shoes and there were no footrests on the wheelchair. The Employee further stated the resident usually held both legs up when the wheelchair was moving. The Employee stated she pushed the resident in the wheelchair on the ramp, locked the wheelchair and was using the lift to raise the chair up to the van and the resident screamed out My foot. The Employee stated she stopped and the resident was holding up the right leg but the left leg was down and her foot was on the floor. The Employee further stated there was a metal bar on the lift that folds out and she thinks the resident ' s foot got caught between the metal bar and the lift. The Employee stated when the resident screamed out, she stopped and looked at the foot and it looked okay and the resident stated she was okay and she proceeded to transfer the resident to the van and transported her to [CONDITION(S)]. The Employee stated when she arrived at the [CONDITION(S)] center she rolled the resident in her wheelchair to the waiting room and asked the resident if she was okay and the resident stated she was okay and she left the [CONDITION(S)] center. The Employee stated she had not had this happen during transports in the past. On 10/12/21 at 3:50 PM the Administrator stated the facility had a contract with the transport company that transported Resident #3 to [CONDITION(S)] on 9/22/21 and the company ' s services were suspended on the day of the incident. The Administrator further stated she had completed a plan of correction related to the incident. The facility ' s corrective actions implemented after the accident to prevent a reoccurrence included the following: 1. Corrective action for the resident involved: On 9/22/21 the resident was transported to the ED for evaluation, following completion of her [CONDITION(S)] appointment at approximately 4:24 PM. 2. Identification of potentially affected residents and corrective actions taken: All current residents requiring wheelchair van transportation have the potential to be affected. On 9/23/21: Van transportation via wheelchair by external van companies were reviewed by the Administrator/DON for the past 30 days for any incidents related to safely transporting residents to and from appointments. No other incidents were found. On 9/23/21 Residents that were cognitively intact who were transported to an appointment were interviewed by the social worker for any concerns related to their transportation and there were no concerns identified. On 9/23/21 grievances and incident reports for the last 30 days were audited by the Administrator and the DON for any identified concerns or incidents and there were no other incidents found. On 9/23/21 any change in condition while out on an appointment that was communicated back to the facility was reviewed by the DON for timely notification of the RP and the physician and no incidents were found. 3. On 9/22/21 the DON began education of all full time, part time and PRN (as needed) nurses/CNAs (Certified Nursing Assistants)/Medication Technicians and agency staff on the following: Leg/footrests are to be in place on the wheelchair for residents who are being transported to appointments. No resident is to be transported to an appointment in a wheelchair without foot/leg rests in place, unless they are a double below or above knee [CONDITION(S)]. Leg/footrests help ensure proper body alignment and positioning as well as prevent injuries during transport or when assisting the resident on/off the van. Appropriate footwear/foot coverings are to be worn when up in the wheelchair for appointments to help aide in potentially preventing alterations in skin integrity such as abrasions/scrapes/scratches or other potential injuries to the feet. When the facility is notified that a resident has experienced a change in condition, while outside of the facility on an appointment, the DON/Administrator are to be notified timely and the physician and the RP are to be notified timely by the assigned nurse of the DON/Administrator. The DON will ensure that any of the above identified staff who do not complete the in-service training by 9/27/21 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation for the above identified staff. The Administrator will assure that the outside contacted company will not resume transporting residents until education has been completed by the contracted van company to assure that residents are safely assisted on/off and are able to verbalize the steps to take if an incident occurs before leaving the facility premises. Education of the van company drivers will be completed by the contracted company by 9/29/21. Quality Assurance Plan: The Administrator will monitor this issue using the Quality Assurance Tool for monitoring of compliance with the safe transport process of wheelchair residents. The monitoring will include monitoring of and direct observation of 2 wheelchair residents who are to be transported to an appointment by the contracted van company to assure they are appropriately positioned in the wheelchair, have leg/footrests in place and are safely loaded on the van prior to leaving the facility premises. The DON will also audit for compliance the notification of change in condition when out on an appointment to assure the RP and physician have been notified timely utilizing the Change in Condition Notification Tool. This will be completed weekly times 4 weeks, then monthly times 3 months or until resolved by the Quality Assurance (QA) Committee. Reports will be presented to the weekly QA committee by the Administrator to ensure corrective action was initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, Therapy, Health Information Management and the Dietary Manager. Date of Compliance: 9/30/21. On 10/13/21 at 1:49 PM the Administrator stated all current staff had been in-serviced. As we are using agency staff, the education is ongoing. If new agency staff work, they are in-serviced prior to working the shift. On 10/13/21 the facility ' s Plan of Non-compliance was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Staff education was completed as well as education of the employees of the transport company involved in the incident including the employee that transported Resident #3 on 9/22/21. The In-service included the following: 1. Report any complaint from the patient and/or any concerns you may have to the nurse before leaving a facility with the patient. Call the station and report the same to person in charge before leaving the facility with the patient. 2. Ensure all wheelchair van patients that are unable to step up in the van is safely in a wheelchair. Call the station to report any concerns. 3. Ensure the patient ' s wheelchair is working properly. Make sure the chair has foot and leg rest as needed. 4. Report anything that may be a hazard to the person in charge immediately. 5. In the event of an emergency on a wheelchair van, call 911. Do what you can to help the patient until help arrives and then call your supervisor immediately. Interviews were conducted with nurses and certified nursing assistants who stated they had received training related to residents being transported to appointments by van and were knowledgeable of the elements in the in-service documented for the staff.

Based on record review, staff and physician interview the facility failed to ensure a resident received physician services that resulted in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #3). The findings included: Resident #3 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 8/25/21 revealed the resident was cognitively intact and required extensive assistance with bed mobility and total assistance for transfers, toileting, and bathing. The MDS noted the resident was not ambulatory and used a wheelchair for mobility. The MDS noted the resident received [CONDITION(S)] while in the facility. The care plan updated on 8/20/21 noted the resident was scheduled for hemodialysis three times a week due to [CONDITION(S)]. The interventions included to arrange transportation to [CONDITION(S)] on scheduled [CONDITION(S)] days. A progress note dated 7/27/21 at 1:35 PM noted the physician ' s office had called and scheduled an appointment for a consult for an AV (arteriovenous) shunt for [CONDITION(S)] for 9/1/21 at 1:30 PM. The note revealed that transport had been arranged with (name of transport company). Review of hospital records revealed the resident was sent to the hospital on 8/26/21 due to a clotted perma cath and was admitted to the hospital. A perma cath is a catheter placed through a vein into or near the right side of the heart and is used for [CONDITION(S)] until a long-term device (AV shunt) is ready to use. A progress note dated 8/27/21 at 10:17 AM noted the resident had a nephrology appointment for 9/1/21 for evaluation and placement of a shunt for [CONDITION(S)] however the resident has already received it therefore the appointment was cancelled. (Name of transport company) made aware to cancel that appointment. The note was signed by Nurse #1. Hospital records revealed the resident was readmitted from the hospital on 8/29/21. A progress note dated 9/8/21 at 9:19 AM revealed the resident had an appointment with a nephrologist scheduled for 9/30/21 at 2:40 PM. Resident currently has a perma-cath. This appointment is for an AV shunt. A progress note dated 9/30/21 at 3:26 PM revealed the resident had an appointment on November 4, 2021 with a nephrologist and transportation had been arranged with (name of transport company). On 10/12/21 at 1:07 PM an interview was conducted with the Director of Nursing (DON) and the Administrator. The DON stated the resident was sent to the hospital with a clogged perma cath (8/26/21) and was admitted to the hospital. The DON stated that Nurse #1 thought the resident was having the AV shunt while in the hospital, so she cancelled the appointment with the nephrologist for the consultation. Nurse #1 joined the interview at 1:15 PM and stated the resident had just had her perma cath changed and thought the doctor ' s appointment was for a clogged perma cath and when the resident went to the hospital she thought the appointment was no longer needed and she cancelled the appointment. The DON stated the resident had an appointment with a nephrologist for a consultation on 10/4/21 at 2:40 PM. The DON further stated that the company that was to transport the resident to the appointment arrived at the facility at 3:00 PM and they called the doctor ' s office to see if they would still see the resident and was told it was too late and that the appointment would need to be rescheduled. The DON stated she asked the van driver why she was late and the driver could not tell her and stated she dropped someone off somewhere else and then came to the facility to transport Resident #3. The DON stated the resident had a consult with a nephrologist on 11/4/21 for her [CONDITION(S)] shunt. On 10/14/21 at 8:45 AM an interview was conducted with the nephrologist that cared for Resident #3. The Nephrologist stated the resident had a perma cath that was being used for [CONDITION(S)] until a shunt could be placed. The Nephrologist further stated there was a chance for infection and they liked to have a shunt put in within 90 days but some patients have a perma cath for a year though this is not preferred. The Nephrologist further stated the delay in getting the shunt had caused no harm and they were monitoring the resident very closely in the clinic.

