Every finding on record at Little River Nursing & Rehab

Based on record review, interview, and facility policy review, the facility failed to ensure (1) gradual dose reductions (GDR) were attempted for psychotropic (anti-anxiety) medications in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days, (2) to ensure a documented explanation as to why a dose reduction attempt would be contraindicated, (3) and a duration for continuation, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1 sampled (Resident # 25) of 5 resident sampled for unnecessary medications. The findings include: 1.The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2025, indicated Resident #25 had diagnoses of heart failure, chronic obstructive pulmonary disease, non-Alzheimer's dementia, scored 10 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS), and received antianxiety (mind altering), antidepressant (mind altering) and hypnotic (mind altering) medications. a. The Care Plan with a revision date of 07/05/2024, indicated Resident #25 used antianxiety medications related to anxiety and staff should monitor for any side effects to medications. b. A Physician's Order dated 05/24/2024, indicated, [Brand name anti-anxiety medication] Oral Tablet 0.5 MG (milligrams) *Controlled Drug* Give 0.5 mg by mouth every 12 hours as needed for Anxiety. c. The form titled Consultant Pharmacist Medication Regimen Review (MRR) dated 10/28/24, indicated Resident #25 had an order for [Name brand anti-anxiety medications] 0.5mg every 12 hours as needed for anxiety since May 2024. The form indicated CMS (Centers for Medicare Services) regulations limit the use of as needed psychotropic (drugs that effect a person's mental status) to 14 days. The form indicated that if the physician believed it was appropriate for the as needed medication to be continued for greater than 14 days, to document the rational and duration for continuing the medication in the medical record. This form was signed by the APN (Advanced Practice Nurse) on 11/10/2024, indicated no change and the clinical rational for continuing was documented below. The only notation on the form after the APN wrote an x next to no change was that the medication should be continued per family. d. On 01/24/2025 at 8:45 AM, the Director of Nursing (DON) was shown the pharmacy consultant MRR recommendation for 10/28/2028, for Resident #25 and confirmed the form did not show the reason or duration for continuing the medication as needed past 14 days. DON was asked if the clinical rational and duration for use of the as needed [Name brand anti-anxiety medication] was documented anywhere else in Resident #25's medical record and DON stated they would look and let the surveyor know. e. On 01/24/25 at 11:20 AM, the DON provided a form titled Letter of Necessity dated 1/24/2025, and signed by the Advanced Practice Registered Nurse (APRN) that indicated the as needed [Name brand anti-anxiety medication] was required to treat anxiety, and Resident #25 should remain on the medication long term for further occurrences of anxiety. The DON was asked if they had found anything in Resident #25's record regarding the pharmacy consultants October 28th recommendation, indicating the clinical reason and duration for continuing the residents as needed [Name brand anti-anxiety medication]. The DON stated that they had not. f. On 01/24/25 at 11:30AM, the DON was asked if the facility had a policy on medication administration. g. On 01/24/25 at 11:55 AM, the policy titled Medication Therapy provided by the DON indicated each resident's medications should include only those medications necessary to treat existing conditions and address significant risks. Medications should be reviewed periodically for continued indications, proper dosage, duration, and possible adverse consequences. The physician will identify situations where medications should be tapered, discontinued or changed to another medication, for example when medications are given in excessive doses, for extensive periods of time, or in the absence of a valid clinical rational.

Based on record review, observation, and interviews, the facility failed to ensure the Comprehensive Care Plan contained the necessary information to fully provide and coordinate care and services for a resident with a stage 3 pressure ulcer for 1 (Resident #39) of 1 sampled resident reviewed for pressure ulcers. The findings are: 1. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025, indicated Resident #39 had diagnoses of Parkinson's disease, pain, depression, had scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), and had one stage 2 pressure ulcer (A Stage 2 pressure ulcer presents with partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.). a. The Care Plan with a revision date of 12/26/2024, did not indicate the presence of, or care instructions for, a pressure ulcer. b. A Physician's Order dated 01/21/2025, indicated cleanse right gluteus with normal saline, pat dry. Apply collagen sheet and cover with dry dressing daily and PRN (as needed) until healed, every day shift for pressure injury until 02/07/2025. c. The form titled Skin and Wound Evaluation dated 01/22/2025, indicated Resident #39 had a stage 3 pressure ulcer to the coccyx (tail bone) that was acquired while in the facility on 12/26/2024. d. On 01/23/25 at 2:20 PM, the Minimum Data Set (MDS) Coordinator confirmed that Resident #39 had a pressure ulcer and had Physician's Orders for wound care since 12/26/24. The MDS Coordinator looked in the electronic record and confirmed Resident # 39's Care Plan did not address the pressure ulcer and since the care plan was how staff knew the goal and interventions for care, this should have been included. The MDS Coordinator was asked if the facility had a policy on care plan. The MDS Coordinator stated she would check and see. e. On 01/23/25 at 2:30 PM, the Director of Nursing (DON) confirmed that Resident #39 had a pressure ulcer and after looking in the electronic record stated the resident had the pressure ulcer since 12/26/24. When asked if Resident #39 ' s Care Plan should address the pressure ulcer, the DON stated the pressure ulcer should be on the care plan so that everyone was on the same page, and Resident #39 was given the care to get the pressure ulcer healed. f. On 01/23/25 at 5:00 PM, the policy titled Care Plans, Comprehensive Person-Centered provided by the MDS Coordinator indicated that the Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident. The care plan will describe the services to be furnished so the residents can attain or maintain their highest practicable physical, mental, and psychological well-being.

Based on observation, interview, and record review, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; failed to ensure food items were dated; ensure leftover food items were used properly to maintain food quality; dietary staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination; and failed to ensure meat items stored in the refrigerator were covered or sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, to ensure 1 ice machine and 1 scoop holder were maintained in clean and sanitary condition to prevent contamination of airborne particles; foods stored in the dry storage area refrigerator and freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; ceiling tiles, vents and walls were free of chips, stains, dust and rust and were maintained in clean sanitary conditions. These failed practices had the potential to affect 76 residents who received meals from 1 of 1 kitchen (Total Census:77. The findings are: 1. On [DATE] at 10:00 AM, the following observations made in the kitchen were: a. An opened box of cream of wheat was on a shelf above the food counter. The box was not covered. b. Two opened boxes of corn starch were on a shelf above the food preparation counter. Neither box was covered or sealed. 2. On [DATE] at 10:01 AM, the following observations were made in the walk-in refrigerator: a. Slices of white cheese in plastic wrap were not sealed. b. Slices of yellow cheese were in plastic wrap on a shelf in the refrigerator not sealed. c. Two opened bags of corn tortillas were on a shelf in the walk-in refrigerator. The bags were not sealed. d. An opened box of sausage was on a shelf in the refrigerator. The box has no date when it was opened. e. A container of chopped garlic was on a shelf in the walk-in refrigerator with an expiration date of [DATE]. f. One container of chopped garlic was on a shelf in the refrigerator with an expiration date of [DATE]. g. Two containers of chopped garlic in water were on a shelf in the refrigerator with an expiration date of [DATE]. h. An opened container of cottage cheese was on a shelf in the walk-in refrigerator with an expiration date of [DATE]. i. An opened container of coleslaw was on a shelf in the walk-in refrigerator, there was no received date on the container to indicate when it was received. j. There was a pan of leftover pureed eggs, a pan of pureed sausage, a pan of regular sausage and regular scrambled eggs were on a shelf in the walk-in refrigerator. The Surveyor asked the Dietary Supervisor what they used leftover pureed and whole sausage food items for. The Dietary Supervisor stated, We use them the next day for the pureed and for the ones on mechanical soft diets. 2. On [DATE] at 10:20 AM, the following observations were made in the walk-in freezer: a. An opened box of breaded hot squares was on a shelf in the freezer. The box was not covered and the bag inside was not sealed. b. An opened box of steak fingers was on a shelf in the walk-in freezer. The box was not covered or sealed. c. An opened box of salt was on a shelf above the food preparation counter. The box was not covered and there was no date on the box to indicate when it was opened. 3. On [DATE] 10:25 AM, the following spices and food items on a shelf above the food preparation counter did not have an opened or received date: a. A container of ground cinnamon. b. A container of ground black pepper. c. A container of Italian seasoning. d. A bag of gluten free bread did not have opened or received date. e. An opened box of cornstarch. The box was not covered or sealed, and no date of when it was opened. f. A container of ground nutmeg. 4. On [DATE] 10:27 AM, the following observations were made on a shelf above the food preparation counter. a. Two opened boxes of baking soda. The boxes were not covered or sealed, and there was no date on the boxes. b. A can of protein supplement was on shelf above the food preparation counter with an expiration date of [DATE]. 5. On [DATE] at 10:38 AM, 17 fruit yogurts were on a shelf in the refrigerator with an expiration date of [DATE]. 6. On [DATE] at 10:41 AM, an opened box of corn was on a shelf in the freezer. The box was not covered or sealed. 7. On [DATE] 10:42 AM, the following observations were made on a shelf in the freezer: a. An opened bag of fries was on a shelf in the freezer. The bag was not sealed. b. An opened box of chicken nuggets was on a shelf in the freezer. The box was not covered or sealed. c. An opened bag of chicken nuggets was on the shelf in the freezer. The bag was not covered or sealed. d. An opened box of corn on the cob was on a shelf in the freezer. The box was not covered or sealed. e. An opened box of mini waffles was on a shelf in the freezer. The box was not covered or sealed. 8. On [DATE] at 10:44 AM, the ice machine panel in the kitchen had wet light brown residue on it. The Surveyor asked the Dietary Supervisor to wipe the panel. The light brown residue easily transferred to the tissue. The Dietary Supervisor was asked to describe what had transferred to the tissue and stated, It was light brown residue. The Surveyor asked, Who uses the ice from the ice machine? The Dietary Supervisor stated, We use it to fill beverages served to the residents at mealtimes. We clean it 2 times a month. 9. On [DATE] at 11:00 AM, the following observations were made in the kitchen: a. The ceiling air vent above the food preparation counter had black grease residue on it. b. Ceiling tile around the vent had dust on it. c. The ceiling air vent in the dish washing machine room had rust, black residue, and dust. There was dust on the ceiling tile from the air vent. d. The ceiling air vent above the steam table and by the door leading to the dining room from the kitchen have rust, black stain, and buildup of dust around the air vent. e. The ceiling air vent by the 3-compartment sink had rust, dirt, and dust buildup on it. 10. On [DATE] at11:05 AM, Dietary Employee (DE) #1 was wearing gloves and turned on the 3-compartment sink faucet and washed the blender bowl. After washing the bowl and the blade, a gloved hand was used to turn off the sink, contaminating the gloves. Without washing hands or changing gloves, the contaminated gloved hand was used to attach the blade to the base of the blender to be used in pureeing food items to be served to the residents for lunch. 11. On [DATE] 11:09 AM, the wall above the dish machine was chipped, exposing the concrete, and had stains. 12. On [DATE] at 11:12 AM, the following observations were made in the storage room: a. An opened box of fish fry breading was on a shelf in the storage room. b. An opened box of rice was on a shelf in the storage room. The box was not covered or sealed. 13. On [DATE] at 11:35 AM, the ice machine panel in the room on the 300 Hall had wet, yellow residue on it. The Surveyor asked the Dietary Supervisor to wipe the panel. The wet black residue easily transferred to the tissue. The Dietary Supervisor was asked to describe what had transferred to the tissue and stated, It was black residue. The Surveyor asked, Who uses the ice from the ice machine and how often do they clean the ice machine? The Dietary Supervisor stated, The maintenance man cleans it once a month. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. 14. On [DATE] at11:37 PM, the ice scoop holder on the counter in a room on the 300 Hall by the ice machine had water standing in it. There was white residue floating in the water and the ice scoop was in direct contact with the residue. The Surveyor asked the Dietary Supervisor to wipe the inside of the ice scoop holder, who did so and stated it was white residue. The Surveyor asked how often they cleaned the scoop holder. The Dietary Supervisor stated, 10 to 6 shift CNAs bring ice scoop holder to dietary once a week for dishwasher to clean when they arrive. 15. On [DATE] at 11:40 AM, the ceiling air vent above the ice machine had rust and dust on it. The ceiling tile around the vent was loose, exposing the cement, there was dust around the vent. 16. On [DATE] at 12:02 PM, DE #2 who was on the tray line serving lunch meal was wearing gloves. DE #2 picked up tray cards and placed them on the trays. Without changing gloves and washing hands, DE #2 picked up plates to be used in portioning food items to be served to the residents for lunch and placed them on each tray with fingers touching the inside of the plates. The Surveyor asked DE #2 what should you have done handling dirty objects and before handling food items and dirty clean equipment? DE #2 stated, I should have changed gloves and washed my hands. 17. On [DATE] at12:16 PM, DE #1 was wearing gloves when he/she turned on the hand washing sink and rinsed a tomato. After rinsing the tomato, DE #1 turned off the sink faucet. DE #1 then placed the tomato on the cutting board to cut. When DE #1 was ready to slice the tomato, the Surveyor asked, what should you have done after touching dirty objects and before handling food items and clean equipment? DE #1 stated, Change gloves and wash my hands. 18. A facility policy titled, Hand Hygiene Policy and Procedure, provided by the Dietary Supervisor on [DATE] at 01:18 PM documented, Indications for hand washing. After contact with inanimate objects. And after removing gloves.

