Every finding on record at Meadows of Corsicana, LLC

Based on observation, interview and record review, the facility failed to establish and maintain an infection control program for 6 (Resident #56, Resident #47, Resident #51, Resident #21, Resident #35 and Resident #8) of 10 residents reviewed for infection control. 1. CNA D did not conduct hand hygiene between residents (Resident #56, Resident #47, Resident #51, Resident #21, and Resident #35) when passing hallway lunch trays. 2. CNA E did not conduct hand hygiene and glove change when performing peri-care when going from front to back and pulled adult wipes from the package with soiled gloves when providing peri-care for Resident #8. These failures could place the residents at risk of transmission of disease and infection and re-hospitalization. Findings included: Observation on 09/30/25 at 12:16 PM of hallway lunch tray pass with CNA D, said she did not conduct hand hygiene when passing a lunch tray to Resident #47's room. CNA D then took a lunch tray to Resident #56's room, and no hand hygiene was conducted. She did not conduct hand hygiene from Resident #56's room, and took a tray to Resident #51, who had signage on the door for enhanced barrier precautions. She did not conduct hand hygiene from Resident #51's room and took a tray to Resident #21's room. She did not conduct hand hygiene from Resident #21's room and took a tray to Resident #35's room. She did not conduct hand hygiene after coming from Resident #35's room and took a lunch tray into Resident #8's room. An interview on 09/30/25 at 12:23 PM with CNA D said she had forgotten to use hand hygiene between each resident when she passed meal trays. She stated the residents could get an infection if staff did not conduct hand hygiene between residents. Observation on 10/01/2025 at 10:44 AM of peri-care (cleansing the resident of urine and feces) for Resident #8 with CNA E said she pulled the adult wipes from the package (which could lead to cross-contamination for the resident) while cleansing the peri-area. CNA E did not change gloves when going from the peri-area to the bottom and continued pulling adult wipes from the package one at a time with soiled gloves. An interview on 10/01/2025 10:59 AM with CNA E said she was trained to change gloves and conduct hand hygiene twice, before starting peri-care and after cleansing the peri-area and the bottom. CNA E stated she would do hand hygiene and glove change three times instead of two, before cleansing the peri-area, before cleansing the bottom, and before placing a clean brief. CNA E stated not changing gloves and doing hand hygiene could lead to an infection to the residents. 1. Record review of Resident #8's undated face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease ( a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.), heart failure (a long-term condition that happens when your heart does not pump blood well enough to give your body a normal supply), osteoporosis (a condition when bone strength weakens and is susceptible to fracture. It usually affects the hip, wrist, or spine), pain, urinary tract infection, hypertension (high pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms vary from person to person and generally include unexplained fatigue and headache), lack of coordination, and an old myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries). Record review of Resident #8's Care Plan, dated 09/17/25, reflected she was incontinent of bowel and bladder, and the goal was to not have skin breakdown related to incontinence through the next review The interventions included to provide incontinent care after each incontinent episode. The care plan further reflected Resident #8 had an ADL self-care performance deficit related to multiple diagnoses, and the goal was to improve the current level of function in ADLs through the review date. The interventions reflected Resident #8 required extensive assistance of one person with personal hygiene, including incontinent care. Record review of Resident #8's Quarterly MDS assessment, dated 09/03/25, revealed a BIMS score of 06, indicating a moderate to severe cognition. Further review of the MDS said Resident #8 was incontinent with bowel and bladder and required extensive assistance of one person with ADLs. Record review of CNA Orientation Skills Checklist for CNA E, dated 06/26/25, reflected that she was checked off on Infection Control, including handwashing/gloves, general guidelines, isolation, and disinfection of shower. The checklist further reflected CNA E was checked off on personal care, including peri care for male and female. An interview on 10/02/25 at 12: 48 PM with the ADM, said she worked in the facility for a year and a half. The ADM stated she was trained in infection control and completed the Nursing Home Infection Preventionist Training in October 2024. She stated all nursing home administrators were required to take this training. She stated the policy for conducting hand hygiene when providing care included anytime a staff member touched a resident or a soiled surface, they must wash and sanitize their hands. She further stated staff members should conduct hand hygiene and glove changes before and after they provided care to a resident, and cross-contamination could occur if staff did not take proper infection control precautions. An interview on 10/02/25 at 1:10 PM with the DON, said she worked in the facility since May 2025. The DON stated she was trained in infection control and completed the Nursing Home Infection Preventionist Training on 05/13/25. She stated the policy for conducting hand hygiene when providing care included staff should conduct hand washing/hand hygiene and put on gloves before providing resident care. She stated all staff members should conduct hand hygiene with hand sanitizer with each glove change unless the hands and/or gloves were visibly soiled. She stated the staff should conduct handwashing with soap and water. She stated staff should conduct hand hygiene and glove changes when providing care when coming into direct contact with a resident, when cleaning anything soiled, providing medications, treatments, gastrostomy tube care, indwelling catheter care, and anything that would be direct care to the resident. She further stated when staff members did not take the proper infection control precautions, they could spread infection from one resident to the other. Record review of Policy & Procedures for Hand Hygiene dated 12/12/24 reflected, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table: hands are visibly dirty, hands are visibly soiled with blood or other body fluids, between resident contacts, after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment, including gloves, before and after handling clean or soiled dressings, linens, etc., before handling items potentially contaminated with blood, body fluids, secretions, or excretions, when, during resident care, moving from a contaminated body site to a clean body site, and after assistance with personal body functions such as elimination, hair grooming, and smoking. 3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 6. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of Policy & Procedures for Perineal Care dated 12/16/24 reflected, Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Policy Explanation and Compliance Guidelines: 6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate.7. Set up supplies.8. Place waterproof pad underneath resident.9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. 10. Re-position the resident in supine position. Change gloves if soiled and continue with perineal care. 16. Remove gloves and discard. Perform hand hygiene.

Based on observation, interviews, and record review, the facility did not store, cook, and give out food in a safe and clean way for 1 of 1 kitchen for kitchen task.The facility failed to ensure food safety by not consistently monitoring, discarding, labeling, and storing food items in the refrigerator and storage areas.These failures could place residents at risk for food-borne illness. Findings included: In the observation on 9/30/2025 9:10AM of the initial walk through of kitchen revealed the following: -Dried egg noodles with open date 6/1/2025 and expiration date 9/1/2025-Dried ziti noodles with open date of 6/2/2025 expiration date 9/2/2025-Dried spaghetti in a plastic bag that was not sealed properly. In the walk-in refrigerator: -A personal size of pudding was fully covered in a bowl. There was no label indicating what the dish contained, the date it was prepared, or the date it should be consumed by. -A plastic storage container of leftover chicken noodle soup. The container was not labeled with its contents, date of preparation or date to be consumed by. -A box of red bell peppers with noticeable mold growth along with a red bell pepper that was cut in half and placed in an unsealable plastic bag. The bag was not labeled with contents or date it was cut nor the date it should be consumed by. -An opened and recapped bottle of partially used hot sauce was not labeled with an open or date to be consumed by no details stating it was an employee's personal bottle or if it was used to prepare food. In an interview on 10/2/2025 at 12:45 PM with DA C, she stated she worked in the facility for one year but worked in food service for a very long time. She stated it was the facility's practicing policy to label all food with the date that it was delivered. She stated any left-over prepared food items should be labeled with their contents, the date prepared and dated 72 hours after to be used by. DA C stated that, dry goods once opened, depending on the item should be labeled with the opened date and the expiration date. She reported that some items were 30 days while seasonings are good for 90 days. DA C stated no food items should be used after the expiration or use by date. She stated meals should not be prepared with visibly molded food items. DA C stated anyone and everyone who works in the dietary department is responsible for ensuring all food items that are past the use by date or molded are removed from the kitchen. She stated that if a resident was given expired food, they could get food poisoning, go to the hospital, or die. She stated if a resident was given a meal prepared with food items that were molded/spoiled they could contaminate the food and give them salmonella. In an interview on 10/2/2025 at 12:49 PM with CK B, he stated he worked in the facility's kitchen for nine months. He stated their policy was to label all prepared food items with the prepared date and three days out. He stated no food items should be used past the use by date, and no molded items should be used to prepare meals. He stated everyone was responsible for ensuring expired or spoiled food was discarded. When asked what could happen to a resident who was served expired or spoiled food, CK B stated the resident could get sick and he would not serve it. In an interview on 10/2/2025 at 12:55 PM with the DM, she stated the facility policy for labeling and storage was when items arrived for delivery they were dated. She stated that prepared foods were labeled with the prepared date, and she liked to use them by two days rather than the standard three days. The DM stated that no expired or spoiled food should be used to prepare meals for the residents. The DM stated all kitchen staff were responsible for ensuring all expired food or spoiled food items should be removed from the kitchen. The DM stated that she checked the refrigerator and the dry storage in the mornings and did a walk through before she went home each day. The DM stated if a resident was served food prepared with expired or spoiled items, they could get a food [NAME] illness. The DM stated the spoiled bell peppers should have been thrown out, she also stated the items in the refrigerator should have been labeled and she ensured they were removed. The DM stated the dried pasta labels should have been updated when the staff placed new packages inside the containers. In an interview on 10/2/2025 12:54 with the DON, she stated if a resident was given expired food or food prepared with spoiled items they could have a reaction, food poisoning, and GI upset. In an interview on 10/2/2025 1:20 PM with the Administrator, she stated she expects all dietary staff were to follow policies and procedures for labeling and storage of food items to prevent food [NAME] illness. She stated she expected the dietary staff not to use expired or spoiled food items in preparation of meals for the Residents. She stated the DM was responsible for ensuring all expired and spoiled food items were removed from the kitchen. She stated if a resident was given a meal prepared with expired or spoiled food items, they could get sick. Record review on 10/2/2025 of Policy Date Marking for Food Safety, the following guidelines are noted under Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.5, The discard day or date may not exceed the manufacturers used-by date, or four days, whichever is earliest. The date of opening or preparation counts as day one. (For example, food prepared on Tuesday shall be discarded on or by Friday.)6. The Head Cook, or designee, shall be responsible for checking the refrigerators daily for food items that are expiring, and shall be or shall discard accordingly.7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.

Based on observation, interview, and record review, the facility failed to make sure that drugs are stored properly, and only authorized persons have access for 1 of 4 medication carts (MC A) reviewed for drug storage and labeling. The facility failed to ensure the F-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:Observation of F-hall on 09/30/2025 at 9:05 a.m., revealed MC A was unattended and unlocked. LVN A was in room F50. The medication cart was partially in front of room F50. The locking mechanism was protruding outward on the medication cart. The state surveyor opened drawers and captured pictures. LVN A was in the room with a resident with the privacy curtain pulled closed. During an interview on 09/30/2025 at 9:10am, LVN A stated she was trained on medication storage. She said the policy was to make sure the narcotics were locked, and the medication cart was locked. She said the medication cart should be locked every time the medication cart was out of sight of the nurse. She said if a medication cart was left unlocked and unattended then other residents could get into the medication cart and take pills that do not belong to them. She said she forgot to lock the medication cart and lock the computer screen. During an interview on 10/02/2025 at 11:01a.m., the DON stated she and staff were trained on medication storage. She said the policy for the medication cart was the medication cart was to be always locked when staff were not actively handing out medication. She said the nurse or MA who was working out of the cart was responsible for ensuring the cart was locked when not in eyesight or in use. She said if the medication cart was left unattended and unlocked, a resident could take medications that were not theirs. She also said a resident could get ahold of medication to which he/she was allergic. She said the ADM and DON monitored to ensure the medication carts were locked. She said the ADM and DON monitored through observation rounds. She said she did not know why LVN A left her medication cart unlocked and unattended. During an interview on 10/02/2025 at 11:12a.m., the ADM stated she and staff were trained on medication storage. She said the policy for the medication cart was that the medication cart was to be locked any time the nurse or MA was away from the cart. She said the nurse who was working on the cart was responsible for ensuring the cart was locked. She said if the medication cart was left unattended and unlocked, it could cause a potential hazard for the residents. She said that the ADM and DON monitored to ensure the medication carts were locked. She said the ADM and DON monitored through daily rounds and audits. She said she did not know why LVN A left her medication cart unlocked and unattended. Record review of Medication Storage Policy, dated 12/16/2024, revealed: General Guidelines:A. All biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.B. Only authorized personnel will have access to the keys to locked compartments.C. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility failed to ensure expired milk in the walk-in refrigerator was discarded in a timely manner. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: In an observation on [DATE] at 10:02 AM, revealed one-gallon of milk that was half-filled had best-by date of [DATE] in the facility's walk- in refrigerator. In an interview with the Dietary Manager on [DATE] at 10:06 AM, revealed she conducted morning walk-in rounds every Monday to check for expired products since new inventory was delivered every Tuesday. She further added she had forgotten to conduct her morning rounds on Monday, [DATE]. She stated that the use-by date on the milk gallon was [DATE] and the milk should have been discarded within three days of use-by date per the facility policy. She also stated that she was not aware if the expired gallon of milk was served to the residents and added she will discard the gallon of milk immediately after the interview. She said the facility utilizes use by date on dairy products to determine their shelf-life. She stated risk to residents if served expired food product was increased chances of food borne illness. In an interview with [NAME] A on [DATE] at 12:55 PM, revealed he was working as a cook in the facility for one year. He stated that Cooks, Dietary aides, and the Dietary Manager were responsible for ensuring expired food items were discarded. He stated that, as a cook, he always checked the expiry date on the foods before using the food item. He stated if he had seen the expired gallon of milk in the walk-in refrigerator, he would have promptly thrown it away. He said the risk of using or serving expired food or dairy items could make the residents sick. Record review of the facility policy titled Refrigerators, Coolers and Freezers dated [DATE], reflected, 2. Dispose of all outdated [NAME] and discard all leftover items greater than 72 hours old . Review of FDA food code dated 2022 reflected, . (K) Disposition of Expired Product at Retail .Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner .

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #18) of 6 residents reviewed for quality of life. The facility failed to ensure Resident #18 had her fingernails and facial hair trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #18's Quarterly MDS assessment dated [DATE] reflected Resident #18 was an [AGE] year-old female with initial admitted to the facility on [DATE]. Resident #18's relevant diagnoses included Anemia, Hypertension, Renal insufficiency, hyperlipidemia, anxiety disorder, senile degradation of brain, severe stage bilateral Glaucoma. Resident #18 needed substantial assistance for bathing and needed setup assistance with ADLs. Resident #18 had BIMS of 7, which indicated severe cognitive impairment. Review of Resident #18's Comprehensive Care Plan revised on 10/27/2023 reflected, problem: [Resident #18] has an ADL self-care performance deficit related to disease processes - Glaucoma, cataract, hyperlipidemia, Hypertension, Anemia, Osteoporosis,& senile degeneration of the brain. Goal: Resident will maintain grooming hygiene with verbal cues. Resident will maintain/improve upper extremity/lower extremity dressing with modified independence. The resident will maintain current level of function with all ADL's and self-care with as much independence as possible through the review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. BATHING/SHOWERING: The resident requires physical help limited to transfer assistance by 1 staff with showering scheduled three times weekly and as necessary. BED MOBILITY: The resident is able to move to and from lying position, turn herself in the bed, with the supervision and set up help of one staff member. DRESSING: Allow sufficient time for dressing and undressing. DRESSING: The resident requires set up help with the supervision of one staff member to dress. EATING: The resident requires set up assistance and supervision of one staff member to eat. PERSONAL HYGIENE: The resident requires limited assistance of one staff member to assist with personal hygiene and oral care. TRANSFER: The resident is able to transfer with set up help and supervision of one staff member. In an observation and interview on 8/26/24 at 11:33 AM, with Resident #18 revealed she had 0.5-0.75 inch of facial hair on her chin. Resident #18s fingernails were at least 1-1.25 inches in length and were chipped. Resident #18 stated that she would like her fingernails to be clipped and did not preferred long nails. She also stated that she did not have a razor to trim her facial hair and added that she could not see very well to take care of the facial hair. She stated that the nursing staff did not offer to trim nails or shave her facial hair. In an interview on 8/26/24 at 1:33 PM, LVN D stated that both CNAs and LVNs were responsible for providing ADLs that included nailcare and facial trimming. He stated if a resident had diagnoses of diabetes (high blood glucose), only nurses were allowed to trim resident's nails. He stated that nailcare and facial hair trimming should be done on shower days and as needed. He stated that he had not had a chance to visit with Residnet#18 at the time of interview and will check on her. He stated that the risk for not performing nailcare was increased risk of infection as well as skin break down and risk of not shaving facial hair could lead to dignity concerns. In another interview on 08/26/24 at 03:37 PM, LVN D stated that he clipped Resident #18's fingernails and shaved facial hair on her chin He stated that it may have been overlooked by the nursing staff who worked on Friday 8/23/24 since Resident #18 was Monday-Wednesday-Friday bath schedule. In an interview on 8/27/24 at 11:08 AM, CNA B stated that she worked the morning shift across multiple halls. She stated she was aware of Resident #18's ADL needs. She stated both CNAs and LVNs were responsible for providing ADL care to the resident. She stated the risk for not performing nailcare can lead to skin breakdowns and not shaving facial hair can lead to dignity concerns. In an interview on 08/27/24 at 03:24 PM, the ADON stated that she has worked since in the facility since last 6 months. She stated that her expectation was that nursing staff should be providing ADL care to residents on shower days and as needed. She stated that both CNAs and LVNs were responsible for providing nail care and shaving facial hair. She stated as the ADON of the facility , she conducted daily rounds on all residents to ensure ADLS were carried out. She said risk to residents for not performing nail care was skin tears and infection . She added risk to residents for not shaving facial hair especially in female resident was loss of dignity. In an interview on 08/28/24 at 09:20 AM, the DON stated she had started working in the facility as the DON about a week ago and was getting to know the residents. She stated her expectation was ADLs such as nail care and hair trimming were offered to residents on shower days and as needed. She stated both CNAs and LVNs were responsible for providing ADL care. As the DON in the facility, she planned to round the residents daily to ensure resident's ADL needs were met adequately. She stated that long, chipped nails could lead to wounds, skin tears and possibly infection She stated that risk to residents with not trimming facial hair could lead to dignity concerns. Record Review of the facility policy titled Activities of Daily Living (ADLs) dated 5/26/2023 reflected, Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; 3.Toileting; 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene

Based on observation, interview and record review, the facility failed to 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 for one (Resident #42) of six residents observed for infection control. CNA B failed to perform hand hygiene between glove changes, and when she went from dirty to clean during incontinence care for Resident #42. These failures placed residents at risk for spread of infection through cross-contamination. Findings included: Record review of Resident #42's face sheet dated 08/27/2024 reflected she was [AGE] years old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. She was admitted with the diagnoses of diabetes mellitus, hypertension (high blood pressure), morbid obesity. Review of Resident#42's MDS assessment dated [DATE] reflected Resident#42 had an intact cognition with a BIMS score of 15. The review further reflected the resident was totally dependent on staff for toileting hygiene and shower/bathing. Review of Resident #42's Care Plan initiated 08/12/2024 reflected the resident was incontinent of bowel and bladder. Resident#42 had an ADL (activity of daily living) self-care performance deficit related to physical limitation and the intervention was for the resident to be assisted by staff for incontinent care. Observation 08/26/2024 at 09:56 AM revealed CNA B entered Resident # 42's room and told the resident she was here to get her up off the bedside commode and clean her buttocks area. CNA B helped Resident#42 to a standing position with Resident#42 using a four wheels walker, cleaned Resident#42's buttocks area using one wipe per stroke. CNA B helped Resident#42 to sit down on her wheelchair. CNA B removed her gloves and proceeded to gather Resident#42's clean gown, clean brief, and socks without any form of hand hygiene. CNA B took Resident#42 to the shower room and got Resident#42's shampoo and body wash from a sack in the shower room. CNA B pulled gloves from her pocket, put them on and proceeded to shower Resident#42. After showering Resident #42, CNA B helped her put on her clothes. CNA B changed gloves without any form of hand hygiene. CNA B took the resident back to her room. CNA B removed her gloves and washed her hands before exiting the room. Interview with CNA B on 08/26/24 at 10:29 AM revealed she was supposed to perform hand hygiene after removing gloves, and before getting Resident#42's bathing supplies for shower. She stated had hand sanitizer in her pocket to use every time she changed gloves and forgot to use it. She stated she had training on hand hygiene, and that she was supposed to wash hands for 20 seconds before entering resident's room and after contact with resident. CNA B stated she was to perform hand hygiene between changing gloves. She stated the risk to residents' was developing infection. CNA B stated she had been in serviced on hand hygiene not long ago by performing hand hygiene in front of the ADON. Interview with the ADON on 08/27/2024 at 2:22 PM revealed she expected staff to wash hands before entering resident's room, and after contact with resident. She stated staff was supposed to perform hand hygiene every time they removed gloves, and before putting on clean gloves. She further stated staff were trained to change gloves with hand hygiene when they went from dirty to clean task, and after care was completed. The ADON stated it was her responsibility to make sure staff were following proper hand hygiene during residents' care. She stated the risk to residents' was developing infection. Review of the facility's policy titled Hand Hygiene revised October 12, 2022, reflected, . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for one (Resident #3) of six residents observed for physician orders for oxygen. The facility failed to provide physician orders for Resident #3, while resident was on oxygen 2 liters via nasal cannula. These failures could place the residents at risk of not receiving necessary care and services that could result to worsen condition. Findings included: Review of Resident #3's Face Sheet dated 08/27/2024 reflected that resident was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Relevant diagnoses included pleural effusion (fluid accumulation around the lungs), muscle weakness, dyspnea (the sensation of difficult or uncomfortable breathing), and hypertension (elevated blood pressure). Review of Resident #3's MDS assessment dated [DATE] reflected that Resident #3 had an intact cognition with a BIMS score of 15. Review of Resident #3's Comprehensive Care Plan dated 08/11/2024 reflected no documentation of Resident#3 oxygen therapy use. Review of Resident #3's Physician's Order on 08/10/2024 reflected no physician orders for continuous and/or as needed oxygen supplement. Review revealed no physician order for when to change the cannula and oxygen tubing. Review of Resident #3's Physician's Order on 08/10/2024 reflected no physician orders to keep the oxygen cannula and tubing in a bag when not in use. Review revealed no physician orders for when to change the humidifier. Review of Resident #3's Physician's Order on 08/10/2024 reflected no physician's order to wash filters from oxygen concentrator. Review revealed no physician order for what to assess, like redness to nares (openings of the nose where the prongs of the cannula are inserted). Observation on 08/26/2024 at 02:27 PM, revealed that Resident #3 was sitting at the edge of the bed, receiving oxygen supplement via nasal cannula. It was also observed that Resident #3 had an oxygen concentrator at the side of the bed. The oxygen concentrator was on with the setting of 2 liter/minute. Resident #3 confirmed that she used oxygen whenever she had breathing difficulty since her admission to the facility two weeks ago. Interview and observation with LVN E on 08/26/2024 at 02:33 PM, she stated she did not know resident was on oxygen or supposed to have oxygen. LVN E went to Resident #3's room to make sure she was using oxygen supplement therapy. LVN B started to search her computer and then stated that she could not find the order for oxygen. LVN B acknowledged that the order for oxygen supplement for Resident #3 was not on the eMAR (electronic medication administration record). LVN B said that it was important to have a physician's order to know what to do, what to assess, and what was the treatment plan. LVN B added that this would put the resident at risk of not having the medications, treatments, and services they needed. She further stated the nurse admitting resident was responsible in transcribing the physician orders upon resident's admission, and the nurse caring for the resident should review the admission order against the order in the residents' electronic system. Interview with the DON on 08/28/2024 at 9:30 AM, the DON stated there should be physician orders on everything done for the resident. The DON said that physician orders served as verification that the resident was assessed, the medical issues were addressed, and the needed treatments or medications were ordered. The DON further added that without those orders, the staff would not know the needed care and the needed treatment. The DON said that the charge nurse is the one responsible in transcribing the physician orders upon admission or when there was a new order from the physician. The DON said that the expectation is for the staff to ensure that physician orders are transcribed to residents' electronic system during admission. The DON concluded, she was new to the facility, been here for one week, and stated moving forward, she will be checking residents' electronic chart to make sure their orders had been transcribed completely during admission process.

Based on interview and record review the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent misappropriation of property when Housekeeper A charged Resident #1 $10 for gas to purchase items from the store. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents. Findings include: Review of Resident #1's face sheet dated 09/22/23, documented a [AGE] year-old female admitted to the facility 04/12/23 with diagnoses that included chronic obstructive pulmonary disease (a chronic lung disease that causes obstructed airflow from the lungs), muscle wasting and atrophy (loss of muscle tissue), type 2 diabetes mellitus without complications, hypertensive heart disease with heart failure (systolic or diastolic heart failure, conduction arrhythmias, especially atrial fibrillation, and increase risk of coronary artery disease), and schizophrenia unspecified (mental illness that affects how a person thinks, feels, and behaves). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 10 indicating moderately impaired cognition. The quarterly MDS also revealed Resident #1 required extensive assistance in various areas of activities of daily living such as bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, and eating. Record Review of discharged resident, dated 09/21/23, revealed Resident #1 was discharged on [DATE]. Attempted interview with Resident #1 without success due to Resident #1 being discharged on [DATE]. Record review of a written interview with AD dated 09/12/23, revealed AD stated at approximately 1:00pm Housekeeper #2 notified me that Housekeeper A has been taking residents debit care and making shopping visits. Housekeeper #2 also stated Housekeeper A takes gas money resident in exchange for services. I confirmed the information with the resident to see if the statement was true. Resident #1 confirmed all details were true upon interactions. Record review of a written interview with Housekeeper A dated 09/12/23 at 1:50pm, revealed Housekeeper A stated Resident #1 asked me to go the store for her last week on 09/08/23 to purchase a 12 pack of big red and she gave me her direct express cared, and she gave me her pin # I bought this and brought the receipt back to her. The other time she asked me to buy Dr. Pepper (12 pack) and a pair of tights. Brought back the receipt as well to her. Interview with Resident #1's responsible party on 09/22/23 at 9:30am, revealed Resident #1's RP was notified of the incident. RP stated Resident #1 was at home and doing fine. RP stated that the facility stated they are going to reimburse Resident #1's $10 that the Housekeeper charged her for gas money. An interview with ADM on 09/21/23 at 4:00pm, revealed ADM stated that Housekeeper A went to pick up some items for Resident #1 without authorization on two occasions. ADM stated when she questioned Housekeeper A about the incident, she admitted to going shopping for the Resident #1 on two different occasions and charging Resident #1 $5 for gas for each trip. ADM stated that Housekeeper A was terminated as a result of exploiting Resident #1 and the facility is in the process of reimbursing Resident #1's $10. ADM stated the facility in- serviced staff on reporting abuse, neglect, and exploitation. The facility immediately had an emergency resident council meeting in order to ensure that the residents are aware of who can shop for them and who cannot. Resident were educated on being exploited. The facility did an exploitation safe survey on the residents in the facility. ADM also stated that the local police department was notified of the incident ADM stated if the situation was not identified then there could have been further exploitation of the residents at the facility. Record review of the facility's Abuse, Neglect and Exploitation Policy, dated 12/2017 revealed Our residents have the right to be free abuse/neglect/misappropriation of resident property/ corporal punishment and involuntary seclusion. Abuse Prevention Our facility is committed to protecting our residents from abuse by anyone including/but not necessarily limited to: employees/other residents/consultants/volunteers/and staff from other agencies providing services to our residents/family members/legal guardians/surrogates/residents responsible parties/friends/visitors, or any other individuals. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse/neglect/mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern/as a minimum: e. The development of investigative protocols governing alleged residents' abuse/theft/misappropriation of resident property and resident-to-resident abuse