Based on review of facility policies and procedures, observations and staff interviews, the facility ' s COVID-19 screening policy and procedure was not implemented when an employee, who had not been screened for COVID, entered a unit that was designated for residents on enhanced droplet precautions for 1 of 1 speech therapist observed (Speech Therapist #1). This occurred during a COVID-19 pandemic. The findings included: Review of the facility ' s policy titled COVID-19 Preparation and Response dated 3/10/20 and last updated on 6/7/20 revealed the following as the purpose for the policy: Residents of nursing homes and other residential facilities will be at particular risk for transmission of COVID-19 and disease complications. COVID-19 can be introduced through facility personnel and visitors; once [MEDICAL CONDITION] enters such facilities controlling its spread is problematic. The section of the policy titled Mitigation, 2c Control of personnel read: All employees are screened as they arrive at the beginning of the shift and upon returning after leaving the facility. Employee screens are conducted by a nurse and consist of a temperature, sign and symptom review and screening questions. On 6/9/20 at 10:10 AM an interview was conducted with the Administrator and the Director of Nursing (DON). The DON stated that all staff enter the front door at the beginning of their shift, sanitize their hands, have their temperature taken, put on a mask and are asked the screening questions and the information entered into a log. The DON further stated they had designated the 200 Hall for residents newly admitted from the hospital and residents readmitted from the hospital and these residents were put on enhanced droplet precautions for 14 days and if no signs or symptoms of COVID-19 after 14 days, the resident was moved to a regular floor. The DON stated the facility had no residents or employees that tested positive for COVID-19 since the beginning of the pandemic. There were currently 8 residents that resided on the 200 Hall. On 6/9/20 at 10:54 AM an employee identified by staff as a speech therapist was observed to enter the facility by using a door at the end of the 200 Hall. The therapist was observed to wear a mask and carried a stack of materials in his hands and walked past a nurse in the hall and continued to walk down the hallway. The therapist was observed at the screening desk at the front door and had his temperature taken and was asked the appropriate screening questions. On 6/9/20 at 10:56 AM an interview was conducted with Speech Therapist #1 who stated he came in the door at the end of the 200 Hall because he had parked his car close to that entrance and he had his hands full. The Therapist further stated he was able to enter that door with the use of a keypad. On 6/9/20 at 11:20 AM the DON stated in an interview that all the doors to the facility had a keypad to gain entrance to the facility. The DON further stated the speech therapist was supposed to enter the facility through the front door like all the staff and get screened prior to being on the hall. On 6/9/20 at 11:45 AM an interview was conducted with the Administrator and the DON. The Administrator stated the speech therapist was supposed to enter the facility through the front door and he had been educated to enter through the front door. The Administrator further stated she would change the code to the door keypads to prevent entry into the facility through those doors. On 6/9/20 at 1:02 PM a second interview was conducted with the Speech Therapist who stated he had received prior education and was aware he was supposed to enter the facility through the front door and it was his error. The Speech Therapist stated he had received another in-service today about entering the facility through the front door. On 6/10/20 at 9:50 AM the Administrator stated in an interview that when Speech Therapist #1 entered the facility through the door on the 200 Hall on 6/9/20, this was the beginning of his shift and the first time the therapist had been in the building that day.

Based on record reviews and staff interviews the facility failed to complete a Discharge Return Not Anticipated Minimum Data Set Assessment for 1 of 1 residents reviewed. (Resident # 1). The findings include: Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Quarterly Minimum (MDS) data set [DATE], Resident #1 was cognitively impaired, and required extensive assistance in most areas of activities of daily living. Resident #1 was discharged from the facility on 9/7/19. During an interview on 1/8/20 at 11:33 AM, the MDS Nurse revealed she did not know why a discharge was not put in. She stated Resident #1 was discharged to the hospital. The MDS Nurse stated usually she checked the census daily to make sure there were no changes with admissions or discharges. During an interview on 1/8/20 at 3:05 PM, the Director of Nursing (DON) stated they need to put assessments in the system when noted in tracking. She stated generally they talked about discharges in medicare meeting. She revealed her expectation was that a MDS assessment should be completed upon a resident's discharge. During an interview on 1/8/20 at 4:54 PM, the Administrator stated a MDS assessment should be completed upon a resident's discharge.

Based on record reviews and staff and resident interviews the facility failed to provide a written summary of the baseline care plan to 1 of 1 residents reviewed. (Resident #2). The findings include: Resident #2 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most recent Admission Minimum Data Set assessment dated [DATE], Resident #2's cognition was intact and she required limited assistance to supervision in most areas of activities of daily living except bathing, in which she was totally dependent. During an interview on 1/7/20 at 1:42 PM Resident #2 revealed no one had talked to her about her a care plan and she did not get a written copy of her care plan. During an interview on 1/8/20 at 2:12 PM, the MDS Nurse stated she discussed information that was in Resident #2's care plan with her. She revealed the care plan was set up 48 hours after Resident #2 was admitted to the facility. The MDS Nurse revealed Resident #2 was not given a copy of her care plan. During an interview on 1/8/20 at 3:00 PM, when Resident #2 was asked if she would like to know what was in her care plan, she said yes. She stated she had not received a copy of her care plan. During an interview on 1/8/20 at 3:27 PM, the Director of Nursing stated Resident #2 should be given of copy of her care plan. During an interview on 1/8/20 at 4:52 PM, the Administrator stated a baseline care plan was supposed to be done within 72 hours of admission to the facility. She revealed her expectation would be that a copy of the care plan should be given to the resident.

Based on observations and staff interviews, the facility failed to properly dispose of expired medication, failed to date opened medication, and correctly store medication for 2 of 2 medication carts (the skilled hall cart and rehab unit cart) that were used to store medications for residents of the facility. Findings included: An observation was conducted on 1/7/2020 at 2:47 PM of the medication cart labeled as the skilled hall cart with Nurse #1 present. In the bottom drawer of the skilled hall medication cart, a bottle of ReNu eye drops with an open date of 10/11/2019 was found. Nurse #1 removed the bottle to be discarded. An interview was conducted with Nurse # 1 on 1/7/2020 at 2:55 PM. Nurse #1 revealed that the eye medications were to be discarded 30 days after opening. An observation was conducted on 1/7/2020 at 2:58 PM of the medication cart labeled as rehab unit cart with Nurse # 2 present. The rehab unit cart revealed a single [MEDICATION NAME] (medication to reduce calcium) 800 milligram (Dosage of medication) tab in blister wrap in the top drawer, and an opened undated bottle of [MEDICATION NAME] eye drops with a dispense date of 12/19/2019. Nurse #2 immediately removed the [MEDICATION NAME] tablet to be discarded and dated the [MEDICATION NAME] eye drops with the dispense date. An interview was conducted with Nurse #2 on 1/7/2020 at 3:10 PM. Nurse # 2 stated that medications, such as [MEDICATION NAME], pulled from the pyxis (a locked medication station) were to be administered immediately. Nurse # 2 stated that all eye drops were to be labeled when opened. An interview with the Director of Nursing (DON) on 1/7/2020 at 3:33 PM revealed that all expired medications were to be discarded and all opened eye drops were to have been labeled with an opened date. The DON stated eye drops should be discarded 30 days after they are opened. The DON stated that any medication pulled from the pyxis station should be administered promptly.