Based on record review and interview, the facility failed to ensure a resident or residents' representative was provided in writing the notice of discharge including the contact number for the Office of Long Term Care (OLTC) as required for 2 (Resident # 30, #183). This failed practice had the potential to affect 2 sampled residents that received a 30-day notice of intent to discharge in the last 120 days. The findings are. 1. Resident # 30 had diagnoses of Alzheimer's disease, Depression, and Insomnia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/12/23 documented that the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview or Mental Status (BIMS). a. On 02/28/2024 at 01:38 PM, the Administrator provided a copy of the 30-Day Notice of Intent to Discharge that was delivered to the son of Resident #30 on 01/13/2024. b. On 03/01/24 at 10:53 AM, #30's 30-Day Notice of Intent to Discharge did not include the contact number for the OLTC. 47916 2. Resident #183 had diagnoses of Dementia, Anxiety disorder, and Senile degeneration of brain. The Quarterly MDS with an ARD of 12/14/2023 documented a BIMS of 05 (0-7 indicates severe cognitive impairment). a. On 02/28/2024 at 01:38 PM, the Administrator provided a copy of the 30-Day Notice of Intent to Discharge that was delivered to the son of Resident #183 on 01/17/2024. b. On 03/01/2024 at 11:00 AM, Resident #183's 30-Day Notice of Intent to Discharge did not include the contact number for the OLTC. c. On 03/01/2024 at 11:11 AM, the Administrator was asked to review the 30-Day Notice of Intent to Discharge sent to Residents #30 and #183. The Surveyor asked who prepared the documents and the Administrator said, Our lawyer. The Administrator was asked to look at the contact information for the OLTC and she confirmed that the contact information should have included the contact phone number for the OLTC with both notices. The Surveyor asked the possible outcome of the contact phone number for the OLTC being left off the documents. The Administrator told the Surveyor that they would not know how to contact the Office of Long-Term Care. d. On 03/01/2024 at 11:44 AM, The Surveyor asked the Director of Nursing (DON) for discharge/transfer policies and the DON provided a policy titled Admission, Transfer, and Discharge Rights documenting .Policy: Federal and State law guarantees residents or potential resident certain rights as related to their admission, transfer of discharge from a skilled nursing facility .Notice Before Transfer .(4) a statement of the residents appeal rights, including the names, addresses, and telephone number of the Office of Long Term Care . e. On 03/01/2024 at 11:53 AM, the Administrator told the Surveyor that she checked her template and realized that she had inadvertently left off the contact phone number for the Office of Long-Term Care, so it was not the lawyers fault the phone number was left off the 30-Day Notice of Intent to Discharge.