Based on interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for enteral nutrition (Resident #2). LVN A failed to follow the physician orders for enteral feedings on 09/07/23 at 6:00pm (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) for Resident #2. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #2 face sheet dated 09/21/23, documented a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), cognitive communication deficit (difficulty with thinking and communicating) , dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), peptic ulcer site (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), chronic kidney disease (when your kidneys are damaged and can't filter blood the way they should), anxiety disorder (excessive nervousness, fear, apprehension and worry), enterocolitis due to clostridium difficile and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration). Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed the resident had a BIMS score of 99 indicting the resident was unable to complete the interview. The quarterly MDS also revealed Resident #2 required total dependence in various areas of activities of daily living such as transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #2's physician order dated 08/21/23 indicated Resident #2 had an order for Glucerna 1.5 cal oral liquid (nutritional supplements) Give 360 ml via peg tube every 6 hours (12:00am, 6:00am, 12:00pm and 6:00pm) for diabetes with a start dated of 08/03/23. Resident #2's order for feedings every 6 hours indicates Resident #2 is receiving continuous feedings. Record review of Resident #2's care plan dated 08/08/23 indicated Resident #2 requires tube feeding related to dysphagia. The care plan interventions include Glucerna 1.5 cal oral liquid (nutritional supplements) Give 360 ml via peg tube every 6 hours for diabetes. Attempted numerous times to contact LVN A for an Interview. No answer but voicemails were left. An interview with ADON on 09/21/23 at 11:10 am, ADON stated she observed Resident #2's Glucerna bottle had the same amount from the previous feeding. ADON stated on 09/07/23 at 8:54pm she notified the administrator that Resident #2 had a documented feeding of Glucerna enteral feeding, but the amount left in the Glucerna bottle had not changed since the prior feeding. ADON stated that LVN A, documented that she had administered the enteral feeding at 5:15pm, but the Glucerna amount was still at the permanent line marked earlier in the day (to document the ounces left since the last/prior feeding). The Glucerna container amount had not changed from the previous feeding, suggesting that the 5:15pm feeding had not actually been given to Resident #2. ADON stated LVN A was suspended pending investigation on 09/07/23 at 9:40pm. The patient did not have any adverse effects from the missed feeding. An order was obtained for an immediate feeding, and family and physician were notified. ADON stated that feeding was given 2 hours and 25 minutes outside of the residents feeding window. ADON stated she spoke with LVN A and LVN A stated she clicked the feeding button but without feeding the Resident #2. ADON stated she contacted the MD for an order for a one time dose of Glucerna 1.5 admin 180 mL via PEG tube. MD requested that resident blood sugars be monitored during the night. Resident FSBS was checked at 12:00am as ordered and was checked again at 3:00am. Resident received feeding and family was notified. ADON stated Resident #2 could develop wounds from lack of nutrition, dehydration, weight loss, and resident would feel hungry if feedings were missed. ADON stated Resident #2 cannot verbalize her wants or needs. An interview with ADM on 09/21/23 at 4:00pm, ADM stated that she was notified by the ADON of the missed feeding for Resident #2. ADM stated that LVN A was suspended on the day of the incident and terminated on 09/14/23. ADM stated that Resident #2 is the only resident that receives tube feeding. ADM stated the facility notified Resident #2's family, physician, and dietician of the incident. ADM stated that Resident #2 had no adverse effects from the missed feeding but the nurses should always follow the physician orders. ADM stated that Resident #2 could have been hungry, dehydrated, or had weight loss if the physician orders are not followed. ADM stated the facility referred to [NAME] Nursing Procedures for instructions on how provide care for tube feedings. Tube Feedings Gastric enteral feeding involves delivery of a liquid feeding formula directly to the stomach via an enteral tube. Its typically indicated for patients who can't eat normally because of dysphagia or oral esophageal obstruction or injury. Gastric feedings also may be given to unconscious or intubated patients or to those recovering from GI tract surgery who can't ingest food orally. Implementation Verify the practitioner's order including the patient's identifiers, prescribed route based on the enteral tube's rep location, enteral feeding device, prescribed enteral formula, administration method, volume and rate of administration, and type, volume, and frequency of water flushes.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Dented can good were removed from the shelve. 3. Sanitation bucket included the correct sanitation. 4. The ice machine was clean and free from debris. These failures could place residents at risk for cross contamination and foodborne illness. Findings included: During an observation of the kitchen freezer on 06/26/2023 starting at 8:09 a.m. revealed a half bag of chocolate chip cookies unlabeled and undated, and a half bag of French fries undated and unlabeled. During an observation and interview with the Dietary Manager of the kitchen walk in refrigerator on 06/26/2023 at 8:10 a.m. revealed a large plastic container with a brown liquid substance that was identified by the dietary manager as cooking grease unlabeled and undated. During an observation on 06/26/2023 at 8:12 a.m., Dietary Aide E placed a small capful of bleach in a green bucket. During an observation on 06/26/2023 at 8:20 a.m. located in the dry storage room revealed (3) 50 oz dented chicken noodle soup cans noted on the shelf with stock items to be used. During an observation on 06/26/2023 at 8:25 a.m., revealed an ice machine with a brown residue on the interior part of the machine. The ice scoop holder had a green/black thick mold like substance with a chalk crystalized white powder dried to the insides on all four sides of the scoop holder. During an interview on 06/28/2023 at 9:57 a.m., Dietary Aide E stated all staff were responsible for labeling and dating. Dietary Aide E stated whoever puts up the groceries was responsible for ensuring dented cans are not left on the shelf. Dietary Aide E stated all staff were responsible for making sure the ice machine was cleaned. Dietary Aide E stated she was not aware until surveyor intervention bleach should not be used in the sanitation bucket or in the kitchen. Dietary Aide E stated the sanitizer from the 3-compartment sink should be used instead of the bleach to clean the workstation, prep, and common areas. Dietary Aide E stated these failures could put residents at risk for food borne illness and cross contamination. During an interview on 06/28/2023 at 12:55 p.m., Cook D stated all staff were responsible for labeling, dating, and cleaning the ice machine. Cook D stated the ice machine should be cleaned daily and as needed. Cook D stated the primary person who received the delivery of food was responsible for checking for dented cans. Cook D stated she was not aware until surveyor intervention bleach should not be used at all in the kitchen. Cook D stated these failures could potentially put residents at risk for food borne illness and cross contamination. During an interview on 06/28/2023 at 1:10 p.m., the Food Service Supervisor stated due to the facility not having a dietary manager since 06/26/2023 she was here until further notice to provide assistance to the dietary staff to ensure they have the policy and procedures to follow. The Food Service Supervisor stated the Dietary Manager was responsible for making sure the kitchen was cleaned appropriately. The Food Service Supervisor stated all food should be labeled and dated with the date it was received, expiration date and the date it was opened. The Food Service Supervisor stated the entire staff was responsible for labeling/dating. The Food Service Supervisor stated the primary person who received the delivery was responsible for checking for dented cans. The Food Service Supervisor stated bleach should never be used in the kitchen. The Food Service Supervisor stated the staff should clean the workstation, prep areas and common areas with soap and water first and then used the sanitizer from the 3 compartments sink to follow. The Food Service Supervisor stated the dietary staff were responsible for cleaning the ice machine daily and as needed. The Food Service Supervisor stated these failures could potentially put residents at risk for food borne illness and cross contamination. Record review of the Ice Machine policy, dated 10/01/2018, indicated .the facility will maintain the ice machine, scoop, and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day Record review of the Food Deliveries policy, dated 10/01/2018, indicated . 2c. All cans must be in good condition and not dented. Record review of the Food Storage policy, last revised on 06/01/2019, indicated 1g. Use the first-in, first out rotation method. Date packages and place new items behind existing supplies, so that the older items are used first Record review of the General Kitchen Sanitation policy, dated 10/01/2018, indicated .the facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness . 9. Clean and rinse immediately prior to use, moist cloths used for wiping food spills on kitchenware and food-contact surfaces of equipment. Clean frequently during use in a sanitizing solution and do not use for any other purpose. When not in use, hold in a sanitizing solution of the proper concentration. 10. Clean and rinse in a sanitizing solution, moist cloths used for cleaning non-food-contact surfaces of equipment such as counters, dining tabletops and shelves and do not use for any other purpose.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 5 halls, 1 of 1 dining room, 1 of 1 kitchen, and 2 of 13 (Resident #23 and Resident #27) residents reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 06/30/2023, indicated Resident #23 was an [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and transient cerebral ischemic attack (temporary blockage of blood flow to the brain). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #23 was usually able to make self-understood and sometimes understood others. The MDS assessment indicated Resident #23 had a BIMS score of 3, which indicated he had severe cognitive impairment. The MDS assessment indicated Resident #23 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident #23's care plan with date initiated 11/23/2022 did not indicate to provide an environment free of pests. 2. Record review of a face sheet dated 03/09/2023 indicated, Resident #27 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and intellectual disabilities (a condition that develops in childhood and affects your capacity to learn and retain new information, and it also affects everyday behavior). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #27 rarely/never understood others and sometimes made herself understood. The MDS assessment indicated Resident #27 had a short-term and long-term memory problem. The MDS assessment indicated Resident #27's cognitive skills were severely impaired. The MDS assessment indicated Resident #27 required extensive assistance with transferring, dressing and personal hygiene. Record review of Resident #27's care plan last revised 06/11/2023 did not indicate to provide an environment free of pests. During an observation on 06/26/2023 at 8:09 AM, multiple flies were observed in the kitchen. During an observation on 06/26/2023 at 8:16 AM, Resident #23 had a fly swatter in his room. Resident #23 had multiple flies in his room. Resident #23 was non-interviewable. During an observation on 06/26/2023 at 10:58 AM, Resident #27 had multiple flies in her room. Resident #27 was in bed and the flies were crawling on both of her legs. Resident #27 was non-interviewable. During an observation of the lunch meal on 06/26/3023 at 11:50 AM, multiple flies observed in the dining area while the residents were eating their meals. During an observation of the breakfast meal on 06/27/2023 at 7:55 AM, observed several residents and staff swatting away multiple flies with their hands in the dining room area. During an observation on 06/27/2023 at 9:02 AM, multiple flies observed down Hall A. Resident #27 had multiple flies in her room, and she kept swatting them away from her ears. During an observation on 06/27/2023 at 11:30 AM, Cook D was swatting away multiple flies in the kitchen while doing food temperatures. During an observation on 06/28/2023 at 10:41 AM, multiple flies observed down Hall A and in Resident #23's and Resident #27's rooms. During an interview on 06/28/2023 at 11:10 AM, the Maintenance Director said he had not notified the exterminator to see if he could do something about the excess flies because it had not been reported to him. The Maintenance Director said all the staff were responsible for making sure there was a clean, safe environment for everyone. The Maintenance Director said it was important to keep the environment free of pests, including flies, because it was their home and it needed to be clean and for a safe environment. During an interview on 06/28/2023 at 3:20 PM, the DON said she had noticed the flies in the halls, dining area, and Resident #23 and Resident #27's rooms. The DON said the Maintenance Director was responsible for notifying the pest control company. The DON said it was important to prevent the residents from getting bites and infections could be spread from the flies. The DON said the residents could ingest the flies, and the flies could aggravate the residents. During an interview on 06/28/2023 at 4:26 PM, LVN A said she had noticed the flies in A hall and in Resident #23's and Resident #27's rooms. LVN A said she had let multiple office management staff know and they said they would all pest control. LVN A said it was important to have an environment free of flies because the flies could lay eggs on the residents and cause infection, and it was unsanitary to have flies in the facility. During an interview on 06/28/2023 at 4:56 PM, the Administrator said she had noticed the flies in the facility. The Administrator said the Maintenance Director was responsible for the facility being free of pests. The Administrator said it was important to have an environment free of pests because they could get on the food and harbor infection. The Administrator said the pests could affect the residents' dignity. Record review of the service reports indicated visits on: 01/20/2023- Fly Program insect light trap maintenance 02/03/2023- Fly Program insect light trap maintenance 03/01/2023- Fly Program insect light trap maintenance 04/30/2023- no indication of treatment for flies 05/22/2023- Fly Program insect light trap maintenance 06/26/2023- Fly Program insect light trap maintenance. Record review of the facility's undated policy titled, Pest Program Specifications, did not address maintaining an effective pest control program.

Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 3 of 17 rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed for environment. The facility failed to repair deep scratches that exposed the sheetrock on the wall behind the head of the bed in room [ROOM NUMBER]. The facility failed to repair crater-like damage on the wall by the recliner in room [ROOM NUMBER]. The facility failed to repair multiple dark reddish stains were on the wall above the bed in room [ROOM NUMBER]. These failures could place the residents at risk for a diminished quality of life and a diminished clean well-kept environment. Findings included: 1. During an observation on 06/26/2023 at 8:03 AM, Resident #28 was in her bed, in room [ROOM NUMBER], an observation was made of deep scratches that exposed the sheetrock on the wall behind Resident #28's head of the bed. Resident #28 said she was unable to see the deep scratches because she was blind. During an observation on 06/27/2023 at 8:58 AM, room [ROOM NUMBER] had deep scratches that exposed the sheetrock on the wall behind the head of the bed. During an observation on 06/28/2023 at 8:10 AM, room [ROOM NUMBER] had deep scratches that exposed the sheetrock on the wall behind the head of the bed. 2. During an observation and interview on 06/26/2023 at 9:12 AM, Resident #32 was in her room, room [ROOM NUMBER], an observation was made a crater-like area of damage to the wall by her recliner measuring approximately 5 inches long and 4 inches wide. Resident #32 said the crater-like damage to the wall had been there since she moved in the room, but at one point it was covered by furniture. Resident #32 said she had told the CNAs it needed to be fixed. Resident #32 said she did not like her wall being damaged. During an observation on 06/27/2023 at 9:42 AM, room [ROOM NUMBER] had crater-like damage to the wall by the recliner. During an observation on 06/28/2023 at 9:50 AM, room [ROOM NUMBER] had crater-like damage to the wall by the recliner. 3. During an observation on 06/26/2023 at 10:58 AM, Resident #27 was in her room, room [ROOM NUMBER], multiple dark reddish stains were on the wall above her bed. Resident #27 was non-interviewable. During an observation on 06/27/2023 at 9:02 AM, room [ROOM NUMBER] had multiple dark reddish stains on the wall above her bed. During an observation on 06/28/2023 at 9:55 AM, room [ROOM NUMBER] had multiple dark reddish stains on the wall above her bed. During an interview on 06/28/2023 at 11:02 AM, the Environmental Supervisor said he was aware of the red stains on the wall in room [ROOM NUMBER], and he verbally told the Maintenance Director he would have to fix it because the housekeeping staff were not able to clean it off the wall. The Environmental Supervisor said the Maintenance Director was responsible for fixing damages to the wall. The Environmental Supervisor said it was important for the walls to be clean and free of damage because the facility was the residents' home, and they should have a clean environment. During an interview on 06/28/2023 11:10 AM, the Maintenance Director said to his knowledge nobody had told him about deep scratches that exposed the sheetrock on the wall behind the head of the bed in room [ROOM NUMBER], the crater-like damage to the wall in room [ROOM NUMBER], and the dark reddish stains on the wall in room [ROOM NUMBER]. The Maintenance Director said he did not make rounds of the residents' rooms to check for any damages. The Maintenance Director said the staff should be putting in a work order online for him to repair any damages. The Maintenance Director said it was important for the rooms to be free of damage for esthetics for the residents, and so the residents would not breathe in the powder from the sheet rock. During an interview on 06/28/2023 at 3:14 PM, the DON said she had seen the deep scratches on the wall in room [ROOM NUMBER], but the Maintenance Director was responsible for addressing it. The DON said she was not aware of the crater-like damage to the wall in room [ROOM NUMBER] and she was not aware of the dark reddish stains on the wall in room [ROOM NUMBER]. The DON said anybody that noticed there was a repair needed, should be putting in a work order for the Maintenance Director to address it. The DON said it was important for repairs to be made to the rooms because of the appearance of the room, and for the residents to feel good about their rooms. The DON said the damages to the walls could make the residents feel embarrassed and it could cause dignity issues. During an interview on 06/28/2023 at 4:25 PM, LVN A said she had noticed the deep scratches in room [ROOM NUMBER], and she had told the Maintenance Director verbally that it needed repair. LVN A said she was not aware of the damages in room [ROOM NUMBER] and room [ROOM NUMBER]. LVN A said it was important for repairs to be done to the rooms because the residents should be able to feel at home and comfortable. During an interview on 06/28/2023 at 4:51 PM, the Administrator said it had not been brought to her attention that room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] required repairs. The Administrator said the Maintenance Director was responsible for ensuring all repairs were done to the rooms, and she expected him to do this. The Administrator said it was important for the residents' rooms to not have any damages for their dignity. Record review of the work order report dated 03/23/2023 - 06/24/2023 indicated a work order to patch, texture, and paint walls in room [ROOM NUMBER]. The work orders did not specify the dates. There were no work orders indicated for room [ROOM NUMBER] and room [ROOM NUMBER]. Record review of the facility's document, titled, Nursing Facility Residents' Rights, dated November 2021, indicated, . Dignity and Respect You have the right to: Live in safe, decent and clean conditions .

43047 Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 9 residents (Residents #37, #11 and #28) reviewed for PASRR. The facility failed to ensure Residents #37, #11 and #28's PASRR Level 1 screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: 1. Record review of Resident #37's face sheet, dated 06/28/2023, indicated Resident #37 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnoses which included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified mood disorder, and auditory/visual hallucinations (perception of hearing and seeing something that was not actually there). Record review of Resident #37's admission MDS, dated [DATE], indicated Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/pr intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #37 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #37 was severely cognitively impaired with a BIMS score of 5. Record review of Resident #37's care plan, with an initiated date of 09/02/2022, indicated Resident #37 used antipsychotic medications related to schizophrenia. The care plan interventions included monitors behaviors, observe for adverse side effects of medications, and keep environment free of clutter and safety hazards. Record review of Resident #37's PASRR Level 1 Screening, completed on 09/02/2022, indicated, in section C0100, no evidence of this individual having mental illness. 2. Record review of Resident #11's face sheet, dated 06/28/2023, indicated Resident #11 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnoses which included Schizoaffective Disorder (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified mood disorder, and auditory/visual hallucinations (perception of hearing and seeing something that was not actually there) with periods of increased energy and decreased need for sleep over several days). Record review of Resident #11's comprehensive MDS, dated [DATE], indicated Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/pr intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #11 sometimes understood others and sometimes made himself understood. The assessment indicated Resident #11 was moderately cognitively impaired with a BIMS score of 9. Record review of Resident #11's care plan, with an initiated date of 07/06/2022, indicated Resident #11 used antipsychotic medications related to schizophrenia. The care plan interventions included monitors behaviors, observe for adverse side effects of medications, and keep environment free of clutter and safety hazards. Record review of Resident #11's PASRR Level 1 Screening, completed on 10/26/2021, indicated, in section C0100, no evidence of this individual having mental illness. During an interview on 06/28/2023 at 1:44 p.m., the MDS coordinator stated she was responsible for ensuring the PASRR Level 1 was completed accurately for Resident #37 and #11. The MDS Coordinator stated she was unaware she should submit a PL1 correction, if the referring entity incorrectly completed the PL1, so the resident could be evaluated for PASRR services. The MDS Coordinator stated after reviewing Resident #37 and #11 medical records and saw they had a diagnosis which included mental illness a new PASRR Level 1 Screening should have been submitted. The MDS Coordinator stated not completing the PASRR accurately could result in residents not been evaluated for eligibility and services. During an interview on 06/28/2023 at 2:25 p.m., the Regional Care Management Specialist stated her expectation was for all PL1's to be completed accurately and timely on all residents. The Regional Care Management Specialist stated Schizophrenia and Schizoaffective Disorder would be considered a mental illness. The Regional Care Management Specialist stated the MDS nurse was responsible for completing the PL 1 correctly. The [NAME] Care Management Specialist stated the MDS Coordinator was responsible for monitoring to ensure the mental illness diagnosis were captured on the PL1's that was received from the referring entity. The Regional Care Management Specialist stated she monitors an accuracy audit twice a month. The [NAME] Care Management Specialist stated her last audit was done on 06/08/2023. The Regional Care Management Specialist stated she was unsure if Residents #37 and #11 were part of the resident sample reviewed. The Regional Care Management Specialist stated not completing the PASRR accurately could result in residents not receiving services they were entitled to. 3. Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), tracheostomy status (a surgically created opening on the neck for air passage to help you breathe when the usual route for breathing is somehow blocked or reduced), and bipolar disorder, current episode depressed, severe, with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was sometimes understood and was sometimes able to make herself understood. The MDS assessment indicated Resident #28 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS section, Preadmission Screening and Resident Review indicated Resident #28 did not have a serious mental illness. The section named Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. The MDS section of Psychiatric/mood disorder indicated diagnoses of anxiety, depression, and bipolar disorder. Record review of the care plan with a date initiated of 05/05/2023, indicated Resident #28 used antidepressant medication Citalopram related to depression. The care plan indicated Resident #28 used psychotropic (medications that alter mood, perceptions, and behavior), antianxiety (medications used for anxiety), and antipsychotic medications (medications used for mental illness). Record review of Resident #28's PASRR Level 1 Screening completed on 05/04/2023 indicated in section C0100 no evidence of this individual having mental illness. During an interview on 06/28/2023 at 2:10 PM, the MDS Coordinator said she was responsible for PASRR. The MDS Coordinator said Resident #28 had been diagnosed with bipolar disorder after admission. The MDS Coordinator said she did not notify PASRR services to have her screened for mental illness. The MDS Coordinator said she was under the impression Resident #28 did not have to be referred for screening due to not being hospitalized at a psychiatric facility. The MDS Coordinator said she had spoken to the local authority from PASRR services, and they had instructed her to refer any resident with a mental illness diagnosis. The MDS Coordinator said it was important for the residents to be screened for PASRR so they could get extra services. The MDS Coordinator said if they were not referred appropriately, they would not be able to get services that the PASRR program offered. During an interview on 06/28/2023 at 4:35 PM, the Administrator said the MDS nurse was responsible for PASRR. The Administrator said she expected for her to make referrals as appropriate. The Administrator said it was important to properly refer to PASRR so the residents could get all the resource they were eligible for. The Administrator said not properly referring to PASRR could affect the residents because they would not be getting the services, they were eligible for. The Administrator stated there was not a policy and procedure regarding PASRR. 46892