Based on observations and staff interviews the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean two of two plate warmers and 4 of 4 sheet pans. Then findings included: During the initial kitchen tour on 1/14/19 at 9:30 AM the plate warmer was observed with dark brown dried food particles inside both wells. During a second observation on 1/16/19 at 9:38 AM the plate warmer was observed with dark brown dried food particles inside both wells. The right well a hairnet and 4 dried dark fruit rinds were observed inside. A third observation on 1/16/19 at 11:26 AM the plate warmer was observed to be in the same condition. A review of the Daily Deep Cleaning schedule dated Jan. 1-31, 2019 page 3, reads as Clean Plate Rack there were no signatures to indicate the plate warmer had been cleaned. During the kitchen observation on 1/16/19 at 9:14 AM 2 sheet pans of prepared chicken were observed on the prep table ready for noon meal. The sheet pans had dark black charred food build up under the rim and bottom of each pan. One half size sheet pan with yeast rolls was observed with a dark black charred food build up under the rim and bottom of pan. In an interview with the Certified Dietary Manger on 1/16/19 at 2:48 PM she indicated they had several cleaning schedules and that she would order new sheet pans. In an interview with the Administrator on 1/16/19 at 3:13 PM stated she would expect the kitchen staff to clean the plate warmer daily and she would order new sheet pans for the kitchen.

Based on record review and staff interviews the facility failed to update a care plan for 1 of 1 residents with a nephrostomy (an artificial opening created between the kidney and the skin which allows the urinary diversion directly from the upper part of the urinary system.) (Resident #27) The findings included: Resident #27 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], Resident #27's cognition was intact. She required extensive assistance in most areas of activities of daily living. Resident #27 was coded in Section H, of the MDS, (Bowel/Bladder) for indwelling catheter (including nephrostomy tube). The resident's bladder continence was coded as not rated because she had a urinary ostomy or no urinary output for the entire seven days. Review of Resident #27's medical record revealed she had a nephrostomy in place since 11/26/18. Review of Resident #27's Care Plan which was updated on 1/8/19 revealed the resident's nephrostomy was not care planned. During an interview on 1/16/19 at 2:49 PM the Director of Nursing revealed nephrostomy was supposed to be care planned. She stated she just noticed nephrostomy was not on the care plan. During an interview on 1/16/19 at 4:29 PM the Administrator revealed care plans should be updated when there were any changes in [DIAGNOSES REDACTED].

Based on observation, record review and staff interviews, the facility failed to post accurate staffing data by including staff providing care for residents on the assisted living hall with staff providing care for residents on the skilled nursing halls and failed to post accurate census by including residents from the assisted living hall with residents on the skilled nursing hall for 3 out of 3 days during the survey conducted 1/14/2019 to 1/16/2019. The findings included: During the initial tour of the facility on 1/14/2019 at 9:30 AM, the Report for Nursing Staff Directly Responsible for Resident Care staff posting form dated 1/14/2019 indicated 1 Registered Nurse (RN) for a total of 8 hours, 2 Licensed Practical Nurses (LPNs) for a total of 16 hours, and 5 nursing assistants (NAs) for a total of 37.5 hours staffed the skilled nursing unit on the 7:00 AM to 3:00 PM shift. The form indicated the resident census was 48 which did not correspond to the number of residents on the resident roster for the skilled nursing unit which was 42. Review of the POS [REDACTED]. The 1/16/2019 posting listed 3 nurses and 5 NA and a census of 47 on the 7:00 AM to 3:00 PM shift. An interview was conducted on 1/16/2019 at with the Medication Aide (MA) who stated she filled out the staff posting forms. The MA stated she put the total census on the posting form for all residents in the building which included the skilled nursing residents and the assisted living residents. The MA stated the staff and staff hours were for all the residents in the building, both the skilled and assisted living residents. The MA stated she had not been instructed to exclude the assisted living residents from the census. On 1/16/2019 at 11:25 AM, an interview was conducted with the Administrator who stated she did not realized the staff posting included both the skilled and assisted living residents. The Administrator stated she expected the form to be filled out to include only the skilled residents, and the staff hours should reflect care only for the skilled residents.

Based on observation, resident and staff interview the facility failed to provide an effective housekeeping and maintenance service by failing to clean stained and dirty floor tiles, failing to repair a cracked sink and stained faucet handles for 1 of 2 halls (Room 101) and failed to maintain 3 of 3 shower rooms in working condition. The findings included. 1. During an observation on 12/5/16 at 12:07 PM the floor tiles in the bathroom in room 101 was observed with a dark brown stain about 1/2 inch wide around the toilet base. There were light tan stains and medium brown stains splattered on the entire bathroom floor tiles. The sink was observed with a 6 inch long crack starting on the right side of the sink descending down to the basin. The faucet handles and the base of the faucet were observed with rust colored stain. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed Resident # 5 was admitted to room 101 on November 9/8/2015. According to her most recent quarterly minimum data set ((MDS) dated [DATE] and her annual MDS of 8/24/16 revealed she was cognitively intact. During an interview on 12/6/16 at 9:15 AM Resident #5 stated, I think they (the facility) think me and my roommate are going to pass away any time and we will never see them (the bathroom floor tiles) cleaned and redone. The Resident stated that when she came to look at the room (Room 101) she had pointed out that the floor tiles were stained and she was informed that the facility would replace the tiles. The resident stated she had been in room 101 since November 2015. The resident further stated she had gone to the resident council meeting a while back and had mentioned the floor and also that she wanted a new sink and new faucet because the sink was cracked and the faucet handles were stained. On 12/06/16 at 9:28 AM the floor tiles in the bathroom in room 101 was observed with a dark brown stain about 1/2 inch wide around the toilet base. There were light tan stains and medium brown stains splattered on the entire bathroom floor tiles. The sink was observed with a 6 inch long crack starting on the right side of the sink descending down to the basin. The faucet handles and the base of the faucet were observed with rust colored stain. . During an interview on 12/06/16 9:39 AM the housekeeping staff stated the floor tiles in the bathroom were stained and the sink had been cracked for a while. She stated she had not told anyone because staff were aware of the condition of the floor. She stated that housekeeping could come and strip the floors. During an interview on 12/7/16 at 9:04 AM the Administrator stated she was aware that the floor in the bathroom for Room 101 was stained and the tiles needed to be replaced. She stated she made daily rounds of Room 101 to identify housekeeping concerns and was aware of the stained tiles. She stated she did not have any documentation of specific concerns and was not aware of the crack in the sink or the faucet handles being stained. On 12/7/16 at 9:10 AM the Maintenance Director/Housekeeping Director stated he was not aware that the tiles in room 101 were stained or that the sink was cracked and the faucet handles were stained. He stated he could strip and clean the floor and replace the sink and handles. 2. During an observation on 12/6/16 at 4:28PM of Bath 1 on hall 100 read an out of order sign. The tile at the base of the shower was missing. Tile missing on the corner of tub at floor level. During an observations on 12/6/16 at 4:31pm of Bath 2 on Hall 100 there was missing tile on the outside of shower wall. There was a hole in wall observed approximately 3 x 4 next to the shower. The corner tile was missing on wall right (2 x3 )and left (3 x6 ) nearest the entrance door. During observations on 12/7/16 at 6:20AM of the hall 200 shower room the following was observed: Broken tiles were observed to the right of the shower wall on the outside of the shower wall that was approximately 12 in length. Black mold seen there. On the wall corner next to toilet the tile was missing. At the shower entrance to the shower the threshold was unattached approximately 2 foot in length. There was what appeared to be red mold next to the wall. Observation of shower rooms on 12/8/16 at 11:50am showed they were in the same condition as previous observations. During an interview with Nursing Assistant #1 on 12/6/16 at 4:10pm she stated the towel on the floor over the threshold in the 200 hall shower room helped because the water runs out of the shower and also the flooring is messed up. During an interview with the Maintenance Director on 12/7/16 at 6:25PM he stated he already had estimates for all three shower rooms to be re-hauled. Interview with Administrator on 12/8/16 at 11:55am she stated corporate had approved repairs but she was still getting quotes. She stated the previous maintenance man had started repairs on the 100 hall but the concrete he applied had separated and the shower rooms were not in use currently. She stated the shower rooms had not been used since approximately October 2016.

