Every finding on record at Lutheran Rehabilitation and Skilled Care Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a splint to secure a fracture he/she sustained to his/her right arm, the Facility failed to ensure he/she was provided care and treatment that met professional standards of practice, when after a follow-up appointment, Resident #1's orthopedist recommended that Nursing remove the splint daily for hygiene. However, the recommendation were not implemented by Nursing and he/she developed a pressure injury and osteomyelitis in his/her right elbow, and required surgical intervention. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in November 2022, diagnoses included Fracture of shaft (a break of the thigh bone between the hip and the knee) of left femur, Dementia, severe, with other behavioral disturbances, Hypertension, Gastro-esophageal reflux disease, Osteoarthritis, Iron deficiency anemia, Hypothyroidism, Hyperlipidemia, and Bilateral Sensorineural hearing loss. Review of Resident #1's Norton Scale Predicting Risk of Pressure Ulcer, dated, 11/16/22, indicated he/she was assessed by nursing to be at high risk for the development of pressure injuries. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 11/23/22, indicated that Resident #1 had severe cognitive impairments and he/she was at increased risk for developing pressure injuries. Review of Resident #1's Orthopedic Report of Consultation, dated 1/10/23, indicated he/she had recommendations for the following: -No skin issues were noted -Active Range of Motion (AROM) and Passive Range of Motion (PROM) right shoulder -Elbow splint removal for hygiene -Weight bearing with assisted transitions only with splint on -Should use right arm to feed him/herself Review of Resident #1's Weekly Skin Audit dated, 1/14/23, indicated that nursing documented that he/she did not have any skin impairments. Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 1/18/23, indicated that on 1/17/23 upon removal of Resident #1's posterior (back side) splint to his/her right arm he/she had an open area to his/her elbow which was red, warm, and swollen. The Report indicated the Nurse Practitioner ordered Resident #1 to be seen at the Hospital for evaluation and he/she was diagnosed with cellulitis of his/her right elbow, placed on antibiotics and an anterior (front side) splint was applied to the right elbow. Review of Resident #1's Nurse Progress Note, dated 1/17/23, indicated that the writer (identified as Nurse #1) and the Unit Manager removed Resident #1's splint from his/her right upper extremity (RUE)/elbow and there was an approximate area 2.0 centimeters (cm) x 2.0 cm x 0.5 cm noted with pocketing, odor, moderate drainage at the site and his/her skin was red and warm. The Note indicated Nurse #1 notified the Nurse Practitioner and ordered Resident #1 to be sent to the Emergency Department (ED) for evaluation. Review of Resident #1's Nurse Progress Note, dated 1/18/23, indicated that he/she returned from the ED and was diagnosed with Cellulitis of his/her right upper limb, Keflex (antibiotic to treat bacterial infection) and Bactrim (antibiotic to treat bacterial infection) were ordered, change dressing daily to his/her right elbow and return to ED for worsening of infection. The Note indicated to follow up with in house Nurse Practitioner for new wound treatment orders. Review of Resident #1's Wound Consultation, dated 1/18/23, indicated he/she had a Stage 4 pressure injury (full thickness wound`) located on his/her right elbow related to the medical device (splint). Review of Resident #1's Orthopedic Report of Consultation, dated 1/20/23, indicated he/she was seen for the Stage 4 pressure injury to his/her right elbow. The Consultation indicated the following findings and recommendations: -Right olecranon pressure injury with osteomyelitis -Incision, bursectomy, and bone debridement on Monday (1/23/23) -Discontinue antibiotics -Wound care; clean wound with hydrogen H2O2 (hydrogen peroxide) and apply dry sterile dressing and elbow pad every day -No sling or splint -No Physical Therapy Review of Resident #1's Physician Interim Orders, indicated there was no documentation to support that an order was obtained from the Physician regarding the recommendations for the Orthopedist related to his/her right elbow and transcribed by the Unit Manager onto his/her Treatment Administration Records (TAR). Review of Resident #1's Facility TAR, dated 1/10/2023 through 1/17/2023, indicated there was no documentation to support his/her right arm splint was removed for hygiene. Further review of Resident #1's Medical Record indicated there were no Nursing Progress Notes with documentation to support Nursing removed his/her right arm splint for hygiene and to assess his/her skin condition beneath the arm splint. During an interview on 2/14/23 at 3:16 P.M., Nurse #1 said that on 1/17/23, he and the Unit Manager removed Resident #1's right arm splint to check his/her skin integrity and upon removing the splint he saw an open area, with foul smelling moderate serosanguineous (fluid yellowish/pink in color) drainage on his/her right elbow and it was red and warm to touch. Nurse #1 said he notified the Nurse Practitioner and said orders were obtained for a treatment to Resident #1's right elbow and to send him/her to the ED for evaluation. Nurse #1 said there was no order on Resident #1's January TAR to remove his/her right arm splint for hygiene and said the only treatments were to monitor Circulation, Sensation, and Movement (CSM) and skin integrity (health of the skin) to his/her right upper extremity every shift. Nurse #1 said he was not aware of the recommendation orders from Resident #1's Orthopedic Consult follow up visit on 1/10/23. During an interview on 2/22/23 at 4:39 P.M., Nurse #2 said that (upon admission Resident #1 did not have an order to remove his/her right arm splint for hygiene) and said she was monitoring CSM and skin integrity to his/her right elbow as ordered. Nurse #2 said she could not recall being told by the Unit Manager or the day Nurse at the change of shift that Resident #1 had new orders to remove his/her arm splint for hygiene. Nurse #2 said she could not remember what interventions were on Resident #1's plan of care for his/her right arm splint and if there was no order to remove the splint then it most likely would not be on his/her plan of care. During an interview on 2/16/23 at 3:24 P.M., the Unit Manager said that on 1/17/23, Resident #1's Family Member asked her if anyone had looked at his/her skin under the arm splint and said she and Nurse #1 went to inspect Resident #1's skin. The Unit Manager said she observed Nurse #1 remove his/her right arm splint and they found an open area on his/her right elbow and said there was redness around the area. The Unit Manager said Nurse #1 notified the Nurse Practitioner and she immediately reported the findings to the Director of Nurses (DON). The Unit Manager said Resident #1's initial Physician orders were not to remove his/her right arm splint and on 1/10/23 he/she returned from an Orthopedic Consult visit with recommendation orders to remove his/her arm splint for hygiene. The Unit Manager said she signed Resident #1's Orthopedic Consult on 1/10/23 and verified recommendations with the Nurse Practitioner to obtain orders. The Unit Manager said that she was responsible for writing Physician orders and transcribing the orders onto Resident #1's January TAR. The Unit Manager said she wrote a Physician's order and transcribed the orders onto Resident #1's TAR and said that the sheet from his/her TAR's probably got lost. However, Review of Resident #1's medical record indicated that there was no documentation to support that on 1/10/23 the Unit Manager wrote a Physician order, transcribed the new recommendation orders to Resident #1's January TAR or that she updated his/her plan of care on 1/10/23. Review of Resident #1's Hospital Discharge Summary, dated 2/02/23, indicated that Resident #1 had an intercondylar distal humerus fracture, which was splinted and due to prolonged splinting, an olecranon ulcer subsequently formed. The Summary indicated that on 1/23/23 Resident #1 was taken to the Operating Room (OR) for right elbow bursectomy, and debridement of olecranon osteomyelitis and he/she was transferred to the Post-Anesthesia Care unit (PACU) for recovery. The Summary indicated Resident #1's right elbow incision was closed with sutures, he/she received a course of Intravenous (IV) antibiotics during his/her hospitalization and he/she was discharged back to the facility on [DATE]. During an interview on 2/14/23 at 3:18 P.M., the Director of Nurses (DON) said that the Facility's Investigation started when the Unit Manager reported to her that after removing Resident #1's right arm splint, an open wound was noted on his/her right elbow, and he/she was sent to the Emergency Department (ED) for evaluation. The DON said Resident #1 returned from an Orthopedic Consult on 1/10/23 with new recommendation orders and to remove his/her right arm splint for hygiene. The DON said review of Resident #1's medical record indicated that a Physician order to remove the splint for hygiene, per the Orthopedist recommendations, although the order was obtained, the order was not transcribed onto his/her TAR and the plan of care was not updated. The DON said it was the responsibility of the Unit Manager to write the Physician's order, transcribe the new orders onto Resident #1's TAR and update his/her plan of care and said that the Unit Manager had not followed through with the Facility's process for Consult recommendations which includes, reviewing the consult, verifying new recommendations/orders with the Physician and or Nurse Practitioner, writing a Physician's order, transcribing the orders to resident's TAR, and update the plan of care. The DON said she expects all Nurses who receives a resident's Consultation Report to follow the Facility's process. On 02/14/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 1/17/23, Resident #1 was transferred to the Hospital for an evaluation, and returned to the facility with new orders for an antibiotics for diagnosis of cellulitis, daily dressing changes to right elbow area and anterior splint with orders to remove splint every shift to inspect his/her skin and pain managed with prescribed pain medication. B. On 1/18/23, Resident #1, and all residents residing in the facility, had a full body skin checks conducted by Nurse Management Staff to verify that no other skin areas were present. C. On 1/18/23, Resident #1 was seen by the Wound Care Specialist in the facility and new dressings orders were confirmed with the Nurse Practitioner. D. On 1/18/23 - 1/20/23, Resident #1's Plans of Care were reviewed and update with interventions related to his/her right humerus fracture. E. On 1/18/23 to 1/24/23, the Staff Development Coordinator, educated Licensed Nursing Staff on the care requirements for Resident #1's splinted right arm. F. On 1/20/23, all residents that utilize splints were reviewed by Nursing Management to verify splints are applied as ordered and no skin issues were identified related to splint usage. G. On 1/22/23, an audit of residents requiring splints/braces was completed by Nursing Management to verify all orders were reflected in the current Care Plan, skin intact, and Certified Nurse Aide (CNA) care card is updated. H. On 1/23/23, an audit was conducted by Nursing Management to review Consult Reports for the past 30 days to verify that all recommendations were followed through. I. From 1/18/23-1/24/23, the Staff Development Coordinator, provided education was provided to Licensed Nursing staff on the requirement to review consultation paperwork thoroughly and ensure all recommendations are followed through and communicated appropriately to staff. J. From 1/18/23-1/24/23, the Staff Development Coordinator provided education was provided to Licensed Nursing staff and Certified Nurse Aides (CNAs') regarding the following: -the implementation and use of a communication binder that will be kept at Nursing Stations for staff to review changes to resident plans of care. - the need for staff to inquire about care needs, such as splints if unaware of a residents plan of care. - the facility process for skin checks, including skin under splints and other medical devices that are to be removed and if not to be removed inspect the surrounding skin area of the medical device. K. The Unit Manager is currently out of the Facility and will be re-educated by Nursing Management upon her return. L. On 1/19/23 Education was provided to the Rehabilitation Department by the Rehabilitation Manager regarding the expectation that education will be provided to staff when a resident has a new splint or brace ordered. M. On 1/18/23, The Facility implemented a new process, that all consult sheets from the previous day will be brought to morning meeting for team review to verify all recommendations were followed through and telephone order slips will be reviewed at morning meeting to verify correct order transcription into the Point Click Care (PCC) computer system. N. The Quality Assurance Nurse and/or Designee will conduct daily audits x2 weeks, then weekly x30 days, and monthly thereafter on all residents that utilize splints and braces to verify Physician orders are followed for the wearing schedule, including skin checks, CNA care cards are up to date, skin is intact, and Nursing Care Plans are correct. The results of the audits will be brought to QAPI meeting quarterly until the committee determines compliance. O. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was admitted with a supracondylar fracture (near the elbow) of the right humerus (long bone in the upper arm) that was immobilized with a splint and who was assessed by nursing to be at increased risk for the development of pressure injuries, the Facility failed to ensure that Resident #1's comprehensive individual Plans of Care related to Activities of Daily Living and Potential for Pressure Ulcers, were updated after an Orthopedic Consultation and identified and described recommendations for interventions staff were to implement and follow in an effort to maintain his/her skin integrity. Findings include: The Facility Policy titled Care Plans, Comprehensive Person-Centered, dated as revised 6/6/22, indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The Policy indicated the Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident, must review and update the care plan and describe the services that are to be furnished to attain or maintain the resident highest practicable physical, mental, and psychosocial well-being. The Facility Policy titled Prevention of Pressure Injuries, dated as revised April 2020, indicated the purpose is to provide information regarding identification of pressure injury risk factors. And interventions for specific risk factors and review the residents' care plan and identify the risk factors as well as the intervention. The Policy indicated that Device-Related Pressure injuries should be monitored regularly for comfort and signs of a pressure related injury and prevention measures associated with specific devices and to consult current clinical practices. Resident #1 was admitted to the Facility in November 2022, diagnoses included Fracture of shaft (a break of the thigh bone between the hip and the knee) of left femur, Dementia, severe, with other behavioral disturbances, Hypertension, Gastro-esophageal reflux disease, Osteoarthritis, Iron deficiency anemia, Hypothyroidism, Hyperlipidemia, and Bilateral Sensorineural hearing loss. Review of Resident #1's Norton Scale Predicting Risk of Pressure Ulcer, dated, 11/16/22, indicated he/she was assessed by nursing to be at high risk for the development of pressure injuries. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 11/23/22, indicated that Resident #1 had severe cognitive impairments and he/she was at increased risk for developing pressure injuries. Review of Resident #1's Orthopedic Report of Consultation, dated 1/10/23, indicated he/she had recommendations for the following: -No skin issues were noted -Active Range of Motion (AROM) and Passive Range of Motion (PROM) right shoulder -Elbow splint removal for hygiene -Weight bearing with assisted transitions only with splint on -Should use right arm to feed him/herself Review of Resident #1's Plan of Care related to Activities of Daily Living and Potential for Pressure Ulcer indicated there was no documentation to support his/her plan of care was updated with interventions identified from his/her Orthopedic Consult visit on 1/10/23. During an interview on 2/22/23 at 4:39 P.M., Nurse #2 said that (upon admission Resident #1 did not have an order to remove his/her right arm splint for hygiene) and said she was monitoring Circulation, Sensation, and Movement (CSM) and skin integrity (health of the skin) to his/her right elbow as ordered on his/her Treatment Administration Record (TAR). Nurse #2 said she could not recall being told by the Unit Manager or the day Nurse at the change of shift that Resident #1 had new orders to remove his/her arm splint for hygiene. Nurse #2 said she could not remember what interventions were on Resident #1's plan of care for his/her right arm splint and if there was no order to remove the splint then it most likely would not be on his/her plan of care. During an interview on 2/16/23 at 3:24 P.M., the Unit Manager said Resident #1's initial Physician orders were not to remove his/her right arm splint and on 1/10/23 he/she returned from an Orthopedic Consult visit with recommendations with instructions to remove his/her arm splint for hygiene. The Unit Manager said she signed Resident #1's Orthopedic Consult from 1/10/23 and verified the recommendations with the Nurse Practitioner and obtained new treatment orders. The Unit Manager said that she was responsible for writing his/her Physician orders and transcribing the orders onto Resident #1's January TAR. The Unit Manager said she wrote a Physician's order and transcribed the orders onto Resident #1's TAR and said that the sheet from his/her TAR's probably got lost. The Unit Manager said she could not remember if she updated his/her plan of care. During an interview on 2/14/23 at 3:18 P.M., the Director of Nurses (DON) said that Resident #1 returned from an Orthopedic Consult with new recommendations to remove his/her right arm splint for hygiene. The DON said Nursing did not transcribe the new Physician's order onto his/her TAR and the plan of care was not updated. The DON said it was the responsibility of the Unit Manager to write the Physician's order, transcribe the new orders onto Resident #1's TAR and update his/her plan of care. The DON said the Unit Manager did not follow through with the Facility's process for consult recommendations which includes, reviewing the consult, verifying new recommendations/orders with the Physician and or Nurse Practitioner, writing a Physician's order, transcribing the orders to resident's TAR, writing a progress note, and update the plan of care. On 02/14/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 1/17/23, Resident #1 was transferred to the Hospital for an evaluation, and returned to the facility with new orders for an antibiotics for diagnosis of cellulitis, daily dressing changes to right elbow area and anterior splint with orders to remove splint every shift to inspect his/her skin and pain managed with prescribed pain medication. B. On 1/18/23, Resident #1, and all residents residing in the facility, had a full body skin checks conducted by Nurse Management Staff to verify that no other skin areas were present. C. On 1/18/23, Resident #1 was seen by the Wound Care Specialist in the facility and new dressings orders were confirmed with the Nurse Practitioner. D. On 1/18/23 - 1/20/23, Resident #1's Plans of Care were reviewed and update with interventions related to his/her right humerus fracture. E. On 1/18/23 to 1/24/23, the Staff Development Coordinator, educated Licensed Nursing Staff on the care requirements for Resident #1's splinted right arm. F. On 1/20/23, all residents that utilize splints were reviewed by Nursing Management to verify splints are applied as ordered and no skin issues were identified related to splint usage. G. On 1/22/23, an audit of residents requiring splints/braces was completed by Nursing Management to verify all orders were reflected in the current Care Plan, skin intact, and Certified Nurse Aide (CNA) care card is updated. H. On 1/23/23, an audit was conducted by Nursing Management to review Consult Reports for the past 30 days to verify that all recommendations were followed through. I. From 1/18/23-1/24/23, the Staff Development Coordinator, provided education was provided to Licensed Nursing staff on the requirement to review consultation paperwork thoroughly and ensure all recommendations are followed through and communicated appropriately to staff. J. From 1/18/23-1/24/23, the Staff Development Coordinator provided education was provided to Licensed Nursing staff and Certified Nurse Aides (CNAs') regarding the following: -the implementation and use of a communication binder that will be kept at Nursing Stations for staff to review changes to resident plans of care. - the need for staff to inquire about care needs, such as splints if unaware of a residents plan of care. - the facility process for skin checks, including skin under splints and other medical devices that are to be removed and if not to be removed inspect the surrounding skin area of the medical device. K. The Unit Manager is currently out of the Facility and will be re-educated by Nursing Management upon her return. L. On 1/19/23 Education was provided to the Rehabilitation Department by the Rehabilitation Manager regarding the expectation that education will be provided to staff when a resident has a new splint or brace ordered. M. On 1/18/23, The Facility implemented a new process, that all consult sheets from the previous day will be brought to morning meeting for team review to verify all recommendations were followed through and telephone order slips will be reviewed at morning meeting to verify correct order transcription into the Point Click Care (PCC) computer system. N. The Quality Assurance Nurse and/or Designee will conduct daily audits x2 weeks, then weekly x30 days, and monthly thereafter on all residents that utilize splints and braces to verify Physician orders are followed for the wearing schedule, including skin checks, CNA care cards are up to date, skin is intact, and Nursing Care Plans are correct. The results of the audits will be brought to QAPI meeting quarterly until the committee determines compliance. O. The Director of Nursing and or Designee, are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when recommendations for new treatment orders from his/her Orthopedic Consultation, despite being reviewed and approved by the Nurse Practitioner, were not transcribed onto Resident #1's Treatment Administration Record (TAR) and his/her Care Plans were not updated with new interventions. Findings include: Resident #1 was admitted to the Facility in November 2022, diagnoses included Fracture of shaft (a break of the thigh bone between the hip and the knee) of left femur, Dementia, severe, with other behavioral disturbances, Hypertension, Gastro-esophageal reflux disease, Osteoarthritis, Iron deficiency anemia, Hypothyroidism, Hyperlipidemia, and Bilateral Sensorineural hearing loss. Review of Resident #1's Orthopedic Report of Consultation, dated 1/10/23, indicated he/she had recommendations for the following: -No skin issues were noted -Active Range of Motion (AROM) and Passive Range of Motion (PROM) right shoulder -Elbow splint removal for hygiene -Weight bearing with assisted transitions only with splint on -Should use right arm to feed him/herself Review of Resident #1's Physician Interim Orders, dated January 2023, indicated there was no documentation to support that an order related to the recommendations from the Orthopedist regarding his/her right elbow was written by the Unit Manager. Review of Resident #1's Facility Treatment Administration Records (TAR), dated 1/10/2023 through 1/17/2023, indicated there was no documentation to support his/her right arm splint was removed for hygiene. Further review of Resident #1's Medical Record indicated there was no documentation to support Nursing staff removed his/her right arm splint for hygiene and/or to assess his/her skin condition underneath the splint. Review of Resident #1's Plan of Care related to Activities of Daily Living and Potential for Pressure Ulcer indicated there was no documentation to support his/her plans of care was updated with interventions identified from his/her Orthopedic Consult visit on 1/10/23. During an interview on 2/14/23 at 3:16 P.M., Nurse #1 said he was not aware of the Orthopedic recommendation for orders from Resident #1's follow up Orthopedic visit on 1/10/23. During an interview on 2/22/23 at 4:39 P.M., Nurse #2 said she could not recall being told by the Unit Manager or the day Nurse at the change of shift, that Resident #1 had new orders to remove his/her arm splint for hygiene. During an interview on 2/16/23 at 3:24 P.M., the Unit Manager said she signed Resident #1's Orthopedic Consult on 1/10/23 and verified recommendation for orders with the Nurse Practitioner and said that she was responsible for writing his/her Physician orders and transcribing the orders onto Resident #1's January TAR. The Unit Manager said she wrote a Physician's order and transcribed the orders onto Resident #1's TAR and said that the page with the order from his/her TAR's probably got lost. The Unit Manager said she could not remember if she updated his/her plan of care. However, Review of Resident #1's medical record indicated that there was no documentation to support that the Unit Manager wrote a Physician order, transcribed the new orders to Resident #1's January TAR or that she updated his/her plans of care on 1/10/23. During an interview on 2/14/23 at 3:18 P.M., the Director of Nurses (DON) said that Resident #1 returned from an Orthopedic Consult on 1/10/23 with new recommendation for orders to remove his/her right arm splint for hygiene and said there was no written Physician's order, that the orders were not transcribed onto his/her TAR, and the plans of care were not updated. The DON said it was the responsibility of the Unit Manager to write the Physician's order, transcribe the new orders onto Resident #1's TAR, and update his/her plan of care. The DON said the Unit Manager did not follow through with the Facility's process for consult recommendations which included, reviewing the consult, verifying new recommendations/orders with the Physician and or Nurse Practitioner, writing a Physician's order, transcribing the orders to resident's TAR, writing a progress note, and update the plan of care. On 02/14/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 1/18/23 and 1/20/23 Resident #1's Physician treatment orders were verified by the Physician, orders were written and transcribed onto his/her TAR's. B. Resident #1's Physician Plan of Care was updated 1/18/23-1/20/23 with all interventions related to his/her right humerus fracture. C. The Unit Manager is currently out of the Facility and will be re-educated by Nursing Management upon her return. D. On 1/22/23, an audit of residents requiring splints/braces was completed by Nursing Management to verify all orders were reflected in the current Care Plan, and Certified Nurse Aide (CNA) care card is updated. E. On 1/23/23, an audit was conducted by Nursing Management to review Consult Reports for the past 30 days to verify that all recommendations were followed through. F. On 1/18/23 through 1/24/23, Education was provided to Licensed staff by the Staff Development Coordinator on the requirement to review consultation paperwork thoroughly and ensure all recommendations are followed through. G. On 1/18/23, the Facility implemented process change in which that all consult sheets from the previous day will be brought to morning meeting for team review to verify all recommendations were followed through and telephone order slips will be reviewed at morning meeting to verify correct order transcription into the Point Click Care (PCC) computer system. H. The Quality Assurance Nurse and/or Designee will conduct daily audits x2 weeks, then weekly x30 days, and monthly thereafter, on all residents that utilize splints/braces and Physician orders are followed, CNA care cards are up to date, and Nursing Care Plans are correct. The audit results will be brought to QAPI meeting quarterly until the committee determines compliance. I. The Director of Nursing and/or Designee are responsible for overall compliance.

