Every finding on record at Mansfield Place

Based on record review, observation, and staff interviews, the facility failed to ensure that each resident received adequate supervision and was protected from avoidable accident hazards. Specifically, the facility failed to prevent a resident (Resident #58) from being struck by a tray cart pushed by a CNA, which caused the resident to fall, sustain multiple traumatic brain injuries, require emergency medical intervention, and ultimately resulted in the resident's death. Resident identifier: #58 Facility Census:56 This failure placed all residents who ambulate or are present in high-traffic hallways at risk for serious harm, injury, or death due to unsafe transportation of tray carts. Findings Include:Record Review of Incident on [DATE]:On [DATE] at 6:17 PM, Resident #58 was observed via camera footage sitting in a chair at the nurse's station.At 6:22 PM, Resident #58 stood and was facing the dining room with his back to NA #1, who was pushing a tall tray cart.CNA #1 struck Resident #58 in the back with the tray cart, causing him to fall forward onto his left side.RN #3 responded immediately and a rapid response was called at 6:23 PM.The Emergency Department (ED) team and a physician arrived at 6:25 PM. A cervical collar was applied, and Resident #58 was transported to the ED.Observation on [DATE] by Surveyors:The area of the incident was observed to be well-lit, clean, and free of clutter or medical equipment.This hallway is a high-traffic area used by staff, residents, and visitors.The resident's position at the time of the incident, as seen in the video footage, showed that visibility may have been obstructed by the tray cart, which measured 5 feet 5 inches in height.Two surveillance cameras were visible in the area.ED Medical Record Review:Resident #58 was diagnosed with:Acute Extensive Traumatic Subarachnoid Hemorrhage (tSAH) - bleeding into the subarachnoid space following head trauma.Acute Left Frontal Intraparenchymal Hemorrhage - a hemorrhagic stroke due to ruptured blood vessels in the brain tissue.Left Parafalcine Subdural Hematoma - blood collection between the brain and dura mater.Resident #58 was life-flighted as a Priority Two Trauma to another hospital due to the severity of injuries.Facility Progress Notes:Resident was reported as unconscious for ~1 minute post-fall.The facility was notified later that evening (around 9:00 PM) that Resident #58 had been transported via Life Flight.On [DATE], the hospital initiated a palliative care consult, determined the resident's status to be Do Not Resuscitate (DNR), and discussed transitioning to comfort care.Facility's Five-Day Report:Abuse/neglect was not substantiated.NA was not observed acting maliciously or at excessive speed.The tray cart was tall, obstructing forward vision.The facility concluded that the resident was in close proximity when he stood and could not be seen by CNA #1.Corrective Actions Taken:As of [DATE], Assistant Administrator (AA #4) reported the following:A new policy requires two staff members to push tray carts-one pushing, one ensuring the path is clear.If only one staff member is available, they must pull the cart instead of pushing. Director of Nursing (DON) provided education records confirming staff training began immediately and was completed by [DATE].Environmental Changes:Bubble mirrors installed in the hallways on [DATE] and completed on [DATE] to improve visibility.Shorter tray carts are being ordered and utilized in hallways; taller carts are reserved for dining room delivery.This deficient practice resulted in Immediate Jeopardy beginning on [DATE] when the resident was struck by a cart, suffered severe head trauma, and subsequently died. The facility's failure to ensure safe cart handling in a high-traffic resident area placed all residents at risk of serious injury or death. Immediate corrective action was required. This is now considered past-noncompliance / facility self-corrected prior to survey entrance.

609 Based on staff Interviews, Record review and Policy review the facility failed to report possible abuse allegations to state agencies within the two hours time frame. This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility. Resident Identifier: #1 Facility Census: 56 This standard was NOT MET as evidenced by: Based upon Staff and Resident Interviews, Record review and Policy review the facility failed to notify State Agencies of the abuse allegation with in the two hours times frame per the CMS guidelines.Findings include: 07/21/2025 1156:InterviewSpoke with resident #1 during interview and she stated there was no issues and everything was good. 07/21/2025 12:47 PM Record reviewDuring record review there was a note placed by SW #17 stating an incident took place that the resident was reluctant to come forward with.attached is the note from the patient chart. Entry was made on 7/21/2025 @ 12:21pm by Social Worker SW#17(as written in chart) Met with (Residents name her) after receiving information from PT that she had expressed concerns with a staff member. (Residents name her) was hesitant at first to talk about the issue and repeatedly stated I don't want to get her in trouble. After some reassurance, she did report having a blonde hair staff member talk a little bit hatefully to her and feels it was because she had soiled her brief. (Residents name her)could not tell Social Worder (SW) anything aside from the color of the aide's hair and that it happened a couple days ago. Reassured her that I would speak with Director of Nursing (DON) in an attempt to determine who the staff member may have been so that education can be provided. Asked (Residents name her)[NAME] if the aide was present in the facility today and she states 'no'. The facility had until 2:21PM on 7/21/2025 to notify state agencies of a potential abuse incident. 07/22/2025 1:13 PMInterviewSpoke with resident #1 again today and she stated I am upset and was crying about how I was made to feel. the tall blond aide with a ponytail, yelled at me because I had an accident, that's not rightPolicy review Upon review of the facility policy for reporting allegations of abuse on Page 5, Section 5 titled INVESTAGATION / REPORTING ; it states that all violations must be reported immediately, but no later than two hours after the allegation is made.

F0880S483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This Standard is NOT MET as evidenced by: Based upon Random observation of lunch cart and Staff Interview, the facility failed to maintain a clean and sanitary transportation of resident meals on tray carts. During lunch service Tall food cart was delivered into main dining hall with a dirty spoon on top of cart. There was also a Styrofoam cup on top of cart that was next to the spoon, intended for a resident meal. Census:56Finding include: 07/22/2025 12:40 PM Observations:During lunch service Tall food cart was delivered into main dining hall with a dirty spoon on top of cart. There was also a Styrofoam cup on top of cart that was next to the spoon, intended for a resident meal. 07/22/2025 12:50 PMInterview:Dietary Supervisor #67 was questioned and she stated that the cup was for a resident and that it was placed on top d/t it not fitting in the tray cart. When asked about how the staff knows who's cup that is, she said its on his meal ticket. I confirmed it was on the residents meal ticket for the cup of soda. It stated soda in cup on top of meal cart. When asked about the spoon she said well shoot and took it off the top and when into the kitchen with it.This confirmed the spoon was not supposed to be there and not inline with standards of practice.

657 Based on staff Interviews, Record review and Policy review the facility failed to follow established care plan and order of the resident and ensure they were checked on every two hours . This failed practice was a random opportunity for discovery, and had the potential to affect all residents residing in the long term care facility. Resident Identifier: #7 Facility Census: 56This standard of care was NOT MET as evidenced by:Findings include:Record review:07/23/2025 10:00 AM Orders placed on 2/3/25Release seatbelt every two hours, reposition, skin checks, proper attachment of seat belt and pericare.Special Instructions: prevent skin breakdown.Every 2 Hours07:00, 09:00, 11:00, 13:00, 15:00, 17:00no documentation showing release belt and checking of resident every two hours as per orderresident #7 unable to self release belts due medical conditions. This is considered a restraint when a patient can not release belt by themselves.Don #102 stated that she would look into the matter and bring me any documentation they find.Interviews:7/23/2025 @1030 Interview with CNA and nurse on hall with residentCNA #101 stated when he is up we check on him every 2 hours, but CNA's don't have a place to chart it. CNA #101 also stated the resident is not up for very long daily as he gets upset and wants back in his room and will throw a fit.RN #40 (newly hired and still in training) was unsure of where to chart a restraint in the system when asked.LPN #98 (Trainer) was also unable to find where to chart that they preformed the check. 7/23/2025 @1040Don #102 said they was unable to located any documentation on the releasing and checking on resident every two hours per order. She said when order was placed it wasn't made a task on the system and therefore didn't show up on the TAR (treatment record). She stated she fixed that error and should be resolved going forward. It will now be a task that a nurse has to check off on their charting.