Based on record review, observations and staff interviews, the facility failed to ensure the safety of residents by failing to immediately report unsafe water temperatures to the Administrator. The facility also failed to contact a professional to determine the cause of unsafe water temperatures on 1 of 2 halls (200 Hall) for three of four weeks in November, 2016 and for one week in December, 2016. The findings include: Review of a facility policy dated 7/1/02 and titled, Hot Water Temperatures read in part, Hot water is tested weekly throughout the facility and Laundry. Water temperatures are dated, logged, area and initialed by person taking temperatures. Using a hand thermometer, turn on hot water faucet and hold thermometer under water for 30 seconds, read and record temperature and turn off faucet. If the temperatures are found to be not within range, thermostat is adjusted and temperature re-checked until found to be back within range. 1. Patient areas 100-800 Halls - - Temp 100-116. There was no information in the facility policy to calibrate the thermometer prior to taking the water temperatures. There was no information on the procedure if the water temperatures exceeded 120 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician, using a calibrated thermometer on 11/15/16, revealed the shower room on the 200 hall read 136 degrees Fahrenheit. A shared bathroom for room 201-202 read, 132 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician on 11/22/16 in the resident's shared bathroom 201-202, read, 134 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician on 11/25/16 in the resident's shared bathroom 201-202, read, 126 degrees Fahrenheit. The shower room on the 200 hall read 129 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician on 12/1/16 in the shower room on the 200 hall read, 135 degrees Fahrenheit. Resident's room, 209, read, 123 degrees Fahrenheit. Resident's shared bathroom 201-202, read 134 degrees Fahrenheit. There was no documentation to reveal the hot water heater had any maintenance done in 2016. On 12/5/16 at 3:30 PM, the water temperature in room 202 was too hot to keep hand under hot water faucet while the hot water was running. The Maintenance Director was notified immediately and was informed by Surveyor that the hot water was too hot to keep hand under running water. The surveyor observed the Maintenance Director calibrating the thermometer to 32 degrees F in ice water. An observation on 12/5/16 at 4:11 PM revealed the hot water temperature in room 202 was 120 degrees F. An observation on 12/5/16 at 4:12 PM revealed the hot water temperature was checked in the bathroom sink in the shower room on the 200 hall. The hot water temperature was 120 degrees F. An observation on 12/5/16 at 4:13 PM, revealed the hot water temperature in the shower room on the 200 hall was 120 degrees F. The Maintenance Director rechecked all temperatures while the surveyor observed. Rechecked temperature in room 202 on 12/5/16 at 4:14 PM, temperature was 118 degrees F. Rechecked temperature in bathroom shower sink, temperature was 118 degrees F. During an interview on 12/5/16 at 4:56 PM, the Maintenance Director stated he had been working at the facility for about two months and he started logging water temperatures in November, 2016. He stated the floor technician was assigned to monitor water temperatures. The Maintenance Director revealed the floor technician notified him when the water temperatures exceeded 120 degrees F. The Maintenance Director stated he did not call the Plumber and he did not inform the Administrator about the high hot water temperatures. He stated he went to the hot water heater and tweaked the thermostat. He stated he reviewed the temperature logs weekly and when the temperatures remained above 120 degrees F he continued to tweak the thermostat to adjust the water temperature. The Maintenance Director stated he had not been trained on how to maintain the hot water system at the facility. He revealed he had some experience prior to coming to the facility. During an interview on 12/05/2016 at 5:14 PM, Nursing Assistant (NA) #2 revealed some residents complained about the water temperatures but she adjusted the water temperature. She stated the water temperature had not been hot enough that she couldn't keep her hands under it. She revealed she always adjusted the water temperature. During an interview on 12/7/16 at 7:00 AM, Nursing Assistant (NA) #3 stated the water in the 200 hall shower and in a resident's bathroom on the 200 hall got really hot. She revealed she always felt the water with her elbow to make sure the water was not too hot. NA#3 revealed that she reported the hot water temperature to the Maintenance Director and he adjusted the water temperature. There were no residents burned by hot water and no staff complained about hot water temperatures. During an interview on 12/05/2016 at 5:36 PM the facility Floor Technician stated he checked water temperatures weekly and he logged the temperatures. The Floor Technician explained that he calibrated the thermometer when he got high temperatures to validate the hot water concern. When the water temperature was 134 degrees F, he told the Maintenance Director. The Floor Technician revealed the 200 Hall had a problem with the water temperatures fluctuating since the high temperature in November 2016. He stated he did not adjust water temperatures, but reported it to Maintenance Director and he adjusted the thermostat on the water heater. He said water temperatures should range from 108-116, no higher than 116. During an interview on 12/6/16 at 10:10 AM the Plumber stated he had been contacted on that morning (12/6/16) about the hot water temperatures being too hot. He revealed he had not been notified by the facility concerning the hot water temperatures prior to 12/6/16. The Plumber stated the problem was a bad circulation pump and he replaced it. During an interview on 12/6/16 at 11:36 AM the Maintenance Facility Consultant revealed he was from the corporate office and that he was not aware the hot water heater had temperatures that reached 136 degrees F. He stated the problem was when there was a demand for water the circulating pump should have evenly distributed the water throughout the resident's rooms and the shower. He stated the Plumber identified a malfunctioning circulating pump and replaced it. The Maintenance Facility Consultant stated the temperatures should be set from 110 to 116 degrees F and no higher. He explained when the temperature reached 136 degrees the hot water heater should have been turned off and someone called to fix it. He stated that all water temperatures down the 200 hall were safe. The Maintenance Facility Consultant stated water temperatures should be checked for each room every day to make sure the hot water was at a safe temperature. He stated when the pump runs it runs all the time to keep the water the same temperature everywhere. During an interview on 12/6/16 at 4:44 PM, the Administrator stated 12/5/16 was the first time she had heard the hot water was running too hot. She revealed the Maintenance Director had not notified her about the high hot water temperatures. During interviews with alert and oriented residents, no residents complained about hot water temperatures.