Based on interview, record review, and policy review the facility failed to obtain a physician's order for COVID-19 testing for one Resident (#1) out of three sampled residents. Findings Include: Review of the facility protocol titled COVID-19 Testing Protocol, dated 2/2/22, indicated the following: -Obtain MD (medical doctor)/NP (nurse practitioner) order for testing Resident #1 was admitted to the facility November 2021. Review of the 2/22 Physician's Orders, did not indicate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Cumulative Report for Resident #1's COVID-19 Polymerase Chain Reaction (PCR) testing indicated he/she had been tested for COVID-19 on 2/1/22, 2/4/22, and 2/7/22. Review of the facility's BinaxNow (a rapid COVID-19 test) line listing, indicated Resident #1 had been tested on [DATE]. During an interview on 2/9/22 at 2:05 P.M., the Assistant Director of Nursing said Resident #1 was tested for COVID-19 on 2/1/22, 2/4/22, and 2/7/22. She further said Resident #1 did not have an active order for COVID-19 testing, as required.

Based on observation, interview, and policy review, the facility failed to ensure staff performed proper hand hygiene when moving between residents on one unit (02) out of two units observed. Findings Include: Review of the facility policy titled Hand Hygiene, undated, indicated the following: -Hand hygiene must be performed after .immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents Specific examples include but are not limited to: -Before and after direct resident care On 2/9/22 at 8:35 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 who wore gloves take a face mask that hung from the resident's wheelchair and apply it to the residents face. She then proceeded to remove a clean mask from a box and applied the mask to the other resident's face. She did not perform hand hygiene or change her gloves between touching the residents' aces. During an interview on 2/9/22 at 2:05 P.M., the Assistant Director of Nursing said Resident #1 was tested for COVID-19 on 2/1/22, 2/4/22, and 2/7/22. She said an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further said Resident #1 did not have a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on policy review, observation and interview, the facility failed to ensure that kitchen sanitation and food/beverage storage was in accordance with Professional Standards for Food Service Safety to minimize the risk for food borne illness. Findings include: Review the facility's Food Safety Requirement Policy, dated 11/01/18, indicated the following: -The facility should follow proper sanitation and food handling practices to prevent the outbreak of food borne illness. -Food and beverages brought in for residents: Food requiring refrigeration will be received by the facility designees for proper and immediate storage, including labeling and dating. Review of the facility's Infection Control: Dietary Policy, dated 2015, indicated the following for food storage: -Food is labeled and dated to allow for rotation of supplies. On 7/14/21 on 7:48 A.M., the surveyor observed the following concerns during the initial tour of the kitchen: -Dried food particles were stuck to the clean pot storage rack -The following 2 items were stored on a shelf near the stove, open to the air and undated: *16 ounce (oz.) boxes of baking soda and corn starch *3 pound (lbs.) box of salt -The following 5 spices were stored on a shelf near the stove and were open to air: *Onion powder *Paprika *Lemon *Pepper seasoning *Cinnamon -A large clear container containing a bag of food thickener had no date when opened -The large can opener was dirty with dried food particles -The large mixer was dirty with dried food splatter -The large covered food blender, not in use, was stored with free standing water inside of it -The following 1 gallon bottles, stored on a lower shelf near a food preparation area, were left undated opened: *Apple cider vinegar *Red wine vinegar *Vanilla extract *Masala cooking wine *White cooking wine -The following 32 oz. bottles, stored on shelf in a food preparation area, were left undated when opened: *Browning and seasoning sauce *Almond extract -The following items stored on shelf in the main kitchen area were open to the air and/or had no dates when opened: *Two 15 oz. bag of cheese puffs *5 lbs. bag of sugar *16 oz. bags potato chips and corn chips *3 lbs. bag of brown sugar *Two 16 oz. bags of gluten free ziti *16 oz. jar of peanut butter Also on this same shelf was a 20 oz. container of strawberry jelly that was open (1/2 full), that had no date when opened and the label indicated to refrigerate when opened. -The walk-in freezer floor had dirty food items on it. On a shelf was a dirty ice cream scoop stored on top of a large container of ice cream. On 7/16/21 at 9:34 A.M., the surveyor observed the nourishment kitchen on the Dementia Care Unit. The following items in the refrigerator were not labeled with a resident's name and/or the date received by the facility: *7.5 ounce (oz.) can straw soda [MEDICATION(S)] *Two 12 oz. bottles of Pepsi Zero *Two 7.5 oz. cans of Coke Zero *Two 18 oz. packets of sliced cheese *Five 7.5 oz. cans of Pepsi Zero *One 20 oz. bottle of diet root beer The following items in the freezer had no resident's name and/or date when brought into the facility: *Two 45 oz. containers of ice cream *2 boxes of frozen juice bars Located in a cabinet, a 16 oz. jar of peanut butter was observed to not be dated as to when it was opened and a 20 oz. container of strawberry jelly that was not dated when opened. The strawberry jelly label indicated to refrigerate when opened. During an interview on 7/16/21 at 9:52 A.M., Unit Manager #2 said any resident's food and drink brought by a visitor has to be labeled with the resident's name and date when brought in. She said the items noted above did not have the proper labeling, but should have. On 7/16/21 at 12:01 P.M., the surveyor observed the following concerns during a second tour of the kitchen: -The same 1 gallon jugs of cooking wines, vinegars and vanilla extract remained undated when opened -The same 3 lbs. box of salt was still open to the air and undated when opened -A bucket of sanitizing solution used for cleaning was tested and the test strip indicated the solution was at approximately 50 parts per million (ppm), not the required 200 ppm. During an interview on 7/16/21 at 1:35 P.M., the Food Service Director said all food items should have been labeled and dated when opened. She said she understood the sanitation and food storage concerns and would address them with her staff.

Based on record review and interview, the facility failed to ensure a transfer notice was sent to the Office of the State Long-Term Ombudsman for two residents (#55 and #38), out a total sample of 19 residents. Findings include: 1. Resident #55 was admitted to the facility in September of 2020. Review of the clinical record, indicated the Resident was transferred to the hospital on 3/24/21 for medical care and was admitted . Further review of the record indicated A Notice of Intent to Transfer, dated 3/24/21, was completed. 2. Resident #38 was admitted to the facility in November of 2020. Review of the clinical record, indicated the Resident was transferred to the hospital on 3/1/21 for medical care and was admitted . Further review of the record indicated A Notice of Intent to Transfer, dated 3/1/21, was completed. During an interview on 7/16/21, Social Worker #1 said there was no evidence the Office of the State Long-Term Ombudsman was notified of Resident #38's, nor Resident #55's transfer, as required. She said she contacted the facility's Ombudsman and was told they had not received either transfer notice.

Based on record review and interview, the facility failed to ensure the plan of care was followed for one resident (#68), out a total sample of 19 residents. Findings include: Resident # 68 was admitted to the facility in May of 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) in one day or weight gain of 5 lbs. in one week. Review of the May 2021 Medication Administration Record (MAR) and the May 2021 Weight and Vital Summary, indicated no documented weights on 5/20/21, 5/22/21 and 5/28/21. Review of the June 2021 Weight and Vital Summary, indicated no documented weights for 6/2/21 through 6/6/21, 6/9/21, 6/10/21, 6/12/21, 6/13/21, 6/16/21 through 6/26/21, 6/28/21 and 6/29/21. Review of the July 2021 MAR and July 2021 Weights and Vitals Summary, indicated no documented weights on 7/1/21, 7/3/21, 7/5/21, 7/6/21, 7/8/21, 7/14/21, and 7/15/21. During an interview on 7/16/21 at 11:27 A.M., Unit Manager #1 said Resident #68 would refuse daily weight checks at times, but that was documented on the MARs or the Weight and Vital Summary sheet. She said Resident #68 should have been weighted daily as ordered but was not.

Based on document review, record review, observation and interview, the facility failed to maintain Professional Standards of Care related to checking placement of a Gastrostomy Tube (G-Tube) (a tube inserted through the abdomen that brings nutrition directly to the stomach) for one Resident (#69) out of a total sample of 19 residents. Findings included: Review of an article in the Journal of [MEDICATION(S)] and Enteral Nutrition titled ASPEN (American Society of Enteral and [MEDICATION(S)] Nutrition) Safe Practices for Enteral Nutrition Therapy, dated 11/4/16, indicated the following: -The auscultatory method of tube tip placement confirmation is unreliable (listening to the sound of air, via stethoscope, injected into an enteral device, G-Tube, to assess for correct placement of the end of the tube). Do not rely on the auscultatory method alone to differentiate between gastric and respiratory placement or gastric and small bowel placement. Resident #69 was admitted to the facility in August of 2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #69 had a G-Tube placed in 2018. Review of the Physician Orders, dated July 2021, indicated the following: -Diet: NPO (Latin for nothing by mouth) -PEG Tube (a type of G-Tube) #20 French (a measurement of tube diameter)/7-10ml balloon (a balloon is used to hold the G-Tube in place to prevent the tube from falling out). -Multiple medications due at 9 A.M. including [MEDICATION(S)] (a drug to reduce the production of glucose used to prevent or lower the blood sugar in type 2 diabetes) tab 1000 milligrams, give one tablet by G-Tube twice daily at 9 A.M. and 9 P.M . -Crush and mix medications with 5 milliliters (ml) water, flush each medication with 10 ml water. -Check G-Tube residual prior to bolus at 6 A.M. and 8 P.M., Hold if greater than 200 ml and notify Medical Doctor/Nurse Practitioner. -[MEDICATION(S)] 1.5 (a type of formula for G-Tube feeding) Give 240ml via G-Tube three times daily at 10 A.M., 1 P.M., and 5 P.M. -[MEDICATION(S)] 1.5 240ml via G-Tube at 8 P.M. -[MEDICATION(S)] 1.5 480ml via G-Tube at 6 A.M. On 7/15/21 at 9:45 A.M., the surveyor observed the medication pass and observed Nurse #2 enter Resident #69's bedroom to administer the medication and bolus feeding. Nurse #2 indicated she would check G-Tube placement prior to administering meds and fluids and, used a 60 cubic centimeter (cc) syringe to insert air into the G-Tube while she listened to the Resident's abdomen with a stethoscope. She pulled back on the plunger of the syringe to check for residual (feeding left over from the previous feeding), stated there was no residual, and administered a water flush, followed by the medications and bolus feedings as ordered. During an interview, at the time of the medication pass, the surveyor asked Nurse #2 why she had inserted the air into the Resident's stomach. Nurse #2 said that was how she was trained to check for placement of a G-Tube by the facility. Nurse #3 said she also checked placement of a G-Tube by inserting air. During an interview on 7/15/21 at 10:49 A.M., the Director of Nurses said air auscultation should no longer be used to confirm placement of a G-Tube prior to the administration of medications and fluids.

Based on record review and interview, the facility failed to ensure the plan of care was followed for one resident (#74) receiving [CONDITION(S)] services, out a total sample of 19 residents. Findings include: Resident # 74 was admitted to the facility in October of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 5:00 P.M. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on 7/5/12 and 7/12/21, and documented as not administered at 5:00 P.M. as ordered on 7/2/21, 7/7/21 and 7/9/21 (all of these dates are days of [CONDITION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/14/21 at 9:45 A.M., Nurse #1 said the [MEDICATION(S)] Sulfate should not have been scheduled at 5:00 P.M. on Mondays, Wednesdays and Fridays, as the Resident was out of the facility at that time to receive [CONDITION(S)] treatment. During an interview on 7/14/21 at 9:50 A.M., Unit Manager #2 said the [MEDICATION(S)] Sulfate should not have been documented as administered at 5:00 P.M. on the days of [CONDITION(S)] treatments. She also said nursing should have notified the Physician when the medication was not administered as ordered but did not.

Based on policy review, record review, observation and interview, the facility failed to ensure that ongoing assessments were completed for the use of bedrails for one Resident (#69), out of a total sample of 19 residents. Findings included: Review of the facility policy Bed Rail Use, dated 11/1/17 and last reviewed 2/3/20, indicated that the facility will document ongoing need for the use of a bedrail through regular reassessment via the reassessment within Point Click Care, the electronic medical record. Resident #69 was admitted to the facility in August of 2013 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the most recent Quarterly Minimum Data Set, dated dated [DATE], indicated the Resident has cognitive impairment as evidenced by a score of 10 out of 15 on the Brief Interview for Mental Status, has had falls since admission and requires extensive assistance for bed mobility. On 7/15/2021 at 8:47 A.M., the surveyor observed Resident #69 in his/her room, in bed with eyes closed. There were half side rails in use on Resident #69's bed. Review of Resident #69's assessments indicated quarterly assessments for the use of side rails, the most recent assessments were dated December 2020. During an interview on 7/15/21 at 3:30 P.M., the Director of Nurses said that side rail assessments are completed quarterly. She said Resident #69's side rail assessments were not done for March and June 2021, as required.

Based on policy review, observation and interview, the facility failed to ensure that an opened vial of insulin was labeled in accordance with Professional Standards, including expiration date, in one medication cart out of the two medication carts observed. Findings included: Review of the facility's pharmacy policy titled Medication Storage in the Facility, effective 9/1/13, indicated that once a multidose vial of medication has been opened, a date opened sticker should be placed on the medication vial and the date opened and the new date of expiration entered on the sticker. It also indicated the new expiration date of the vial or container will be thirty days unless regulations/guidelines require different dating. On 07/15/21 at 2:50 P.M., the surveyor observed the medication storage on the third floor unit and observed an opened vial of [MEDICATION(S)] insulin in one of the drawers in Medication Cart A. A pharmacy generated label was on the vial as well as a yellow sticker with fields for date opened, discard date and nurse's initials. The fields on the yellow sticker were blank. There was a handwritten marking of 7/2 in black magic marker on the pharmacy label; the rest of the label was printed. During an interview, at the time of the observation, Nurse#4 said that opened vials of insulin are to have the dates sticker applied and completed to indicate the date opened and the date to discard and the nurse's initials and this was not done, as required. She stated that opened vials of insulin are only good for 28 days and she could not tell when the vial had been opened based on the information on the pharmacy label. During an interview on 7/15/21 at 3:02 P.M., the Assistant Director of Nurses verified that the sticker was not completed with the nurse's initials, the date opened and the date to be discarded and that it should have been done, as required. She said she could not tell when the vial had been opened based on the information present on the pharmacy label.