46892 Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 17 residents (Resident #21, Resident #39, ad Resident #28) reviewed for care plans. The facility failed to ensure Resident #21's care plan indicated he used oxygen. The facility failed to ensure Resident #39's care plan indicated the proper usage of her grab bar. The facility failed to care plan Resident #28's tracheostomy. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #21's face sheet, dated 06/27/2023, indicated Resident #21 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (blood sugar disorder), Parkinson's disease (nervous system disorder that impacts movement) and heart failure (heart doesn't pump blood adequately). Resident #21's order summary report dated 06/27/23 indicated oxygen at 1 liter per minute as needed for oxygen under 88% and oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. Record review of Resident #21's quarterly MDS assessment, dated 02/12/2023, indicated Resident #21usually understood others and usually made himself understood. The MDS assessment indicated a BIMS score of 12 indicating moderately impaired cognition. The MDS indicated Resident #21 was on oxygen therapy. Record review of Resident #21s care plan (no date) did not indicate that Resident #21 was on oxygen. During an observation and interview on 06/28/23 at 01:25 PM, Resident #21 stated he wore his oxygen every night. Resident #21's oxygen concentrator was next to his bed and set at 2 liters via nasal cannula. During an interview on 6/28/23 at 10:37 AM, the MDS coordinator stated she was responsible for care planning Resident #21's oxygen. The MDS coordinator stated Resident #21 did not always wear his oxygen and she usually did not care plan oxygen if the resident did not use it. The MDS coordinator stated the oxygen should have been care planned because she marked oxygen on the MDS assessment. The MDS coordinator stated the importance of care plans being correct, was so nursing staff knew what to expect and was aware of the goals and interventions for individual residents. During an interview on 6/28/23 at 10:18 AM, the DON stated the MDS coordinator was responsible for care planning oxygen on Resident #21 because it was on the MDS assessment. The DON stated the importance of care planning oxygen on Resident #21 was so staff would know Resident #21's goal and they would be aware of his interventions. The DON stated if the care plan was not correct, then something important could have gotten missed. During an interview on 6/2/23 at 11:17 AM, the Administrator stated care plans should be correct so staff would know how to care for each resident, and they would be able to meet their individual needs. The Administrator stated the MDS coordinator was responsible for making sure the care plans were correct and she expected them to be correct. The Administrator stated care plans were reviewed quarterly in the care plan meetings. 2. Record review of Resident #39's face sheet, dated 06/27/2023, indicated Resident #39 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (blood sugar disorder), schizoaffective disorder (mood disorder) and epileptic seizures (brain imbalance that impacts consciousness). Record review of Resident #39's quarterly MDS assessment, dated 05/20/2023, indicated Resident #39 sometimes understood others and sometimes made herself understood. The MDS assessment indicated a BIMS score of 99 indicating Resident #39 was not able to complete the interview. The MDS assessment indicated Resident #39 required extensive assistance with bed mobility and one-person physical assist. The MDS indicated Resident #39 required extensive assistance with transfers and one-person physical assist. The MDS indicated Resident #39 required substantial/maximal assistance with rolling from lying on her back to the left and right side. The MDS indicated Resident #39 required maximal assistance to move from sitting on the side of the bed to lying flat in the bed. Record review of Resident #39's care plan (no date) indicated Resident #39 used physical restraint bed rails related to safety, security, and bed mobility. The interventions indicated to anticipate and intervene for potential causes that had precipitated prior falls or accidents. During an observation and interview on 06/27/2023 at 5:46 PM, Resident #39 was in her bed asleep and had a grab bar attached to one side of the hospital bed not facing the wall. During an interview on 6/28/2023 at 10:18 AM, the ADON stated she was responsible for making sure the care plan was correct and she made the mistake of indicating Resident #39's grab bar was used as a restraint. The ADON stated she thought all grab bars were care planned as restraints and she knew better now and would go back and fix it. The ADON stated that during care plan meetings each department went over the care plans to make sure they were correct. The ADON stated care plan meetings were quarterly for every resident. During an interview on 6/28/2023 at 10:37 AM, the MDS Coordinator stated the ADON was responsible for care planning the grab bar on Resident #39, and she was responsible for overlooking the care plan to make sure it was correct. The MDS Coordinator stated she must have overlooked the word restraint. The MDS Coordinator stated Resident #39 did not have a grab bar that was used as a restraint. The MDS coordinator stated Resident #39 used her grab bar for assistance with positioning in bed. The MDS coordinator stated the importance of care planning correctly was so nursing staff knew what to expect with residents. The MDS coordinator stated if something was not care planned correctly, then staff might know the goals or interventions for that resident. The MDS coordinator stated Resident #39 should not have been care planned that she had a grab bar as a restraint, and it was an oversight. During an interview on 6/28/2023 at 10:18 AM, the DON stated Resident #39 was able to use the grab bar on her bed to assist with moving around in the bed. The DON stated the ADON was responsible for care planning the grab bar correctly and it should not have been care planned as a restraint. The DON stated the importance of care planning correctly was so the team was aware of how to properly care for the residents and followed the interventions and goals provided. The DON stated the ADON had made a mistake care planning the grab bar as a restraint and it could have resulted in staff not knowing the grab bar was not used as a physical restraint. During an interview on 6/28/2023 at 11:17 AM, the Administrator stated the importance of care planning correctly was to ensure staff knew how to care for each resident and how to meet their individual needs. The Administrator stated the MDS coordinator was responsible for making sure the care plans were correct and she expected them to be done correctly. The Administrator stated care plans were reviewed quarterly in the care plan meetings. 3. Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), and tracheostomy status (a surgically created opening on the neck for air passage to help you breathe when the usual route for breathing is somehow blocked or reduced). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was sometimes understood and was sometimes able to make herself understood. The MDS assessment indicated Resident #28 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #28 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The MDS assessment indicated Resident #28 had tracheostomy care while a resident at the facility. Record review of the Order Summary Report dated 06/28/2023, indicated Resident #28 had the following orders: Change tracheostomy collar, tracheostomy tubing, oxygen tubing, and condensation trap as needed start date 05/17/2023 Change tracheostomy collar, tracheostomy tubing, oxygen tubing, and condensation trap at bedtime every 7 day(s) start date 05/17/2023 Remove reusable inner cannula. Place in sterile water and clean. Replace once inner cannula cleaned as needed for copious secretions start date 05/17/2023 Remove reusable inner cannula. Place in sterile water and clean. Replace once inner cannula cleaned every day shift for tracheostomy care Suction tracheostomy as needed for tracheostomy care as needed for increased secretions start date 05/17/2023 Tracheostomy care - Cleanse with normal saline with 4X4 around tracheostomy stoma (opening in the neck), pat dry, apply T-drain sponge and secure with tracheostomy collar as needed for copious secretions start date 05/17/2023 Tracheostomy care - Cleanse with normal saline with 4X4 around tracheostomy stoma, pat dry, apply T-drain sponge and secure with tracheostomy collar every day shift start date 05/17/2023 Tracheostomy humidification set at 28% with continuous O2 at 5LPM via concentrator. Compressor settings at 32psi (pressure setting) as needed for per resident request. Tracheostomy humidification start date 05/17/2023 Tracheostomy humidification set at 28% with continuous O2 at 5LPM via concentrator. Compressor settings at 32psi at bedtime start date 05/17/2023. Record review of the care plan initiated on 05/05/2023 indicated, the care plan did not include Resident #28's tracheostomy. During an observation on 06/26/2023 at 8:03 AM, Resident #28 was in her bed, tracheostomy observed with oxygen being provided. During an interview on 06/28/2023 at 2:00 PM, the MDS Coordinator said she was responsible for making sure the care plans were completed. The MDS Coordinator said the ADON should have put Resident #28's tracheostomy in her care plan. The MDS Coordinator said the care plans were reviewed quarterly by the interdisciplinary team to ensure they were complete. The MDS Coordinator said it was important for Resident #28's tracheostomy to be included in her care plan because it gave staff a footprint to go by so they could provide her care. The MDS Coordinator said the care plans made the residents care personalized. During an interview on 06/28/2023 at 2:53 PM, the ADON said she was not responsible for care planning Resident #28's tracheostomy. The ADON said the MDS Coordinator should have included Resident #28's tracheostomy in her care plan. The ADON said it was important for Resident #28's tracheostomy to be in her care plan because it helped troubleshoot the problems and have better interventions for her care. The ADON said the tracheostomy not being part of Resident #28's care plan could cause harm to her. During an interview on 06/28/2023 at 3:23 PM, the DON said the ADON and MDS coordinator reviewed the care plans randomly to ensure they were complete. The DON said they had noticed some of the care plans missing items, and if they found something missing it would immediately be corrected. The DON said it was important for Resident #28's tracheostomy to be included in her care plan so the interdisciplinary team would know that she had it, and if there were any interventions that needed to be added they could be added. The DON said it was important to ensure all the residents care plans were individualized to provide them the best quality of life. During an interview on 06/28/2023 at 4:59 PM, the Administrator said the MDS Coordinator was responsible for completing and ensuring the care plans were tailored to each person. The Administrator said she expected the MDS Coordinator to do this. The Administrator said it was important for the care plan to be tailored to each person so they could effectively care for the residents and ensure all of the residents' needs were met. The Administrator said not having an individualized care plan could result in the residents not receiving the care they needed, and things could get missed. Record review of the facility's policy titled, Comprehensive Care Plans, implemented 10/24/2022, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . all Care Assessment Areas triggered by the MDS will be considered in developing the plan of care. The care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 7 meetings (June 2023, April 2023, March 2023, January 2023, and December 2022) reviewed for QAPI. The facility did not ensure the Infection Control Representative attended their QAPI meetings in June 2023, April 2023, and December 2022. The facility did not ensure the Medical Director attended their QAPI meetings in March 2023 and January 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of the facility's Infection Control Representative Committee sign-in-sheets indicated the Infection Control Representative did not sign in for their meetings in June 2023, April 2023, and December 2022. The Medical Director did not sign in for their QAPI meetings in March 2023 and January 2023. During an interview on 6/28/23 at 8:15 AM, the Medical Director stated QAPI meetings were held every 2nd Wednesday of the month. The Medical Director stated he could not remember if he attended the meetings on June 2023, April 2023, and December 2022. The Medical Director stated he was often late to the meetings, and he might have missed the sign in sheets that were passed around. The Medical Director stated he was expected to attend all the QAPI meetings and sign the sign-in sheets that he had attended. The Medical Director stated if he was not present for the meeting, then he would make sure he reviewed the meeting later. The Medical Director stated the importance of attending the meetings was to discuss infection control and evaluate wounds. During an interview on 6/28/23 at 10:18 AM, the ADON (Infection Control Representative) stated she could not remember if she had attended the meetings in June 2023, April 2023, and December 2022.The ADON stated she had been working night shift and if she was not able to attend the meetings, then the DON would review the meetings with her the next day. The ADON stated she was expected to be present for the QAPI meetings and sign the sign-in sheets that she had attended. The ADON stated the importance of attending QAPI meeting was to review everything as an interdisciplinary team and make sure nothing important was missed. During an interview on 6/28/23 at 11:17 AM, the Administrator stated the ADON was probably working on the floor the night prior to the QAPI meeting and not able to attend. The Administrator stated the DON was responsible for reviewing the QAPI meetings with the ADON the following day and the ADON should have signed the attendance form at that time. The Administrator stated the importance of attending the QAPI meetings was to oversee everything going on in the building, discuss improvements, and make sure everyone was aware of what needed to be fixed. The Administrator stated that if staff members were not present for the meetings, then resident care might not be fully met, because staff members would not be on the same page. Record review of the facility's policy Quality Assessment and Assurance Committee, implemented on 10/24/22, indicated the committee will be composed of, at a minimum: the Director of Nursing, The Medical Director, at least three other facility staff members, one of which will be the Administrator, owner, a board member or other individual in a leadership role and the Infection Preventionist.

Based on interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 17 residents (Resident #35) reviewed for nutrition. The facility did not ensure dietary recommendations was implemented for Resident #35. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization . Findings included: Record review of Resident #35's face sheet, dated 06/28/2023, indicated Resident #35 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included end stage renal disease, essential hypertension (high blood pressure), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #35's physician order summary report, dated 06/27/2023, indicated an active physician's order for active liquid protein (nutritional supplement), 30 ml by mouth two times a day for health with a start date 02/17/2023. The physician order summary report indicated Resident #35 attended hemodialysis on Mondays, Wednesdays, and Fridays with chair time from 4:00 p.m.- 8:00 p.m. with an order date of 12/08/2022. Record review of Resident #35's quarterly MDS, dated [DATE], indicated Resident #35 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #35 was unable to complete the interview for the BIMS score. Record review of Resident #35's care plan, with an initiated date of 04/18/2023, indicated Resident #35 had a nutritional problem or potential nutritional problem related to ESRD, DMII and poor appetite. The care plan interventions included administer medications as ordered-liquid protein for weight gain, monitor/document/report PRN any s/s of dysphagia (trouble swallowing), and provide, serve diet as ordered. Record review of the quarterly renal nutritional assessment completed by the dietician dated 05/24/2023 revealed increase active liquid protein to 60 ml by mouth two times a day from 30 ml by mouth two times a day. During an interview on 06/28/2023 at 1:53 p.m., the DON stated usually when the dietician comes to the facility and make any recommendations, the dietitian would inform her by providing documentation of those changes. The DON stated she would then implement the changes with the MD approval. The DON stated she was unsure if documentation was provided, or the dietician input her note in PCC. When asked how the dietician recommendation was missed, the DON stated, it was human error. The DON stated there was not an effective system in place to ensure dietary recommendations were left undone. The DON stated the potentially failure could cause changes in her homeostasis (a state of balance among all the body systems needed for the body to survive and function correctly). An attempted telephone interview on 06/28/2023 at 2:20 p.m. with the Dietitian, was unsuccessful. During an interview on 06/28/2023 at 3:08 p.m., the Administrator stated she expected all dietary recommendations to be followed. The Administrator stated this failure could cause Resident #35 to not get adequate protein. Record review of the Dietary Manual dated 11/10/2021, indicated . patients who need to increase their protein intake may also benefit from supplementation with protein foods. You can help these patients meet their needs by adding commercial protein powder or liquid to foods and beverages per facility protocol

Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 17 residents (Resident #31) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #31's nutritional approaches on the quarterly MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #31's face sheet dated 06/27/23 indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had a diagnoses which included type 2 diabetes (the way the body processes blood sugar), hypertension (force of the blood against the artery walls is too high) and schizoaffective disorder (mood disorder). Record review of Resident #31's quarterly MDS dated [DATE] indicated Resident #31 had a BIMS score of 99 due to Resident #31 was unable to complete the interview. The quarterly MDS indicated Resident #31 made himself-understood and had the ability to understand others. Section K of the MDS indicated Resident #31 had a parental/IV feeding while he was a resident at the facility. Record review of Resident #31's order summary report dated 06/27/23 did not indicate Resident #31 had a parental/IV feeding. Resident #31's orders indicated he received a regular texture diet with reduced concentrated sweets. Record review of Resident #31's care plan (no date) did not indicate Resident #31 had a parental/IV feeding. Resident #31's care plan initiated 2/17/22 indicated he had a potential nutritional problem related to dementia. The interventions indicated to serve diet as ordered. During an observation and interview on 06/26/23 at 11:11 AM, Resident #31 did not have a parental/IV feeding. Resident #31 stated he had never had a parental/IV feeding. During an interview on 6/28/23 at 10:37 AM, the MDS coordinator stated Resident #31 did not have a tube feeding or IV and never had one. The MDS coordinator stated she must have marked on the MDS that Resident #31 had a parental/IV feeding by mistake. The MDS coordinator stated she was responsible for completing all the MDS assessments in the facility and she should have caught the mistake when it triggered the care plan. The MDS coordinator stated the Corporate MDS nurse double checked all the MDS assessments at random for her. The MDS coordinator stated marking the MDS assessment incorrectly would, Have everyone looking for Resident #31's peg tube and he did not have one, it would throw off billing, it would make the care plan incorrect, and it would be fraud. During an interview on 6/28/23 at 10:118 AM, the DON stated the MDS coordinator was responsible for making sure the MDS assessment was correct and the Corporate MDS nurse was responsible for double checking the MDS coordinator. The importance of making sure the MDS assessment was correct would be to prevent fraud. During an interview on 6/28/23 at 11:17 AM, the Administrator stated the MDS coordinator was responsible for making sure the MDS assessments were correct, and she expected them to be correct. The Administrator stated the Corporate MDS nurse checked the MDS assessments routinely and the IDT team talked about MDS's in their meetings. The importance of making sure the MDS assessment was correct would be because it impacted Resident #31's RUG level and if the MDS assessment was not correct, then the facility could get into trouble, and it would not be a true reflection of Resident #31. During an interview on 6/28/23 at 11:17 AM, the Administer stated the facility did not have a policy on MDS assessments and the facility followed the RAI manual.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 17 residents (Resident #28) reviewed for activities. The facility failed to provide activities for Resident #28. The facility failed to ensure Resident #28 had activities care planned. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), and tracheostomy status (a surgically created opening on the neck for air passage to help you breathe when the usual route for breathing is somehow blocked or reduced). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was sometimes understood and was sometimes able to make herself understood. The MDS assessment indicated Resident #28 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #28 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The staff interview for Resident #28 for activity preferences on the MDS assessment indicated it was very important to her to have books, newspapers, and magazines to read, to listen to music, to be around animals such as pets, to keep up with the news, to do things with groups of people, to do her favorite activities, to go outside to get fresh air when the weather was good, and to participate in religious services or practices. Record review of the care plan initiated on 05/05/2023 indicated Resident #28 did not have activities in her care plan. During an observation on 06/26/2023 at 8:03 AM, Resident #28 was in bed with TV on. During an observation and interview on 06/26/2023 at 10:30 AM, Resident #28 was in bed her TV was on. Resident #28 said she was blind and stayed in her bed most of the time due to her tracheostomy (opening on the neck for air passage to help you breathe) and requiring oxygen. Resident #28 said staff was not going into her room to do any activities. Resident #28 said she would enjoy having company in her room because she was usually alone. During an observation on 06/26/2023 at 4:19 PM, Resident #28 was in bed with TV on. During an observation on 06/27/2023 at 9: 50 AM, Resident #28 was in bed with TV on. During an observation on 06/27/2023 at 2:50 PM, Resident #28 was in bed with TV on. During an interview on 06/28/2023 at 9:49 AM, the Activity Director said he started in May 2023. The Activity's Director said residents that were bedbound or did not leave their room received in-room one-on-one activities. The Activity Director said the last time he did a one-on-one activity with Resident #28 was in May 2023 and he did not remember the exact date. The Activity Director said he was new, and he was working on forming his activity program and the one-on-one activities for residents who were bed bound or did not leave their room. The Activity Director said he should have been doing one-on-one activities with Resident #28 daily, but he had not had time due to trying to catch up because he was behind due to being new. The Activity Director said he did not document anything on paper, if he did an activity with a resident, he documented it in the electronic health record. The Activity Director said he was responsible for including activities in the residents' care plans. The Activity Director said he did not know why Resident #28 was not care planned for activities. The Activity Director said it was important for the all the residents to have activities to improve their quality of life. The Activity Director said not doing the one-on-one activities could affect Resident #28's overall mental health. The Activity Director said it was important for activities for the residents to be care planned so the staff know what the residents like to do. During an interview on 06/28/2023 at 3:25 PM, the DON said the Activity Director was responsible for ensuring the residents received activities, including one-on-one activities. The DON said Resident #28's care plan should include activities, and the Activity Director was responsible for putting activities in the care plan. The DON said it was important for Resident #28 to receive one-on-one activities because she was blind and spent most of the time in her bed. The DON said it was important for activities to be in the residents' care plans so that staff would know what the residents' interests were and provide them things they enjoy doing. During an interview on 06/28/2023 at 4:41 PM, the Administrator said she tried to be involved in the activities, but the Activity Director was responsible for providing the activities for the residents. The Administrator said the Activity Director did not have a set plan for one-on-one activities, but that the one-one-one activities should be care planned. The Administrator said it was important for the residents to have activities, including one-on-one, for their livelihood and for their social interaction. The Administrator said not having activities could make the residents feel lonely and depressed. Record review of the undated Job Description for the Activity Director, provided by the Administrator in place of a policy, indicated, The Activity Director will be responsible for planning, coordinating, and directing the resident's activity program and the maintenance of necessary documentation. Essential Functions Organize both individual and group activities based on the needs of the residents Ensure that multiple activities are occurring for both high and low functioning residents . Develop the activities component of the Comprehensive Care Plan from the completed activity assessment . Provide activities for residents that are bedfast and/or unable to participate in group activities one to one and documents in the appropriate record .