Based on Record review and Staff interview, the facility failed to maintain medical records on each resident by not noting residents received Pharmacy Reviews/ Recommendations for the month of June, 2024. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the long term care facility. Facility Census: 56 Findings Include: During Record review on 07/23/25 it showed residents did not have a Pharmacy Recommendation or review for the month of June, 2024. for Resident's #2, #6, and #18.During an interview with the Director of Nursing (DON) on 07/23/24 at 10:00 AM who stated ( I think that was around the time i took this position and they were done i have the list, i just did not note it in the resident's chart. At this time the DON provided surveyors with a list of residents who had Pharmacy reviews/Recommendations for the month of June, 2025. The report was from the Pharmacy and showed residents #2. #6. and #18 did actually have Pharmacy Reviews/ Recommendations done for the month in question. At this time the DON confirmed it should have been noted in the residents chart that they received pharmacy reviews.

Based on record review and staff interviews, the facility failed to follow orders to release Resident #7 from the seat belt every two (2) hours. This was a random opportunity for discovery during the Long Term Care Survey. Resident identifier: #7 Facility Census: 56 Findings include:Record review:07/23/2025 10:00 AM Orders placed on 2/3/25Release seatbelt every two hours, reposition, skin checks, proper attachment of seat belt and pericare.Special Instructions: prevent skin breakdown.Every 2 Hours07:00, 09:00, 11:00, 13:00, 15:00, 17:00no documentation showing release belt and checking of resident every two hours as per orderresident #7 unable to self release belts due medical conditions. This is considered a restraint when a patient can not release belt by themselves.Don #102 stated that she would look into the matter and bring me any documentation they find.Interviews:7/23/2025 @1030 Interview with Nurse Aide (NA) and nurse on hall with residentNA #101 stated when he is up we check on him every 2 hours, but CNA's don't have a place to chart it. CNA #101 also stated the resident is not up for very long daily as he gets upset and wants back in his room and will throw a fit.Registered Nurse (RN #40) (newly hired and still in training) was unsure of where to chart a restraint in the system when asked.Licensed Practical Nurse (LPN #98) (Trainer) was also unable to find where to chart that they preformed the check. 7/23/2025 @1040Don #102 said they was unable to locate any documentation on the releasing and checking on resident every two hours per order. She said when order was placed it wasn't made a task on the system and therefore didn't show up on the TAR (treatment record). She stated she fixed that error and should be resolved going forward. It will now be a task that a nurse has to check off on their charting.

637 Based on record review and staff interview, the facility failed to do a change in condition Minimum [NAME] Set (MDS) after resident #9 developed a pressure ulcer, and correctly documented on the MDS from 6/26/25 the status of Resident #9's injuries. This failed practice was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #9 Facility Census: 56Findings include: 7/22/2025 3:27 PM Record Review MDS on 6/29/25 -section m0210 states that there is an unhealed Pressure Ulcer (PU) / injury section M0300does not state PU stg(stage) 4 or unstageable on left 4th toe, or that it is resolvedwas not resolved until 6/30 according to charting States there is a deep tissue injury (no location given) Section M1040 stated there were no other wounds (Z) is markedL(left) foot 3rd toe abrasion was not resolved until 6/30 Wound note review6/6/25 there was a wound found on L 4th toe found by Registered Nurse (RN #3). 6/9/25 was re assessed by Registered Nurse (RN#44) and ordered updated6/16/25 weekly assessment done by RN #44, cont. treatment for L 4th toe6/23/25 weekly assessment done by RN #3, cont. treatment of L 4th toe. Left 3rd toe noted to have eschar.6/30/25 weekly assessment done by RN #44, noted Left 3rd and 4th toe injuries are resolved. InterviewDirector of Nursing (Don #102) Stated she is aware of some consistency issues when charting wounds on both in house forms and the MDS. Different nurses call wounds by different names sometimes.

Based on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately . This failed practice was found true for 2 of 5 residents reviewed for the PASRR care area during the Long Term Care Survey. Resident Identifier: #2 and #23 Facility Census: 56 Findings include: a) Resident #2 During Record review on 07/22/25 of Resident #2's most recent PASRR completed on 02/17/25 which revealed no diagnosis were checked. Further record review of Resident#2's medical diagnosis revealed they were diagnosed with Bipolar Disorder on 04/21/25 as Primary DiagnosisAn interview with the Social Worker on 07/27/25 at 11:30 am was completed and confirmed Bipolar Disorder was not marked on Resident #2's PASRR. b) Resident #23During Record review on 07/23/25 of resident #23's medical diagnosis revealed the following diagnoses Anxiety disorderSchizoaffective disorderDepression, unspecifiedFurther record review on 07/23/25 of resident #23's PASRR revealed Major Depression was checked. Further research regarding Major Depression and Depression on Psych Central webpage found the following definition Unspecified depressive disorder is a diagnostic term. It means you show symptoms characteristic of a depressive disorder, but they don't meet the specific criteria for more common depressive disorders, such as major depressive disorder. (https://psychcentral.com/depression/unspecified-depressive-disorder#definition)During an interview on 07/23/25 at approximately 11:45 AM the Social Worker stated If they have a diagnosis for Depression i mark Major Depression on the PASRR confirmed Depression should be checked under Other on the PASRR.

Based on observation, resident interviews and staff interviews, the facility failed to promote and facilitate resident self-determination through support of resident choice regarding having access to the dining room during meals and activities. This failed practice had the potential to affect an unlimited number of residents currently residing in the facility. Facility census: 45. Findings included: A review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Visitation- COVID-19 with a revision date of 05/08/23 read as follows. .Communal Activities, Dining and Resident Outings: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. a) Resident #11 During an interview, on 10/02/23 at 11:52 AM, Resident #11 stated, I always eat in the dining rooms, but we have to eat in our rooms since COVID. During an observation on 10/02/23 at 12:00 PM residents were not in the dining rooms for the noon meal. b) Interviews During an interview on 10/03/23 at 11:39 AM, the Activity Volunteer Coordinator (AVC) #68 stated the Residents have not eaten in the dining room and/or the activity area since the shut down due to COVID and was sometime in the middle of September. During an interview on 10/03/23 at 11:42 AM, the Director of Nursing (DON) stated we have been on lock down due to COVID since 09/11/23. We did not have group activities or communal dining. I have been following the CMS guidelines. The DON was asked Have you read the updated revision of the CMS guidelines?. No response was given. During an observation, on 10/04/23 at 9:14 AM, there were a few residents sitting in the dining area and a few residents in the activity area. During an interview on 10/04/23 at 9:25 AM, the DON stated I read the CMS guidelines and we are now open for group activities and communal dining. The Infection Preventionist is the one that shut us down, not me. I was following her direction. The DON acknowledged that communal dining should have taken place during the COVID outbreak according to the CMS guidelines. During an interview on 10/04/23 at 10:54 AM, The Infection Preventionist (IP) #113 stated on 09/11/23 one (1) resident was asymptotic and tested positive. Then we tested all the residents and staff, I think it was eight (8) residents that tested positive. We started N-95 and goggles and stopped all group activities and communal dining. The IP was asked Do you know what the CMS guidelines are for group activities and communal dining when a COVID outbreak is present? The IP #113 stated I did not know about it. I am used to working in the hospital. I am updated now. .