Based on record review and interview, the facility failed to ensure the medical record was complete and accurate for four Residents (#20, #55, #74 and #91), out a total sample of 19 residents. Findings include: 1. For Resident #20, the facility failed to ensure complete and accurate documentation on the Medication Administration Record (MAR). Resident #20 was admitted to the facility in April of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the June 2021 Physician's Orders indicated the following: -[MEDICATION(S)] (antipsychotic medication) 5 milligrams (mg), one tablet by mouth daily at 8:30 A.M. and 2.5 mg at bedtime, 8:30 P.M. (original date ordered 11/23/20). -[MEDICATION(S)] (stool softener) 100 mg, give one capsule by mouth twice daily, 9:00 A.M. and 5:00 P.M., (original date ordered 4/17/19). -Acetaminophen (pain reliever) 325 mg, give two tablets by mouth twice daily, 8:30 A.M. and 8:30 P.M. (original date ordered 10/20/20). -[MEDICATION(S)] (antianxiety medication) 10 mg, give one tablet by mouth twice daily, 8:30 A.M. and 8:30 P.M. (original date ordered 8/11/20). -[MEDICATION(S)] (blood pressure medication) 100 mg, give one half tab by mouth twice daily, 8:30 A.M. and 8:30 P.M. (original date ordered 8/10/20). -[MEDICATION(S)] (blood pressure medication) 25 mg extended release, give one tablet by mouth at 5:00 P.M. -[MEDICATION(S)] (antidepressant medication) 15 mg, give one tablet by mouth at bedtime, 8:30 P.M., (original date ordered 3/17/20). Review of the July 2021 MAR indicated no documentation of medication administration for the following dates: -[MEDICATION(S)] 5 mg at 8:30 A.M. on 7/4/21 and 2.5 mg at 8:30 P.M. on 7/9/21. -[MEDICATION(S)] 100 mg at 5:00 P.M. on 7/9/21 and 7/15/21. -Acetaminophen 650 mg at 8:30 P.M. on 7/9/21. -[MEDICATION(S)] 10 mg at 8:30 P.M. on 7/9/21. -[MEDICATION(S)] 50 mg at 8:30 P.M. on 7/9/21. -[MEDICATION(S)] 25 mg at 5:00 P.M. on 7/9/21. -[MEDICATION(S)] 15 mg at 8:30 P.M. on 7/9/21. During an interview on 7/16/21 at 9:35 A.M., Unit Manager (UM) #2 said nursing should have documented on the MAR when the above medications were administered, but had not. She said the Resident had likely been administered the medications as ordered, but the July 2021 MAR documentation was incomplete. 2. For Resident #55, the facility failed to ensure the care and service of the Foley catheter was carried over to the July 2021 Physician's Orders. Resident #55 was admitted to the facility in November of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the clinical record review indicated Resident #55 was admitted to the facility with a Foley catheter and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 Physician's Orders, indicated no ordered care and services for the Foley Catheter. Review of the July 2021 Medication Administration Record indicated care and services were being provided for the Foley catheter. During an interview on 7/15/21 12:24 P.M., the Director of Nurse said, after reviewing the July 2021 Physician's Order, there was an error made during editing from June to July 2021 and the orders were omitted, but should not have been. She said the care and services were being provided. 3. For Resident #74, the facility failed to ensure care and service of an internal jugular (IJ) catheter used for [CONDITION(S)] was accurate for the July 2021 Physician's Orders. Resident #74 was admitted to the facility in October of 2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record indicated the Resident was hospitalized [DATE] through 6/9/21 and was readmitted to the facility with a left chest wall IJ tunneled catheter to be used when receiving [CONDITION(S)] treatments. Review of the June 2021 Physician's Orders indicated the following (when the Resident was readmitted from the hospital): [CONDITION(S)] access site: IJ tunneled permacath, monitor for hemorrhage or occlusion, port capped and clamped. Review of a Physician's Order, dated 6/30/21, indicated the following: Keep left arteriovenous (AV) fistula (an abnormal connection between an artery and vein) cover with a 4 by 4 dressing, monitor for signs and symptoms of infections and check bruit/thrill (rumbling sound/sensation) each shift. Review of the July 2021 Physician's Orders did not include the IJ tunneled [CONDITION(S)] access site. Review of the July 2021 Treatment Administration Record (TAR) indicated care in service were in place for the AV fistula. During an interview on 7/14/21 at 9:45 A.M., Nurse #1 said the Resident's AV fistula was not being used yet for [CONDITION(S)] treatment. He said, after reviewing the July Physician's Orders and TARs, that the documentation was incomplete for the IJ tunneled catheter. He said the documentation for the care and service for the IJ tunnel catheter was unclear. During an interview on 7/14/21 at 3:09 P.M., the Director of Nurses said the July Physician's Orders and TARs for the care and services for the IJ tunneled catheter were incomplete and it appeared to be an error with editing, She said the Resident did continue receive monitoring of the IJ tunneled catheter site monitor each shift. 4. For Resident #91, the facility failed to accurately document the correct discharge status on a Discharge Minimum Data Set (MDS). Resident #91 was admitted in April of 2021. Review of Discharge MDS, dated [DATE], indicated Resident #91 discharged to an Acute Hospital on 6/2/21. Review of the Nursing Progress Notes, dated 6/2/21, indicated Resident #91 discharge to her son's home in the community. During an interview on 7/19/21 at 11:21 A.M., Consulting Staff #1 said she had reviewed Resident #91's Medical Record and Resident #91 discharged to the community with her son. She further said the MDS was documented inaccurately and it should have been coded as discharge to Community.

Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing to (1.) properly wear Personal Protective Equipment (PPE) on 2 of 2 resident units (2.) perform hand hygiene when indicated and (3.) during a COVID-19 outbreak, avoid placing residents in the same room with residents who have conditions that may increase the risk of an adverse outcome from infection or that may facilitate transmission. Findings include: 1.) Review of the facility's policy titled Infection Control Transmission-Based Precautions undated, indicated: * Sequence for donning Personal Protective Equipment (PPE): - Gown: fully cover torso from neck to knees, arms to end of wrists, and wrap around the back; fasten in back of neck and waist. * Sequence for removing PPE: - Gown: gown front and sleeves are contaminated, unfasten ties, pull away from neck and shoulders, touching inside of gown only, turn gown inside out, fold or roll into a bundle and discard. During an initial interview with the Director Of Nursing (DON) on 1/14/21 at 8:30 A.M., she said that the facility was currently in a COVID-19 outbreak, and that the most recent positive case was a staff member on 1/8/21. She explained the facility's PPE requirements and process: * All staff were required to enter the units via a clean stairwell. Outside the unit door they would properly don (put on) an isolation gown, face shield or goggles and a face mask. She said that staff were required to wear this at all times when on a unit. * Each resident room had a gown designated to each staff hanging inside the room. When staff enter the room, they are required to remove their unit gown and put on their patient specific gown within the room. * Upon exiting the unit staff leave via the dirty stairwell. There, staff doff (remove) their isolation gown and disinfect their eye protection. On 1/14/21 at 9:10 A.M., the surveyor observed the second floor unit (27 COVID-19 negative residents, 23 residents who have been recovered greater than 6 months from COVID-19 and 1 resident that was recovered less than a month from COVID-19). The following observations were made: * At 9:17 A.M., Certified Nursing Assistant (CNA) #1 exited a resident room wearing an isolation gown tied only at the top and exposing his full backside to pathogens. The residents in the room he exited were negative for COVID-19. * At 9:20 A.M., Nurse #1 was observed standing at her medication cart. She wore an isolation gown that was tied only at the top, and her backside was fully exposed to pathogens. On 1/14/21 at 10:28 A.M., the surveyor observed the 3rd floor unit (12 COVID-19 negative residents, 9 residents recovered greater than 6 months from COVID-19 and 5 residents recovered less than a month). The following observations were made: * At 10:28 A.M., Nurse #2 was standing at her medication cart preparing medications. Nurse #2 wore a gown that was tied only at the neck, and fully exposing her backside to pathogens. * At 10:31 A.M., Nurse #3 stood in a resident doorway with her backside facing in to the room, preparing medications. Nurse #3's gown was tied only at the neck, fully exposing her backside to pathogens. All three residents in the room were negative for COVID-19. * At 10:44 A.M., Nurse #3 was observed standing in a resident room doorway, with her backside facing in to the room, preparing medications. Nurse #3's gown was tied only at her neck, fully exposing her backside. * At 10:45 A.M., Nurse #3 pulled her gown over her head, rather than untieing it, exposing her hands, face and head to any pathogens on the gown. Nurse #3 then hung the gown on a hook and placed another gown, already pretied over her head, once again exposing her hands, face and head to any pathogens on the gown. Both residents in the room were COVID-19 negative. During an interview with the DON at 12:25 P.M., contrary to the facility's policy, which indicated that gowns should be tied at the neck and waist and fully cover the torso and back, and contrary to the interview with her at 8:30 A.M., the DON said she was not sure if gowns should be tied at both the neck and waist. 2.) Review of the Centers for Disease Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Dec. 14, 2020, indicated the following: * Hand Hygiene-HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. * Put on clean, non-sterile gloves upon entry into the patient room or care area. * Change gloves if they become torn or heavily contaminated. * Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. On 1/14/21 at 9:10 A.M., the surveyor observed the second floor unit (27 COVID-19 negative residents, 23 residents who have been recovered greater than 6 months from COVID-19 and 1 resident that was recovered less than a month from COVID-19). The following observations were made: * At 9:23 A.M., CNA #1 was observed to go in and out of 3 resident rooms, removing breakfast trays and placing them in a tray truck, that was parked in the corridor. As CNA#1 entered and exited each room, CNA #1 did not perform hand hygiene, contaminating the trays surface, the food trucks surface, and potentially the environment and resident in each room. * At 9:27 A.M., a Maintenance Worker (MW) opened a door and entered the unit through the dirty stairwell. The MW entered a resident room where three residents resided that were all negative for COVID-19. Without performing hand hygiene, the MW fixed the air mattress on a bed that one of the residents lay in. A short while later, the MW exited the room and without performing hand hygiene he walked down the corridor. He stopped at a resident, placed his hand on a wheelchair that the resident was seated in, contaminating the wheelchairs handle. Then, without performing hand hygiene, the MW removed a book from a shelf and flipped through the pages, contaminating the book and its pages. On 1/14/21 at 10:28 A.M., the surveyor observed the 3rd floor unit (12 COVID-19 negative residents, 9 residents recovered greater than 6 months from COVID-19 and 5 residents recovered less than a month). The following observations were made: * At 10:44 A.M., Nurse #3 was standing at her medication cart preparing medications. Nurse #3, then, without performing hand hygiene, put on a pair of gloves, contaminating the gloves, and entered the room to administer the medication, potentially contaminating the residents in the room and environment. Both residents in the room were COVID-19 negative. During an interview with the DON at 12:25 P.M., she said staff should always perform hand hygiene prior to putting on and removing gloves, as well as after contact with the resident's environment, to prevent the spread of pathogens and contamination to the staff and residents. 3.) Review of the facility's policy titled Infection Control Transmission-Based Precautions; Droplet Precautions undated, indicated the following: * Make decisions regarding resident placement on a case by case basis, after considering infection risks to other residents in the room and available alternatives. When single rooms are in short supply, apply the following principles for making decisions on resident placement: - Prioritize residents who have excessive cough and sputum production for single resident room placement. - Avoid placing residents on droplet precautions in the same room with residents who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission. Review of the Centers for Disease Control guidance titled People With Certain Medical Conditions, with a revision date of 12/23/20, indicated the following: *Adults of any age with certain underlying medical conditions are at increased risk for severe illness from [MEDICAL CONDITION] that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization , admission to the ICU, intubation or mechanical ventilation, or death. Review of the Centers For Disease Control and Prevention guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance. *Health care personnel (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also wear an N95 or equivalent or higher-level respirator, instead of a facemask, for Aerosol generating procedures. On 1/14/21 at 10:28 A.M., the surveyor observed the 3rd floor unit (12 COVID-19 negative residents, 9 residents recovered greater than 6 months from COVID-19 and 5 residents recovered less than a month). The unit had 4 rooms that were entirely vacant. The following observations were made: * At 10:32 A.M., Resident #1 was observed in his/her room, seated on his/her bed that was next to the door. The door was fully open and Resident #1 was self-administering a nebulizer treatment (A nebulizer, is a piece of medical equipment that a person with asthma or another respiratory condition can use to administer medication directly and quickly to the lungs and an aerosolizing procedure). Resident #1's roommate (Resident #2) lay in bed and was visible from the doorway, as the curtain was only partially pulled, and Resident #2 was not wearing a face mask. Resident # 1 and #2 were both COVID-19 negative. On 1/14/21 at 11:49 A.M., during an interview with Resident #1, he/she said that he/she always self-administers his/her own nebulizer treatment in his/her room and that he/she and his/her roommate never left the room. During this interview, Resident #2 was observed in bed sleeping. On 1/14/21 at 12:00 P.M., the surveyor interviewed Nurse #3 who was caring for Resident #1 and Resident #2, Nurse #3 said the following: * Resident #1 always administers his/her own nebulizer treatments and only did them in his/her bedroom. * Resident #2 did not leave the room, or wear a protective mask, when Resident #1 received his/her nebulizer treatment. * Both Resident #1 and Resident #2 are negative for COVID-19 During an interview with the DON on 1/14/21 at 12:25 P.M., the surveyor shared the observations of Resident #1 self-administering a nebulizer treatment with the door wide open and curtain partially pulled while Resident #2 was lying in bed in the room, without a mask. The DON indicated the following: * Both Resident #1 and Resident #2 were negative for COVID-19. * She said that she was not concerned with the two COVID-19 negative residents sharing a room, despite one performing an aerosol generating procedure multiple times a day, as she felt that their beds were far enough apart. * She said that she had not discussed this with Department of Public Health (DPH) Epidemiologist assigned to the facility. A.) A brief record review, on 1/14/21 at 12:45 P.M., for Resident #1 indicated: * Resident #1 was admitted to the facility in September 2019, and had [DIAGNOSES REDACTED].>malignant neoplasm of unspecified bronchus or lung and [MEDICAL CONDITIONS]. * The most recent Minimum Data Set (MDS) assessment indicated that on the Brief Interview for Mental Status (MDS) exam Resident #1 scored a 15/15 indicating intact cognition. Further, the MDS indicated Resident #1 had no behaviors. * A clinical nursing admission note for Resident #1 indicated that he/she had a chronic cough, was oxygen dependant and required nebulizer treatments 5 times a day. B.) A brief record review, on 1/14/21 at 12:50 P.M., for Resident #2 indicated: * Resident #2 was admitted to the facility in December 2020, and had [DIAGNOSES REDACTED]. *The most recent Minimum Data Set (MDS) assessment indicated that on the Brief Interview for Mental Status (MDS) exam Resident #2 scored a 14/15 indicating intact cognition. Further, the MDS indicated Resident #2 had no behaviors * A clinical nursing note, dated 1/6/21, indicated that Resident #2 required supervision at meals for coughing and on that date had to be suctioned twice. During a follow-up interview with the DON on 1/14/21 at 1:33 P.M., she agreed that Resident # 1 and Resident #2 both had significant respiratory histories and were vulnerable. Despite Resident #1 administering aerosol generating procedures several times a day, and despite Resident #2's fragile respiratory status, she said that she was not concerned with cohorting the roommates. CMS considers CMS and CDC COVID-19 guidance to be a national standard. The facility failed to abide by the standard and transmission-based precautions identified in its own policies and procedures, thus increasing the potential for transmission of COVID-19 in the facility.