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 2 residents (Resident #9) reviewed for pressure ulcers. LVN A failed to follow the physician orders when providing wound care to Resident #9. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 06/28/2023, indicated Resident #9 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel with high blood sugars), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #9 was able to make self-understood and sometimes understood others. The MDS assessment indicated Resident #9 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #9 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #9 was at risk of developing pressure ulcers/injuries. The MDS assessment did not indicate Resident #9 had pressure ulcers/injuries. Record review of the care plan with date initiated 04/03/2022 did not indicate Resident #9 had a pressure ulcer. Record review of Resident #9's Order Summary Report dated 06/26/2023 indicated clean wound to right buttock with wound cleanser or normal saline, pat dry with gauze, apply collagen powder and barrier cream, and cover with a dry dressing every day shift for stage 2 wound with an order start date of 06/20/2023. During an observation on 06/26/2023 starting at 2:41 PM, LVN A did not perform hand hygiene prior to beginning wound care on Resident #9. LVN A applied gloves and removed the dirty dressing. LVN A did not change gloves or perform hand hygiene after removing the dirty dressing. LVN A used the dirty gloves and cleaned Resident #9's wound with normal saline, patted it dry, applied anapest gel (ointment used for wounds) and collagen powder, covered with calcium alginate, and applied a clean dressing to the wound. Using the same dirty gloves LVN A repositioned resident and covered him with his sheets. After this, LVN A removed the dirty gloves and performed hand hygiene. During an interview on 06/28/2023 at 2:41 PM, the ADON said she was responsible for overseeing the wound care orders and making sure the nurses were following the physician orders when providing wound care. The ADON said she monitored this by performing the annual competencies. The ADON said the wound care for Resident #9 included to clean the wound pat it dry, apply collagen and barrier cream and cover the wound with a dry dressing. The ADON said the anasept and calcium alginate should not have been applied to Resident #9's wound to right buttock. The ADON said it was important to follow the wound care orders because that was how the physician would like it to be. The ADON said not following the physician's order could cause the wound to worsen. During an interview on 06/28/2023 at 3:39 PM, the DON said the ADON monitored wound care and the orders. The DON said she expected for the nurses to follow the physician orders for wound care. The DON said it was important to follow the physician order for wound care to ensure the wound care was healing and would not deteriorate. During an interview on 06/28/2023 at 5:03 PM, the Administrator said nurse management was responsible for ensuring the nurses followed the physician's orders for wound care. The Administrator said she expected for the nurses to follow the physician's orders for wound care. The Administrator said it was important to make sure that the wound did not deteriorate, and that the treatment was effective. During an interview on 06/26/2023 at 6:00 PM, LVN A said wound care should be provided per the physician's orders. LVN A said she thought she looked at the order and the anasept and the calcium alginate were part of the wound care order for Resident #9. LVN A said it was important to follow the physician's order for wound care because the physician knew what was best for the wound. LVN A said not following the physician's order for wound care could affect the healing of the wound. Record review of the facility's policy titled, Pressure Injury Prevention and Management, implemented on 08/15/2022, indicated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal hand oral hygiene for 1 of 3 residents (Resident #34) reviewed for Activities of Daily Living. The facility did not provide scheduled showers for Resident #34. This failure could place residents at risk of not receiving services/care and a decreased quality of life. Findings Include: Record review of the consolidated physician order dated 6/28/2023 indicated, Resident #34 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Nontraumatic subarachnoid hemorrhage (a blood vessel that burst into the brain), Aphasia, (loss of ability to understand or express speech), Age-related osteoporosis (weak or brittle bones), Pain in right arm, Hemiplegia (paralysis of one side of the body) affecting the right dominant side. Record review of the quarterly MDS dated [DATE] indicated, Resident #34 sometimes understood others and sometimes made herself understood. The MDS indicated Resident #34 was unable to complete the interview with a BIMS interview. The MDS indicated Resident #34 had a short- and long-term memory problem. The MDS indicated Resident #34 did not reject evaluation or care. Resident #34 required extensive assistance with transferring, dressing, and personal hygiene. Record review of the comprehensive care plan initiated 05/19/2023 indicated, Resident #34 had an activities of daily living (ADL) self-care performance deficit related to injury to shoulder and CVA. The care plan indicated interventions included Resident #34 required total dependence x1 staff for showering 3 times weekly and as necessary. Record review of the Shower List updated on 06/08/2023 indicated, Resident #34 was scheduled for showers 3 times weekly. Record review of the Shower Sheet dated 06/15/2023 indicated, Resident #34 received a shower on 6/15/2023. There were no showers/baths documented between 06/15/2023 through 06/28/2023. Record review of Resident #34's nursing notes dated 6/15/2023 through 06/28/2023 showed no refusals of showering/bathing. During an observation on 06/26/2023 at 08:11 AM, Resident #34 was observed with disheveled, uncombed oily hair, and 1/2 inch facial hairs on chin and across upper lip. During an observation on 06/27/2023 at 07:53 AM, Resident #34 was observed in dining hall eating breakfast. Resident #34 had 1/2 inch facial hairs on chin and across upper lip. During an interview and observation on 06/27/2023 at 09:17 AM, RN F said Resident #34 did not reject care. RN F said Resident #34 was nonverbal for the most part and usually only nodded her head for yes or no. RN F was observed providing treatment to Resident #34's toes. Resident #34 was observed with combed oily hair and 1/2 inch facial hairs on chin and across upper lip. During an observation on 06/28/2023 at 07:53 AM, Resident #34 was observed in lobby area. Resident #34 had combed oily hair and 1/2 inch facial hairs on chin and across upper lip. During an observation on 06/28/2023 at 03:15, Resident #34 was observed in lobby area. Resident #34 had combed oily hair and 1/2 inch facial hairs on chin and across upper lip. During an interview on 06/28/2023 at 02:51 PM, CNA B said the CNAs were responsible for giving the residents their showers. CNA B said there was a shower schedule posted at the nurse's station in the shower logbook to let the CNAs know who needed a shower on what day and shift. CNA B said it was important for residents to receive their showers to prevent infections and to be healthy. CNA B said she felt like female residents with chin hairs was undignified. CNA B said once the shower was completed, the shower sheet was placed in the shower sheet logbook. CNA B said she reported to the nurse if bathing was incomplete because they checked with the resident and made another offer. During an interview on 06/28/2023 at 02:59 PM, CNA G said the CNAs were responsible for giving the residents their showers. CNA G said there was a shower schedule posted at the nurse's station in the shower logbook to let the CNAs know who needed a shower on what day and shift. CNA G said it was important for residents to receive their showers to prevent infections and promote good appearance. CNA G said she knew female residents required facial shavings due to face hair. CNA G said the completed shower sheets were placed in the shower sheet logbook once the bath was done. CNA G said she reported to the nurse if the bath was incomplete, because the nurse checked with the resident and made another offer. During an interview on 06/28/2023 at 03:05 PM, CNA H said the CNAs were responsible for giving the residents their showers. CNA H said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. CNA H said it was important for residents to receive their showers so staff could observe their skin and to maintain the resident's cleanliness. CNA H said the completed shower sheet was placed in the shower sheet logbook. CNA H said if a resident refused, or a shower/bath was not given to a resident, she reported to her floor nurse so that someone else could try to ask the resident. During an interview on 06/28/2023 at 03:10 PM, LVN K said the CNA should report when a resident was not showered/bathed to the charge nurse. LVN K said it was the charge nurse's responsibility to follow up on refusals or baths not completed after communicated by the CNAs. LVN K said she expected the residents to receive their scheduled showers to prevent infections, maintain skin integrity, and maintain hygiene. LVN K said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. LVN K said no staff reported a refusal of showering/bathing to her. LVN K said she noticed Resident #34 was disheveled yesterday, after the CNA assigned had left the facility. LVN K said she could not locate the shower sheet of Resident #34 yesterday, but often the sheets had not been placed in the shower logbook properly by the CNAs. LVN K said ultimately if showers and bathing were un-resolved, she notified the ADON or DON. During a telephone interview on 06/28/2023 at 03:15PM, CNA L said she gave Resident #34 a bed bath on 06/27/2023 because she did not have enough time to give a shower. CNA L said she forgot to fill out the shower sheet because it was time to go off her shift. CNA L said, it slipped her mind to let the nurse know that she had not washed Resident #34's hair or shaved the facial hairs per the Plan of Care. CNA L said she had not completed those items. CNA L said Resident #34 refused because of her arm. CNA L said she should had notified the nurse so that someone else could attempt to provide the necessary care. CNA L said it was important for residents to receive their scheduled showers to be clean and healthy. During an interview on 06/28/2023 at 03:24 PM, the DON said it was the CNAs responsibility to give the residents their showers. The DON said there was a shower list that identified what resident received a shower on which day and shift. The DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON said she expected the CNAs to communicate with the charge nurses daily to ensure resident's needs met. The DON expected the shower sheets completed by the CNAs and turned into the shower logbook daily. The DON said she expected the charge nurses to verify the showers given by the CNAs daily by checking the shower logbook. The DON said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible to ensure the oversight of resident 's bathed and showered appropriately according to the resident's Plan of Care. The DON said the importance of the residents receiving their scheduled showers was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. During an interview 06/28/2023 at 04:01 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical staff are responsible for making sure the baths/showers were provided for the residents. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good, infection control and dignity. Record review of facility policy and procedure titled, Activities of Daily Living (ADLs) implemented 5/26/23, indicated . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 6. Documentation shall be completed at the time of service, but no later than the shift in which care service occurred.