Based on record reviews, observations and staff interviews, the facility failed to provide oversight of the Maintenance Director who failed to notify the Administrator of hot water temperatures exceeding safe temperature ranges of 100-116 degrees Fahrenheit on one of two halls (200 hall) for three of four weeks in November, 2016 and for one week in December, 2016. The findings include: Review of a facility policy dated 7/1/02 and titled, Hot Water Temperatures read in part, Hot water is tested weekly throughout the facility and Laundry. Water temperatures are dated, logged, area and initialed by person taking temperatures. Using a hand thermometer, turn on hot water faucet and hold thermometer under water for 30 seconds, read and record temperature and turn off faucet. If the temperatures are found to be not within range, thermostat is adjusted and temperature re-checked until found to be back within range. 1. Patient areas 100-800 Halls - - Temp 100-116. There was no information in the facility policy to calibrate the thermometer prior to taking the water temperatures. There was no information on the procedure if the water temperatures exceeded 120 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician, using a calibrated thermometer on 11/15/16, revealed the shower room on the 200 hall read 136 degrees Fahrenheit. A shared bathroom for room [ROOM NUMBER]-202 read, 132 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician on 11/22/16 in the resident's shared bathroom [ROOM NUMBER]-202, read, 134 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician on 11/25/16 in the resident's shared bathroom [ROOM NUMBER]-202, read, 126 degrees Fahrenheit. The shower room on the 200 hall read 129 degrees Fahrenheit. A review of temperature log documentation taken by the facility Floor Technician on 12/1/16 in the shower room on the 200 hall read, 135 degrees Fahrenheit. Resident's room, 209, read, 123 degrees Fahrenheit. Resident's shared bathroom [ROOM NUMBER]-202, read 134 degrees Fahrenheit. There was no documentation to reveal the hot water heater had any maintenance done in 2016. On 12/5/16 at 3:30 PM, the water temperature in room [ROOM NUMBER] was too hot to keep hand under hot water faucet while the hot water was running. The Maintenance Director was notified immediately and was informed by Surveyor that the hot water was too hot to keep hand under running water. The surveyor observed the Maintenance Director calibrating the thermometer to 32 degrees F in ice water. An observation on 12/5/16 at 4:11 PM revealed the hot water temperature in room [ROOM NUMBER] was 120 degrees F. An observation on 12/5/16 at 4:12 PM revealed the hot water temperature was checked in the bathroom sink in the shower room on the 200 hall. The hot water temperature was 120 degrees F. An observation on 12/5/16 at 4:13 PM, revealed the hot water temperature in the shower room on the 200 hall was 120 degrees F. The Maintenance Director rechecked all temperatures while the surveyor observed. Rechecked temperature in room [ROOM NUMBER] on 12/5/16 at 4:14 PM- temperature was 118 degrees F. Rechecked temperature in bathroom shower sink, temperature was 118 degrees F. During an interview on 12/5/16 at 4:56 PM, the Maintenance Director stated he had been working at the facility for about two months and he started logging water temperatures in November, 2016. He stated the floor technician was assigned to monitor water temperatures. The Maintenance Director revealed the floor technician notified him when the water temperatures exceeded 120 degrees F. The Maintenance Director stated he did not call the Plumber and he did not inform the Administrator about the high hot water temperatures. He stated he went to the hot water heater and tweaked the thermostat. The Maintenance Director stated he reviewed the temperature logs weekly and when the temperatures remained above 120 degrees F he continued to tweak the thermostat to adjust the water temperature. The Maintenance Director stated he had not been trained on how to maintain the hot water system at the facility. He revealed he had some experience prior to coming to the facility. During an interview on 12/05/2016 at 5:36 PM the facility Floor Technician stated he checked water temperatures weekly and logged the temperatures. The Floor Technician explained that he calibrated the thermometer when he got high temperatures to validate the hot water concern. When the water temperature was 134 degrees F, he told the Maintenance Director. He revealed the 200 Hall had a problem with the water temperatures fluctuating since the high temperature in November 2016. The Floor Technician stated he did not adjust water temperatures, but reported it to the Maintenance Director and he adjusted the thermostat on the water heater. He said water temperatures should range from 108-116, no higher than 116. During an interview on 12/6/16 at 10:10 AM the Plumber stated he had been contacted on that morning (12/6/16) about the hot water temperatures being too hot. He revealed he had not been notified by the facility concerning the hot water temperatures prior to 12/6/16. The Plumber stated the problem was a bad circulation pump and he replaced it. During an interview on 12/6/16 at 11:36 AM the Maintenance Facility Consultant revealed he was from the corporate office and that he was not aware the hot water heater had temperatures that reached 136 degrees F. He stated the problem was when there was a demand for water the circulating pump should have evenly distributed the water throughout the resident's rooms and the shower. He stated the Plumber identified a malfunctioning circulating pump and replaced it. The Maintenance Facility Consultant stated the temperatures should be set from 110 to 116 degrees and no higher. He explained when the temperature reached 136 degrees the hot water heater should have been turned off and someone called to fix it. He stated that all water temperatures down the 200 hall were safe. The Maintenance Facility Consultant stated water temperatures should be checked for each room every day to make sure the hot water was at a safe temperature. He stated when the pump runs it runs all the time to keep the water the same temperature everywhere. During an interview on 12/6/16 at 4:44 PM, the Administrator stated 12/5/16 was the first time she had heard the hot water was running too hot. She revealed the Maintenance Director had not notified her about the high hot water temperatures.

Based on observations, resident and staff interviews and record review, the facility failed to provide oversight for the transportation coordinator since the April 2015 training and failed to have manufacturer's instructions on site for the use of the resident securement system, including the use of a lap belt and shoulder strap which could have resulted in a high likelihood of serious bodily injury. Findings included: Immediate Jeopardy began on 3/11/16 when Resident #20 was transported on the facility van without the lap belt or the shoulder harness used to secure her in her wheelchair. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 3/22/16 at 3:50 PM. During an interview with Resident #20 on 3/18/2016 at 1:00 PM and 3/22/16 at 9:50 AM she stated on her 3/11/16 transport to the hospital, using the facility van, NA #3 failed to use the lap belt and shoulder strap to secure her in her wheelchair. She stated that she was told by the van driver the seatbelt was broken. The Maintenance Supervisor was interviewed on 3/22/16 at 10:24 AM. He stated the prior administrator had taught staff to transport residents safely in the van and had checked off their skills related to the use of the safety equipment. NA #3 was interviewed on 3/22/16 at 11:28 AM. She stated since her training by the corporate representative, she had received no oversight or skills check. The Administrator was interviewed on 3/22/16 at 12:34 PM. She stated staff who transported residents in the van were expected to follow protocol. She stated she had not observed NA #3 for skills competency in using the van's safety equipment. In review of her records, she could provide no evidence the NA had been observed since her previous training. The Immediate Jeopardy was removed on 3/23/16 at 3:15 PM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure implementation of the change in process in providing transportation for appointments. Cross reference to F323. The facility policy and procedure for Resident Transportation, revised in June 2009 indicated all drivers would be responsible and held accountable in part to: · Operate motor vehicles in a safe manner at all times · Comply with all applicable state laws and regulations · Require all occupants to use seat belts at all times · Comply with organizational policy on transport of passengers The Transportation Coordinator job description, with a revision in June 2009, indicated the transportation coordinator had to have a wheelchair safety training and a skills checklist completed prior to transporting residents. Additionally, the transportation coordinator must have the ability to plan, organize and follow up on work assignments and must have the ability to make independent decisions and work well under pressure. The Administrator and the DON were notified of the Immediate Jeopardy on 3/22/16 at 3:50 PM. On 3/23/16 at 3:15 PM, the facility provided the following credible allegation: Corrective Action for Affected Residents The nursing home investigated allegations that the facility van seatbelt was broken starting on 3/18/16 and ending 3/23/16. NA #3 was interviewed by the state surveyor and the Director of Nursing on 3/18/16 and confirmed that the seatbelt was not broken but that she did not utilize the seatbelt in the company van when transporting Resident #20. Resident #20 did not receive any physical injuries related to the event. On 3/18/16 the administrator observed the seat belt was in good repair and not broken. On 3/19/16 a 24 hour report of neglect was submitted by the Director of Nursing to the Healthcare Personnel Registry. A phone call was made on 3/19/16 to NA #3 informing her that she needed to contact the Director of Nursing prior to returning to work. All company van transportations by any employee were suspended by the administrator on 3/19/2016 until another van driver can be hired and trained. Commercial transportation companies will be used to scheduled necessary transports for the facility. After review of the incident, it was decided that the employee would be removed from transportation duties permanently but would be allowed to continue employment as a nursing assistant. She returned to work on 3/22/16 but was dismissed early pending further investigation. NA #3 was moved to the duties of transportation aide and central supply on 2/12/15. She received training from the corporate van trainer on 4/29/15 according to the sign and dated skilled checklist. Prior to the corporate training she was trained by the previous transportation aide and the administrator. Both had been trained by the corporate van trainer. They did not complete a skills checklist for this training. The corporate van trainer has been trained directly from van products. He utilizes the training he received, manufacturer guidelines, and a skills checklist to educate. A skills validation is also completed where the staff member must demonstrate the skills appropriately. The only other employee who transports is the Social Worker. She was also trained and has a skills checklist dated 1/26/12 originally but received retraining in using the process outlined above. She was reeducated by the corporate van trainer on 8/22/15 also. The transportation aides ' direct supervisor is the Administrator. Corrective Action for Potentially Affected Residents All residents who have been transported by NA #3 in the company van have the potential to be affected by this alleged practice. On 3/22/16 the Director of Nursing, Administrator, Social Services and Support Nurse interviewed alert and oriented patients who had been transported by NA #3 from 2/2/16 to 3/22/16. 