Based on observation, interview and record review, the facility failed to appropriately use Personal Protective Equipment (PPE) on one of two units. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) website indicated newly admitted or readmitted residents should be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Further review indicated that all PPE was to be removed prior to exiting the room . Review of the facility's Bed Board (color coded document that included the COVID-19 status of each resident and which room they were in), indicated Unit 2 had both recovered and negative residents, and had one room with three residents in their 14 day quarantine due to being new admissions to the facility. During an observation on July 1, 2020 at 9:10 A.M., Nurse #1 had gown, mask, and eye goggles on and was at the medication cart. Nurse #1 then entered the room with the quarantined residents, took a gown from behind the door and put it over the gown he had on and then entered the room to help set the breakfast tray up. Nurse #1 removed the gown and hung it on the door, performed hand hygiene, exited the room and went back to the medication cart. He then prepared medications, went back to the room where he again donned a gown over the gown he was wearing, removed the outer gown when he exited the room and then performed hand hygiene. During an interview on July 1, 2020 at 9:15 A.M., Unit Manager (UM) #1 said the staff was supposed to put a gown over the gown they had on prior to entering the quarantined room. She said they were supposed to wear a face shield as well. During an interview on July 1, 2020 at 9:20 A.M., Nurse #1 told the surveyor he had been told to put a gown over a gown before entering the quarantined room. He said he wasn't sure about a face shield but would find out. UM #1 joined the conversation and said Nurse #1 should have put on a face shield to go into the quarantined room and clean it before exiting the resident's room.

Based on observation and interview, the facility failed to provide food and drink that was palatable and of appetizing temperature in the main dining room. Findings include: During the Resident Council meeting on 3/4/20 at 11:05 A.M., 4 out of 7 residents who ate in the main dining room said that the eggs and oatmeal served at breakfast were always served cold and that the texture of the oatmeal was too thin. The following observations were made in the kitchen, during the breakfast service, on 3/5/20 from 7:40 A.M. through 9:10 A.M.: - Cooked food items were covered and resting in the steam table. - A tray with covered cups of pre-thickened milk was resting on the tray line counter - The cook took holding temperatures for hot foods at 7:54 A.M. - A facility food service worker was observed to distribute a cup of pre-thickened milk on a resident tray at 8:32 A.M. No holding temperature was observed prior to distribution. The Food Service Director (FSD) took the temperature of the pre-thickened milk at 8:34 A.M. upon surveyor request. The temperature of the pre-thickened milk was 65 degrees Fahrenheit (F). - A food service worker was observed to transport the last breakfast food truck from the kitchen to the main dining room at 9:10 A.M . The surveyor received the test tray at 9:18 A.M., after all resident breakfast trays were served. Test tray temperatures were taken with the FSD starting at 9:18 A.M. Temperature and palatability were as follows: - Puree eggs 116 degrees F; warm to taste, not hot (down from holding temperature of 168 degrees F) - Poached egg 99 degrees F; barely warm to taste (down from holding temperature of 165 degrees F) - Scrambled eggs 112 degrees F; lukewarm to taste and watery consistency (down from holding temperature of 204 degrees F) - Fried egg 90 degrees F; cold to taste (down from holding temperature of 160 degrees F) - Cream of rice cereal 128 degrees F; warm to taste, not hot, and thin consistency (down from holding temperature of 167 degrees F) - Super cereal 127 degrees F; warm to taste, not hot (down from holding temperature of 190 degrees F) - Pre-thickened milk was warm to taste During an interview on 3/5/20 at 10:34 A.M., the surveyor reviewed the resident's concerns about cold eggs and cereal as well as the test tray results. The FSD said the food temperatures should be holding after they leave the kitchen and she wasn't sure why they were not. The FSD also said that the thickened milk was served from a pre-thickened container at room temperature and, to be palatable, it should have been served cold.

Based on observation and interview, the facility staff failed to ensure appropriate requirements were maintained relative to the storage, distribution and service of food in accordance with professional standard for food service safety. Findings include: Review of the facility's Infection Control-Dietary Policy, dated 2015, indicated the following: -The Dietary Department will be maintained in a clean and sanitary manner to prevent foodborne illness. -Dietary Staff will practice proper food handling procedures, including but not limited to hand washing, wearing disposable gloves to perform certain food handling tasks and discarding gloves on the completion of the task. -Food is labeled and dated to allow for rotation of supplies. -Food temperatures are monitored regularly and logs are maintained. Review of the facility's Dietary Services Handwashing Policy, dated 5/22/17, indicated the following; -Employees must always thoroughly wash their hands when touching anything that may contaminate their hands and when changing gloves. -After washing their hands, employees should never do anything that could re-contaminate their hands before returning to work. On 3/3/2020 at 7:23 A.M., the following concerns were observed while walking through the kitchen: -The top of the dish machine was dirty with dust and food crumbs -The underside of the large mixer (where the mixing blade is attached) was very dirty with dried food particles -A large bin of flour and a large bin of oatmeal were undated -A container thick-it stored on shelf in the main storeroom was open to the air and was undated when opened The following items were stored on a shelf in the main kitchen and were not dated when opened: -6 pound (lb.) container of sprinkles, a 5 lb. bag of muffin mix, a 4 lb. container of food enhancer, a box of cream of wheat and a bag of wild rice. -A ham salad sandwich was partially unwrapped and undated on a shelf in the 2 door refrigerator. On 3/4/2020 12:00 P.M., the following concerns were observed during a second tour of the kitchen: -The underside of the large mixer remained dirty -The box of Cream of Wheat remained open and undated, stored on a shelf in the kitchen. There also was a bag of milk powder that was open to the air and undated, on the shelf. -The flour and oatmeal storage bins remain undated. -A gallon bottle of soy sauce, 1/4th full, was stored on a shelf. The label indicates to refrigerate when opened. -A trash buckle near the lunch service area was uncovered. Additionally at this time, during the observation the lunch meal service the following concerns were noted: -Food temperatures were not taken for green beans, soup, pureed soup and gravy and the meals were already being served. -Dietary Staff #1 was observed wearing gloves while serving the meal. She was observed leaving the service area and handling oven mitts, opening and closing the refrigerator and picking up equipment. Each time she returned to the serving area without removing the dirty gloves, washing her hands and donning new gloves before returning to serve the lunch meal. She was observed handling food garnishes and sandwiches with her gloved hands. During an interview on 3/4/2020 at 12:30 P.M., the Food Service Director said the cook should have changed her gloves, washed her hands and donned new gloves each time she left the meal service area. She said all items served at a meal should have their temperature checked and recorded. She said the other storage and sanitation should not have occurred and issues would be addressed by re-educating the staff.

Based on interview and record review, the facility failed to ensure one resident (#17) was included in the care plan process, out of a total sample of 22 residents. Findings include: Resident #17 was admitted to the facility in September 2019. Review of the Quarterly Minimum Data Set assessment, dated 9/12/19, indicated Resident #17 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. During an interview on 3/03/20 at 8:22 A.M., Resident #17 said he/she didn't like to go anywhere because sometimes the portable oxygen ran out. Resident #17 said he/she hadn't been to the care plan meetings because of that. Review of a progress note, dated 9/23/19, indicated Resident #17 had a care plan meeting. The note did not indicate that the care plan was reviewed with the resident or that he/she declined to attend. There was no care plan conference attendance sign in sheet for the meeting. Review of a care plan conference attendance sign in sheet, dated 12/26/19, indicated that a care plan meeting was held and neither Resident #17 nor the resident's representative signed as being in attendance. Review of a progress note, dated 12/26/19, indicated Resident #17 had a care plan meeting. The note did not indicate that the care plan was reviewed with the resident or that he/she declined to attend. During an interview on 3/03/20 at 3:03 P.M., Social Worker #1 said that they usually wrote a note to indicate if the resident or the resident representative attended the care plan meetings, and she wasn't sure what happened in this case. She said they didn't document if Resident #17 refused to attend the care plan meetings. She said she didn't know where the sign in sheet was for September's care plan meeting.

Based on interview and record review, the facility failed to maintain professional standards relative to documenting injection sites for Trulicity (medication to control blood sugar) and ensure the sites were rotated, for one resident (#26) in a total sample of 22 residents. Findings include: Resident #26 was admitted to the facility in July 2017 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].M. Review of the January 2020 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the February 2020 MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the March 2020 MAR indicated [REDACTED]. During an interview on 3/4/20 at 11:40 A.M., Unit Manager #2 reviewed the January 2020, February 2020 and March 2020 MARs with the surveyor. She said the injection site documentation was missing for several days when Trulicity was administered. She said nursing should have documented the site of injection after each administration of the medication, but it was not done consistently.

Based on record review and interview, the facility failed to ensure the coordination of care between the nursing home and hospice in order to ensure that the most current plan of care was provided for one resident (#65) in a total sample of 22 residents. Findings include: Resident #65 was admitted to the facility in July of 2019 with [DIAGNOSES REDACTED]. Review of the record indicated Resident #65 was admitted to hospice on 8/9/19. Further review of the record indicated the last Hospice Comprehensive Assessment and Plan of Care update was on 12/31/19. There was no evidence of hospice nursing visits after 1/15/20, hospice aide visits after 1/10/20, or social worker visits after 12/31/19. During an interview on 3/3/20 at 2:01 P.M., Unit Manager (UM) #2 said she wasn't sure how many times per week the hospice aide provided visits. She said the schedule should have been in the hospice binder, but she was unable to find any schedules after December 2019. The UM reviewed the hospice binder and said she couldn't find any documented evidence of nurse, aide or social worker visits since January of 2019. The UM further said she wasn't sure why the record was not up to date and she would need to call the agency to ask them to fax the current schedules and documentation.