Based on observation, record review, and interview, the facility failed to ensure there was a physician's order for oxygen for 2 (Resident #16 and #58) sampled residents, failed to ensure an oxygen in use sign was on the residents door for 1(Resident #68) sampled residents, and failed to ensure that humidifier bottles, tubing, and masks were dated and stored correctly for 2 (Resident #16 and #34) sampled residents to reduce the potential for respiratory complications. This failed practice had the potential to affect 16 residents that were receiving oxygen therapy. The findings are: 1. Resident #58 had diagnoses of Cancer, Respiratory failure, and Pulmonary embolism. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/5/2024 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and used oxygen therapy. a. On 02/28/24 at 07:40 AM, Resident #58 did not have an order for oxygen therapy. b. On 02/26/24 at10:54 AM, Resident #58 was receiving oxygen at 4 liters per nasal cannula. When asked, the resident reported using oxygen most of the time. c. On 02/27/24 at 12:02 PM, Resident #58 was receiving oxygen at 4 liters per nasal cannula. d. On 02/28/24 at 08:35 AM, Resident #58 was receiving oxygen at 4 liters per nasal cannula. e. On 02/28/24 at 10:25 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, does [Resident #58] use oxygen? LPN #1 stated, Yes. LPN #1 was asked, What is [Resident #58's] oxygen flow rate set on? LPN #1 stated, It is set on two liters, but I will double check to be sure. The Surveyor asked, do you see an order for oxygen in the resident's record? LPN #1 stated, I do not see one, but I could be overlooking it. LPN #1 was asked, Should there be a physicians order for oxygen use? LPN #1 stated. Yes. LPN #1 was asked who was responsible for ensuring there is an order for oxygen use? LPN #1 stated, All the nursing staff are. The DON [Director of Nursing], floor nurse or any nurse providing care. LPN #1 was asked does Resident #58 have a care plan for oxygen use. LPN #1 stated, I can see it under his/her care profile. The Surveyor directed LPN #1 to the part of the electronic record that said care plan and LPN #1 stated, I do not usually look there I look at the care profile and it states oxygen at 2 liters per minute nasal cannula. LPN #1 was asked to accompany the Surveyor to Resident #58's room and was asked, what is Resident #58's Oxygen set at? LPN #1 looked at the flow rate on the oxygen concentrator and stated, It is set at four liters. I am going to turn it down to where the profile says it should be and I am going to call the doctor and verify what the flow rate should be. 2. Resident #68 had diagnoses of Heart Failure, Atrial Fibrillation, and Diabetes Mellitus. The Admission MDS with an ARD of 02/05/2024 documented that Resident #68 scored 15 (13-15 indicates cognitively intact) on the BIMS. a. A Physician's Order dated 02/15/24 documented, .O2(Oxygen) via (by) NC (Nasal Cannula) at 2LPM (Liters Per Minute) to keep O2 saturation levels above 92% PRN (as needed) as needed for O2 below 92% related to ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE . b. On 02/26/24 at 10:56 AM, Resident #68 was receiving oxygen at 2 liters per nasal cannula. There was no Oxygen in Use sign on the door. c. The Care Plan with an initiation date of 2/20/24 documented, .The resident has Congestive Heart Failure .New Goal: The resident will verbalize less difficulty breathing (Dyspnea) and be more comfortable through the review date .New Intervention: .OXYGEN SETTINGS: O2 via NC @ 2LPM PRN to keep sats 92% or above . d. On 02/27/24 at 11:05 AM, Resident #68 was in their room receiving oxygen at 2 liters per nasal cannula. The resident was asked, how often do you use your oxygen? Resident #68 stated, I have been using it all the time for the past few days. There was no sign on the door stating, Oxygen in use. e. On 02/28/24 at 10:20 AM, Resident #68 was in their room receiving oxygen at 2 liter per nasal cannula. There was not an Oxygen in Use sign on the resident's door. f. On 02/28/24 at 10:30 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, does Resident #68 use oxygen? LPN #1 stated, Yes. LPN #1 was asked, is there a sign on Resident #68's door stating oxygen in use? LPN #1 looked at Resident #68's door and stated, No. LPN #1 was asked, Should there be a sign on the resident's door if oxygen is in use? LPN #1 stated, Yes. LPN #1 was asked, why is it important that there is a sign on the resident's door stating oxygen in use? LPN #1 stated, It is important, so others know that oxygen is being used. There are certain things like lip protectives that you cannot be used with oxygen and nothing flammable should be taken near oxygen. LPN #1 was asked, who is responsible for ensuring there is a sign on the door when oxygen is being used? LPN #1 stated, I believe the nurses are responsible. g. On 02/29/24 at 12:05 PM, the Surveyor asked the Director of Nursing (DON), should there be signage posted on Resident's door when there is oxygen in use? DON stated, yes. The Surveyor asked the DON, why is it important to have signage posted? The DON stated, So that everyone knows oxygen is in use and there is nothing flammable. The Surveyor asked the DON who is responsible for ensuring that signage is posted? The DON stated, Me. 47916 3. Resident #16 had diagnoses of Chronic Systolic Heart Failure, Atrial Fibrillation, and Peripheral Vascular Disease. The Significant MDS with an ARD of 12/21/2023 documented a BIMS score of 12 (8-12 indicates moderate cognitive impairment). a. The Paper Care Plan for Resident #16 dated 11/24/2023 documented, .Resident has potential for difficulty breathing related to chronic condition CHF (chronic heart failure) .Administer/monitor effectiveness of treatments (see current physicians orders) Oxygen .Change oxygen tubing, water and clean oxygen filter per facility policy. A Care Plan: (Dated 12/27) documented, .albuterol nebulizer per order Ipratropium-Albuterol per order. b. On 02/26/24 at 10:57 AM, the Surveyor observed the concentrator was turned off, humidifier bottle not dated, tubing dated 02/26/2024. Resident #16 reported wearing oxygen at night. c. On 02/26/24 at 11:08 AM, Resident #16's family member was present and said the resident had Congestive Heart Failure and had had 5 bypasses. He wears oxygen at night . I am not sure how much. d. On 02/27/24 at 07:13 PM, per record review of Resident #16's weights and vitals, on 02/20/24 at 11:45 PM, Resident #16's oxygen saturation was 97% on Oxygen via nasal cannula. Oxygen was documented from 12/13/2023-02/20/24. The Surveyor did not find a physician's order for oxygen or Ipratropium-Albuterol. e. On 02/27/24 at 07:13 PM, the Significant Change MDS with an ARD of 12/21/2023, and the End of PPS Part A MDS with an ARD of 01/12/2024 indicated no oxygen therapy. f. On 02/28/24 at 09:45 AM, the Surveyor observed LPN #2 in room [ROOM NUMBER], and noted an updraft mask resting on the bedside table. The Surveyor asked LPN #2 why the oxygen mask should be stored and who is responsible for storage. LPN #2 told the Surveyor It should be in a storage bag, so it won't be dirty. The Surveyor asked Resident #16 how many liters of oxygen he/she wears at night. Resident #16 was unaware. LPN #2 offered to check how many liters Resident #16 is on and told the Surveyor, I cannot find an order for oxygen. The Surveyor asked should residents have an order for oxygen. LPN #2 told the Surveyor residents should have an order before they get anything. The Surveyor asked who was responsible for checking the orders. LPN #2 stated, Nursing. I am going to place a PRN [as needed] standing order for oxygen now. 4. Resident #34 had diagnoses of Chronic Obstructive Pulmonary Disease, Paroxysmal Atrial Fibrillation, and Type II Diabetes Mellitus. The Admission MDS with an ARD of 12/25/2023 documented a BIMS of 15 (13-15 indicates cognitively intact), and that the resident required moderate assistance for eating, and is dependent for bed mobility, transfers, dressing, bathing, and personal hygiene. a. A Physicians Orders documented, .Date 01/24/2024 Oxygen: Oxygen at 2 Liters per minute via Nasal Cannula as needed for to keep [oxygen saturation] above 92% Date 01/24/2024 Nebulizer: Assess after administering Nebulizer Treatment Document Lung Sounds as . every 6 hours Date 01/24/2024 Nebulizer: Assess prior to administering Nebulizer Treatment Document Lung Sounds as . 8=Diminished every 6 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED Date 01/24/2024 Oxygen: Tubing and Humidifier Change, Clean Concentrator Filter every night shift every Friday. Date 01/24/2024 Nebulizer: Tubing and Mask Change every night shift every Friday. b. A Care Plan with an initiated date of 12/29/23 documented, .Risk for Ineffective Airway Clearance Resident Will Maintain Airway Patency (Revision on: 02/21/2024) Administer nebulizer treatment, per order . Provide oxygen as indicated by Resident condition and/or provider order . c. On 02/26/24 at 11:46 AM, Resident #34's updraft mask was observed lying in the floor to the right of the bedside table, the tubing was undated, and the storage bag dated 02/17/2024 was hanging on the wall, well out of reach of Resident #34. d. On 02/27/24 at 08:45 PM, the Surveyor noted a storage bag for the updraft tubing and mask hanging up on the wall, out of reach of Resident #34 dated 02/17/2024. The updraft mask was resting on the bedside table near a used vial of albuterol, and the mask was dated 12/17/2024. e. On 02/27/24 at 08:58 PM, the Surveyor asked LPN #3 to check the tubing date on Resident #34's updraft tubing, and mask. The LPN #3 told the Surveyor the bag and mask are dated 02/17/2024. LPN #3 was asked when the tubing, storage bag and mask should have been changed. LPN #3 told the Surveyor on 02/24/2024, Friday. g. On 02/28/24 at 01:55 PM, the Administrator provided a policy titled, Oxygen Administration (Revised October 2010) documenting, . Preparation 1. Verify that there is a physicians order for this procedure . 2. Review the residents care plan to assess for any special needs of the resident .Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure . 4. No Smoking/Oxygen in Use signs .Steps in the Procedure .2. Place an Oxygen in Use sign on the outside of the room entrance door. Close the door . The Administrator also provided a policy titled Administering Medications through a Small Volume (Handheld) Nebulizer (Revised October 2010) documenting, .29. When equipment is completely dry, store in a plastic bag with the residents name and the date on it. 30. Change equipment and tubing every seven days, or according to manufacturer's protocol .

Based on observation, interview, and record review, the facility failed to ensure meals were prepared and served according to the planned written menu and facility quantified recipe for super calorie meals to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 3 residents who received meals from 1 of 1 kitchen. The findings are: 1. On 02/26/24, the menu for the noon meal documented the residents on pureed diets were to receive a #6 scoop (2/3 cup) of pureed chicken and dumpling and a #8 scoop (1/2 cup) of pureed cornbread and 2 #10 (3/8 cup) scoops of pureed dessert. 2. On 02/26/24 at 12:12 PM, Dietary Employee (DE) #2 used a #8 scoop (1/2 cup) to serve a single portion of pureed chicken and dumpling, instead of a #6 (2/3 cup), a #8 (1/2 cup) scoop of pureed desserts, instead of 2 #10 scoops equivalent to 3/4 cup and there was no pureed cornbread served to the residents on pureed diets as specified on the menu. 3. On 02/26/24 at 01:17 PM, the Surveyor asked Dietary Employee (DE #2), what size of scoop did you used for the dessert, and how many servings did you give to each resident on the pureed diets. DE #2 stated, I filled the containers with a number 8 scoop [1/2 cup] and I gave one scoop per person. The Surveyor asked if he/she looked at the menu before serving. DE #2, while looking at the menu, stated, I did not read this before serving, cornbread was not served. The Surveyor asked DE #2 what scoop was supposed to be used for the dessert, and for the chicken and dumplings. DE #2 stated, while looking at the menu, They were supposed to use a number 6 scoop for the chicken and dumplings, and for the dessert two number 10 scoops. 4. On 02/27/24, the facility quantified recipe for cereal plus documented for 5 servings use 2 1/2 cup of nonfat dry milk, 1 3/4 cup plus 1 tablespoon of whole milk, 2 1/4 cup of oatmeal 1/2 cup of light brown sugar and 1/2 cup of margarine bulk. Portion size one cup. a. On 02/27/24 at 07:40 AM, DE #1 used a #8 (1/2 cup) scoop to serve a single portion of super plus cereal to the residents on fortified foods, instead of 1 cup as specified on the menu. b. On 02/27/24 at 09:00 AM, the surveyor asked DE #1, how you prepare the super plus, what scoop size did you use to serve super plus, and how many servings did you give to each resident? DE #1 stated, I used one half cup of brown sugar, heavy cream, cinnamon, and cream of wheat. I used a number 8 scoop, and I gave a serving each.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 02/26/24 at 10:56 AM, Dietary Employee (DE) #1 used an 8 ounce (1 cup) spoon to place 5 servings of chicken and dumpling into a blender and pureed. At 10:57 AM, DE #1 poured chicken and dumplings into a pan and placed it in the oven. The consistency of the pureed chicken and dumplings was lumpy and not smooth. 2. On 02/26/24 at 11:20 PM, DE #1 placed 4 servings of breaded fish into a blender, added chicken broth and pureed. At 11:23 PM, DE #1 poured breaded fish into a pan and placed it on the steam table. The consistency was thick, sticky, gritty, and not smooth. 3. On 02/26/24 at 11:28 AM, DE #1 used a 6 ounce spoon to place 5 servings of carrots into a blender and puree. DE #1 poured the pureed carrots into a pan and placed it on the steam table. The consistency of the pureed carrots was loose and not formed. 4. On 026/24 at 01:17 PM, the surveyor asked DE #1 to look at the pureed dessert. DE #1 did so, and stated, The texture is gritty because I used pudding mixture. I don't think it was mixed in well and should have been pureed longer. The Surveyor asked DE #2 to describe the pureed fish consistency. The DE #2 stated, It is thick with string in it and needed to be pudding consistency, should have been ran more. The Surveyor asked DE#2 to look at the chicken and dumplings and describe the consistency of it. DE #2 stated, It is too thin, and lumpy. 5. On 02/27/24 at 12:24 PM, the following observations were made during the noon meal service: a. A pan of pureed pork chops was on the steam table. The consistency of the pureed meat was lumpy, thick and was not smooth. b. On 02/27/24 at12:27 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed pork chop served to the residents on pureed diets. She stated, It has lumps and was thick. c. On 02/27/24 at 12:32 PM, the Surveyor asked Certified Nursing Assistant #1 to describe the consistency of pureed meat and bread served to the residents on pureed for lunch. She stated, Pureed meat was gritty looking and thick and pureed bread was thick and sticky. d. On 02/27/24 at 12:33 PM, DE #2 was asked to describe the consistency of the pureed meat and bread served to the residents on pureed diets. DE #2 stated, Pureed meat was lumpy and thick. Pureed bread was thick and needed to be pureed longer.