Based on observation and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation during the noon meal, resident hand hygiene was not performed. This had the potential to affect more than a limited number of residents. Facility census: 45. Findings included: a) Hand Hygiene During a dining observation on 10/03/23 beginning at 12:11 PM, this surveyor observed several wet washcloths in a trash bag. The Cardinal Way noon meal trays arrived at 12:15 PM. Nurse Aide (NA) #2 and the Director of Nursing (DON) were observed passing four (4) lunch trays. During the observations hand hygiene was not offered to the residents prior to receiving their noon meal trays. This surveyor intervened and inquired about hand hygiene. During the observation no hand hygiene was provided to the residents prior to the noon meal being served. After several resident trays were delivered, this surveyor intervened. Hand sanitizer wipes were not placed on the meal trays. There were no hand sanitizer bottles observed near the serving areas. During an interview on 10/03/23 at 12:19 AM (NA) #2 stated, I am supposed to use the washcloths in the bag to wash the residents' hands but I have not had time to do it. NA #2 was asked what is on the washcloth? NA #2 stated hot water. NA #2 acknowledged the resident did not receive hand hygiene prior to their noon meal. During an interview on 10/03/23 at 12:22 PM, the DON was asked how did you sanitized the residents' hands prior to noon meal delivery? The DON stated the washcloths were used and they have peri wash on them. The DON said, We wipe the residents' hands. This surveyor informed the DON that hand hygiene was not provided, and the washcloths only had hot water on them per NA #2. The following Residents had received their noon meal trays prior to hand hygiene: -Resident #3 -Resident #26 -Resident #12 -Resident #20 -Resident #39 -Resident #37

Based on facility documentation and staff interview the facility failed to have required members attend and participate in the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility census: 45. Findings included: a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no certified Infection Preventionist (IP), Administrator/ Chief Executive Officer (CEO), or the Medical Director attended the meeting quarterly. During an interview 10/04/23, at 1:38 PM the CEO verified the required members were not in attendance for the quarterly QAA meetings. No other information was provided prior to the end of the survey on 10/04/23.

Based on observation, policy review and staff interview, the facility failed to store food in accordance with professional standards for food safety. The facility failed to dispose of expired food items. The facility also failed to accurately document the nourishment room refrigerator temperature log. This failed practice had the potential to affect all residents currently receiving nourishment from the nourishment room and the Resident's food storage refrigerator. Facility census: 45. Findings included: A review of the facility policy titled Temperature Control with a revision date of ,d+[DATE] read as follows: .Procedure: Proper temperature control is a necessary practice to prevent possible food spoilage or bacterial growth, which could result in a food-borne illness. 1. Temperature records are maintained for all refrigeration and freezer units both in the Dietary Department and on patient care areas (Diet Kitchens). The Dietary Department personnel are responsible for checking and recording temperatures daily. a) Nourishment Room During a tour of the nourishment room on [DATE] at 11:19 AM with the Dietary Manager revealed the following issues: - 28 sugar free Jello with an expired manufacture date -a container of mac and cheese with an expired manufacture date of [DATE]. The Dietary Manager (DM) acknowledged the failure to discard those that were out of date. The DM stated we stock the refrigerator, but we don't check the food for expiration. During an interview on [DATE] at 11:35 AM, the Director of Nursing (DON) stated The dietary is supposed to check the expiration date the nursing staff does not do that. b) The Resident Food Storage Refrigerator Refrigerator Temperature Log A review of the [DATE] Resident Storage Refrigerator Temperature Log on [DATE] at 11:35 AM, revealed the documentation was incomplete. The refrigerator and freezer were void of temperatures for the following dates: -[DATE] -[DATE] -[DATE] -[DATE] -[DATE] An immediate interview with DM, acknowledged the refrigerator temperature log was incomplete and should have been completed daily and stated that the Activity staff is responsible for the temperatures in the resident's food storage refrigerator. During an interview on [DATE] at 11:39 AM the Activities Volunteer Coordinator (AVC) #68 stated the Activity staff date and label the resident's food when it comes in, we also are responsible for checking the refrigerator/freezer temperatures daily. The AVC #68 acknowledged the refrigerator temperature log was incomplete and should have been completed daily. The AVC #68 stated that we have been forgetting to do the temperatures since we have been on lock down.

Based on observation, record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This failed practice had the potential to affect an unlimited amount of residents residing in the facility. Resident Identifiers: Resident #11. Facility census: 64. Findings included: A review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Visitation- COVID-19 with a revision date of 05/08/23 read as follows. .Communal Activities, Dining and Resident Outings: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. a) Resident #11 During an interview on 10/02/23 at 11:52 AM, Resident #11 stated I usually attend all the activities but since COVID we have not had any in a long time. I am so bored in my room. During a record review on 10/03/23 at 7:59 PM, Resident #11's medical record revealed an activity participation record with the following notes: -dated 09/21/23 Staff talked with Resident from outside his COVID room. -dated 09/27/23 staff talked with resident from doorway. Resident is just not very happy dealing with the COVID restrictions. :(Typed as written) Further review of medical records revealed a activity participation record for the month September 2023 On the following dates no activities participation was coded: -09/14/23 -0918/23 -09/24/23 On the following dates Conversation on phone: -09/15/23 -09/16/23 -09/19/23 -09/20/23 -09/22/23 -09/26/23 -09/28/23 -09/29/23 -09/30/23 On the following dates One to One and TV were coded:-09/12/23 -09/13/23 -09/15/23 -09/16/23 -09/17/23 -09/19/23 -09/20/23 -09/21/23 -09/22/23 -09/23/23 -09/25/23 -09/26/23 -09/27/23 -09/28/23 -09/29/23 -09/30/23 b) Observations During an the initial tour of the facility on 10/02/23 at 11:35 a review of the monthly activity calendar revealed the group activities for 10/03/23 as follows: -12:00 PM Lunch Bunch -2:00 PM Bingo -5:00 PM Supper Club -7:00 PM (A person's name) Show During an observation on 10/02/23 at 12:00 PM residents were not in the dining rooms for the noon meal. During an observation on 10/02/23 at 2:00 PM The Dining Area/Activity Area were void of any resident participating in bingo. c) Interviews During an interview on 10/03/23 at 11:39 AM the Activity Volunteer Coordinator (AVC) #68 stated We have not had group activities since the shut down due to COVID, that was sometime in the middle of September. During an interview on 10/03/23 at 11:42 AM the Director of Nursing (DON) stated we have been on lock down due to COVID since 09/11/23. We have not had group activities or communal dining. I have been following the CMS guidelines. The DON was asked Have you read the updated revision of the CMS guidelines?. No response was given. During an interview on 10/04/23 at 9:14 AM, AVC #68 stated we just opened back up today. I was helping a resident get a drink. We have not had group activities since 09/11/23 due to the COVID outbreak. When the residents are in isolation for COVID we stand at the door and visit, we have not been going into the rooms so we don't spread it to the other units. The residents that are not on COVID isolation have provided in room activities such as arts and crafts, bible study, manicures, read the newspaper and 1:1 visits. The AVC #68 was asked Do you or your staff not go into the COVID isolation residents rooms to supply them with any type of activity?. The AVC stated No. The AVC #68 acknowledged that all residents should have been given the choice to participate in a group and/or in room activities. During an interview on 10/04/23 at 9:25 AM, the DON stated I read the CMS guidelines and we are now open for group activities and communal dining. The Infection Preventionist is the one that shut us down, not me. I was following her direction. The DON acknowledged that group activities should have taken place during the COVID outbreak according to the CMS guidelines. During an interview on 10/04/23 at 10:54 AM The Infection Preventionist (IP) #113 stated On 09/11/23 one (1) resident was asymptotic and tested positive. Then we tested all the residents and staff, I think it was eight (8) residents that tested positive. We started N-95 and goggles and stopped all group activities and communal dining. The IP was asked Do you know what the CMS guidelines are for group activities and communal dining when a COVID outbreak is present? The IP #113 stated I did not know about it. I am used to working in the hospital. I am updated now.