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #1) of six residents reviewed for significant medication errors. RN A and RN B failed to administer correct doses of [MEDICATION NAME] gel (anti-nausea medication) on two separate occasions, to Resident #1. Both RN A and RN B administered 125mg/1ml of [MEDICATION NAME] gel, this was 5 times the dose as written in the Physician order. The correct dose as written was 25mg/0.2ml. The resident expired 11 hours after the 2nd incorrect dose was administered. This failure resulted in an Immediate Jeopardy situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed residents receiving medications at risk for harm and/or death. Findings include: Review of Resident # 1's Face Sheet dated [DATE] reflected Resident # 1 was a [AGE] year-old female admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated [DATE] reflected Resident #1 received Hospice services, interventions included administering of medications as needed to manage pain and other uncomfortable symptoms. Review of the Significant change in status Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 had intact cognition. Review of Resident # 1's physician orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. In an interview on [DATE] at 09:35 AM, RN C stated a facility nurse called the Hospice agency on the morning of [DATE] to report Resident #1 had nausea and vomiting. RN C said she delivered Two syringes containing [MEDICATION NAME] gel 125mg/1ml and ten [MEDICATION NAME] tablets to the facility on [DATE] at approximately 3:45 PM. A written order containing instructions on administering the medications was given and verbal instructions were reviewed with a facility nurse. RN C said on the morning of [DATE], A facility nurse (LVN A) called the Hospice agency to request additional [MEDICATION NAME] Gel. RN C stated she told the facility nurse it was impossible to need more [MEDICATION NAME] gel, that enough for 10 doses was delivered the day previously. RN C stated the facility nurse (LVN A) said Oh my gosh, that's happened before, they must have given the whole syringe. RN C said after the discovery of the medication error, the hospice agency checked to be sure there were no other residents with orders for [MEDICATION NAME] gel in multi dose syringes and will no longer order multiple use syringes of [MEDICATION NAME] gel. In an interview on [DATE] at 10:30 AM with DON, she said Resident #1 was on Hospice services and had been declining. The DON said the medication error was reported to her by the charge nurse on [DATE] approximately 08:00 AM, she said the charge nurse also reported the error to the Hospice agency. In an interview on [DATE] at 11:30 AM the DON stated she had in-serviced RN B on [DATE] prior to her working the 11:00 PM shift. The DON stated she had not yet in-serviced all nursing staff on medication administration, she said she intended to incorporate the Inservice with annual medication competencies planned for the following week. She stated she had not in serviced RN A because she has not been scheduled to work. In a telephone interview [DATE] at 12:00 PM Physician #1, said the standard dose of [MEDICATION NAME] gel given topically is anywhere from 12.5 mg to 0.25 mg every ,[DATE] hours as needed. The maximum dose is 25mg every ,[DATE] hours. Physician #1 said Resident #1 was very advanced in her terminal illness and the medication error of administering 125mg of [MEDICATION NAME] gel could have contributed to her death, but it would be impossible to say for sure because she was declining. Physician #1 suggested the investigator speak with Resident #1's primary hospice physician. In a telephone interview on [DATE] at 12:30 PM, Physician #2, said Resident #1 was in a very fragile condition, she had end stage heart failure and liver disease. When questioned if he felt the dose of 125 mg of [MEDICATION NAME] gel contributed to Resident #1's death? Physician #2 said yes, 125mg is not a safe dose, five times the dose of any medication could be a toxic dose. In a telephone interview on [DATE] at 2:30 PM RN A stated, I didn't know I did the error until they told me RN A said she looked at the order prior to administering the gel, I just missed it, I don't know what happened, I thought it was the whole syringe. RN A said many Hospice medications come in single use syringes, usually [MEDICATION NAME] is in an injection form or pills and she had never given [MEDICATION NAME] topical gel. RN A said she administered the whole syringe topically to the inner wrist of Resident #1 at 7:00 PM on [DATE]. In an interview on [DATE] at 3:00 PM the DON said she did not feel the medication error contributed to the death of Resident #1, she said I know it's a strong dose, and would cause her to sleep, but not contribute to her death. In an interview on [DATE] at 3:05 PM LVN A said she worked the day shift on [DATE], she said Resident #1's daughter reported to her Resident #1 was continuing to have nausea. LVN A said she noticed an empty box at the nurse's station which was labeled with Resident #1's name and the medication [MEDICATION NAME] gel. LVN A stated she called the hospice agency to request more [MEDICATION NAME]. She said when she told the hospice nurse they needed more [MEDICATION NAME], she was told they should still have more doses of the [MEDICATION NAME] gel. LVN A said she realized the nurses must have given the whole syringe. She said in the past she almost did the same thing, with another resident, but had the order clarified before administering the gel. LVN A said she told the DON what happened and closely monitored Resident #1 throughout the day. She said Resident #1 was sleepy throughout the day and her o2 sats (oxygen saturation levels) were up and down. She said she reported to Hospice, the resident was groggy and her O2 sats were all over the place the Hospice nurse came to see Resident #1 that afternoon. In a telephone interview [DATE] at 12:55 PM RN B said she first learned of the medication error when the DON called her at home on [DATE] at approximately 08:00 AM. RN B said on the morning of [DATE] just before shift change, approximately 07:00 AM, it was a very busy morning, Resident #1 complained of nausea, she was unable to take the oral anti-nausea medication, RN B said she went to the medication cart where the syringe was stored, she retrieved the syringe then administered the whole syringe topically to Resident #1. RN B stated, I just got too comfortable with taking report, RN B stated she was not instructed during report by the nurse going off shift the previous night, to give the whole syringe it was implied. RN B stated she had administered a different Hospice medication (ABH Gel) to a different resident the week previous via a single use syringe. She said she felt it was the same, a single use syringe. Review of Hand in Hand Hospice notes dated [DATE] 10:00 AM revealed documentation stating Resident #1 resting in bed asleep upon arrival. Easily aroused with verbal stimuli. Patient alert and oriented x3 (oriented to person, place, and time). Respirations even and unlabored. Review of Hand in Hand Hospice notes dated [DATE] 01:00 PM revealed documentation stating Resident #1 awakens to verbal stimuli, but very sleepy, did not open eyes. Noted wheezing in upper lobes and lower lobes diminished but clear. Review of hand to hand Hospice notes dated [DATE] 6:50 PM revealed documentation stating Resident #1 lying in bed. Hospice Nurse auscultated apical heartrate for 1 full minute and noted no heartbeat. Auscultated lung sounds and noted no respirations for 1 full minute. Pronounced patient. Time of death documented as 06:53 PM [DATE]. Review of facility policy with effective date [DATE] titled Medication Administration Policy 5.3 General Guidelines for Medication Administration Medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. Procedure: 4. Read the label comparing to the MAR before preparing the medication. Review of undated Inservice training guide titled Rights of Medication Administration revealed the following: 3. Right Dose check the order, confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. Review of nursing staff in-service dated [DATE], titled Medication Administration 1. Always follow the 10 rights of drug administration as follows: 10 Rights of Drug Administration - Right Drug, Right Patient, Right Dose, Right Route, Time and frequency, Documentation, History and Assessment, Drug Approach and Right to Refuse, Drug to Drug interaction and Evaluation, Education and Information. The Inservice attendance record signature sheet contained the names of RN A and RN B. Review of Medication Administration Incident Report dated [DATE] 10:15 AM revealed the following: Description of incident: Resident was given full syringe of [MEDICATION NAME] (1ml) 25mg/0.2ml when directions read apply 0.2ml to skin of inner arm every 4 hours as needed. The Administrator was notified and received the IJ template on [DATE] at 4:00 PM that an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator and approved by the Program Manager on [DATE] at 5:26 PM. Plan of Removal [DATE] 1.Immediate re-education to DON by regional specialist on the definition of a significant medications error per the CMS regulation. Completion on [DATE] 2.DON initiate re-education on [DATE] for licensed nurses and certified medication aides on the following areas and will be completed by [DATE]. The education was initially started on [DATE]. a) The rights of medication administration b) Administration of medication that is delivered in syringes c) Facility abuse and neglect policy Those on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Director of Nursing will be responsible to ensure the above noted education is completed. 3.An Ad hoc QAPI meeting was held on [DATE] with the facility medical director, facility administrator, facility DON, and the social services director to review the incident and corrective actions put in place. A monitoring visit was made on [DATE] In an interview on [DATE] at 12:19 LVN A stated she had received an in-service the morning of ,[DATE] 2019 on the five rights of medication, and on abuse and neglect. In an interview on [DATE] at 12:21 PM Medication Aide A advised she was in-serviced on Friday [DATE] on medication errors and medication via syringe, she advised this was after state investigation. She stated that she also had received abuse and neglect training on Friday [DATE], that in-service is still ongoing for staff. She reported no concerns for the facility. In an interview on [DATE] at 12:23 PM Medication Aide B stated she had received an in-service the morning of ,[DATE] 2019 on the five rights of medication, use of syringes, and on abuse and neglect. Review of the In-Service Training report dated [DATE] reflected instruction as follows: Not all prefilled medication syringes are a one time dose. All prefilled syringes must be checked using the rights of medication to ensure the correct dosage is administered. The Inservice sign in sheet reflected signatures for 13 certified medication aides and 4 LVN's. Review of all In-services for medication errors, significant medication errors, and Abuse/Neglect/Exploitation revealed appropriate documentation for response to the Immediate Jeopardy citation. The Administrator was notified the IJ had been removed on [DATE]. The facility remained out of compliance at a severity level of actual harm.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of six residents reviewed for medication administration. RN A and RN B failed to administer correct doses of [MEDICATION NAME] gel (anti-nausea medication) on two separate occasions, to Resident #1. Both RN A and RN B administered 125mg/1ml of [MEDICATION NAME] gel, this was 5 times the dose as written in the Physician order. The correct dose as written was 25mg/0.2ml. The resident expired 11 hours after the 2nd incorrect dose was administered. This failure resulted in an Immediate Jeopardy situation identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. This failure placed residents receiving medications at risk for harm and/or death. Findings include: Review of Resident # 1's Face Sheet dated [DATE] reflected Resident # 1 was a [AGE] year-old female admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated [DATE] reflected Resident #1 received Hospice services, interventions included administering of medications as needed to manage pain and other uncomfortable symptoms. Review of the Significant change in status Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 had intact cognition. Review of Resident # 1's physician orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. In an interview on [DATE] at 09:35 AM, RN C stated a facility nurse called the Hospice agency on the morning of [DATE] to report Resident #1 had nausea and vomiting. RN C said she delivered Two syringes containing [MEDICATION NAME] gel 125mg/1ml and ten [MEDICATION NAME] tablets to the facility on [DATE] at approximately 3:45 PM. A written order containing instructions on administering the medications was given and verbal instructions were reviewed with a facility nurse. RN C said on the morning of [DATE], A facility nurse (LVN A) called the Hospice agency to request additional [MEDICATION NAME] Gel. RN C stated she told the facility nurse it was impossible to need more [MEDICATION NAME] gel, that enough for 10 doses was delivered the day previously. RN C stated the facility nurse (LVN A) said Oh my gosh, that's happened before, they must have given the whole syringe. RN C said after the discovery of the medication error, the hospice agency checked to be sure there were no other residents with orders for [MEDICATION NAME] gel in multi dose syringes and will no longer order multiple use syringes of [MEDICATION NAME] gel. In an interview on [DATE] at 10:30 AM with DON, she said Resident #1 was on Hospice services and had been declining. The DON said the medication error was reported to her by the charge nurse on [DATE] approximately 08:00 AM, she said the charge nurse also reported the error to the Hospice agency. In an interview on [DATE] at 11:30 AM the DON stated she had in-serviced RN B on [DATE] prior to her working the 11:00 PM shift. The DON stated she had not yet in-serviced all nursing staff on medication administration, she said she intended to incorporate the Inservice with annual medication competencies planned for the following week. She stated she had not in serviced RN A because she has not been scheduled to work. In a telephone interview [DATE] at 12:00 PM Physician #1, said the standard dose of [MEDICATION NAME] gel given topically is anywhere from 12.5 mg to 0.25 mg every ,[DATE] hours as needed. The maximum dose is 25mg every ,[DATE] hours. Physician #1 said Resident #1 was very advanced in her terminal illness and the medication error of administering 125mg of [MEDICATION NAME] gel could have contributed to her death, but it would be impossible to say for sure because she was declining. Physician #1 suggested the investigator speak with Resident #1's primary hospice physician. In a telephone interview on [DATE] at 12:30 PM, Physician #2, said Resident #1 was in a very fragile condition, she had end stage heart failure and liver disease. When questioned if he felt the dose of 125 mg of [MEDICATION NAME] gel contributed to Resident #1's death? Physician #2 said yes, 125mg is not a safe dose, five times the dose of any medication could be a toxic dose. In a telephone interview on [DATE] at 2:30 PM RN A stated, I didn't know I did the error until they told me RN A said she looked at the order prior to administering the gel, I just missed it, I don't know what happened, I thought it was the whole syringe. RN A said many Hospice medications come in single use syringes, usually [MEDICATION NAME] is in an injection form or pills and she had never given [MEDICATION NAME] topical gel. RN A said she administered the whole syringe topically to the inner wrist of Resident #1 at 7:00 PM on [DATE]. In an interview on [DATE] at 3:00 PM the DON said she did not feel the medication error contributed to the death of Resident #1, she said I know it's a strong dose, and would cause her to sleep, but not contribute to her death. In an interview on [DATE] at 3:05 PM LVN A said she worked the day shift on [DATE], she said Resident #1's daughter reported to her Resident #1 was continuing to have nausea. LVN A said she noticed an empty box at the nurse's station which was labeled with Resident #1's name and the medication [MEDICATION NAME] gel. LVN A stated she called the hospice agency to request more [MEDICATION NAME]. She said when she told the hospice nurse they needed more [MEDICATION NAME], she was told they should still have more doses of the [MEDICATION NAME] gel. LVN A said she realized the nurses must have given the whole syringe. She said in the past she almost did the same thing, with another resident, but had the order clarified before administering the gel. LVN A said she told the DON what happened and closely monitored Resident Welch throughout the day. She said Resident #1 was sleepy throughout the day and her o2 sats (oxygen saturation levels) were up and down. She said she reported to Hospice, the resident was groggy and her O2 sats were all over the place the Hospice nurse came to see Resident #1 that afternoon. In a telephone interview [DATE] at 12:55 PM RN B said she first learned of the medication error when the DON called her at home on [DATE] at approximately 08:00 AM. RN B said on the morning of [DATE] just before shift change, approximately 07:00 AM, it was a very busy morning, Resident #1 complained of nausea, she was unable to take the oral anti-nausea medication, RN B said she went to the medication cart where the syringe was stored, she retrieved the syringe then administered the whole syringe topically to Resident #1. RN B stated, I just got too comfortable with taking report, RN B stated she was not instructed during report by the nurse going off shift the previous night, to give the whole syringe it was implied. RN B stated she had administered a different Hospice medication (ABH Gel) to a different resident the week previous via a single use syringe. She said she felt it was the same, a single use syringe. Review of Hand in Hand Hospice notes dated [DATE] 10:00 AM revealed documentation stating Resident #1 resting in bed asleep upon arrival. Easily aroused with verbal stimuli. Patient alert and oriented x3 (oriented to person, place, and time). Respirations even and unlabored. Review of Hand in Hand Hospice notes dated [DATE] 01:00 PM revealed documentation stating Resident #1 awakens to verbal stimuli, but very sleepy, did not open eyes. Noted wheezing in upper lobes and lower lobes diminished but clear. Review of hand to hand Hospice notes dated [DATE] 6:50 PM revealed documentation stating Resident #1 lying in bed. Hospice Nurse auscultated apical heartrate for 1 full minute and noted no heartbeat. Auscultated lung sounds and noted no respirations for 1 full minute. Pronounced patient. Time of death documented as 06:53 PM [DATE]. Review of facility policy with effective date [DATE] titled Medication Administration Policy 5.3 General Guidelines for Medication Administration Medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. Procedure: 4. Read the label comparing to the MAR before preparing the medication. Review of undated Inservice training guide titled Rights of Medication Administration revealed the following: 3. Right Dose check the order, confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. Review of nursing staff in-service dated [DATE], titled Medication Administration 1. Always follow the 10 rights of drug administration as follows: 10 Rights of Drug Administration - Right Drug, Right Patient, Right Dose, Right Route, Time and frequency, Documentation, History and Assessment, Drug Approach and Right to Refuse, Drug to Drug interaction and Evaluation, Education and Information. The Inservice attendance record signature sheet contained the names of RN A and RN B. Review of Medication Administration Incident Report dated [DATE] 10:15 AM revealed the following: Description of incident: Resident was given full syringe of [MEDICATION NAME] (1ml) 25mg/0.2ml when directions read apply 0.2ml to skin of inner arm every 4 hours as needed. The Administrator was notified and received the IJ template on [DATE] at 4:00 PM that an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator and approved by the Program Manager on [DATE] at 5:26 PM. Plan of Removal [DATE] 1.Immediate re-education to DON by regional specialist on the definition of a significant medications error per the CMS regulation. Completion on [DATE] 2.DON initiate re-education on [DATE] for licensed nurses and certified medication aides on the following areas and will be completed by [DATE]. The education was initially started on [DATE]. a) The rights of medication administration b) Administration of medication that is delivered in syringes c) Facility abuse and neglect policy Those on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Director of Nursing will be responsible to ensure the above noted education is completed. 3.An Ad hoc QAPI meeting was held on [DATE] with the facility medical director, facility administrator, facility DON, and the social services director to review the incident and corrective actions put in place. A monitoring visit was made on [DATE] In an interview on [DATE] at 12:19 LVN A stated she had received an in-service the morning of ,[DATE] 2019 on the five rights of medication, and on abuse and neglect. In an interview on [DATE] at 12:21 PM Medication Aide A advised she was in-serviced on Friday [DATE] on medication errors, she advised this was after state investigation. She stated that she also had received abuse and neglect training on Friday [DATE], that in-service is still ongoing for staff. She reported no concerns for the facility. In an interview on [DATE] at 12:23 PM Medication Aide B stated she had received an in-service the morning of ,[DATE] 2019 on the five rights of medication, and on abuse and neglect. Review of the In-Service Training report dated [DATE] reflected instruction as follows: Not all prefilled medication syringes are a one time dose. All prefilled syringes must be checked using the rights of medication to ensure the correct dosage is administered. The Inservice sign in sheet reflected signatures for 13 certified medication aides and 4 LVN's. Review of all In-services for medication errors, significant medication errors, and Abuse/Neglect/Exploitation revealed appropriate documentation for response to the Immediate Jeopardy citation. The Administrator was notified the IJ had been removed on [DATE]. The facility remained out of compliance at a severity level of actual harm.