Based on observation, interview, and record review, the facility failed to ensure resident laundry was covered when transported in the hall to resident rooms to prevent clothing from coming into contact of staff uniforms, and to prevent cross contamination. This failed practice affected 1 (Resident #29) of 5 sampled (Residents #18, #34, #51, #58, #68) residents and had the potential to affect 16 residents residing on 200 Hall; the facility failed to ensure that medical equipment used in isolation rooms were appropriately disinfected to prevent the spread of germs and to prevent cross contamination that affects all 77 residents living in the facility; the facility failed to ensure that staff use proper hand hygiene while providing incontinence care to Resident #71. The Finding are: 1. Resident #71 had diagnoses of Dementia and Overactive Bladder. There was an order for a catheter, to be changed every month on the 6th and as needed if dislodge. According to Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/10/24 Resident #71 scored 99 (unable to complete the interview) on Brief Interview of Mental Status (BIMS), had no behavior issues documented, had an indwelling catheter, and was always incontinent of bowel. a. On 02/27/24 at 03:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 and #3 provide peri-care to Resident #71, who had a indwelling catheter and had been incontinent of bowel. The Surveyor observed on entry, a pack of wipes on the resident's bedside table, with several wipes already pulled sitting on top of the pack, and a waste basket near the foot of the bed. Resident #71 was already lying on the left side with CNA #3 in front of her, who held Resident #71 in place, and CNA #2 behind. CNA #2 began to wipe Resident 71 using the right hand and using the left hand to aid in holding Resident #71. After wiping, CNA #2 discarded the dirty wipe with the right hand and with the same hand grabbed a wipe from the pile of pulled wipes. This process continued until all pulled wipes were gone. CNA #2, with the same right gloved hand, pulled wipes from the pack and continued wiping Resident #71. CNA #2, using a wipe, cleaned the catheter tubing by wiping away from the resident about a centimeter from the insertion site. CNA #2 then with same gloved right hand tucked a clean brief under Resident #71. CNA #2 with same gloved right hand grabbed Resident #71's left knee while CNA #3 placed hands under the resident ' s shoulder and hips. Together they turned Resident #71 onto the right side. CNA #3 pulled wipes from the pack and wiped the left side of Resident #71's buttocks and pulled the clean brief over. Both CNA #2 and #3 secured the clean brief with gloves they had used to wipe Resident #71. CNA #2 then grabbed the control to raise the head of the bed with the same right gloved hand used to provide incontinence care. b. On 02/27/24 at 03:10 PM, the Surveyor asked CNA #2, what should you have done when you ran out of pulled wipes? CNA #2 stated I should have changed my gloves. The Surveyor asked, did you ever change gloves during or after providing incontinence care? CNA #2 stated No. The Surveyor asked, what did you touch with your gloves on? CNA #2 stated, Bed remote with the same gloves and I know I should have changed them. The Surveyor asked, Did you touch the resident? CNA #2 stated, Did I touch her? Yeah, I sure did, and I should have changed my gloves. The Surveyor stated, I noticed that you did clean the catheter tubing, did you get as close as you could to the insertion? CNA #2 stated I tried to get close as I could, but I don't think I went down as far as I could have went. c. On 02/29/24 at 12:05 PM, the Surveyor asked the Director of Nursing (DON), when staff is providing incontinence care to a Resident, should the staff member remove a clean wipe from the pack with the gloved hand use to wipe stool? The DON stated, No. The Surveyor asked why not? The DON stated, That is cross contamination, hands are not clean. The Surveyor asked, should the staff member place gloved hands used to clean stool on the resident's knee? The DON stated, No ma'am. The Surveyor asked, should the staff member raise the head of bed with the bed control with the gloved hand used to clean stool? The DON stated, No they should not have touched the bed control. The Surveyor asked, what could be a negative outcome from that? The DON stated, Spread germs on something reused for personal care. The Surveyor asked, should staff apply a clean brief with gloved hands used to clean stool? The DON stated No they should not they should have changed their gloves. d. On 02/29/24 at 01:08 PM, the Surveyor was provided a policy titled [Facility] Nursing & Rehab Procedure Subject Hand Hygiene Policy: Hand hygiene is the single most important procedure to reduce the risks of transmitting microorganisms from one person to another or from one site to another. All staff must comply with the Hand Hygiene policy. 2. Resident #29 with diagnoses of Cerebral Infarction, Dysphagia, and Influenza. The Quarterly MDS with an ARD of 09/22/2023 indicated a BIMS score of 14 (13-15 indicates cognitively intact). The Resident required limited assistance for dressing and toileting, and supervision for eating, bed mobility, transfers, and personal hygiene. a. On 02/28/2024 at 07:32 AM, the Surveyor observed CNA #6 and Environmental #1 handing Resident #29's clothing on hangers. CNA #6 and Environmental #1 were pulling and tugging on the hangers, and Resident #29's clothing came into contact with staff uniforms. The Surveyor asked what they were holding between them. Environmental #1 told the Surveyor they were clean clothes, that Resident #29 was coming off isolation and being moved back to their room. The Surveyor asked what their procedure was for transporting clean clothes down the hallway. d Environmental #1 said, Clothes are supposed to be covered, and I am going to do that right now. The Surveyor observed Environmental #1 take the clothing into a resident room. c. On 02/28/24 at 01:57 PM, the Infection Preventionist provided a policy titled, Subject: Infection Control Standard Precautions (Effective date: 11/28/2017) documenting, .3. All staff are expected to follow standard infection control practices to ensure their own safety, and that of other workers, residents, and visitors . d. On 02/29/24 at 10:44 AM, the DON was asked what procedure staff was expected to follow when transporting clean clothing or laundry belonging to residents in the hallway, and why. The DON told the Surveyor that clothing and laundry should be covered during transportation to rooms for infection control, and to prevent the spread of infection and expects staff to follow this procedure. 3. On 02/28/24 at 10:15 AM, the Surveyor observed CNA #7 don personal protective equipment (PPE) and enter Isolation room [ROOM NUMBER] with a lift. a. On 02/28/24 1at 10:30 AM, the Surveyor observed CNA #7 exit room [ROOM NUMBER] and rolled the lift to the Nurse's Station where it rested against the Nurse's Station. The Surveyor informed CNA #7 that she observed her don PPE and enter room [ROOM NUMBER] with the lift, and CNA #7 was asked to walk the Surveyor through the process of cleaning and disinfecting the lift after being in an isolation room. CNA #7 told the Surveyor that the lift was not cleaned because they did not have any [named] disinfectant in there. The Surveyor asked CNA #7 why it would be important to disinfect the lift after removing it from an isolation room. CNA #7 told the Surveyor because you could take the germs to someone else. b. On 02/28/24 at 01:57 PM, the Infection Preventionist provided a policy titled, Subject: Infection Control Standard Precautions documenting, .Policy: LRNR will follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions . Precautions include a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status . These include: hand hygiene; use of gloves . 3. All staff are expected to follow standard infection control practices to ensure their own safety, and that of other workers, residents and visitors. Procedure . 3. Hands and other skin surfaces must be washed immediately and thoroughly . 9. Any equipment that becomes contaminated should be cleaned at once and disinfected with a 1:10 bleach solution. c. On 02/29/2024 at 10:55 AM, the Surveyor asked the DON if staff was expected to clean equipment when it comes out of an isolation room. The DON told the Surveyor that equipment should be cleaned when it ' s been in an isolation room to prevent the spread of organisms that someone is on isolation for. The DON was asked what the equipment from isolations rooms should be cleaned with, and the cleaning process. The DON told the Surveyor that they use [named] wipes, and directions on the container should be followed. 47916