Based on record review and staff interview, the facility failed to revise a care plan regarding an actual fall with injury and discontinued medications for Resident #34. This was true for one (1) of 5 (five) residents reviewed under the care areas of accidents and unnecessary medications during the survey process. Resident identifier: #34. Facility census: 45. Findings included: a) Resident #34 Fall with injury. On 10/02/23 at 1:12 PM, a record review was completed for Resident #34. The review found the resident had one (1) documented fall with injury on 08/12/23 resulting in a left proximal femur fracture. A progress note dated 08/12/ 23 at 3:06 PM stated the following: Resident was heard fall in her room. When we got to the room she was laying in the doorway saying that her hip was hurting. She was laying on her left side. She was placed on back board and gurney and transferred to the ED (Emergency Department) for further evaluation. She said she was going to the bathroom and ran into the doorway. All necessary paperwork sent with her. (Name of Health Care Surrogate) was notified on transfer. Resident was transferred to (Name of acute care facility). She has a fractured left proximal femur. (Name of facility physician) called to get information. (Name of Health Care Surrogate) was notified. discharged from ED (emergency department) at 1420 (2:20 PM). (Typed as written.) The quarterly Minimum Data Set (MDS) review dated 08/22/23 section J indicated multiple falls were documented throughout this timeframe. The falls were listed as follows: --1 (one) with no injury --2+ (two plus) injury except major --1 (one) major injury The care plan was reviewed on 10/02/23 at 2:00 PM, which listed the focus area as potential for injury from falls as evidenced by (AEB) unsteady gait; and the resident did have an actual fall with a major injury. The goal stated resident will incur no serious injuries from falls through the next evaluation. A reportable dated 08/12/23 completed by the facility regarding the actual fall with injury was reported to the appropriate state agencies as required. The statement included in the reportable was Resident went to (Name of acute care facility) for repair surgery. Resident returned to the facility on [DATE]. Resident will continue to receive all care as needed. (Typed as written.) On 10/03/23 at 2:20 PM, an interview with the Clinical Supervisor #70 which stated, It's not been updated .I haven't updated any care plans recently. No further information was obtained during the survey process. b) Discontinued medications. On 10/03/23 at 2:00 PM, a review of unnecessary medications was completed for Resident #34. The current physician's orders were reviewed. The current physician's orders did not include Seroquel (antipsychotic) which was discontinued on 09/09/23 and Melatonin (supplement) which was discontinued on 09/06/23. However, the care plan lists interventions stating, Administer med (medication) Seroquel 25 mg (milligram) daily and melatonin 3 mg at bedtime as ordered by physician under the focus area of mood problem related to depression as evidenced by irritability, sad affect, crying/tearfulness, angry outbursts, hopelessness, withdrawn, etc. Resident has elopement behaviors with agitation. Resident is prescribed anti-psychotic and anti-depressant medications. (Typed as written.) On 10/03/23 at 2:20 PM, an interview was held with the Clinical Supervisor #70 which stated, It's not been updated .I haven't updated any care plans recently.

Based on observations, medical record review, family interview and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to follow physician orders for Resident #36 to be up in a wheelchair daily and Resident #36 Restorative nursing three (3) times a week. This was true for one (1) of 12 residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: Resident #36. Facility census: 45. Findings included: a) Resident #36 During the initial tour on 10/02/23 at 11:35 AM Resident #36 was lying in bed watching TV. During an interview on 10/02/23 at 2:35 PM Resident #36's wife stated, He needs to be out of bed for at least a couple hours a day but they are not doing that either. During a record review on 10/02/23 at 7:30 PM Resident #36 medical record review revealed a Physician order dated 05/09/23 up in wheelchair w/c daily with footrest. Every Shift: Day and Evening. Further record review revealed Residents #36 Point of Care Activities of Daily Living (ADL) transfer documentation was coded 8) Activity did not occur on the following days: -10/02/23 -10/01/23 -09/30/23 -09/29/23 -09/28/23 -09/27/23 -09/26/23 -09/25/23 -09/22/23 -09/15/23 -09/14/23 -09/13/23 -09/10/23 -09/08/23 During an observation on 10/03/23 at 9:20 AM Resident #36 was lying in bed watching TV. During an observation on 10/03/23 at 12:15 PM Resident #36 was lying in bed and appeared to be resting. During an interview on 10/03/23 at 1:58 PM, the Director of Nursing (DON) stated There is no reason why he should not be up in a wheelchair, he can watch TV in his room instead of in his bed. The DON acknowledged the physician order for Resident #36 to be in a wheelchair daily was not being followed. During an observation on 10/03/23 at 3:30 PM Resident #36 was lying in bed watching TV. During an observation on 10/04/23 at 11:15 AM Resident #36 was lying in bed watching TV. The DON acknowledged the physician order for Resident #36 to be in a wheelchair daily was not being followed. b) Resident #36 During a record review on 10/02/23 at 7:30 PM Resident #36 medical records revealed a Physician order dated 07/27/23 Restorative nursing three (3) times a week for ROM (Range of Motion)/Stretching to both lower extremities for maintenance of ROM and worsening contractures. Further record review revealed Residents #36 Point of Care (ADL) Restorative Nursing Minutes documentation was coded No Restorative Nursing Data Recorded on the following days: -10/02/23 -10/01/23 -09/30/23 -09/29/23 -09/28/23 -09/26/23 -09/25/23 -09/24/23 -09/23/23 -09/22/23 -09/21/23 -09/20/23 -09/19/23 -09/18/23 -09/17/23 -09/16/23 -09/15/23 -09/14/23 -09/13/23 -09/11/23 -09/10/23 -09/09/23 -09/08/23 -09/06/23 -09/05/23 -09/04/23 -09/03/23 -09/02/23 During an interview on 10/03/23 at 1:58 PM the DON stated, We have not done restorative since the COVID outbreak, we have been limited. The restorative nurse had COVID and was out for five (5) days. Before that she was off two (2) months for surgery. She is our only restorative aide, so nothing gets done. The DON acknowledged the physician order for the Restorative three (3) times a week was not being followed.

Based on medical record review, family interview and staff interview, the facility failed to provide care required to maintain good hygiene to a resident who was dependent for Activities of Daily Living (ADL) care one (1) of one (1) reviewed for ADL care area during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident #36. Facility census: 45. Findings included: a) Resident #36 During an interview on 10/02/23 at 2:35 PM, Resident #36's wife stated He has not had a shower due to COVID outbreak. I was in today and gave him one, or it probably would have been a couple more weeks. He needs to be out of bed at least a couple hours a day but they are not doing that either. A review of the facility shower schedule on 10/03/23 at 10:35 AM revealed Resident #36's showers are scheduled for every Tuesday and Saturday. Scheduled for the following: -09/30/23 -09/26/23 -09/23/23 -09/19/23 -09/16/23 -09/12/23 -09/09/23 -09/05/02 -09/02/23 Further review of the medical record revealed Point of Care Bathing was coded received shower on the following days: -09/23/23 -09/19/23 -09/12/23 -09/05/23 -09/02/23 Further record review revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/14/23 revealed the following: Section G, titled Activities of Daily Living Assistance, Section G0120 titled Bathing A. Bathing: Self Performance coded 4) Total dependence. B. Bathing: Support provided coded 2) one-person physical assist. During an interview on 10/03/23 at 1:58 PM the DON stated, There is no reason why he has not received a shower. The DON acknowledged Resident #36 did not receive the care required to maintain good hygiene and requires assistance with ADL's.

Based on observation and staff interview, the facility failed to dispose of expired medications stored in the medication room. This was a random opportunity for discovery. Facility census: 45. a) Medication Room On 10/03/23 at 10:00 AM, a tour of the medication room was completed. Within the over-the-counter medications, two (2) bottles of Oyster Shell Calcium 500 mg (milligram) plus Vitamin D were found to be expired in July 2023. On 10/03/23 at 10:06 AM, the Director of Nursing (DON) was notified and confirmed the two bottles were expired.

Based on record review and staff interview, the facility failed to transmit a discharge assessment with the Assessment Reference Date (ARD) of 05/02/23 for Resident #14. This was true for one (1) of three (3) discharges reviewed during the survey process. Resident identifier: #14. Facility census: 45. Findings included: a) Resident #14 On 10/03/23 at 11:15 AM, a record review was completed for Resident #14. The resident was admitted to the facility on [DATE] and discharged on [DATE]. The review found the discharge Minimum Data Set (MDS) had not been transmitted upon the discharge date of [DATE]. On 10/03/23 at 12:40 PM, an interview was held with Clinical Supervisor #70. The Clinical Supervisor #70 stated, the discharge (return not anticipated) assessment dated [DATE] is in process now .I missed it .it needed submitted .I just completed it today. No further information was obtained during the survey process.