Based on records reviewed and interviews for one of six sampled residents (Resident #1), who required the assistance of two staff members and the use of a mechanical lift for transfers, the Facility failed to ensure that Resident #1 was provided with the necessary care and treatment to avoid physical injury, harm, and pain when he/she was transferred with a mechanical lift without the appropriate number of staff required to complete a mechanical lift transfer. - When on [DATE], CNA #14 transferred Resident #1 alone with a mechanical lift without assistance from another staff member and Resident #1 fell to the floor. CNA #14 left Resident #1 on the floor and then left the room to get CNA #15. Upon return to Resident #1's room, CNA #14 and CNA #15 manually lifted Resident #1 off of the floor and put him/her into bed without immediately notifying a nurse about the fall. Therefore, Resident #1 was not properly assessed by nursing for pain, injury or to determine, if it was clinically appropriate to move Resident #1 or to keep him/her on the floor until the Emergency Medical Services (EMS) arrived to prevent further potential injury and harm. Findings Include: The Facility Policy titled Mechanical Lift, reviewed [DATE], indicated that a mechanical lift allowed two staff members to transfer a patient safely. The Policy indicated that two people were required when using the mechanical lift where there is no resident weight bearing. Resident #1 was admitted to the Facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was severely cognitively impaired, was non-ambulatory, was dependent on and required extensive staff assitance of two staff members for transfers. Resident #1's Activity of Daily Living Care Plan, indicated that Resident #1 required two staff members and the use of a mechanical lift with transfers. Resident #1's Pain Care Plan, indicated that Resident #1 was unable to verbalize pain and unable to request pain medication. An Incident Report, dated [DATE], indicated that at 7:50 [NAME]M. on [DATE], Resident #1 sustained a skin tear during a mechanical lift transfer from his/her bed to his/her chair. The Incident Report indicated that CNA #14 reported that while transferring Resident #1 with the mechanical lift, his/her head bumped the metal part of the lift and he/she sustained a skin tear above his/her left eyebrow. The Facility Hospital Transfer Form, dated [DATE], indicated that key clinical information and reason for Resident #1's Hospital transfer was due to a skin injury to the left side of his/her forehead. The Form indicated that additional relevant information was that the injury occurred as a result of Resident #1 bumping his/her head on the mechanical lift. An Emergency Department Trauma History and Physical Consult Note, dated [DATE], indicated that Resident #1 arrived at 9:40 [NAME]M. via Emergency Medical Services (approximately one and a half hours after Nurse #1 observed Resident #1's laceration). The Note indicated that Resident #1 reportedly was accidentally struck in the head by a mechanical lift. On [DATE] Surveyor #1 observed the Facility Video Camera Footage from [DATE], which showed following; - 7:41:15 [NAME]M., CNA #14 walked into Resident #1's room alone with the mechanical lift; - 7:43:17 [NAME]M., CNA #14 walked out of Resident #1's room and went into a room a few doors down; -7:43:32 [NAME]M., CNA #14 and CNA #15 exit the other room, and go into Resident #1's room together; - 7:45:05 [NAME]M., CNA #14 and CNA #15 exited Resident #1's room; - 7:46:59 [NAME]M., CNA #14 is seen walking out of Resident #1's room with the mechanical lift; -7:49:16 [NAME]M., Nurse #1 is then seen entering Resident #1's room. Surveyor #1 interviewed Nurse #1 at 12:06 P.M. on [DATE]. Nurse #1 said that, at approximately 7:50 [NAME]M. (exact time unknown) on [DATE], CNA #14 asked him to go check Resident #1. Nurse #1 said when he went into Resident #1's room he observed that Resident #1 was in bed with a face cloth on the left side of his/her forehead and he/she had a laceration over his/her left eyebrow that was moderately bleeding. Nurse #1 said that CNA #14 told him that when she and another aide attempted to transfer Resident #1 with the mechanical lift, the metal part of the lift hit Resident #1. Nurse #1 said he was not told at that time that Resident #1 had fallen to the floor. Surveyor #1 interviewed CNA #14 at 1:21 P.M. on [DATE]. CNA #14 said that she was Resident #1's primary CNA and had provided care for Resident #1 on a regular basis. CNA #14 said Resident #1 required the use of a mechanical lift with assistance of two staff members for transfers. CNA #14 said she was familiar with Resident #1's Plan of care related to his/her care needs and said his/her transfer status was written on a sheet for CNA's that was located at the nurse's station. CNA #14 said that, sometime between 8:00 [NAME]M. and 8:30 [NAME]M. (exact time unknown) on [DATE], while she and CNA #15 transferred Resident #1 with the mechanical lift, one of the clips of the sling that suspended Resident #1 from the lift became unhitched from the lift and Resident #1 fell backwards and fell to the floor. CNA #14 said that she and CNA #15 picked Resident #1 off the floor and put him/her into bed because she panicked. CNA #14 said that she observed blood dripping down the side of Resident #1's left eye and said she also observed a scrape on the top of Resident #1's head. CNA #14 said that she told Nurse #1 that Resident #1 had been on the floor and said she did not tell the Unit Manager or Supervisor that Resident #1 had fallen to the floor because she was scared. Surveyor #1 interviewed CNA #15 at 3:07 P.M. on [DATE]. CNA #15 said sometime between 8:00 [NAME]M. and 8:30 [NAME]M. (exact time unknown) on [DATE], while she was in another resident's room providing care, CNA #14 came into the room and asked if she could help her. CNA #15 said she went to Resident #1's room and observed him/her lying on the floor between two beds. CNA #15 said that Resident #1 was breathing hard, and had blood in his/her hair. CNA #15 said she told CNA #14 to call a nurse and said that CNA #15 told her no and that she would tell the nurse later. CNA #15 said CNA #14 took Resident #1's upper body and CNA #14 asked her to hold his/her legs and they picked Resident #1 up and put him/her into bed. CNA #15 said she did not tell a nurse that Resident #1 was on the floor or that they had picked Resident #1 up off the floor and put him/her into bed. CNA #15 said after CNA #14 told her that she told Nurse #1 that they had both transferred Resident #1 with the mechanical lift together, that she told the Nursing Supervisor she had not assisted CNA #14 with the mechanical lift transfer to get Resident #1 out of bed. Surveyor #1 interviewed the Unit Manager at 10:05 [NAME]M. on [DATE]. The Unit Manager said when she arrived at the Facility, at approximately 8:15 [NAME]M. (exact time unknown) on [DATE], she went to Resident #1's room and observed Resident #1 in bed and Nurse #1 and CNA #14 were in the room. The Unit Manager said she asked CNA #14 what happened. The Unit Manager said CNA #14 told her that part of the sling went up as she and CNA #15 transferred Resident #1 with the mechanical lift and CNA #14 grabbed Resident #1 to prevent him/her from falling and the bar of the mechanical lift hit Resident #1's head. The Unit Manager said at approximately 9:30 [NAME]M. (exact time unknown) on [DATE], CNA #15 told her and the Nursing Supervisor that she never assisted CNA #14 with transferring Resident #1 with the mechanical lift. The Unit Manager said CNA #15 said she saw Resident #1 on the floor when she went into his/her room, and said CNA #15 said that she and CNA #14 put Resident #1 into bed, and CNA #14 told CNA #15 that she would tell the nurse. Surveyor #1 interviewed the Nursing Supervisor at 10:33 [NAME]M. on [DATE]. The Nursing Supervisor said that, at approximately a few minutes before 8:00 [NAME]M. (exact time unknown) on [DATE], Nurse #1 called her and told her Resident #1 sustained an injury to his/her forehead when the iron part of the mechanical lift hit him/her during a transfer. The Nursing Supervisor said she went to Resident #1's room, observed Resident #1's in bed, his/her forehead was bleeding moderately, and a pressure dressing was applied to the wound. The Nursing Supervisor said that CNA #14 told her that CNA #15 had been with her during the mechanical lift transfer and the bar of the lift hit Resident #1's head. The Nursing Supervisor said she called Resident #1's Physician and told him that Resident #1 had sustained a skin opening that was bleeding and said she called the Ambulance to transfer Resident #1 to the Hospital. The Nursing Supervisor said that, at approximately 9:00 [NAME]M. (exact time unknown), she called the Hospital and reported that Resident #1 sustained an injury to his/her forehead from the mechanical lift. The Nursing Supervisor said that, at approximately 9:30 [NAME]M. (exact time unknown), CNA #15 told her, with the Unit Manager present, that while she was assisting a resident with care, CNA #14 came into the room and asked her for help. The Nursing Supervisor said that CNA #15 told them that when she arrived in Resident #1's room she observed Resident #1 on the floor. The Nursing Supervisor said that CNA #15 told them that she asked CNA #14 if they should get a nurse, and that CNA #15 told them that CNA #14 said that she would tell a nurse after they put Resident #1 back into bed. The Nursing Supervisor said that, sometime between 12:00 P.M. and 1:00 P.M., she called the Hospital to notify them that Resident #1 had fallen (which was approximately two to three hours after Resident #1 was transferred to the Hospital). Surveyor #2 interviewed Non-Sampled Resident #9 at 10:35 [NAME]M. on [DATE]. Non-Sampled Resident #9 said that he/she observed CNA #14 alone in Resident #1's room when CNA #14, by herself, placed one hand on Resident #1 and one hand on the mechanical lift to move Resident #1. Non-Sampled Resident #9 said she heard a big bang and observed Resident #1 on the floor and not in the mechanical lift. Non-Sampled Resident #9 said (after Resident #1 fell from the mechanical lift) CNA #14 left Resident #1 alone on the floor and ran off out of the room. Surveyor #1 interviewed Resident #1's Physician at 1:38 P.M. on [DATE]. Resident #1's Physician said that a resident should not be moved after a fall until assessed by nursing. Surveyor #1 interviewed the Director of Nursing (DON) at 2:02 P.M. on [DATE]. The DON said that, at approximately 8:00 [NAME]M. (exact time unknown) on [DATE], she received a phone call from the Nursing Supervisor and was told that Resident #1 was hit in the head by the mechanical lift and that staff controlled the bleeding to his/her left eyebrow and were going to transfer him/her to the Hospital Emergency Department as a precaution. The DON said that, at approximately 9:30 [NAME]M. (exact time unknown), she received another phone call from the Nursing Supervisor who told her that she had just been told by CNA #15 that Resident #1 had been on the floor and was put back into bed by CNA #14 and CNA #15. The DON said that it was determined that Resident #1 fell and was picked up off the floor and it was not reported to nurses in a timely manner. The Hospital History and Physical Note, dated [DATE], indicated that circumstances surrounding Resident #1's presentation were not entirely clear though the initial report was that Resident #1 was hit in the head with a mechanical lift. The Note indicated that there was a laceration above Resident #1's left eye and a computed tomography scan (also known as a CT scan, detailed imaging that uses computer processing to create cross sectional images of bones, blood vessels, and soft tissues in the body) revealed that he/she sustained a subdural hematoma (a collection of blood build up outside the brain), cervical spinal fractures (bones in the neck), and rib fracture. The Note indicated that, given the extensive nature of the injuries, Resident #1 was activated as a trauma and he/she underwent further diagnostic imaging which revealed a pneumothorax (condition when air leaks into the space between the lungs and chest wall which can be the result of a [MEDICATION NAME] or penetrating chest injury), two left rib fractures, and a [MEDICATION NAME] spinal (area of spine behind abdomen) fracture. The Hospital History and Physical Note indicated that there had been multiple stories regarding the events that transpired, however it seemed that Resident #1 had been dropped from the mechanical lift. The Hospital Death Pronouncement Note, dated [DATE], indicated that Resident #1 died at 5:55 [NAME]M. on [DATE].