Based on observation, record review, and interview, the facility failed to ensure that dryer lint in the laundry room was regularly removed to prevent an excessive build-up that could contribute to the potential for fire hazards for 1 of 1 onsite laundry. This failed practice had the potential to affect all 77 residents that have linens or clothing cleaned in the facility laundry. The findings are: a. On 02/27/24 at 02:50 PM, the Surveyor asked how often lint is cleaned from the 2 on-site dryers and Environmental #2 told the Surveyor every 2-3 hours. b. On 02/27/24 at 03:00 PM, the Surveyor asked Environmental #2 to remove the lint filter. The lint filter was removed from dryer number 2, located on the far right, and the Surveyor observed a solid sheet of lint covering the entire filter, 1/4 thick. The sheet of lint began to droop in the middle without breaking. Environmental #2 was asked how long it had been since the lint was cleaned from the dryer and the Surveyor was told 09:00 AM. The Surveyor asked if they keep a log when the lint filter was cleaned. Environmental #2 provided a log showing on 02/27/2024 lint was removed from dryers at 09:00 AM. There was also an entry for 11:00, and 03:00. Environmental #2 confirmed to the Surveyor that lint was last cleaned at 09:00 AM, not at 11:00, and he/she was preparing to do it again at 03:00 PM. The Surveyor counted out the hours and Environmental #2 agreed it had been 6 hours since the dryer filter was last cleaned. The Surveyor asked what procedure was used for cleaning the lint filter in the dryers and Environmental #1 said, every 2-3 hours we remove the lint. The Surveyor asked why it was important to remove lint from the dryer, and Environmental #1 told the Surveyor it is a fire hazard. The Surveyor asked for a copy of the log showing when lint filters are cleaned. c. On 02/27/24 at 03:00 PM, Environmental #1 provided a copy of the log and told the Surveyor they would like to point out that Environmental #2 was getting ready to clean the filter again at 03:00 PM. Environmental #1 confirmed that Environmental #2 told the Surveyor it had been 6 hours since the lint filter had been cleaned out. d. On 02/28/24 at 01:55 PM, the Surveyor was told by the Administrator that they did not have a laundry policy.

Based on observations, interviews, and record review, the facility failed to ensure proper incontinence care was provided to 1 (Resident #71) of 3 sampled residents (Residents #23, #71, and #28) dependent on staff for incontinence care on 400 Hall. This failed practice had the potential to affect 18 Residents dependents on staff for incontinence care. The Findings are: 1. Resident #71 had diagnoses of Dementia and Overactive bladder. There was an order for a catheter to be changed every month on the 6th and as needed if dislodged. According to the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/24, Resident #71 scored 99 (unable to complete the interview) on a Brief Interview of Mental Status (BIMS) and had no behavior issues documented. The MDS documented that Resident #71 had an indwelling catheter and was always incontinent of bowel. a. On 02/27/24 at 03:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 and #3 provide perineal care to Resident #71 who had a catheter and had been incontinent of bowel. The Surveyor observed on entry, a pack of wipes on the resident's bedside table, with several wipes already pulled sitting on top of the pack, and a waste basket near the foot of the bed. Resident #71 was already lying on left side with CNA #3 in front of him/her, who held Resident #71 in place, and CNA #2 behind. CNA #2 began to wipe feces from Resident #71 using their right hand while using their left hand to aid in holding Resident #71 on their left side. After wiping, CNA #2 discarded the dirty wipe with the right hand and with the same hand grabbed a wipe from the pile of pulled wipes. This process continued until all pulled wipes were gone. CNA #2, with same right gloved hand, pulled wipes from the pack and continued wiping Resident 71. CNA #2 used a wipe to clean the catheter tubing wiping away from the resident about a centimeter away from the insertion site and discarded the wipe. CNA #2 then, with same gloved right hand, placed a clean brief under Resident #71. CNA #2, with same gloved right hand, grabbed Resident #71's left knee. CNA #3 placed their hands under the resident's shoulder and hips, and together they turned Resident #71 onto the right side. CNA #3 pulled wipes from pack, wiped the left side of the Resident's buttocks, and pulled the clean brief over. Both CNA #2 and #3 secured the clean brief with the gloves they had used to perform incontinence care for Resident #71. CNA #2 then grabbed the control to raise head of bed with same right gloved hand used to provide incontinence care. b. On 02/27/24 at 03:10 PM, the Surveyor asked CNA #2 what should you have done when you ran out of pulled wipes? CNA #2 stated I should have changed my gloves. The Surveyor asked did you ever change gloves during or after providing incontinence care? CNA #2 stated No. The Surveyor asked what did you touch with your gloves on? CNA stated, Bed remote with the same gloves and I know I should have changed them. The Surveyor asked, Did you touch the Resident? CNA stated, Did I touch her? Yeah, I sure did, and I should have changed my gloves. The Surveyor informed CNA #2, I noticed that you did clean the catheter tubing did you get as close as you could to the insertion site? CNA #2 stated I tried to get as close as I could, but I don't think I went down as far as I could have went. The Surveyor asked what issue could that cause? CNA #2 stated Infection. c. On 02/28/24 at 01:37 PM, the Surveyor asked CNA #4, when you are providing care to a female resident who has a catheter do you clean the tubing? CNA #4 stated Yes. The Surveyor asked which way do you clean? CNA #4 stated Away. The Surveyor asked do you fully clean the perineal area? CNA #4 stated Yes. The Surveyor asked why is it important to do that. CNA #4 stated, To make sure there is not [feces] in there. d. On 02/29/24 at 12:05 PM, the Surveyor asked the Director of Nursing (DON), when staff is providing incontinence care to a resident should the staff member remove clean wipes from the pack with the gloved hand used to wipe stool? The DON stated, No. The Surveyor asked, why not? The DON stated, That is cross contamination hands are not clean. The Surveyor asked, should the staff member place the gloved hand used to clean stool on the resident's knee? The DON stated, No ma'am. The Surveyor asked, should the staff member raise the head of bed with the bed control with the gloved hand used to clean stool? The DON stated, No they should not have touched the bed control. The Surveyor asked, should staff apply a clean brief with gloved hands used to clean stool? The DON stated No they should not they should have changed their gloves. The Surveyor asked, if a female resident has a catheter should staff fully clean the perineal area when providing incontinence care? The DON stated, Yes. The Surveyor asked why is it important to do that. The DON stated, To keep the perineal area clean. e. On 02/29/24 at 01:08 PM, the Surveyor was provided a policy titled, [Facility] Nursing & Rehab Perineal Care Checklist, which documented, .Female .Ask resident to separate legs and flex knees .Wipe abdominal fold lateral (side to side) .Secondly, wipe each fold horizontally (top to bottom) .Then use one gloved hand to stabilize and separate the labia, with the other hand, wipe perineal area from front to back three times or more if needed (using clean area of wipe or new wipe with each stroke). Change gloves as needed .Change gloves, then wipe thigh in downward position, change gloves. Turn resident. Remove soiled brief. Change gloves. No additional rinsing or drying is required. Apply moisture barrier if needed and clean brief .