Based on facility documentation and staff interview, the facility failed to re-evaluate Resident #27's ability to remove a physical restraint easily. This is true for one (1) of one (1) reviewed for restraints, during the long-term care survey process. Resident I identifier: #27. Facility census: 45. Findings included: a) Resident #27 Observation of a Merry [NAME] outside Resident #27's room, during the initial tour on 10/02/23 at 2:08 PM. During a medical record review on 10/03/23 at 10:32 AM of Resident #27's order form 09/21/21 revealed: -Release from the merry walker offer toilet or ambulation every 2 hours. -Resident may be up in merry walker for safe ambulation throughout the facility. Continued review of Quarterly Minimum Data Set (MDS) assessment on 08/24/23 Section P, Restraints and Alarms, indicated no physical restraints. During an interview on 10/03/23 at 11:38 AM the Minimum Data Set Nurse (MDS) #70 stated that Resident #27's Merry [NAME] is not considered a physical restraint because she can remove it herself. The MDS Nurse #70 was asked to provide the evidence of the assessments. No evidence was provided prior to exiting the facility. On 10/03/23 at 1:19 PM, the MDS Nurse #70 stated they would re-evaluate Resident #27's ability to remove a physical restraint easily.

Based on observation, interviews, record review and policy review the facility failed to ensure bottles of insulin vials were locked and secured in a medication cart. This was a random opportunity for discovery. The failed practice had the potential to affect an unlimited number of residents. Resident identifiers: #2, #23, #34 and #39. Facility census: 42. Findings included: Record review of the facility's policy titled Administration of Medications, revised on 10/2021, showed all medications are stored and locked when walking away from medication cart. a) Resident #2 An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. One (1) insulin bottle stated Resident #2's name and was a [MEDICATION(S)] insulin vial. During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated that everyone else leaves the insulin bottles out on top of the medication carts too. During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated that insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart. During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated that the insulin vials should have been locked up in the medication cart. A review of Resident #2's medical record showed an physician order for [MEDICATION(S)]; give 12 units sub-Q daily-Once A Day at 9:00 AM. b) Resident #23 An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. The one (1) insulin bottle stated Resident #23's name and was a [MEDICATION(S)] Mix U-100 insulin vial. During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated everyone else leaves the insulin bottles out on top of the medication carts too. During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart. During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated the insulin vials should have been locked up in the medication cart. A review of Resident #23's medical record showed an physician order for [MEDICATION(S)] Mix U-100 give 36 units in the morning once a day at 8:30 AM. c) Resident #34 An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. The one (1) insulin bottle stated Resident #34's name and was a [MEDICATION(S)] Solution U-100 insulin vial. During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated everyone else leaves the insulin bottles out on top of the medication carts too. During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart. During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated the insulin vials should have been locked up in the medication cart. A review of Resident #34's medical record showed an physician order for [MEDICATION(S)] Solution give U-100; Three times a day at 6:00 AM, 11:30 AM, 5:30 PM. d) Resident #39 An observation on 04/19/22 at 9:00 AM, showed a white container that sat on top of the unsupervised Cardinal Way medication cart. The white container held four (4) vials of insulin. The one (1) insulin bottle stated Resident #39's name and was a [MEDICATION(S)] Solution U-100 insulin vial. During an interview on 04/19/22 at 9:15 AM, Licensed Practical Nurse (LPN) #37 stated everyone else leaves the insulin bottles out on top of the medication carts too. During an interview on 04/19/22 at 9:20 AM, Licensed Practical Nurse (LPN) #23 stated insulin was not to be left on top of the mediation carts and that insulin was to always be locked up in the medication cart. During an interview on 04/19/22 at 9:30 AM, Director of Nursing (DON) stated the insulin vials should have been locked up in the medication cart. A review of Resident #39's medical record showed an physician order for [MEDICATION(S)] Solution give U-100: Before meals and at bedtime at 7:00 AM, 11:00 AM, 5:00 PM and 10:00 PM.

Based on observation, medical record review, and staff interview, the facility failed to provide the necessary care and services to reach and/or maintain the highest possible level of functioning and well-being for one (1) of three (3) Stage 2 sample residents reviewed for range of motion (ROM). Services and interventions to prevent a decline in ROM were not provided, resulting in actual harm. The resident developed contractures which caused pain when attempts to reposition the resident were made. Resident Identifier: #8. Facility Census: 59. Findings include: a) Resident #8 During a Stage 1 interview, on 02/03/15 at 03:59 p.m., Licensed Practical Nurse (LPN) #20 said the resident had a contracture of the left upper extremity. On 02/04/15 at 02:05 p.m., observation of the resident revealed her left arm drawn tightly into her body, with the left hand resting on her chest. Her fingers were stiffly curled into a partial fist. The resident was not interviewable and did not attempt to lift or straighten out her left arm or hand when asked to do so. On 02/05/15 at 10:40 a.m., review of the quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/16/15, did not identify the resident had a contracture. The resident was unable to complete the Brief Interview for Mental Status (BIMS) assessment. The MDS revealed Resident #8 needed total care with transfers, locomotion, bathing, and toileting, and extensive assistance with bed mobility, dressing, eating, and personal hygiene. The assessment for functional limitations in range of motion showed no impairment for the resident's upper or lower extremities. Resident #8's diagnoses included Dementia, [MEDICAL CONDITION], and Arthritis. No diagnoses were noted for any type of neurological deficit or weakness. Review of the resident's care plan, on 02/05/15 at 11:30 a.m., revealed the last care conference was on 01/28/15. The current care plan included a problem of altered self-care deficit related to "left sided weakness..." with a problem start date of 10/29/14. Two (2) of the approaches under this care area, created 10/29/14, were "up in geri-chair as tolerated related to poor trunk control and leaning to left side" and "turn and position every one (1) to two (2) hours and as needed." A care area for "Alteration in nutritional status" included, "unable to feed herself leaning to left side...." On 02/05/15 at 3:22 p.m., an interview with Nurse Aide (NA) #40, who had provided care for Resident #8, revealed Resident #8 "...used to be independent before she had her stroke." Review of the NA Kiosk, the tool to inform NAs about individual resident care, with NA #40, found the instructions included "poor trunk control make sure to periodically rearrange, two (2) person assist, use pillows on weak side, position in bed turned two (2) hours." Employee #40, who was also the restorative nursing aide, could not remember Resident #8 ever receiving any restorative nursing services. Review, on 02/05/2015 at 1:20 p.m., of an occupational therapist's (OT) progress note dated 11/06/14 revealed, "OT received evaluation order due to concerns with L (left) hand contracture. OT attempted to see pt (patient) 11/5/14, sleeping unable to rouse but did tolerate PROM (passive range of motion) to L hand, wrist, elbow without s/o (signs of) pain. Attempted again with resident sleeping. She was alert briefly and able to follow commands to 'squeeze my hand' and 'open up your fingers' demonstration functional grip strength. She again tolerated PROM to L hand and wrist without c/o (complaint of) or s/o (signs of) pain. At rest, her L hand is in a good resting posture without increased tone noted. At this time, it does not appear as though her hand is contracted. Spoke with RN (registered nurse), (RN's name), will recommend restorative for AROM (active range of motion) and PROM while awake. OTR (occupational therapist, registered) will continue to monitor resident and reassess as needed." An observation, on 02/05/15 at 2:27 p.m., found the resident lying in bed with her eyes closed. Her upper trunk was tilted to the left, with her left arm pulled tightly to her body. The resident's left hand was rigidly drawn resting on her chest. The resident was lying in poor body alignment with her right hip raised off the bed approximately three (3) inches, her right knee was up in the air bent at a 30 degree angle, and the bottom of her right foot was resting on the bed. The resident's head rested on one (1) pillow. No other pillows were present on the resident's bed to support the resident's body position. Review of medical records, on 02/05/15 at 4:37 p.m., revealed a nursing progress note dated 11/03/14, "Left hand noted to be contracting OT eval (evaluate) order," and a physician's orders [REDACTED]." On 02/09/15 at 10:56 a.m., a joint interview with Restorative Nurse #49, the LPN #19, who noted Resident #8's decline and change in condition, and Minimum Data Set (MDS) Nurse #50, took place. The interview revealed the resident was sent to the hospital emergency department for an evaluation due to left sided weakness on 10/09/14. According to LPN #19, "The resident was unable to sit up straight, but kept falling over." She said, "I got the order to send the resident to the hospital emergency department for evaluation." The MDS nurse stated, "At that time the resident started drawing her left hand and she had not done so before." The MDS nurse also stated a [DIAGNOSES REDACTED].#49 confirmed she had a conversation with the occupational therapist in November (2014) and was aware of the OT's recommendation for restorative nursing services. When asked if Resident #8 had received restorative nursing, Restorative Nurse #49 stated she did not get an order for [REDACTED]. Restorative Nurse #49 and LPN #19 agreed, based on Resident #8's condition, it would be good nursing practice to do some range of motion exercise interventions for Resident #8. Review, on to 02/09/15 at 11:35 a.m., of the hospital emergency department record, dated 10/09/14, revealed the clinical impression was "focal neurological deficit - likely [MEDICAL CONDITION]." The emergency department record noted, "New left upper and lower extremity weakness. Patient rotated to left. Left hand and arm held in flexion." On 02/09/15 at 12:33 p.m., interview with Occupational Therapist (OT) #97, revealed OT evaluated Resident #8, "...due to a decline related to a possible [MEDICAL CONDITION]." OT #97 stated the "...resident presented guarding her left, and would not use her left arm, but guarded it." The OT stated, "...I was able to do ROM without the resident grimacing or showing signs of pain," and, "The resident did not need the skilled services of a therapist, but restorative nursing could do the services the resident needed, so I referred (Resident #8's name) to restorative nursing." The OT explained the referral process and the form used. OT #97 appeared surprised when informed the resident had not had any restorative nursing services to date. The OT was unable to provide a copy of Resident #8's referral to restorative nursing services or physician's orders [REDACTED]. On 02/09/15 at 12:50 p.m., upon request, OT #97 observed, assessed, and compared Resident #8's current condition to her condition observed by OT in the November 2014 evaluation. The resident was in her room sitting in a geri-chair with her left arm drawn to her body, her left hand resting on her chest, her fingers curled into a partial fist, and leaning over on the left arm of the geri-chair with her head resting on her left shoulder. OT #97 attempted to do range of motion to the resident's left arm; however, the resident grimaced each time the OT attempted to move the arm. The OT remarked she thought the resident was more afraid that the OT was going to hurt her than the resident was actually experiencing pain. The OT tried to get the resident to open her left hand; however, the resident only opened her right hand. The OT gently attempted to help the resident open her left hand and was unable to fully open and straighten the fingers. When asked if the resident was different now than when assessed on 11/06/14, the therapist said, "Yes, definitely." OT #97 stated Resident #8 had had a decrease in ROM to the left hand with some arthritis, and commented, "Now there is a contracture of the two (2) little fingers of the left hand, as well as decreased ROM of the middle finger." OT #97 stated "(Resident #8) could benefit now from the use of a splint, and I will see to that." The resident was also in need of being repositioned; however, when the OT went to straighten the resident's neck, she winced and cried out. The OT immediately stopped. She stated she needed to get a second person to assist and needed to get a pillow to prop up the resident's side. She then left the room. Review of a multi-disciplinary rehabilitation screening found a screening dated 11/24/14 which included, "Left weakness noted 10/09/14 with headache with significant decline." A screening, dated 12/29/14, noted the, "total dependence with lift for transfers no skilled treatment received at this time." There was no mention found in the evaluations regarding the resident's repositioning needs. .