12 patients were transported. 4 residents were not able to be interviewed. 2 stated that they were not sure if the seatbelt was utilized. 5 stated they did not remember a seatbelt being used during transport 1 stated it was not used. Systematic Changes On 3/23/16 the Administrator and Director of Nursing were educated by the regional director of operations on the following: A contract van company must be used anytime there is a vacancy in the transportation aide role unless another employee is available that has received the mandatory corporate van training can provide the transportation. No employee must transport a patient unless they have been trained by the corporate van trainer and a skills checklist is completed. The administrator and Director of Nursing will attend the van training to ensure proper knowledge of the system in order to verify that it is completed correctly. Investigations of all incidents involving transportation by the facility van will be completed by the Administrator and Director of Nursing as soon as the allegation or issue is identified. The investigation will include interviewing the resident involved, employee involved, other possible witnesses, and other potentially affected patients. During the investigation the employee will be notified promptly that they are suspended until the investigation is completed. Disciplinary actions will remain at the discretion of the administrator and will be dependent on the nature of the allegation and investigation findings. However, if the allegations are substantiated a 3 working day suspension will be implemented. The Credible Allegation was validated on 3/23/16 at 3:15 PM when the Administrator and the Director of Nursing validated they had been made aware the facility van was no longer to be used for resident transport and that when the van returned to use, they would be expected to complete random audits to assure safety compliance. The Administrator stated the van keys were in her office and the van parked in the parking lot of the facility. During an interview with Nurse #3, she validated all staff had been made aware, by the Administrator and the Director of Nursing that the facility van would not be used for resident transportation and the facility would be using an outside transport agency when residents were scheduled for appointments.

Based on observation, staff, resident and family member interviews and record review, the facility failed to utilize the shoulder harness and lap belt to properly secure the resident into the wheelchair for 1 of 1 alert and oriented resident (Resident # 20) using the facility's transportation van which could have resulted in a high likelihood of serious bodily injury. Immediate Jeopardy began on 3/11/16 when Resident #20 was transported in the facility's transportation van without the use of a lap belt or shoulder strap to secure her in her wheelchair. The facility's Administrator was notified of the Immediate Jeopardy on 3/22/16 at 3:50 PM. The Immediate Jeopardy was abated on 3/23/16 at 3:15 PM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure implementation of the change in process in providing transportation for appointments. Findings included: A Resident Securement User Instruction sheet with a revision in October 2010, sent to the facility by the corporate trainer on 3/22/16, after Immediate Jeopardy was called, indicated in part under Paragraph B, titled Secure Passenger , 1. Attach Lap Belts- to use the integrated stiffeners to feed belts through the openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. Point a. On the aisle side, attach belt with female buckle to rear tie down pin connector; ensuring buckle rests on passenger's hip. Point b. Attach Shoulder Strap- Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Note: Combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 2/15/16 Admission Minimum Data Set (MDS) indicated Resident #20 was cognitively intact. The MDS also identified the resident required extensive assistance for bed mobility, transfer, walking in her room, toilet use and personal hygiene. She was coded as not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking and surface to surface transfer. The MDS also indicted the resident required the use of a walker or wheelchair for mobility. Resident #20 was interviewed on 3/18/2016 at 1:00 PM. Resident #20 stated she was transported to the hospital in the facility van. She stated that she was transported with her wheelchair secured to the van but a seat belt was not put around her waist or upper torso to secure her to the wheel chair. Resident #20 stated that she was told by the van driver the seatbelt was broken. NA #3 was interviewed on 3/18/2016 at 2:15 PM. She stated that she did transport Resident #20 to the hospital and then back to the facility without the seat belt around her waist or her upper torso. She stated that she was already running late and she had to get the resident to the hospital for a scheduled surgery. She stated, I understand that is not a good reason and I realize the seat belt should always be on. The transport aide #3 stated that the seat belt was not broken and she would from now on transport all residents in the transport chair because it has a seat belt attached. Resident #20 was interviewed on 3/22/16 at 9:50 AM. She stated she had been transported by the facility's van twice in the last month; once for a physician's appointment and once to the hospital for a procedure. On both trips, the resident stated NA #3, the van driver, had secured her wheelchair to the floor of the van, but did not apply a seat belt across her upper torso and waist to secure her into the wheelchair. Resident #20 stated she was alarmed there was no seat belt and asked NA #3 why she had not placed a seat belt, adding NA #3 told her the van seat belt was broken. Per the facility's transportation log, the resident was transported to a physician's appointment on 3/3/16 and to the hospital for a procedure on 3/11/16. The Maintenance Supervisor (MS) was interviewed on 3/22/16 at 10:24 AM. The MS stated it was his responsibility to maintain service of the van. He added if there were any problems, these problems were communicated to him by NA #3, who drove the van. The MS added he had received no reports of the seat belts not working properly on the van. He added he completed a weekly safety check list in which the seat belts were checked for any problems. The MS added while checking the seat belts was part of the weekly check, no other staff person had specifically asked him to check the seatbelts related to any malfunction. Resident #20's family member was interviewed by phone on 3/22/16 at 10:57 AM. He stated while he did not observe how Resident #20 was transported to the hospital on [DATE], he was there when the driver, identified as NA #3, placed her in the van for the trip back to the facility. The family member stated the 4 harnesses were placed on the wheelchair to secure the wheelchair to the van floor, but NA #3 had not placed the seat belt around Resident #20's waist or upper torso. When NA #3 had been asked why she was not using the seat belt, the family member replied the NA told him the seat belt was broken and had been broken for a while. The family member was concerned if there had been a wreck, Resident #20 would have become a projectile, adding not using the seat belt was a very unsafe practice. The family member stated while he had no previous observations, his mother had relayed to him she had been transported before without NA #3 using the seatbelt. NA #3 was interviewed on 3/22/16 at 11:09 AM. She stated the last day she drove the van was on 3/18/16 and added she had been relieved of her duties as facility van driver because she had not secured Resident #20 into the van using a seat belt. She stated on 3/11/16, Resident #20 had a 6:30 AM hospital appointment. When she arrived at the facility at 6:15 AM, Resident #20 was not up or dressed. She stated after helping the resident to dress, they were running behind for the 6:30 AM appointment and she did not have time to place the seat belt. NA #3 acknowledged she had not placed the seat belt around Resident #20 for the return trip to the facility adding she had no excuse for not placing the seat belt on the return trip. She denied she had transported residents before 3/11/16 without a seat belt. NA #3 stated she had received training prior to driving the van from the previous van driver and the previous facility administrator. She added while both of these people had trained her to use the straps to secure the wheelchair to the floor of the van, they had not taught her how to use the seat belts. NA #3 stated another person had also trained her and made sure she could use both the straps to secure the wheelchair to the van floor and the seat belts correctly. NA #3 stated prior to transport she was not informed of any resident's [DIAGNOSES REDACTED]. She stated she knew Resident #20 had a [DIAGNOSES REDACTED]. She added she knew if there had been a wreck, Resident #20 could have been seriously injured without being secured with seatbelts. NA #3 added she knew seatbelts were legally required and stated she had no good excuse for not using the seatbelts. NA #3 stated when Resident #20 and the family member inquired about why the seat belt was not being used, she had not offered to hook the seatbelt and only pointed to the box where the seat belts were stored. She denied telling the resident and family member the seatbelt was broken. At 11:28 AM on 3/22/16 an observation was made of NA #3 