Based on observations, record reviews, and interview, the facility failed to ensure that a toothbrush was stored in a manner that prevented the spread of infection for 1 (Resident #71) of 3 sampled Residents dependent on staff for oral care. The failed practice had the potential to affect 8 Residents on 400 Hall dependent on staff to provide oral care. The findings are: 1. Resident #71 had a diagnosis of Dementia. According to the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/10/24 for Resident #71 scored 99 (unable to complete the interview) on Brief Interview of Mental Status (BIMS) and had no behavior issues documented. The Admission MDS with ARD of 1/10/24 documented that Resident #71 had impairment on both sides of upper and lower extremities and that Resident #71 was dependent on staff for oral hygiene. a. On 02/26/24 at 01:23 PM, the Surveyor observed Resident #71's toothbrush in a denture cup on the back of toilet. b. On 02/28/24 at 03:45 PM, the Surveyor observed a denture cup on the sink with a short white toothbrush inside of it uncovered. The Surveyor did not note a name or date. c. On 02/29/24 at 11:30 AM, the Surveyor observed a short white toothbrush on top of the bathroom mirror outside of any packaging. The Surveyor did not note a name or date. d. On 02/29/24 at 11:30 AM, the Surveyor asked Certified Nursing Assistant (CNA) #5, should that toothbrush be on top of the mirror? CNA #5 stated No. e. On 02/29/24 at 12:05 PM, the Surveyor asked the Director of Nursing (DON), how should a Resident's toothbrush be stored? The DON stated, Upright in a case so that it is not touching the sink. The Surveyor asked the DON, how do you differentiate who the toothbrush belongs to when there are 2 Resident's in the same room? The DON stated, Different colors, names, room numbers on the case. f. On 03/01/24 at 12:28 PM, the Surveyor was provided a policy titled Activities of Daily Living (ADL), that documented, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on record review and interviews, the facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program by incorporating the recommendations from the PASARR Level II determination and evaluation report into the Resident' s assessment, care planning, and transitions of care for 1 (Resident #23) of 4 sampled Residents with mental illness. This failed practice had the potential to affect 8 Residents residing in the facility with diagnoses of mental illness. The findings are: 1. Resident #23 had a diagnosis of Bipolar disorder without medication management. According to Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/24 Resident #23 scored 11 (8-12 indicates moderate impairment) on a Brief Interview of Mental Status (BIMS) and had no behavior issues documented. The Annual MDS with an ARD of 1/10/24 documented that Resident #23 was not considered by the state level II PASRR process to have serious mental illness, intellectual disability or a related condition dating back to 1/25/22. a. On 02/27/24 at 11:40 AM, Resident #23 had a diagnosis of Bipolar disorder with no Evaluation of Medical Need Criteria (Form 703) or Mental Illness/Mental Retardation/Developmental Disability - Level I Identification Screen (Form 787) noted in records. b. On 02/28/24 at 02:15 PM, the Surveyor requested the Pre-Admission Screening Resident Review (PASARR) from the Minimum Data Set (MDS) Coordinator #1. c. On 02/28/24 at 02:50 PM, The Minimum Data Set (MDS) Coordinator #1 informed the Surveyor, We have a plan in place we have contacted [State Designated Professional Associates] and they are going to email us another packet' for [Resident #23]. I have seen the packet we just don't have it now. The Surveyor asked if a Resident is considered a Level II should it be reflected on the MDS? MDS Coordinator #1 voiced that it should. The Surveyor asked, in reference to Annual MDS with Assessment Reference Date (ARD) of 1/10/24, what does question A1500 document? MDS Coordinator #1 stated, No. The Surveyor asked what should it say? MDS Coordinator #1 stated, Yes. The Surveyor asked, in reference to Annual MDS with (ARD) of 01/18/23, what does question A1500 document? MDS Coordinator #1 stated No. The Surveyor asked what should it say? MDS Coordinator #1 stated, Yes. The Surveyor asked, in reference to Annual MDS with (ARD) of 01/25/22, what does question A1500 document? MDS Coordinator #1 stated, No. The Surveyor asked what should it say? MDS Coordinator #1 stated, Yes. The Surveyor asked why is it important for the MDS to reflect if the Resident is considered by the State a level II? MDS Coordinator #1 stated To trigger areas that need to be care planned. The Surveyor asked how would you know if any specialized services were recommended by [State Designated Professional Associates] for a Resident? MDS Coordinator #1 stated, You wouldn't know without the level II. d. On 02/29/24 at 12:05 PM, the Surveyor asked the Director of Nursing (DON) if a Resident had any specialized services recommended from the PASARR evaluation how would you know that information? DON stated, From [State Designated Professional Associates] what they recommend we would do so they would get the best possible care here. e. On 02/29/24 at 01:08 PM, the Surveyor was provided a policy titled Little River Nursing and Rehab Policy and Procedures Subject: PASARR which documented c. Upon completion of the level 2 evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on record review and interview, the facility failed to accurately complete the assessment of 1 (Resident #23) of 4 sampled Residents with mental illness to ensure the residents received any care and therapy that could have been recommended and deemed essential for their highest practicable functioning. This failed practice had the potential to affect 8 Residents in residing in the facility with mental illnesses. The findings are: 1. Resident #23 had a diagnosis of Bipolar disorder without medication management. According to the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/10/24 Resident #23 scored 11 (8-12 indicates moderate impairment) on a Brief Interview of Mental Status (BIMS) and had no behavior issues documented. The Annual MDS with ARD of 1/10/24 documented that Resident #23 was not considered by the State Level II Pre-Admission Assessment Screening Record Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition dating back to 1/25/22. On 02/27/24 at 11:40 AM, Resident #23 had a diagnosis of Bipolar disorder with no Evaluation of Medical Need Criteria (Form 703) or Mental Illness/Mental Retardation/Developmental Disability - Level I Identification Screen (Form 787) noted in records. b. On 02/28/24 at 02:15 PM, the Surveyor requested Resident #23's PASARR from the MDS Coordinator #1. On 02/28/24 at 02:50 PM, MDS Coordinator #1 informed the Surveyor, We have a plan in place we have contacted [State Designated Professional Associates] and they are going to email us another packet' for [Resident #23]. I have seen the packet we just don't have it now. The Surveyor asked if a Resident is considered a Level II should it be reflected on their MDS? MDS Coordinator #1 voiced that it should. The Surveyor asked, in reference to the Annual MDS with an ARD of 1/10/24, what does question A1500 document? MDS Coordinator #1 stated, No. The Surveyor asked, what should it say? MDS Coordinator #1 stated, Yes. The Surveyor asked, in reference to the Annual MDS with an ARD of 01/18/23, what does question A1500 document? MDS Coordinator #1 stated No. The Surveyor asked what should it say? MDS Coordinator #1 stated, Yes. The Surveyor asked, in reference to the Annual MDS with an ARD of 01/25/22, what does question A1500 document? MDS Coordinator #1 stated, No. The Surveyor asked what should it say? MDS Coordinator #1 stated, Yes. The Surveyor asked why is it important for the MDS to reflect if the Resident is considered by the State a Level II? MDS Coordinator #1 stated, To trigger areas that need to be care planned. The Surveyor asked, how would you know if any specialized services were recommended by [State Designated Professional Associates] for a Resident? MDS Coordinator #1 stated You wouldn't know without the Level II. On 02/29/24 at 12:05 PM, the Surveyor asked the Director of Nursing (DON) why is it important to accurately assess on the MDS if a Resident is considered by the state a level II PASARR? The DON stated, So you are displaying accurate information. d. On 02/29/24 at 12:59 PM, the Surveyor was provided a portion from the CMS (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) section A1500 PASRR (cont.) documented code 1, yes: If PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on record review and interview the facility failed to complete a discharge assessment for 1 Resident #56 of 5 sampled residents (R #45, R #47, R #56, R #64, R #67) who had discharged from the facility. The findings are: 1. Resident #56 had diagnoses of Coronary Artery Disease, Heart Failure, Diabetes Mellitus. The 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/22 documented a score of 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). A Record review completed on 12/30/22 showed that the resident had discharged from the facility on 8/16/22 back to the community with home health. The medical record did not have completed a discharge assessment in it. On 12/29/22 at 1:44pm, the Surveyor asked the Minimum Data Set (MDS) Coordinator Should a resident that has been discharged from the facility have a discharge assessment in their Medical Record? The MDS Coordinator stated, Yes, but we are behind on some of them. The Surveyor asked the MDS Coordinator, Do you have a discharge assessment for Resident #56? The MDS Coordinator stated, No, we are trying to get caught up with those. The Surveyor asked, When should a discharge assessment be completed? The MDS Coordinator stated, I think it's within 14 days of discharge. The facility policy titled Resident Assessments states on page 1 section A. (5) Discharge Assessment - Conducted when a resident is discharged from the facility .

Based on record review and interview the facility failed to submit the Comprehensive assessment in a timely manner for 1 resident (R #4) of the 4 residents sampled (R #4, R #35, R #39, R #49). The findings are: 1. Resident #4 had diagnosis of Hypertension, Parkinson's Disease, Depression. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/22 documented a score of 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). a. The Quarterly MDS with an ARD date of 5/23/22 documented an assessment completion date of 10/03/22. b. A policy provided on 12/30/22 at 9:00am, by the MDS Coordinator titled Resident Assessments stated, The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments . c. On 12/30/22 at 9:15am, the Surveyor asked the MDS Coordinator, How often should Resident Assessments be completed, to ensure they are done in a timely manner? The Minimum Data Set (MDS) Coordinator stated, On admission, quarterly and yearly. The Surveyor asked, What is the time frame for completing the Quarterly Resident Assessment? The MDS Coordinator stated, I think it's 14 days after the ARD. The Surveyor asked, If a Resident Assessment had an ARD of 5/23/22 and it was completed on 10/03/22 would that be done in a timely manner? The MDS Coordinator stated, No, we are working on getting them caught up.

Based on observation, record review, and interview, the facility failed to review and revise the care plan for 1 (Resident #6) of 5 sampled residents (Resident #2, R #4, #6, R #26, R #29) who had been discharged from hospice services to long term care in the last 120 days per list provided by Minimum Data Set (MDS) 12/30/22 at 9:00am. The findings are: 1. Resident #6 had diagnoses of Heart Failure, Essential Hypertension, and Parkinson's Disease. The Significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/22 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). 2. A Physician's Telephone Order dated 10/20/22 documented, Discharge from [Organization Name #1] hospice services to consult [name of organization discharge from [Organization Name #1] hospice services to consult [name of organization #2] hospice. R #6 was not admitted to [Organization Name #2] hospice and transitioned to long term care. The facility did not revise the care plan for R #6 to reflect the change from hospice services to long term care. On 12/29/22 at 2:45pm, the Surveyor asked the MDS Coordinator, Who is responsible for updating the care plans? The MDS Coordinator stated, That would be me. The Surveyor asked, When should a resident's care plan be revised? The MDS Coordinator stated, When there is a change in the treatment or services of the resident. The Surveyor asked, Why is it important to review and revise the care plan? The MDS Coordinator stated, So that the staff know how to care for a resident. The Surveyor asked, If a resident is discharged from hospice services should that change be reflected one the care plan? The MDS Coordinator stated, Yes, along with a significant change MDS being completed. According to the policy Care Planning-Interdisciplinary Team provided by the MDS Coordinator on 12/30/22 at 9:00am stated on page 9 number 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents

Based on interview and record review the facility failed to ensure an in-service was completed and documented related to an unwitnessed fall for 1 (Resident #1) of 4 (Resident #1, #2, #3, and 4) sampled residents. The findings are: Resident #1 had diagnoses of [CONDITION(S)] and other psychoactive substance abuse. A discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/25/22 documented the resident's cognitive skills for daily decision making was severely impaired according to a Staff Assessment of Mental Status (SAMS). The Resident required total dependence for bed mobility, transfers, toilet use, and dressing. A Care Plan dated 7/31/22 documented, .Floor bed .Floor mat put in place . An Incident Report dated 7/31/22 at 4:30 PM documented, .This nurse noted res[resident] crying out. Upon entering room this nurse noted resident on floor lying prone between bed and wall. Resident unable to voice what happened .Type of Injury .Skin Tear .In serviced Certified Nursing Assistants (CNA)s on proper use of wedge pillows .Encouraged CNAs to proper placement of pillow and wedge. Encouraged increase rounds on residents . a. On 9/22/22 at 1:30 PM, The Surveyor asked Licensed Practical Nurse (LPN) #1, Was Resident #1 able to move around in the bed by herself? She stated, I've never seen her do that. She moves her face a lot. She couldn't move you have to move her. b. On 9/22/22 at 1:40 PM, The Surveyor asked LPN #3, Was Resident #1 able to move around in the bed by herself? She stated, Not that I've ever seen. You would put her one way but the way her body was contracted she would lean toward one way if the pillows are not positioned correctly. c. On 9/22/22 at 1:50 PM, The Surveyor asked CNA #1, Was Resident #1 able to move around in the bed by herself? She stated, Not that I can see. d. On 9/2/22 at 1:57 PM, The Surveyor asked CNA #2, Was Resident #1 able to move around in the bed by herself? She stated, Not really, but if she would cough real [really] hard, she would lean. That's why we had the wedges, and she had the low boy bed. e. On 9/22/22 at 2:15 PM, the Medical Records were reviewed for Resident #1. There was no documentation that an in-service on abuse, and an in-service on how to properly place wedge pillows had been completed with the staff. f. On 9/22/22 at 2:30 PM, The Surveyor asked the Director of Nursing (DON), Can I get a copy of the in-service that was conducted with the CNAs after Resident #1 had a fall? He stated, Let me get it. g. On 9/22/22 at 2:39 PM, the DON returned to the Conference Room. He stated, I don't have the in-service. I called LPN #2 and she said she did a verbal in-service. h. On 9/23/22 at 9:07 AM, The Surveyor asked LPN #2, When did Resident #1 have a fall? I think she had 2. I heard she rolled or fell off the bed. What about the other fall? She stated, I was at the nursing station charting. I heard her crying. She cries when they change her or she's in pain. I got up to go look at her, but there was nobody in the room. She was asked, What interventions were put in place after the fall? She stated, A verbal education of the pillows and wedges. The Surveyor asked, Who all did you give a verbal in-service too? At that time, it was CNA #3, and CNA #4, I don't know her last name. The Surveyor asked, Can you tell me why the in-service wasn't documented, and why all staff weren't in serviced. She stated, It slipped my mind. I didn't think about writing an in-service. The Surveyor asked, Did she have any devices on her bed to keep her from falling? Aside from the pillows, no. The Surveyor asked, Was she able to move around in the bed by herself? She stated, Not completely, but when she coughs. The Surveyor asked, Was she able to move around in the bed by herself? She stated, I've never seen her do that. She moves her face a lot. She couldn't move you had to move her. or fall asleep her head would drop. A real big turn, no. i. On 9/23/22 at 9:30 PM, the DON provided a form titled, Abuse and Neglect Policy ad Procedure. It documented, .Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate . j. On 9/23/22 at 10:55 AM, The Surveyor asked the DON, Was Resident #1 able to move around in the bed by herself? He stated, Yes, she could move her head. The Surveyor asked, What interventions were put in place after she fell ? He stated, Inservice staff on being in bed properly, fall mats, and low bed in lowest position. The Surveyor asked, Can you tell me why all staff wasn't in-serviced after she fell on [DATE]?' He stated, My weekend nurse did an in-service with the staff that was present. We didn't do a facility wide. I informed my nurse that we need to do an in-service with everybody. The Surveyor asked, If an in-service is completed for an unwitnessed fall should that in service be documented? He stated, Yes. The Surveyor asked, When was the last abuse in-service? He stated, It was February of this year.

Based on observation and interview, the facility failed to ensure food items were dated when received, stored in closed containers after opening, and used within manufacturer's recommended time frames after thawing; and failed to ensure the kitchen ice machine and kitchen equipment were maintained in clean and sanitary condition to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 62 residents who received meals and ice from the kitchen (total census: 62), as documented on a list provided by the Dietary Manager on 8/12/2021. The findings are: 1. On 08/09/2021 at 1:15 PM, the following observations were made in the kitchen: a. There was a bulk container of powdered sugar and a bulk container of food thickener in the storeroom. Neither container had a received date. The Dietary Manager was asked if the containers should be dated and stated, Yes. b. There was a two-gallon zip-locked bag of elbow macaroni noodles dated 8/2/21 and a two-gallon zip-locked bag of egg noodles dated 6/3/21 that were not tightly sealed. When asked how previously opened food items should be stored, the Dietary Manager stated, In a closed bag. c. There was a pinkish substance on the bottom of the internal shield of the ice bin. When the Dietary Manager took a white napkin and wiped the substance, it transferred to the napkin. The Dietary Manager stated, We just cleaned this out not even two weeks ago. The maintenance guy did it. When asked to describe the substance, the Dietary Manager stated, It looks like Kool-Aid. He was asked how often the ice machine was cleaned and stated, Once a month. d. On a shelf in the walk-in refrigerator, there was a partial case of twenty nutritional milkshakes with a received date of 7/8/2021. The manufacturer's instructions on the side of the box documented, .Keep Frozen . The manufacturer's handling instructions on the carton of each milkshake documented, .Store Frozen . Thaw under refrigeration (40 F [Fahrenheit] or below). After thawing, keep refrigerated. Use within 14 days after thawing . The Dietary Manager was asked about the milkshakes and stated, To be honest, I didn't know they had to be used within 14 days. I threw them out. 2. On 08/12/2021 at 10:20 AM, the following observations were made in the kitchen: a. A fan covered with a gritty grayish substance was hanging from the ceiling and blowing toward the food preparation area in the back of the kitchen. b. There was an opened box of baking soda on the shelf in front of the oven.

Based on observation, record review, and interview the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 3 (Residents (R) #18, #21, and #32) of 6 (Residents #11, #18, #21, #22, #32 and #38) sampled residents who had orders for oxygen. This failed practice had the potential to affect 11 residents who had physicians' orders for oxygen, as documented on a list provided by the Director of Nursing (DON) on 08/13/21 at 8:30AM. The findings are: 1. Resident #18 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/24/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen while a resident. a. A Care Plan dated 8/30/20 documented, .Resident has a potential for difficulty breathing related to chronic condition [CONDITION(S)] . b. On 8/10/21 at 8:49 AM, Resident #18 was lying in bed with the head elevated. The oxygen concentrator at the bedside was set at 2.5 liters per minute via nasal cannula, instead of 2 liters per minute as ordered by the physician. c. On 8/10/21 at 2:05 PM, Resident #18 was lying in bed with the head elevated. Oxygen was in use at 2.5 liters per minute. 2. Resident #21 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/27/21 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen while a resident. a. The Physician's Order dated 2/20/21 documented, Oxygen: QS Oxygen 2 L/M via n/c continuous to keep SPO2 above 92% . b. A Care Plan updated 7/13/21 documented, . Resident has a potential for difficulty breathing related to chronic condition [CONDITION(S)] . c. On 8/9/21 at 11:52 AM, Resident #21 was lying in bed with the head elevated. The oxygen concentrator at the bedside was set at 3 liters/minute via nasal cannula, instead of 2 liters per minute as ordered. Respiration were even and unlabored. d. On 8/10/21 at 8:11 AM, Resident #21 was lying in bed with the head of bed elevated, eating breakfast. Oxygen was on at 3 liters per minute via nasal cannula. e. On 8/10/21 at 12:29 PM, Resident #21 was sitting up in a chair at the bedside. Oxygen was in use at 3 liters per minute via nasal cannula. 3. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/23/21 documented the resident scored 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance with activities of daily living and received oxygen therapy. a. The Physician Order dated 6/19/21 documented, .Oxygen: qs [every shift] oxygen 2 l/m [liter per minute] via nc [nasal cannula] prn [as needed] to keep SPO2 [pulse oximetry] above 92 . b. The Care Plan with a review date of 6/29/21 documented, Problem: Resident has potential for breathing difficulty related to chronic condition: CHF [Congestive Heart Failure] . Goal: Resident will be maintained at their respiratory baseline with a patent airway and unlabored respirations . Approaches: . Administer/monitor effectiveness of treatments (see current physicians orders) for Oxygen . c. On 08/10/21 at 08:15 AM, Resident #32 was sitting up in a wheelchair. Oxygen was in use at 3 liters per minute via nasal cannula, instead of 2 liters per minute as ordered. d. On 08/10/21 at 2:31 PM, Resident #32 was sitting in a wheelchair in her room. Oxygen was in use at 3 liters per nasal cannula. e. On 08/11/21 at 09:13 AM, Resident #32 was sitting up in her wheelchair watching television. Oxygen was in use at 3 liters per nasal cannula. f. On 08/11/21 at 1:35 PM, Licensed Practical Nurse (LPN) #1 was asked to accompany the surveyor to Resident #32's room. Once in the room, LPN #1 was asked, What is the resident's oxygen flow rate? LPN #1 stated, It is set at 3 liters. LPN #1 was asked, What should the oxygen flow rate be? LPN #1 stated, I think it should be set at 2 liters, but I will have to check the MAR [Medication Administration Record]. LPN #1 was asked, Who is responsible for ensuring the oxygen is set at the correct flow rate? LPN #1 stated, The nurses are. LPN #1 was asked, How often should oxygen flow rate be checked? LPN #1 stated, It should be checked every shift or every time we go into the resident's room. 4. On 08/12/21 at 08:05 AM, the DON was asked, Who is responsible for ensuring the residents oxygen is set at the correct flow rate? The DON stated, All of the nurses are responsible. The nurse on the floor and management nurses when they make rounds. It's a team responsibility. The DON was asked, How often should the residents' oxygen flow rate be checked? The DON stated, Every time the nurse goes into the room, but definitely once a shift. The DON was asked, Should doctor's orders for oxygen flow rate be followed? The DON stated, Yes, ma'am they should. 5. The facility policy titled, Oxygen Administration provided by the Assistant Director of Nursing on 08/12/21 at 8:55AM, documented, .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order .