Based on observation, record review, staff interview, and review of manufacturer's recommendations, the facility failed to provide care and services to prevent accidents to the extent possible for six (6) of sixteen (16) residents reviewed for safe use of mechanical lifts. Resident #44 was injured while being transferred on a mechanical lift device on three (3) occasions within a three (3) month period. The facility failed to recognize this pattern of injury related to the use of the mechanical lift, and failed to ensure direct care staff were trained or re-trained as needed. Nursing personnel used a lift which did not coincide with the physical or cognitive needs of Resident #1, resulting in a potential for an accident during a transfer, and directives for the use of mechanical lifts for Residents #70, #17, #13, and #49 contained conflicting information. During the initial tour of the facility, two (2) bottles of cleanser were found in areas which were accessible to residents. These practices affected six (6) residents; however, they had the potential to affect more than a limited number of other residents. Resident identifiers: #44, #2, #70, #17, #13, and #49. Facility Census: 55. Findings include: a) Resident #44 The facility incident and accident reports were maintained on a computerized system. When asked for a list of all incidents/accidents occurring in the previous six (6) months, staff provided a list with no resident names or resident numbers to associate with the occurrence. The list only had an "occurrence number", and description such as "fall incident", "clinical incident", "medication incident", to broadly describe the incident/accident. Employee #101, Quality Assurance Coordinator, Registered Nurse (RN), confirmed, when interviewed on 08/21/13 at 9:51 a.m., there was no method for staff to quantify or track individual resident's incidents. On 08/21/13 at 4:15 p.m., a random selection of facility incident and accident reports was requested for review. During this review it was noted Resident #44 incurred injuries on three (3) occasions between the months of April 2013 and June 2013. On 04/26/13 a report described the resident experienced swelling and a blue tinge above the right eyebrow. The incident report indicated while being transferred from bed to chair, the nurse aide was removing the Hoyer lift pad hooks when the Hoyer lift metal bar swung back striking the resident on the forehead, just above the right eyebrow. On 05/30/13 the same resident received a skin tear during a transfer using a Hoyer lift. Again on 06/14/13, the resident received another skin tear while being transferred with a Hoyer lift. Both incident reports revealed the skin tears came from the Hoyer lift pad rubbing the resident's skin. (Note: The facility referred to the total lift utilized in their facility as a Hoyer lift, however, the brand name for the lift was "Uno Lift." ) A medical record review was conducted on 08/21/13 at 4:30 p.m.. This review revealed three (3) nursing notes dated 04/26/13, 05/30/13 and 06/14/13. These notes consistently reflected the same information contained in the incident reports. There was no documentation contained in the medical record which indicated the incidents involving this resident were discussed and interventions put in place to prevent further injury related to the use of a lift with this resident. Resident #44's care plan was reviewed. The care plan contained the following problem statement, "Altered self-care r/t (related to) dementia with psychosis and decreased mobility AEB (as evidenced by): requires total care for all ADLs." The care plan contained the following intervention related to this problem, "Hoyer lift for transfers." The resident's "Resident Record," which described the specific services nursing assistants were to provide and equipment to use, was reviewed. This indicated Resident #44 was transferred using a Hoyer lift. . The DON, was interviewed on 08/22/13 at 8:50 a.m.. She stated, regarding the incidents which occurred with Resident #44, the incidents were discussed during their fall/incident meeting. She could provide no evidence of this discussion or information that indicated interventions were implemented, after the first accident, in an effort to prevent additional injuries. During the first accident, the resident was bruised from being hit in the head with the lift bar. The DON stated if a reevaluation of the resident's lift status was warranted, then therapy would do an evaluation to determine the appropriate form of transfer for the resident. She had no information to suggest this step was taken following the injury to Resident #44. The DON reported the therapist utilized a "Multidisciplinary Rehab Screening" form to complete and document the evaluations performed by therapy, and to communicate which method of transfer the residents required. Resident #44's medical record was again reviewed at 10:30 a.m. on 08/22/13. The most recent "Multidisciplinary Rehab Screening" for Resident #44 was completed on 12/08/12, prior to any of the three (3) injuries incurred with the Hoyer lift. Employee #51, Director of Rehabilitation Services, was interviewed at 10:52 a.m. on 08/22/13. She reported they must have missed doing the resident's quarterly screen. She reported it appeared the resident should have had an evaluation in March 2013, but apparently the evaluation was missed. Employee #51 reported she recalled talking about the incidents involving Resident #44 and the Hoyer lift. She reported they were under the impression the resident was flailing her arm while in the lift. There was no opinion as to the cause of the injury when the resident was struck in the head with the bar. Employee #51 reported they did not reevaluate the resident for appropriateness of the continued use of the Hoyer lift following any of the three (3) incidents. Neither the nursing notes, nor the incident reports, revealed anything to support the opinion of Employee #51, that the resident was flailing her arms during the transfers. The behavior monitoring sheets, completed by the licensed nurses, and the resident record and elimination sheets, completed by the nurse aides, were reviewed for the months of April 2013, May 2013 and June 2013. None of these sheets indicated Resident #44 was resistive to care or flailed her arms during the aforementioned transfers. The in-service training documentation for the use of lifts was reviewed on 08/22/13 at 9:30 a.m. The documentation revealed of the twenty-five (25) currently employed nursing assistants (NA), only five (5) had received training on the use of the mechanical lifts utilized by this facility. This training was provided on 01/06/11 for four (4) current employees, and on 09/15/11 for another current employee. Those five (5) employees were Employee #8, Employee #11, Employee #7, Employee #13, and Employee #10. Four (4) nursing assistants (NAs) were interviewed regarding their training for use of the facility's lifts. Employee #11 was interviewed at 12:00 p.m. on 08/22/13. At 12:03 p.m. on 08/22/13, Employee #9 was interviewed. Employee #16 was interviewed at 12:05 p.m. on 08/22/13. At 12:08 p.m. on 08/22/13, Employee #8 was interviewed. None of the employees interviewed could state when or how they received training on the correct use for either of the lift devices used at this facility. The facility directives regarding who was to be transferred with a mechanical lift and which mechanical lift was to be used were