hooking a wheelchair to the van with a surveyor seated in the wheelchair. The wheelchair was secured to the van floor using a 4 point strap restraint. She then took the part of the seatbelt, that was hanging from the left side of the van from near the ceiling that extended across the resident's lap, placing the upper torso strap under the arm of the chair so that both parts extended across the surveyor's lap. Both of the straps were twisted several times. The NA picked up another part of the seatbelt out of a box on the right floor of the van and hooked the hanging part that went across the resident's lap to the part taken from the box. The NA found it difficult to find the right slot in the floor into which to put the end of the seatbelt and acknowledged that was one reason why she had not used the seatbelt. The NA stated she was unsure if she had the right size part taken from the box and added she was unsure what the pieces in the box were used for. She stated since training back last June, no one had observed her securing a resident prior to transport. The NA added even during training, she had restrained her instructor and no one had ever observed her securing a resident in the van for transport. After the NA had completed securing the surveyor in the chair, the surveyor was able to slide down with the seatbelt ending up at mid abdominal area. The surveyor was able to almost able to stand up with the seat belt fastened. The Administrator was interviewed on 3/22/16 at 12:34 PM. The Administrator stated she first became aware NA #3 was transporting residents without a seatbelt when the surveyor brought it to her attention on Friday, 3/18/16. She stated Resident #20, her family members or staff had not mentioned their concern about the lack of using a seatbelt to her before. On finding out NA #3 had not used the seatbelt during Resident #20's transport, the Administrator stated she immediately suspended the NA from transporting residents, filed a 24 hour report alleging resident neglect which had been faxed on 3/19/16 at 3:59 AM. Arrangements were made to use outside services for resident transportation. The Administrator stated she was unsure if other staff were qualified to use the van, but the van was parked and not being used. The Administrator stated she had expected NA #3 to have used the seatbelt since lack of a seatbelt could have caused endless dangers including resident injury. The Business Office Manager (BOM) was interviewed on 3/22/16 at 12:51 PM. She reported there was no operator's manual for the lift, securing a wheelchair to the van floor or the use of the seatbelts in the van since the facility utilizes several different vans and several different lift systems. The BOM added the corporate trainer had received his training directly from the manufacturer and came to the facility to provide 1:1 training. She added if there was an issue and the van driver needed information on how to hook up something, the expectation was to call the corporate trainer. The Director of Nursing (DON) was interviewed on 3/22/16 at 1:00 PM. She stated she first became aware NA #3 had been transporting residents without using a seatbelt on Friday, 3/18/16, when the surveyor and she spoke with NA #3. The NA admitted she had not used a seatbelt while transporting the resident for her 3/11/16 appointment. After the conversation, NA#3 went home and then the DON stated she called the NA back as part of the 24 hour investigation. The NA acknowledged she was in a rush, and had not wanted to be late to Resident #20's appointment and therefore she failed to use the seatbelt on Resident #20. For the trip back, there was no reason given by the NA for not using the seatbelt. Later that night, a 24 hour report was faxed and the NA was suspended for 3 days while a discussion was with the Corporate Risk Management and a nurse consultant to determine if NA #3 would be allowed back. The DON stated she had called NA #3 on Saturday night to tell her of her suspension, but since the NA had not called back, she was notified of the suspension on Sunday morning at 7:00 AM when she arrived for work. An administrative decision was made not to transport residents using the facility van and an outside transportation company would be used until someone could be hired and trained. The DON stated she was still investigating the concern of not using seat belts and had not talked to other alert and oriented residents the NA may have transported to see if NA #3 had used a seat belt while transporting other residents. The DON stated it would have been important to validate the NA's story that she had failed to use the seatbelt on other residents, but she had not done so because she had worked the 11 to 7 shift on Saturday night and failed to ask for assistance with the interviews. She stated she had accepted what the NA had told her about always using the seatbelt on all residents except Resident #20. She stated no one from the facility had interviewed Resident #20; adding the facility staff had heard from the surveyor on 3/18/16 that Resident #20 stated the seatbelt was broken. The Administrator and the DON were notified of the Immediate Jeopardy on 3/22/16 at 3:50 PM. On 3/23/16 at 3:15 PM, the facility provided the following credible allegation: Corrective Action for Affected Residents The nursing home investigated allegations that the facility van seatbelt was broken starting on 3/18/16 and ending 3/23/16. NA #3 was interviewed by the state surveyor and the Director of Nursing on 3/18/16 and confirmed that the seatbelt was not broken but that she did not utilize the seatbelt in the company van when transporting Resident #20. Resident #20 did not receive any physical injuries related to the event. On 3/18/16 the administrator observed the seat belt was in good repair and not broken. On 3/19/16 a 24 hour report of neglect was submitted by the Director of Nursing to the Healthcare Personnel Registry. A phone call was made on 3/19/16 to Employee #3 informing her that she needed to contact the Director of Nursing prior to returning to work. All company van transportations by any employee were suspended by the administrator on 3/19/2016 until another van driver can be hired and trained. Commercial transportation companies will be used to scheduled necessary transports for the facility. After review of the incident, it was decided that the employee would be removed from transportation duties permanently but would be allowed to continue employment as a nursing assistant. She returned to work on 3/22/16 but was dismissed early pending further investigation. Employee #3 was moved to the duties of transportation aide and central supply on 2/12/15. She received training from the corporate van trainer on 4/29/15 according to the sign and dated skilled checklist. Prior to the corporate training she was trained by the previous transportation aide and the administrator. Both had been trained by the corporate van trainer. They did not complete a skills checklist for this training. The corporate van trainer has received training directly from van products. He utilizes the training he received, manufacturer guidelines, and a skills checklist to educate. A skills validation is also completed where the staff member must demonstrate the skills appropriately. The only other employee who transports is the Social Worker. She was also trained and has a skills checklist dated 1/26/12 originally but received retraining in using the process outlined above on 4/29/15. She was re-educated by the corporate van trainer on 8/22/15 also. The transportation aides' direct supervisor is the Administrator. Corrective Action for Potentially Affected Residents All residents who have been transported by employee #3 in the company van have the potential to be affected by this alleged practice. On 3/22/16 the Director of Nursing, Administrator, Social Services and Support Nurse interviewed alert and oriented patients who had been transported by employee #3 from 2/2/16 to 3/22/16. 12 residents were transported. 4 residents were not able to be interviewed and 2 stated that they were not sure if the seatbelt was utilized. 5 stated they did not remember a seatbelt being used during transport 1 stated the seatbelt was not used. Systematic Changes A new transportation aide will be hired and trained by the corporate van trainer prior to any patient being transported using the only facility owned van. This new employee and any other facility staff that may transport patients in the van will be trained. No employee who has not been trained by the corporate van trainer will be allowed to transport until this training (including the completion of a skills checklist) is complete. The van training will include proper securing of a wheelchair in the facility van and the utilization of seatbelts for all transports according to the manufacturer ' s guidelines. If securing belts, hooks or seat belts are in disrepair the transportation will be rescheduled and the van will not be utilized until repairs can be made. The transportation checklist will also be utilized to remind staff to properly secure the wheelchair and to use a seat belt. A van inspection will also be conducted by the corporate van trainer prior to any patient transport to ensure that all latches, hooks and belts are in proper working order. Additionally, the skills checklist includes secure resident for transport with approved system safety device . This was updated on 3/23/16 to read: secure resident for transport with approved system safety device which includes: using the seat belt to secure the person and using approved safety straps, belts and hooks to secure the chair. Investigations of all incidents involving transportation by the facility van will be completed by the Administrator and Director of Nursing as soon as the allegation or issue is identified. The investigation will include interviewing the resident involved, employee involved, other possible witnesses, and other potentially affected patients. During the investigation the employee will be notified promptly that they are suspended until the investigation is completed. Disciplinary actions will remain at the discretion of the administrator and will be dependent on the nature of the allegation and investigation findings. However, if the allegations are substantiated a 3 working day suspension will be implemented. The Credible Allegation was validated on 3/23/16 at 3:15 PM when the Administrator and the Director of Nursing validated they had been made aware the facility van was no longer to be used for resident transport. During an interview with Nurse #3, she validated all staff had been made aware the facility van would not be used for resident transportation and the facility would be using an outside transport agency when residents were scheduled for appointments.