Based on observation, record review and interview, the facility failed to ensure staff members sat at eye level while assisting residents with eating to promote dignity and respect for 1 (Resident #27) of 6 (Residents #38, #52, #14, #12, #40, and #27) sampled residents who required assistance with eating. This failed practice had the potential to affect 17 residents who required assistance with eating, as documented on a list provided by the Staffing Coordinator on 8/13/21 at 8:42 a.m. The findings are: Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/21 documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and required limited 1-person assistance with eating. a. A Care Plan dated 3/18/21 documented, .is a slow eater and is fed by staff, observe and record intake . b. On 08/09/21 at 12:28 PM, the resident was in bed with the head of bed elevated to 45 degrees. The resident received a pureed meal of enchilada and refried beans. Certified Nursing Assistant (CNA) #1 was standing over the resident at the bedside to feed her. The only interaction with the resident was to tell her to open her mouth. At 12:32 PM, CNA #1 removed the meal tray from the room and placed it on the cart. The CNA was asked if she was finished and stated, She don't eat much, then walked away from the surveyor. c. On 8/12/21 at 4:00 PM, the Director of Nursing (DON) was asked, Should staff sit down and be eye level with the resident while feeding them? She stated, Absolutely, staff should never stand over a resident while feeding them. She was asked, Should the staff interact with the resident while feeding them, other than just saying 'open your mouth?' She stated, Yes they should, and that CNA is no longer here. d. The facility policy titled Assistance with Meals, provided by the Staffing Coordinator on 8/13/21 at 8:42 AM, documented, .Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example a. Not standing over residents while assisting them with meals .

Complaint # substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to develop and implement new interventions to prevent further falls and failed to consistently implement planned fall prevention interventions for 2 (Residents #1 and #5) of 4 case mix residents (Residents #1-3 and #5) who were at risk for falls. This failed practice resulted in actual harm to Resident #1, who sustained a fracture to the 4th and 5th digits of the left hand as a result of a fall from bed, and had the potential to affect 33 residents who were at risk for falls, according to a list provided by the Director of Nursing (DON) on 7/7/11 at 1:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/15/11 documented the resident had a score of 2 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) score, required extensive assistance of 2 plus persons for transfers and bed mobility, total assistance of 1 person for locomotion on and off the unit, not steady only able to to stabilize with human assistance when being transferred from surface to surface, and since admission or prior assessment has had 2 falls with no injury, 1 fall with non-major injury and 1 fall with major injury. a. The Care Plan dated 3/18/11 documented, "...Falls - At risk for falls related injury as evidenced by Previous Fall related to functional problem: contractures to upper extremities unaware of functional limitation... Approaches: use fall risk screen to identify risk factors, report falls to physician, hospice and responsible party... Provide environmental adaptations, low/platform bed..." b. The Incident and Accident (I/A) reports dated 3/10/11 and 3/15/11 documented the resident was found in the floor beside the bed on the floor mat. There were no documented injuries. c. The physician's orders [REDACTED]. (diagnosis) Dementia unaware of functional limitation." d. The I/A reports dated 3/25/11, 4/2/11 and 5/8/11 documented the resident was found in the floor beside the bed on the floor mat. There were no documented injuries. e. The Nurse's Notes dated 6/4/11 at 7:00 a.m. documented, "called to Res. (resident) rm (room) by CNA (certified nursing assistant), Res found on floor lying on floor mat beside bed on (L) (left) side, Res c/o (complains of) arm hurting. Res noted to be laying on L arm. ROM (range of motion) checked and BLE (bilateral lower extremity) and BUE (bilateral upper extremity) moved without difficulty, no other acute distress noted at this time, assisted back to bed..." f. The I/A Report dated 6/4/11 at 7:00 a.m. for the above incident documented, "Res. (resident) found on floor on the floor mat laying on L (left) side. ...continue POC (plan of care) low bed with mat, out to ER (emergency room ) for eval. (evaluated) D/T (due to) edema Lt (left) hand 4th, 5th finger..." g. The Nurse's Notes dated 6/4/11 at 3:35 p.m. documented, "Res lying supine in low bed, L hand noted to have swelling and bruising to hand and fingers, called hospital and reported Res condition d/t (due to) previous fall informed the nurse at hospital that MD (medical doctor) would call back... At 3:50 p.m. doctor called back with orders to send to hospital outpatient x-ray..." h. The hospital records dated 6/4/11 documented, "Fall at NH (nursing home) c/o (complaint of) pain Lt hand..." The "ER Orders and Findings" dated 6/4/11 documented, "...83 y/o (year old) from the nursing home for x-rays of L hand after fall from low bed. ...Diagnosis: [REDACTED]." i. The Care Plan revised 6/21/11 documented, "3/18/11 - Falls - At risk for falls related injury as evidenced by Previous Fall related to functional problem: contractures to upper extremities unaware of functional limitation... Approaches: use fall risk screen to identify risk factors, report falls to physician, hospice and responsible party... Provide environmental adaptations, low/platform bed... 6/4/11 - fell on side from low bed to mat, sent to ER returned with 2 broke fingers..." There was no documentation of any new interventions to prevent further falls. j. On 7/6/11 at 9:00 a.m., the facility was asked to provide all I/A reports from the past 6 months for Resident #1. The I/A report dated 6/4/11 had no witness statements attached to indicate an investigation was conducted. k. On 7/7/11 at 8:55 a.m., Certified Nursing Assistant (CNA) #1 was asked if she knew how Resident #1 had fractured her fingers. CNA #1 stated that it was on a Saturday and when she entered the resident's room, the bed was elevated. She indicated she provided care to Resident #1 and, "when I left out, I lowered her bed." CNA #1 stated, "after I had gone to care for another resident in another room, when I finished, I came out and heard her (Resident #1) screaming. I went in and (Resident #1) was on the floor, the bed was up (elevated)." CNA #1 was asked approximately how much time had passed when she heard the resident scream. CNA #1 stated, "about 5 minutes." CNA #1 stated that CNA #2 and CNA #3 were witnesses to the fact that when CNA #1 left the resident's room, she lowered the bed before leaving the room. CNA #1 stated at about 3:00 p.m. on 6/6/11, she had documented a witness statement and left it on the DON"s desk. l. On 7/7/11 at 9:00 a.m., CNA #2 stated, "...I was at the door and I did see (CNA #1) lower the bed before we left the room." CNA #2 stated at the time of the resident's fall, she saw the resident on the floor, the bed was up and had not been lowered. m. On 7/7/11 at 9:25 a.m., CNA #3 was asked about the I/A regarding Resident #1. CNA #3 stated, "...me and (CNA#1) went to check on (Resident #1), her bed was up. When we left out of her room, we lowered it. We went to another resident's room, we came out and heard her (Resident #1) screaming. We went to check on her, she was in the floor. Her bed had been raised again." CNA #3 stated, "We were all busy that morning... They had said (CNA #1) had not lowered the bed. But I was in there. I know (CNA #1) lowered that bed." n. On 7/7/11 at 9:57 a.m., during a telephone conversation with LPN #1, she was asked if she knew anything about Resident #1's fractures. She stated, "...She had fell on me. CNA called me in, she (Resident#1) was laying halfway on the floor and on the bed. She was okay with ROM. Later that day, I noticed swelling to her hand when I went to do her accu check...." LPN #1 was informed of the information provided by the CNAs. LPN #1 was asked when she entered Resident #1's room did she notice if the bed was elevated or not at the time of the resident's fall? LPN #1 stated, "When I entered the room I don't think it was. I don't remember the bed being up. I don't remember anyone reporting to me it was. I could've over looked it, I could be wrong." LPN #1 was asked if she obtained any witness statements from the CNAs. LPN #1 stated, "if it was an unwitnessed fall, I usually get witness statements. If there were no witness statements attached to the I/A report then there were none." o. On 7/7/11 at 9:10 a.m., the DON was asked if she was aware of the allegation that Resident #1's bed was elevated at the time of the fall. The DON stated, "No." The DON was asked if the facility had conducted inservices instructing staff to make sure that if residents required the use of a low bed, the beds are in the lowest position to ensure safety. The DON stated, "No..." and indicated that if she had known of the information she would have intervened. 2. Resident #5 had [DIAGNOSES REDACTED]. a. An Incident/Accident (I/A) Report dated 2/1/11 documented, "CNA (Certified Nursing Assistant) was assisting res (resident) to bed and CNAs knee caught res hand between bed rail and caused a skin tear approx (approximately) 0.4 cm (centimeters) in length. Additional comments and/or steps taken to prevent recurrence: (blank)." b. An I/A dated 6/15/11 documented, "Was in room across the hall giving meds (medications) to another resident when one of my residents informed me that (resident) had fallen out of her w/c (wheelchair) to the floor... Resident was leaning over to get something off floor and fell over... Additional comments and/or steps taken to prevent recurrence: Admit to (hospital) with head contusion." c. As of 7/5/11 at 3:00 p.m., there was no documentation to indicate interventions had been developed and implemented for the above I/As. d. On 7/7/11 at 9:00 a.m., the Director of Nursing was asked about the I/A dated 2/1/11 and if there were any interventions to prevent recurrences such as inservicing the CNA. She stated, "If it's not attached to the I/A, then we don't have anything." The DON was asked if there were any interventions to prevent recurrences implemented after the resident fell on [DATE]. She stated, "No."