confusing and inconsistent. Two (2) lists were available to NAs and they did not have the same information. During an observation, nursing assistants were heard to disagree on which method was to be used for transferring a resident. An interview was conducted with Employee #96, Director of Nursing (D0N), at 8:50 a.m. on 08/22/13. The DON stated some of the staff were trained on the use of lifts in 2011. She reported this was all the documentation she had regarding the training of nurse aides related to the use of the mechanical lifts currently utilized by the facility. The DON further confirmed no additional training was provided following any of the three (3) injuries incurred by Resident #44. . . b) Resident #1 On 08/21/13, upon entrance to the facility at approximately 8:15 a.m., Resident #1 was observed sitting in the Activity Room in her wheelchair asleep. Her head was falling to one side, unsupported. The resident's medical record was reviewed. It was noted the resident was ordered to be transferred with a sit to stand lift. At 12:15 p.m. on 08/21/13 staff approached the resident to toilet her. The nursing assistant (NA) assigned to the resident for that day, Employee #14, requested assistance from a restorative licensed practical nurse (LPN), Employee #66. The NA asked the LPN to borrow her gait belt. The LPN replied the resident was to be transferred with a sit to stand lift. Employee #14, (NA) and Employee #66, (LPN), were observed transferring Resident #1 using a stand up lift (Sabina II with a support vest). The resident's feet were placed on the platform by Employee #14. The resident's hands were placed on the handle bars. As Employee #66 raised the lift, Employee #14 attempted to hold the resident from behind using the resident's clothing. During this time the resident was saying, "I am falling." The resident was lifted,but was unable to hold onto the bars as required with this type of lift. The vest of the lift rose up under the resident's arms, leaving her hanging with the vest high up under her arms. The manufacturer's recommendations for use of the Sabina II lift used to transfer Resident #1 were reviewed. These recommendations and instructions stated, "Sabina with support vest to be used on oriented, partial weight bearing and able to ambulate short distances." Interview with Employee #96, Director of Nursing (DON), on 08/22/13 at 1:30 p.m., revealed Resident #1 was last assessed on 04/15/13 for a stand up lift. When asked how often residents were assessed by therapy for transfers, it was confirmed the time frame was every three (3) months, or as needed for changes in a resident's transfer ability. It was confirmed this resident had not been assessed in over four (4) months. Employee #96 also confirmed Resident #1 was non-ambulatory and confused. The DON provided a "Patient/Resident Functional Assessment Form for Lifting" which was provided by the manufacturer as guidance on proper lift choice. The DON confirmed the Sabina II with support vest was not the proper lift for Resident #1, as the resident was confused, unable to hold the handle bars, unable to follow commands, and nonambulatory. An interview was held with Employee #14, nursing assistant, on 08/26/13 at 11:00 a.m.. When asked about the transfer equipment and assistance needed for the transfer of Resident #1, she stated, "It always takes two (2) to transfer this resident due to being confused and someone has to hold her up by her clothing when using the sit to stand lift." . c) Residents #70, #17, #13 and #49 On 08/22/13 at 9:00 a.m., reviews of rehabilitation screenings, the Kardex, care plans, and the tickler system ( a small card containing the resident's name, room number,toileting needs, transfer needs, shower schedule and swallowing deficits, used by nursing personnel to provide care) were conducted relative to these residents' transfer needs. The documents reviewed were the directives available for staff to provide care for residents. Due to the inconsistencies in the directives, the assessed safe method for lifting these residents could not be ascertained. Nursing staff members were not provided clear and concise information to ensure each resident was lifted by the method which was assessed as safest for any of the four (4) residents. 1) Resident #70 - No Rehabilitation screening could be located in the resident's chart. - The Kardex was dated 08/07/13 and stated, "The use of a Hoyer lift and assist of two persons for transfers." - The resident's care plan dated 08/23/13 contained no transfer directions. - The section for transfer needs on the tickler card was blank. On 08/22/13 at 9:45 a.m., Employee #9, a nursing assistant (NA) was interviewed. The NA said a lift was not used for this resident. 2) Resident #17 - A rehabilitation screening dated 04/15/13 stated, "Ambulating 100 to 200 feet consistently with a front wheeled walker and restorative aide. Independent ambulation to and from bathroom but is incontinent. Occasionally ambulates in hallway independently with front wheeled walker." - The Kardex dated 07/05/13 stated "Stand up lift." - The care plan dated 07/10/13 contained no transfer directions. - The tickler stated, "Independent." On 08/22/13 at 9:45 a.m., Employee #9, NA, was interviewed. The NA said the stand-up lift was used for transfers of this resident. 3) Resident #13: - A rehabilitation screening dated 01/24/13 stated, "Sliding board transfers and supervision with all transfers." - The Kardex dated 06/21/13 stated, "Hoyer lift for transfers." - The care plan dated 06/26/13 stated, "Hoyer lift for all transfers." - The tickler stated, "Independent with transfers." On 08/22/13 at 9:45 a.m., Employee #9, NA, was interviewed. The NA said a Hoyer lift was used for this resident for transfers. 4) Resident #49 - The rehabilitation screening dated 07/08/13 stated, "Hoyer lift for transfers." - The Kardex dated 06/13/13 stated, "Hoyer lift." - The care plan dated 06/26/13 stated, "Hoyer lift for all transfers." - The tickler stated "Assist of two." On 08/22/13 at 9:45 a.m., Employee #9, a NA,was interviewed. The NA said a Hoyer lift was used for this resident for transfers. d) During the initial tour of the facility on 08/19/13 at 12:30 p.m., the main shower rooms, one (1) on each hallway, were observed. The shower rooms were observed with open and unlocked storage of cleaning supplies. The cleaning supplies contained chemicals that could be hazardous to residents. The door to the shower room on B hall was fully open, allowing easy entry. The A hallway shower room door was closed; however, it was not locked, and could also be easily entered. Observed in both shower rooms was one (1) spray bottle containing a clear liquid labeled "Virex Tb" sitting in an unlocked cabinet. Virex Tb is a disinfectant used for surface cleaning. According to the information found on the material safety data sheet (MSDS), the Virex Tb included danger hazards to skin, eyes and clothing, and was labeled as corrosive. The MSDS also stated, "Causes skin and eye burns...Harmful or fatal if swallowed... Combustible liquid and vapor." On 08/19/13 at 12:32 p.m., Employee #96, director of nursing (DON), and Employee #68, licensed practical nurse (LPN), were asked to confirm the observations of the improperly stored chemicals. After touring the shower rooms, Employee #96 and Employee #68 confirmed the door to the cabinet in which the cleaner was stored should have been locked to prevent possible accidental access by residents. .