Based on staff interviews and record reviews the facility failed to failed to prevent weight loss for 1 (Resident #42) of 2 residents with weight loss. Resident#42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident#42 required some assistance with meals and was not on a prescribed weight loss plan. She was also at a low cognitive level. The Care Area assessment dated [DATE] indicated Resident #42 triggered for nutrition and pressure ulcer risk. These two risk areas were to be care planned. The care plan problem onset dated 8/3/11 for nutrition indicated Resident #42 only ate preferred foods associated with the dislike of the therapeutic diet. The goal was continued on 6/27/12 to follow the therapeutic diet of no added salt for the next 90 days. A record review of the facility weights was reviewed. The weights for Resident #42 was the following: 192 lbs (10/19/11), 191 lbs (11/1/11), 192 lbs (12/12/11), 170 lbs (1/24/12), 168 lbs (2/16/12),163 lbs (3/6/12), 156 lbs (4/10/12), 156 lbs (5/8/12) and 155 lbs (6/1/12). There was a greater than 10% weight loss in one month for January 2012. A record review of the facility nurse notes was conducted. The note dated 1/26/12 indicated the physician had called the facility and asked about Resident #42 eating the last few days due to Resident#42 family member had called the physician about Resident #42 appetite. The note dated 1/27/12 indicated Resident #42 had eaten only 25% of her meal and was drowsy. The family member was concerned about Resident#42 changes and poor appetite. There was a fax sent to the physician about this concern. A record review of the facility physician orders [REDACTED]. A record review of the facility weekly wound review assessment was conducted. It indicated a new wound was acquired in the facility on 2/7/12. The wound was located on the left buttock. It was a stage II wound. A record review of the facility nursing remarks document dated 2/16/12 revealed a report of a low appetite and constipation to the physician. A record review of the facility nutrition notes was conducted. The nutrition note dated 10/19/11 revealed Resident #42 weight at 192 lbs. There was a recommendation of a protein liquid of 30 milliliters (ml) once daily due to a low [MEDICATION NAME] level of 2.8. The note dated 2/22/12 indicated a current body weight of 168 lbs. There was a decubitus to the buttocks area at stage II. The diet was a no added salt diet. There was a recommendation of a high calorie nutrition supplement at 60 ml twice daily. This was to aid in the prevention of significant weight loss. The nutrition assessments dated 3/20/12 and 6/6/12 indicated there was weight loss over the last six months. The Registered Dietitian and Physician were made aware and there were recommendations. The facility nutrition notes dated 5/25/12 revealed Resident #42 current body weight was 156 lbs. There was significant weight loss indicated for the three and six month periods. There was a recommendation to liberalize the diet to a regular diet. A record review of the facility medical nutrition therapy recommendation document dated 2/22/12 revealed a recommendation of a high calorie nutrition supplement at 60 ml twice daily due to a decrease in food and beverage intake and risk for weight decrease. The recommendation was approved by the physician on 2/29/12. A record review of the physician orders [REDACTED]. A record review of the physician orders [REDACTED]. A record review of Resident #42 meal ticket dated 6/28/12 dinner meal revealed a no added salt diet was served. An interview with the Dietary Manager (DM) on 6/28/12 at 3:15 pm revealed Resident #42 had significant weight loss in the last nine months. She notified the Registered Dietitian (RD) in January 2012 of the significant weight loss. She would usually call the RD when there was a weight loss. The RD visits the facility monthly. The DM indicated she would do nutrition intervention in between the RD visits. There was a nutrition shake started three times daily but Resident #42 did not drink it. This nutrition shake was stopped. Resident #42 never indicated why she did not like her no added salt diet. She had started snacks three times daily but Resident #42 did not eat the snacks. She then had stopped the snacks. The DM did not have documentation of the snacks or nutrition shakes that were started. An interview with the RD on 6/28/12 at 4:57 pm revealed Resident #42 had significant loss the last 180 days and she had recommended a high calorie supplement back in February 2012. When she had visited in May 2012, she saw another decline in weight status and recommended to liberalize Resident #42 diet to a regular diet. When she visits monthly, the DM would provide her with a list of people with significant weight loss and dietary consults. The Quality of Life (QOL) team would meet weekly and discuss residents with weight loss between her monthly visits. The QOL team would do nutrition interventions between her visits. A record review of the facility weekly QOL committee minutes was reviewed. Resident #42 was discussed on 1/16/12, 2/29/12, 3/15/12, 3/23/12, 3/30/12, 4/5/12, 4/13/12, 4/19/12, 5/4/12, 5/10/12, 5/18/12 and 5/31/12. The meeting dated 2/29/12 indicated a weight of 161 lbs. There was indication of a multivitamin in place. The meeting dated 3/15/12 and 3/23/12 did not indicate interventions. The meeting dated 3/30/12 indicated a weight status of 159 lbs. There was a recommendation for a liquid protein and high calorie supplement. The meeting dated 4/5/12 indicated a facility medical recommendation on 3/6/12 for a liquid protein supplement at 30 ml and high calorie supplement 60 ml twice daily. It indicated this recommendation was faxed on 4/2/12 for the third attempt and for the physician to respond. The meeting dated 4/13/12 indicated the weight status was at 156 lbs. The protein liquid and high calorie supplement had started. An interview with the Administrator and QA Nurse Consultant on 6/29/12 at 11:38 pm revealed they started to conduct daily clinical meetings to review weights. There were trials of this meeting which started in March 2012 and officially started 6/11/12. There was weekly and monthly QOL meetings where weight loss and nutrition problems were discussed. Then there would be a Quarterly QOL performed for weights as well. The Social Worker, DM, Director of Nursing (DON), Administrator and other Administrative staff attended these meetings. An interview with the DON and Administrator on 6/30/12 at 12:12 pm revealed they have the new daily QOL meetings now to address weight concerns more quickly. They would expect to have nutrition intervention for significant weight loss immediately.