Based on records reviewed and interviews for one of six sampled residents (Resident #1) who required two staff members and use of a mechanical lift for all transfers, the Facility failed to ensure that interventions in Resident #1's plan of care were implemented and followed related to activities of daily living and assistance with transfers. When on 9/15/19, Certified Nurse Aide (CNA) #14 transferred Resident #1 using a mechanical lift without assistance from another staff member, and Resident #1 was injured during the transfer. Resident #1 was transferred to the Hospital Emergency Department for evaluation and treatment for [REDACTED]. Findings Include: Resident #1 was admitted to the Facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was severely cognitively impaired, was non-ambulatory, was dependent on and required extensive staff assistance of two staff members for transfers. Resident #1's Activity of Daily Living Care Plan, indicated that Resident #1 required two staff members and the use of a mechanical lift with transfers. The Hospital History and Physical Note, dated 9/15/19, indicated that circumstances surrounding his/her presentation were not entirely clear though the initial report was that Resident #1 was hit in the head with a mechanical lift. The Note indicated that there was a laceration above Resident #1's left eye and a computed tomography scan (also known as a CT scan, detailed imaging that uses computer processing to create cross sectional images of bones, blood vessels, and soft tissues in the body) revealed that Resident #1 sustained a subdural hematoma (a collection of blood build up outside the brain), cervical spinal fractures (bones in the neck), and rib fracture. The Note indicated that, given the extensive nature of the injuries, Resident #1 was activated as a trauma and he/she underwent further diagnostic imaging which revealed a pneumothorax (condition when air leaks into the space between the lungs and chest wall which can be the result of a [MEDICATION NAME] or penetrating chest injury), two left rib fractures, and a [MEDICATION NAME] spinal (area of spine behind abdomen) fracture. Review of the Facility's Incident Report, dated 9/15/19, indicated that at approximately 7:50 [NAME]M. on 9/15/19, Resident #1 sustained a laceration on his/her forehead during a mechanical lift transfer from his/her bed to his/her chair. The Report indicated that CNA #14 reported that while transferring Resident #1 with the mechanical lift, his/her head bumped the metal bar of the lift and he/she sustained a laceration above his/her left eyebrow. The Hospital History and Physical Note indicated that there had been multiple stories regarding the events that transpired, however it seemed that Resident #1 had been dropped from the mechanical lift. The Facility's Interview Note with Non-Sampled Resident #9 (Resident #1's roommate), dated 9/16/19, indicated that the previous morning (9/15/19) Non-Sampled Resident #9 said he/she observed CNA #14 bring the mechanical lift into the room and a little while later heard a thud. The Note indicated Non-sampled Resident #9 said he/she observed Resident #1 on the floor with his/her head toward the top of the bed. The Note indicated that Non-Sampled Resident #9 said that CNA #14 was alone in the room using the mechanical lift, that CNA #14 left the room after Resident #1 fell and said CNA #14 then came back with another staff member (later identified as CNA #15). On 9/26/19 Surveyor #1 observed the Facility Video Camera Footage from 9/15/19, which showed following; - 7:41:15 [NAME]M., CNA #14 walked into Resident #1's room alone with the mechanical lift; - 7:43:17 [NAME]M., CNA #14 walked out of Resident #1's room and went into a room a few doors down; -7:43:32 [NAME]M., CNA #14 and CNA #15 exit the other room, and go into Resident #1's room together; - 7:45:05 [NAME]M., CNA #14 and CNA #15 exited Resident #1's room; - 7:46:59 [NAME]M., CNA #14 is seen walking out of Resident #1's room with the mechanical lift; -7:49:16 [NAME]M., Nurse #1 is then seen entering Resident #1's room. Surveyor #2 interviewed Non-Sampled Resident #9 at 10:35 [NAME]M. on 9/26/19. Non-Sampled Resident #9 said that, on 9/15/19, he/she observed CNA #14, who was alone in their room, had one hand on Resident #1 and one hand on the mechanical lift to move Resident #1. Non-sampled Resident #9 said she heard a heard a big bang, and saw that Resident #1 was on the floor and not in the lift. Non-Sampled Resident #9 said (after Resident #1 fell from the mechanical lift) CNA #14 left Resident #1 alone on the floor and left the room. Surveyor #1 interviewed the Nursing Supervisor at 10:33 [NAME]M. on 10/1/19. The Nursing Supervisor said that CNA #14 told her that CNA #15 had been with her during the mechanical lift transfer and that the metal bar of the lift hit Resident #1's head. The Nursing Supervisor said that at approximately 9:30 [NAME]M., CNA #15 came to her and told her that she had not assisted CNA #14 with Resident #1's mechanical lift transfer. The Nursing Supervisor said CNA #15 told her that CNA #14 came and asked her for help with Resident #1 and that when she (CNA #15) went to Resident #1's room, Resident #1 was on the floor. Surveyor #1 interviewed CNA #14 at 1:21 P.M. on 9/26/19. CNA #14 said that she was Resident #1's primary CNA and had provided care for Resident #1 on a regular basis. CNA #14 said Resident #1 required the use of a mechanical lift with assistance of two staff members for transfers. CNA #14 said she was familiar with Resident #1's Plan of care related to his/her care needs and said his/her transfer status was written on a sheet for CNA's that was located at the nurse's station. CNA #14 said she told the Unit Manager and the Nursing Supervisor that Resident #1 sustained the laceration above his/her left eye as a result of being hit by the metal bar of the mechanical lift, and had not reported that Resident #1 had fallen from the mechanical lift, because she was scared. CNA #14 said CNA #15 assisted her with Resident #1's transfer, and said she had not transferred Resident #1 with the mechanical lift alone. CNA #14's statement was not consistent with statements made by Non-Sampled Resident #9 who said CNA #14 acted alone, with CNA #15 who denied assisting CNA #14 with Resident #1's mechanical lift transfer out of bed, or with interviews conducted with the Unit Manager and the Nursing Supervisor, who both said CNA #15 reported to them that she had not assisted CNA #14 with the mechanical lift transfer. Surveyor #1 interviewed CNA #15 at 3:07 P.M. on 9/26/19. CNA #15 said on 9/15/19, (exact time unknown) while she was in another resident's room providing care, CNA #14 came into the room and asked if she could help her. CNA #15 said she went to Resident #1's room and observed Resident #1 lying on the floor between two beds. CNA #15 said that Resident #1 was breathing hard, and had blood in his/her hair. CNA #15 said she asked CNA #14 why she transferred Resident #1 alone when he/she required two people and said she questioned CNA #14 why she did not ask her for help. CNA #15 said that CNA #14 told her shortly afterwards, after they had picked up Resident #1 and put his/her back into bed, that she told the Nursing Supervisor they had both transferred Resident #1 out of bed with the mechanical lift. CNA #15 said she was upset by that, because it was not true and said she told the Nursing Supervisor that she had not assisted CNA #14 with Resident #1's mechanical lift transfer out of bed, CNA #15 said she reported that she had helped pick Resident #1 up off of the floor with CNA #14, and put him/her back to bed. Surveyor #1 interviewed the Director of Nursing (DON) at 2:02 P.M. on 9/26/19. The DON said that, at approximately 8:00 [NAME]M. on 9/15/19, she received a phone call from the Nursing Supervisor and was told that Resident #1 was hit in the head by the mechanical lift and that staff controlled the bleeding to his/her left eyebrow and were going to transfer him/her to the Hospital Emergency Department as a precaution. The DON said that, at approximately 9:30 [NAME]M., she received another phone call from the Nursing Supervisor who told her that she had just been told by CNA #15 that Resident #1 had been on the floor and was put back into bed by CNA #14 and CNA #15. The DON said that she arrived at the Facility at approximately 10:15 [NAME]M. and the Nursing Supervisor told her that CNA #14 continued to maintain that Resident #1 had not fallen. The DON said CNA #14 confessed that she and CNA #15 picked Resident #1 up off the floor.

Based on records reviewed and interviews for one of six sampled residents (Resident #1) who required the assistance of two staff members and use of a mechanical lift for transfers, the Facility failed to ensure that Resident #1's safety was maintained during a mechanical lift transfer. - When on [DATE], Resident #1 was transferred alone with a mechanical lift by Certified Nurse Aide (CNA) #14 without assistance from another staff member and fell to the floor during the transfer. Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed and admitted with a [MEDICAL CONDITION], multiple internal injuries and died the following day. Findings Include: The Facility Policy titled Mechanical Lift, reviewed [DATE], indicated that a mechanical lift allowed two staff members to transfer a patient safely. The Policy indicated that two people were required when using the mechanical lift where there is no resident weight bearing. Resident #1's Activity of Daily Living Care Plan, indicated that Resident #1 required two staff members and the use of a mechanical lift with transfers. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was severely cognitively impaired, was non-ambulatory, was dependent on and required extensive staff assistance of two staff members for transfers. An Incident Report, dated [DATE], indicated that at 7:50 [NAME]M. on [DATE], Resident #1 sustained a skin tear during a mechanical lift transfer from his/her bed to his/her chair. The Incident Report indicated that CNA #14 reported that while transferring Resident #1 with the mechanical lift, his/her head bumped the metal part of the lift and he/she sustained a skin tear above his/her left eyebrow. The Incident Report indicated that Resident #1's Nurse Practitioner was notified of the incident at 8:45 [NAME]M. The Facility Hospital Transfer Form, dated [DATE], indicated that key clinical information and reason for Resident #1's Hospital transfer was due to a skin injury to the left side of his/her forehead. The Form indicated that additional relevant information was that the injury occurred as a result of Resident #1 bumping his/her head on the mechanical lift. A Nurse Progress Note, timed at 3:26 P.M. on [DATE], indicated that the Note was a clarification/correction and the origin of injury was reportedly due to a fall to the floor that occurred during a mechanical lift transfer. The Hospital History and Physical Note, dated [DATE], indicated that circumstances surrounding Resident #1's presentation were not entirely clear though the initial report was that Resident #1 was hit in the head with a mechanical lift. The Note indicated that there was a laceration above Resident #1's left eye and a computed tomography scan (also known as a CT scan, detailed imaging that uses computer processing to create cross sectional images of bones, blood vessels, and soft tissues in the body) revealed that he/she sustained a subdural hematoma (a collection of blood build up outside the brain), cervical spinal fractures (bones in the neck), and rib fracture. The Note indicated that, given the extensive nature of the injuries, Resident #1 was activated as a trauma and he/she underwent further diagnostic imaging which revealed a pneumothorax (condition when air leaks into the space between the lungs and chest wall which can be the result of a [MEDICATION NAME] or penetrating chest injury), two left rib fractures, and a [MEDICATION NAME] spinal (area of spine behind abdomen) fracture. The Hospital History and Physical Note indicated that there had been multiple stories regarding the events that transpired, however it seemed that he/she had been dropped from the mechanical lift. The Hospital Death Pronouncement Note, dated [DATE], indicated that Resident #1 died at 5:55 [NAME]M. On [DATE] Surveyor #1 observed the Facility Video Camera Footage from [DATE], which showed following; - 7:41:15 [NAME]M., CNA #14 walked into Resident #1's room alone with the mechanical lift; - 7:43:17 [NAME]M., CNA #14 walked out of Resident #1's room and went into a room a few doors down; -7:43:32 [NAME]M., CNA #14 and CNA #15 exit the other room, and go into Resident #1's room together; - 7:45:05 [NAME]M., CNA #14 and CNA #15 exited Resident #1's room; - 7:46:59 [NAME]M., CNA #14 is seen walking out of Resident #1's room with the mechanical lift; -7:49:16 [NAME]M., Nurse #1 is then seen entering Resident #1's room. Surveyor #2 interviewed Non-Sampled Resident #9 at 10:35 [NAME]M. on [DATE]. Non-Sampled Resident #9 said that he/she observed CNA #14 alone in Resident #1's room when CNA #14, by herself, placed one hand on Resident #1 and one hand on the mechanical lift to move Resident #1. Non-Sampled Resident #9 said she heard a big bang and observed Resident #1 on the floor and not in the mechanical lift. Non-Sampled Resident #9 said (after Resident #1 fell from the mechanical lift) CNA #14 left Resident #1 alone on the floor and ran off out of the room. Surveyor #1 interviewed CNA #14 at 1:21 P.M. on [DATE]. CNA #14 said that, sometime between 8:00 [NAME]M. and 8:30 [NAME]M. (exact time unknown) on [DATE], while she and CNA #15 transferred Resident #1 with the mechanical lift, one of the clips of the sling that suspended Resident #1 from the lift became unhitched from the lift and Resident #1 fell backwards and fell to the floor. CNA #14 said that she and CNA #15 picked Resident #1 off the floor and put him/her into bed because she panicked. CNA #14 said that she observed blood dripping down the side of Resident #1's left eye and said she also observed a scrape on the top of Resident #1's head. CNA #14 said that she told Nurse #1 that Resident #1 had been on the floor and said she did not tell the Unit Manager or Supervisor that Resident #1 had fallen to the floor because she was scared. Surveyor #1 interviewed CNA #15 at 3:07 P.M. on [DATE]. CNA #15 said, sometime between 8:00 [NAME]M. and 8:30 [NAME]M. (exact time unknown) on [DATE], while she was in another residents room, CNA #14 came into the room and asked if she could help her. CNA #15 said she went to Resident #1's room and observed him/her lying on the floor between two beds. CNA #15 said that Resident #1 was breathing hard, and had blood in his/her hair. CNA #15 said she told CNA #14 to call a nurse and said that CNA #14 told her no and that she would tell the nurse later. CNA #15 said CNA #14 took Resident #1's upper body and asked her to hold his/her legs and they picked Resident #1 up off the foor and put him/her into bed. CNA #15 said she did not tell a nurse that Resident #1 was on the floor or that they put him/her into bed. CNA #15 said, after CNA #14 told her that she told the Nursing Supervisor that they had both transferred Resident #1 out of bed with the mechanical lift together, said she told the Nursing Supervisor that she had not helped CNA #14 with the mechanical lift transfer. Surveyor #1 interviewed the Director of Nursing (DON) at 2:02 P.M. on [DATE]. The DON said that, at approximately 8:00 [NAME]M. (exact time unknown) on [DATE], she received a phone call from the Nursing Supervisor and was told that Resident #1 was hit in the head by the mechanical lift and that staff controlled the bleeding to his/her left eyebrow and were going to transfer him/her to the Hospital Emergency Department as a precaution. The DON said that, at approximately 9:30 [NAME]M. (exact time unknown) she received another phone call from the Nursing Supervisor who told her that she had just been told by CNA #15 that Resident #1 had been on the floor and was put back into bed by CNA #14 and CNA #15. The DON said it was determined that Resident #1 fell during the mechanical lift transfer, that he/she was picked up off the floor and that the fall was not reported to nurses in a timely manner.