Based on medical record review, staff interview, and observation, the facility failed, for two (2) of fourteen (14) sampled residents and one (1) randomly observed resident, to provide adequate supervision and/or assistive devices to promote resident safety. Resident #22 was assessed as having a decline in urinary continence on her comprehensive assessment of July 2009. Resident #22's care plan was revised on 08/05/09 to address, among other concerns, late loss activities of daily living (ADLs) and falls. After Resident #22 had a fall with injury on 08/10/09, the care plan was not revised with interventions to promote increased safety, including safe toilet use. Resident #22 subsequently fell in her room related to an episode of urinary incontinence on 09/07/09 and sustained injuries. Additionally, review of documentation related to offerings of scheduled toileting reflect a lack of consistent provision of staff supervision with toileting at regular intervals on a daily basis. The nursing assistant in the activity / dining room by herself was not aware Residents #15 and #8 required additional supervision for swallowing problems. Resident identifiers: #22, #15, and #8. Facility census: 56. Findings include: a) Resident #22 Review of Resident #22's nursing notes, on 09/07/09 at 2:25 p.m., revealed the following entry: "9/7/09 0130 (1:30 a.m.) Residents (sic) alarm sounding. Upon entering room resident was found laying (sic) on (R) (right) side. Resident stated she had wet herself and her feet slid. Resident was assessed & noted 0.2 cm cut to back of head scant amt (amount) bleeding. Resident c/o (complained of) (R) shoulder pain, (R) elbow pain and (R) arm pain. (Name) RN supervisor was called and notified ... Noted abnormality to R humerus. ..." The resident was subsequently transferred to the emergency room for treatment. Review of the facility's patient safety events revealed Resident #22 had another fall less than a month earlier, which also required medical intervention. On 08/10/09 at 1735 (5:35 p.m.), "Called to room (number) by housekeeping, resident lying on left side. C/O pain in Left shoulder, elbow, and hip, able to squeeze my hand, weak grip, screamed in pain with elbow. rolled (sic) onto back 9 (sic) logrolled) able to move l (left) leg on command but c/o pain from hip to back. 3 cm x 3 cm laceration with skin flap on l (left) elbow sic) steri stripped small 2cm open area below this area. Logrolled onto stretcher and trasferred (sic) to gurney. ..." The resident was subsequently transferred to the emergency room for treatment. Record review revealed Resident #22 was a [AGE] year old female admitted to the facility on [DATE]. Her monthly recapitulation of physician's orders [REDACTED]. Treatment orders included: "Bed pad alarm for safety. Personal alarm for safety. Resident is to ambulate with wheeled walker with supervision to and from functions and meals." Her most recent minimum data set assessment (MDS), a comprehensive annual assessment with an assessment reference date (ARD) of 07/24/09, revealed, in Section B, she had both short-term and long-term memory problems, she was not able to recall the current season, location of her own room, the names and faces or staff members, or that she was in a nursing home, and her cognitive skills for daily decision-making were moderately impaired. The 07/24/09 MDS also recorded, in Section G, the resident required limited assistance by one (1) staff member with the following ADLs: bed mobility, transfer, walk in room, walk in corridor, and toilet use. In Section J4, the assessor noted the resident had a previous fall within the past thirty-one (31) to one hundred eighty (180) days. Review of the resident's two (2) most recent consecutive assessment found she had a decline in bladder continence. On the quarterly MDS, with an ARD of 04/24/09, the assessor encoded Item H1b as "1", indicating the resident was usually continent with incontinent episodes occurring once a week or less. On the 07/24/09 annual MDS, the assessor encoded Item H1b as "2", indicating the resident was now occasionally incontinent of bladder two (2) or more times a week but not daily. Review of the resident's comprehensive plan of care for 08/05/09 through 11/05/09 found reference to the toileting schedule as follows - "Toilet upon rising, before and after meals and out of room activities, before going to bed and offer toielting (sic) during each bed check at HS (hour of sleep)." However, there was no mention of other interventions developed to promote improved bladder continence, which was a factor in the resident's fall on 09/07/09. (See citations at F315 and F279.) Further review of the resident's care plan revealed the following problem statement with respect to ADLs and falls: "Alteration in ADL / mobility status with potential for falls R/T (related to) osteoarthritis, Alzhiemers (sic), dememtia (sic) AEB (as evidence by) extensive assist with bathing, dressing, locomotion off unit; limited assist with bed mobility, transfers, ambulation, toilet use, hygiene; feeds self after tray set up." The goals associated with this problem statement were: "Will have no decline with late loss ADLs (eating, toilet use, bed mobility, transfers) thru next review. Will have no fall with injury thru next review." In addition to interventions to promote the resident's cooperation with and/or participation in bathing, grooming / personal hygiene, and bed mobility, staff was to: "... Cue / encourage resident to plant feet solidly on floor to assist with transfers and prevent falls QS (every shift). Ensure safe environment ie bed in low position with wheels locked, personal items within reach, call bell in reach, floor dry, clean and clutter free QS. Ensure resident is wearing appropriate foot wear (sic) ie non-skin (sic) shoes / slippers / socks QS. Remind resident frequently during each shift not to attempt to transfer / ambulate self independently and to ring call bell for assist. ... May have Merriwalker (sic) for independent ambulation PRN (as needed). Personal and bed alarm for safety QS. ... Resident to ambulate with front wheeled walker with supervision to and from functions and meals." Interventions such as reminding the resident to not attempt to transfer / ambulate independently and to ring the call bell for assistance are of questionable value given the resident's memory and cognitive impairments. Additionally, while other ADLs were addressed in this care plan, interventions to promote safe toilet use were not. Also in this same care plan was the following problem statement: "Cognitive Loss (sic) related to Alzheimer's dementia, impaired decision making and poor safety awareness." None of the goals or interventions associated with this problem statement spoke to the resident's poor safety awareness. No revisions were made to the resident's care plan after the fall with injury on 08/10/09 (which occurred five (5) days after the resident's comprehensive care plan was reviewed and revised) to promote increased safety and prevent a subsequent fall with injury. Review of documentation of related to toileting (forms titled "Toileting Schedule for Activity Room" and "Midnight Toileting Schedule") found inconsistent / incomplete documentation to reflect Resident #22 was, on a daily basis, offered assistance with toileting at the intervals specified to reduce episodes of incontinence and promote safe toileting, given that Resident #22 was to be reminded to not transfer / ambulate independently. b) Residents #15 and #8 A lunch time observation, on 09/09/09, found Employee #1 to be the only staff member assisting ten (10) residents to eat in the activity / dining area. Among the residents present were Residents #15 and #8. The following morning, Employee #1, when asked which residents who ate in the activity / dining area had swallowing problems, identified all residents who received pureed foods were at a risk for swallowing problems. Employee #1 further related that none of the residents with regular diets had swallowing problems. Medical record review, on 09/10/09, revealed both Residents #15 and #8 received regular consistency diets and both had been identified in their comprehensive care plans as having swallowing problems. On page 3 of Resident #15's comprehensive care plan, under the problem of alteration in nutrition dated 07/08/09 through 10/01/09, found the following intervention: "Periodically monitor for swallowing difficulty (coughing, red face, wet voice) report any problems to the nurse." On page 8 of Resident #8's comprehensive care plan, under the problem of alteration in nutrition dated 08/19/09 through 11/19/09, found the following intervention: "Periodically monitor for swallowing difficulty (coughing, red face, wet voice) report any problems to the nurse." On the afternoon of 09/10/09, the director of nursing (DON - Employee #80), when questioned regarding any form of communication which identified for the nursing assistants which residents who received regular consistency diets also had swallowing problems, related there was no such communication. The DON further related Employee #1 had been with the facility for several years, and Resident #15 had previously choked in the activity / dining room during a meal. .