Based on record review, observations and staff interviews, the facility failed to follow the resident's plan of care relative to ADL (Activities of Daily Living) and falls care plan interventions, for 2 residents (#8 and #9), out of a total sample of 18 residents. Findings include: 1. For Resident #8, the facility failed to follow the resident's ADL care plan relative to the following: 2 assist for bed mobility and positioning was not provided and the resident's call bell was not within reach, as planned. Resident #8 was admitted to the facility in 3/2014. Review of the ADL care plan of 6/14/16 indicated the following interventions: 2-3 staff members for Hoyer lift transfers, 2 assist for bed mobility and positioning, dependent for incontinence care requiring 2 assist at bed level and call bell within reach. Review of the Change in Condition Note of 8/15/16 indicated the resident experienced a fall. During review of the facility investigation with Unit Manager (UM)#1 (on 9/6/16 at 2:05 P.M.), she said that CNA (#2) attempted to provide the resident's care independently and during the resident repositioning in bed, she/he rolled out of the bed onto the floor. UM #2 said that CNA #2 did not follow the resident's care plan relative to the resident requiring 2 assist for bed mobility and positioning and, as a result, the resident sustained [REDACTED]. During an interview with CNA #4 on 9/6/16 at 1:45 P.M., she said the resident required 2 assist during positioning in bed and the resident would ring the call bell at times. During observation of the resident with CNA #4 at 1:50 P.M., it was observed that the resident was sitting in a wheelchair, next to her/his bed, and the call bell was under the resident's bed covers and not within the resident's reach, as planned. The facility failed to follow the resident's ADL care plan and as a result the resident fell out of bed, sustaining a fractured shoulder. Please refer to F 323. 2. For Resident #9, the facility failed to follow the resident's ADL (Activities of Daily Living) and falls care plan relative to the following: appropriate footwear was not being worn and physical assist of 1 was not being provided, as planned. Resident #9 was admitted to the facility in 3/2013. Review of the ADL care plan of 8/11/15 indicated the following interventions: 1 assist for ambulation with rolling walker and 1 to 2 assist with transfers. Review of the falls care plan of 8/11/15 indicated the staff were to ensure appropriate footwear was utilized. Review of the Progress Note of 8/30/15 indicated the resident experienced a fall. Review of the facility investigation regarding the fall with Unit Manager (UM) #1 (on 9/6/16 at 2:35 P.M.), indicated that the resident was ambulating, in the hall, with her/his walker, with a CNA (Certified Nursing Assistant) following behind her/him, when Resident #9 fell . UM #1 said the CNA should have been providing physical assist while the resident was ambulating, as care planned. UM #1 said the resident sustained [REDACTED]. The care plan was updated to include: Rehab. screen. Review of the ADL and falls care plans of 11/10/15, 2/9/16, 5/3/16 and 7/26/16 remained unchanged relative to 1 assist for ambulation with rolling walker, 1 to 2 assist with transfers and to ensure appropriate footwear was utilized. Review of the Change in Condition Note of 8/12/16 indicated the resident experienced a fall, with no injuries. The resident fell , in the hallway, after missing a step due to the old shoe she/he was wearing. During review of the facility investigation with UM#1 (on 9/6/16 at 2:35 P.M.), she said the resident had on an older loafer shoe and the back/heel of the loafer was folded down inside the shoe. She further said that the resident did not have appropriate footwear on, at the time of the fall, as planned. The falls care plan was updated to include: resident would utilize non-skid/slipper socks until new shoes were secured. On 8/31/16 at 9:40 A.M. during the facility Initial Tour, a surveyor and UM #1 observed the resident sitting in a chair, in the hallway, with non-skid slipper socks on her/his feet with her/his foot inside a loafer shoe. The resident's heel was observed to be out of the loafer. UM #1 said to the surveyor, as the surveyor and UM #1 passed by the resident and proceeded down the hallway, that the resident had fallen recently due to the loafer shoes Resident #9 had on. The resident did not have appropriate footwear on, at the time of the observation, as planned. On 8/31/16 at 1:25 P.M., the surveyor observed the resident sitting in a straight back chair, in the hallway, with loafer shoes on, with the heel of the resident's foot resting on the heel of the shoe which was folded down inside of the loafer. The resident was observed to also have non-skid/slipper socks on her feet inside/on the shoe. The resident did not have appropriate footwear on, as planned. On 9/1/16 at 1:30 P.M., the surveyor observed the resident independently ambulating down the hallway, with a walker, however, the resident was not being assisted by staff while ambulating, as planned. On 9/6/16 at 8:45 A.M., the surveyor observed the resident independently ambulating out of her/his room, with a walker, into the hallway. The resident then ambulated a short distance down the hallway, without 1 assist, as planned. During an interview with CNA #3 on 9/6/16 at 1:35 P.M., she said the resident required 1 assist for transfers and ambulation and that (the resident) wore loafers routinely prior to this past weekend. The facility failed to follow the resident's care plan and as a result, the resident fell and sustained a laceration over her/his eyebrow and required 4 sutures (to close the wound). Please refer to F 323.

Based on record review, observations and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 2 of 10 applicable residents (#8 and #9), in a total sample of 18 residents. Findings include: 1. For Resident #8, the facility failed to provide adequate supervision to prevent a fall, resulting in the resident sustaining a fractured shoulder. Resident #8, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment of 5/27/16 indicated that the resident was severely cognitively impaired; required extensive assist of 2 for bed mobility, totally dependent for transfers with 2 plus physical assist and totally dependent for dressing. Review of the ADL (Activities of Daily Living) care plan of 6/14/16 indicated the following interventions: 2-3 staff members for Hoyer lift transfers, 2 assist for bed mobility and positioning, dependent for incontinence care requiring 2 assist at bed level and keep call bell within reach. Review of the Change in Condition Note of 8/15/16 indicated the resident experienced a fall, requiring transfer to the local Emergency Department for evaluation and treatment. During review of the facility investigation with Unit Manager (UM)#1 (on 9/6/16 at 2:05 P.M.), she said that after the resident was transferred into bed by 2 CNAs (Certified Nursing Assistant's) with a Hoyer lift, that one of the CNAs (#1) brought the mechanical lift out of the room while the other CNA (#2) stayed with the resident. UM #1 said that CNA (#2) attempted to provide care independently and during repositioning the resident in bed, she/he rolled close to the edge of the bed and fell out of the bed onto the floor. UM #2 further said that CNA #2 did not follow the resident's care plan relative to the resident requiring 2 assist for bed mobility and positioning and as a result, the resident sustained [REDACTED]. During an interview with CNA #4 on 9/6/16 at 1:45 P.M., she said the resident required 2 assist during positioning in bed and that the resident would ring the call bell at times. During observation of the resident with CNA #4 at 1:50 P.M., it was observed that the resident was sitting in a wheelchair, next to the bed, and the resident's call bell was under the resident's bed covers and not within the resident's reach, as planned. On 9/6/16 at 2:00 P.M., the surveyor observed 2 CNAs transferring the resident into bed utilizing a Hoyer lift. The facility failed to provide adequate supervision to prevent the resident from falling out of bed and sustaining significant injury. 2. For Resident #9, the facility failed to provide adequate supervision and effective interventions to prevent falls, resulting in the resident sustaining a laceration over the left eyebrow, requiring 4 sutures to close the wound. Resident #9, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set Assessment (MDS) of 7/24/15 indicated that the resident was severely cognitively impaired; required one person physical assist for transfers and ambulation in room and in the corridor; unsteady during ambulation; utilizing a walker and having a previous fall since prior assessment. Review of the ADL (Activities of Daily Living) care plan of 8/11/15 indicated the following interventions: 1 assist for ambulation with rolling walker and 1 to 2 assist with transfers. Review of the falls care plan of 8/11/15 indicated the staff were to ensure appropriate footwear was utilized. Review of the Progress Note of 8/30/15 indicated that staff were running to the resident who had stood up with her/his walker and tripped over her/his feet landing on the floor, sustaining a laceration over the left eyebrow. Review of the facility investigation regarding the fall with Unit Manager (UM) #1 (on 9/6/16 at 2:35 P.M.), indicated that the resident was ambulating, in the hall, with her/his walker, with a CNA (Certified Nursing Assistant) following behind her/him. The investigation indicated the resident was attempting to ambulate through a narrow/congested area when she/he bent forward in an attempt to move another resident's wheelchair and fell . During interview with UM #1, she said the Progress Note documentation was inaccurate because the Nurse didn't get the whole story before she wrote the Progress Note and said the circumstances surrounding the fall were accurately documented in the facility investigation. UM #1 further said the CNA should have been providing physical assist while the resident was ambulating, as care planned. UM #1 also said the CNA should have been utilizing a gait belt. UM #1 said the resident sustained [REDACTED]. The care plan was updated to include: Rehab. screen. Review of the quarterly MDS assessments of 10/23/15, 1/22/16 and 4/15/16 remained essentially unchanged except in coding of Resident #9's falls. In the 10/23/15 MDS the resident was coded as having 2 falls, in the 1/22/16 and 4/15/16 MDS the resident was coded as having no falls and in the 7/8/16 Annual MDS the resident was coded as having 1 fall. Review of the ADL and falls care plan of 11/10/15, 2/9/16, 5/3/16 and 7/26/16 remained unchanged relative to 1 assist for ambulation with rolling walker, 1 to 2 assist with transfers and ensure appropriate footwear was utilized. Review of the Change in Condition Note of 8/12/16 indicated the resident experienced a fall, with no injuries. The note indicated the resident fell , in the hallway, after missing a step due to the old shoe (she/he) was wearing. During review of the facility investigation with UM#1 (on 9/6/16 at 2:35 P.M.), she said the resident had on an older loafer shoe and the back/heel of the loafer was folded down inside the shoe and that the resident did not have appropriate footwear on, at the time of the fall, as planned. The falls care plan was updated to include: resident would utilize non-skid/slipper socks until new shoes were secured. On 8/31/16 at 9:40 A.M. during the facility Initial Tour, a surveyor and UM #1 observed the resident sitting in a chair, in the hallway, with non-skid slipper socks on her/his feet with her/his foot inside a loafer shoe. The resident's heel was observed to be out of the loafer. UM #1 said to the surveyor, as the surveyor and UM #1 passed by the resident and proceeded down the hallway, that the resident had fallen recently due to the loafer shoes she/he had on. She further said the facility had telephoned the family requesting a new pair of shoes, however, had not heard back from the family nor had received the new shoes yet. The resident did not have appropriate footwear on, at the time of the observation, as planned. On 8/31/16 at 1:25 P.M., the surveyor observed the resident sitting in a straight back chair, in the hallway, with loafer shoes on, with the heel of the resident's foot resting on the heel of the shoe which was folded down inside of the loafer. The resident was observed to also have non-skid/slipper socks on her feet inside/on the shoe. At 1:35 P.M., the surveyor observed UM#1 approach the resident and said I called your (family member), he'll be getting you new shoes, you shouldn't wear these shoes, let's take them off On 9/1/16 at 1:30 P.M., the surveyor observed the resident independently ambulating down the hallway, with a walker, however, the resident was not being assisted by staff while ambulating, as planned. The resident did have non-skid/slipper socks on. On 9/6/16 at 8:45 A.M., the surveyor observed the resident independently ambulating out of her/his room, with a walker, into the hallway. The resident took a few steps down the hallway (without 1 assist, as planned) when a CNA came out of the resident's room, holding a plastic bag of dirty laundry. The CNA was then observed to drop the plastic bag, as she passed by the surveyor, put a gait belt on the resident, then provided 1 assist with ambulation into the dayroom. During an interview with CNA #3 on 9/6/16 at 1:35 P.M., she said the resident is very forgetful, required 1 assist for transfers and ambulation, could be a little shaky at times on (her/his) feet, a gait belt should be used for safety when (she/he) walking and that (the resident) wore loafers routinely prior to this past weekend. During an interview with the facility Regional Nurse and Director of Nursing on 9/7/16 at 3:35 P.M. (requested by the facility), the Regional Nurse said she had interviewed the CNA who was assigned to the resident (on 8/31/16) and said that the CNA informed her that the resident only had non-skid/slipper socks on and did not have the loafers on (on 8/31/16) despite the surveyor observations (on 8/31/16 at 9:40 A.M. and at 1:25 P.M. and the observation of UM #1 taking the resident's loafers off at 1:35 P.M.). The facility failed to provide adequate supervision and effective interventions to prevent falls.

Based on record review, staff and resident interviews, the facility failed to ensure that 1 (#5) of 13 applicable residents, in a total sample of 20, received appropriate treatment and services to restore/maintain as much bladder function as possible. Findings include: For Resident #5, the facility failed to assess bladder function and implement appropriate interventions to restore or maintain as much bladder function as possible when the resident had a decline in bladder continence. Review of the facility's Urinary Management System policy, dated 9/2011, indicated that residents are assessed when indicated by a change in the resident's condition. Documentation should identify the implementation of a three day voiding pattern. Resident #5 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. Review of the resident's Initial MDS (Minimum Data Set) Assessment, dated 2/19/13, indicated the resident was cognitively intact, required extensive assist for transfers and toileting, and was always continent of bladder. Review of the Nurse's Aide Care Card (no date) indicated the resident was continent of bladder. Review of the 2/2013 Nursing Flow Sheet indicated the resident was always continent of bladder. Review of a Bladder Control Assessment, dated 2/17/13, indicated the resident was alert and continent. Review of a Licensed Nursing Summary, dated 2/25/13, indicated the resident was continent of bladder. Review of the 3/2013 Nursing Flow Sheet indicated the resident was always incontinent of bladder. Review of the Licensed Nursing Summary, dated 3/27/13, indicated the resident was incontinent of bladder. Review of the 4/2013 Nursing Flow Sheet indicated the resident was always incontinent of bladder. Review of the Quarterly MDS, dated [DATE], indicated the resident was not on any current toileting program or trial, and was always incontinent of bladder. Review of the resident's care plan, revised 5/18/13, indicated no interventions to manage bladder incontinence. Review of the 5/2013 through 7/3/13 Nursing Flow Sheets indicated the resident was always incontinent of bladder. During an interview on 7/3/13 at 11:45 A.M., Unit Manager (UM) #2 confirmed that no further assessment had been done to address a decline in bladder continence. She also said no bladder training had been done, there was no documentation of a three day voiding pattern and, no care plan was developed for urinary incontinence. During an interview on 7/3/13 at 12:00 P.M. with Certified Nurse's Assistants #1 and #2, they said Resident #5 is always incontinent. He/she asks to use the toilet but is usually wet before they get him/her there. During an interview on 7/3/13 at 1:30 P.M. with the Director of Nurses, she said she was unaware of any further assessment completed when the resident had a decline in bladder function, and there was no care plan to address bladder incontinence. During an interview on 7/3/13 at 1:45 P.M., Resident #5 said he/she always needs help to go to the toilet, and usually doesn't make it in time.