Based on observation, interview, and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #8) of four residents reviewed for falls. CNA A, who was aware Resident #8 needed two person assistance with her ADLs, attempted to provide care for the resident without assistance, which resulted in the resident falling to the floor, hitting her head, resulting in a closed-head injury and a [MEDICAL CONDITION] requiring treatment at the emergency room . This failure could affect the 59 residents, including Resident #8, who were at high risk for falls and placed them at risk for falls, bruises, fractures, and/or more serious injuries. Findings included: The facility's Resident Admission Record dated 09/05/13 reflected Resident #8 was a [AGE] year-old female admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. The facility's Nursing Data Collection Tool dated 03/11/14 reflected Resident #8 had short term memory problems and was severely impaired for decision-making. The Tool further reflected the areas of the resident's limitations was blank, prior falls in the past 180 days was blank, and how Resident #8 transferred between bed and chair was blank. The Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #8 had a Brief Interview Mental Status (BIMS) score of three, which indicated severe cognitife impairment. The MDS assessment reflected Resident #8 sometimes understood, with difficulty thinking and disorganized thinking that fluctuated. Resident #8 required extensive assistance of two staff members for transfers, dressing, bed mobility, and was totally dependent on staff for bathing. Resident #8 had fallen once since readmission to the facility on [DATE], with no injuries. Resident #8's Fall Risk assessment dated [DATE], and completed by LVN D, reflected a score of 14, which indicated she was a high risk for falls. The Care Area Assessment summary dated 03/13/14 reflected care plan decisions concerning ADLs and falls, to be care planned: "1. Dependent on staff for all grooming and all personal hygiene due to cognitive impairment... 2. Non ambulatory, uses a Geri chair, has history of falls, and fall risk assessment...." The Care Plan dated 03/20/14 reflected goals for Resident #8 included: "1. (Resident #8) was dependent upon staff for toileting, dressing, and mobility. Approaches included extensive assist of two for bed mobility, dressing, and total dependence for bathing, transfer with mechanical lift...." Further review of Resident #8's care plan dated 03/20/14 revealed no goals or approaches related to fall prevention or undetermined neurological movements. The facility's Point of Care History for CNAs (Activities of Daily Living Sheets for Certified Nurse Aides) reviewed for dates from 03/04/14 through 05/12/14 revealed Resident #8 required extensive to total assist of two staff members for bed mobility, and transferring on all three shifts. Resident #8 was totally dependent, and at times required extensive assistance with the mechanical lift. Resident #8 always required two staff members on all three shifts for dressing and was totally dependent on staff for all mobility. The monthly consolidated Physician order [REDACTED].#8 was to have her bed in the low position with a floor mat in place every shift. A specialty mattress with bolster sides was to be used at all times. The facility's Incident Reporting Logs dated from 03/01/14 through 05/07/14 reflected Resident #8's last fall was in January 2014. The facility's Incident/Accident Report dated 05/12/14 at 5:40 a.m. reflected Resident #8 had fallen from a sitting position on the side of the bed while awaiting transfer. The report reflected Resident #8 was assisted by CNA A when she began shaking. CNA A lost control of Resident #8, and she fell off the bed onto the floor. Resident #8 was assessed by LVN B, with a laceration to the forehead, bruising and a complaint of knee pain. Resident #8 was transferred to the hospital for evaluation. Further review revealed investigation findings and follow-up steps to prevent recurrence due to Resident #8's medical condition of involuntary movements: to continue with the low bed and mat. In addition, the Incident/Accident Report reflected Resident #8 was a two person transfer, but "may need to increase (Resident #8) to a two person assist when getting dressed. Nurses notes dated 03/01/14 through 05/12/14 reflected Resident #8 had fallen to the floor hitting her head and had a notable amount of bleeding from her head. Resident #8 was yelling and shaking, 911 was called and Resident #8 was transferred to the emergency room . On 05/12/14 at 10:00 a.m., Resident #8 returned from the emergency room with steri-strips to her forehead with a small amount of bleeding noted. Discharge instructions from the emergency room for Resident #8 dated 05/12/14 reflected, "(Resident #8) fell from a height, off furniture, approximately three feet earlier this morning. (Resident #8) sustained injury to the head, laceration, 3 cms (centimeters), of the forehead." A Cat Scan (CT) of the cervical spine was completed with results being negative for injury, and the results of a CT of the head reflected Resident #8 had a prominent left frontal scalp injury. Resident #8's final [DIAGNOSES REDACTED]." Observation on initial tour on 05/12/14 at 9:45 a.m. revealed Resident #8 was in her low bed with two staff members in the room. Resident #8 had notable dark bruising to the upper part of her forehead into her left eye, and a fresh laceration with 2-3 steri-strips noted on her forehead, which was oozing blood. An interview on 05/12/14 at 9:45 a.m. with CNA C revealed Resident #8 had just come back from the hospital from a fall during the night. CNA C said she had been told by the night shift CNA Resident #8 fell from sitting on the side of the bed, but that was all she knew. Observation on 05/12/14 at 12:20 p.m. revealed Resident #8 was eating lunch in bed. Resident #8 had a moderate amount of swelling and dark bruising to her forehead and her left eye was swollen and had dark bruising. The surveyor queried Resident #8 concerning her fall and trip to the hospital. Resident #8 said she did not remember falling, or going to the hospital, and she had no pain. An interview conducted on 05/12/14 at 1:50 p.m. with CNA C revealed Resident #8 could only assist herself to eat, everything else had to be done for her. CNA C said Resident #8 "shakes" even when she was in the bed, and if she was moved. CNA C two people were needed when they provided care for her, because Resident #8 had these "shaking" episodes, or "jerking" episodes, and "you" did not know when it was going to happen, but most of the time, it was when she was moved. CNA C said at times, "you" would think she was going to shake right out of the shower chair, even the shower bed. "When we get ready to transfer her, we use the stand-up lift. It is safer than using the Hoyer lift, because of the jerking and shaking." When the surveyor queried further whether CNA C could care for Resident #8 by herself, she replied, absolutely not. An interview was conducted on 05/12/14 at 2:05 p.m. with LVN D. LVN D stated Resident #8 was alert and confused at times. LVN D said one never knew when Resident #8 was going to be alert and understand what was needed, and when she would not, because it could change very quickly. LVN D said Resident #8 was a total care for all ADLs except for eating. In addition, LVN D said Resident #8 was a two person assist with all her ADLs. When the surveyor queried why Resident #8 was a total assist of two, LVN D said Resident #8 had this neurological condition in which she jerks and shakes. Resident #8 had this condition ever since she (LVN D) had been working in the facility, which was approximately five years. LVN D said, "You had better have a hold of (Resident #8) when she starts jerking, even with the mechanical lift, because she can be very difficult." LVN D said, "It is just like this morning. They said she just starting shaking and fell right off the bed." An interview on 05/12/14 at 2:15 p.m. with CNA E revealed Resident #8 was very difficult to move, dress, and transfer. CNA E stated she would never think about trying to take care of Resident #8 by herself. CNA E said Resident #8 had these jerking motions anytime you moved her, and sometimes the motions were worse than other times. An interview on 05/12/14 at 2:30 p.m. with CNA F revealed Resident #8 was very hard to shower and today, she (CNA F) was the shower aide. CNA F stated, "We rotate on who is the shower aide for the day. It takes me and sometimes two other people just to shower her (Resident #8) because we are afraid she is going to fall out of the shower chair or off the shower bed because of her movements. This morning I told somebody I could not believe that another nurse aide tried to care for (Resident #8) by herself. We all know better." An interview conducted on 05/12/14 at 3:30 p.m. with LVN G revealed Resident #8 was a total care resident except for eating, and she was confused in the evenings. LVN G said Resident #8 required the assistance of two staff for all ADLs due to her involuntary movements. LVN G said she had helped the CNAs with Resident #8 on the evening shift many times. An interview was conducted on 05/13/14 at 4:30 a.m. with LVN H. LVN H stated she had been performing neurological checks on Resident #8 for a fall. The surveyor queried LVN H if she was aware of Resident #8's jerking movements. LVN H said she had been a nurse in the facility for about three years, and Resident #8 had those movements for that length of time, sometimes worse than others. LVN H was aware there was supposed to be two staff members when Resident #8 had care given. An interview conducted on 05/13/14 at 4:40 a.m. with CNA A revealed the CNA normally worked on the evening shift, but had volunteered to work the night shift because they needed someone. CNA A said she went into Resident #8's room to get her up and get her ready for breakfast. CNA A said she knew she was supposed to have another staff member to help her, but she did not ask anyone. When the surveyor queried as to why she did not wait to get another staff member, CNA A said she thought she could just do it by herself. CNA A said "(Resident #8) has these jerking movements. That is why we use two people." CNA A said she got Resident #8 dressed and had her up on the side of the bed, and was reaching for the mechanical lift when Resident #8 started jerking really hard and, CNA A said she could not hold onto Resident #8, who fell off the side of the bed and "hit" the floor. CNA A said she felt really bad. She had cared for Resident #8 for a long time, and she knew she was supposed to have two people because of her jerking motions. "I just thought I could do this without somebody (helping)." An interview was conducted on 05/13/14 at 11:05 a.m. with the DON and the facility's only ADON. Both the DON and ADON were aware there was a problem. The DON said normally they took Incident/Accident Reports into the morning stand-up meeting and discuss them, but that morning, the Administrator was busy, so they did not have their morning stand up meeting. The DON said she had spoken to CNA A the day before and started counseling her, but needed to get with the Administrator for him to sign the paper work and talk about the accident. The DON said this was how they would normally handle this type of situation. The DON and ADON both said they were aware of Resident #8's involuntary movements and knew the resident had been a two person assist with all ADLs for a long time. The surveyor reviewed the Incident/Accident Report with the DON, who said she had not had time to look at the entire report. The surveyor brought to the DON's attention, the recommendations indicated to prevent recurrence. The DON said the CNA had not been working at the facility that long, and she did not know Resident #8 was a two person assist for all ADLs, and she needed to be educated. On 05/13/14 at 11:52 a.m., CNA C, CNA I, and CNA J were observed transferring Resident #8 from the Geri-chair to the bed using the stand-up mechanical lift. Incontinent care was performed, and Resident #8's clothing was changed. The surveyor observed during these tasks a large amount of involuntary jerking movements involving Resident #8's arms and legs. The three CNAs involved in the care of Resident #8 said, "You see how it would take two people to help her in order to keep her safe." An interview conducted on 05/13/14 at 12:04 p.m. with LVN B revealed, "(CNA A) came running down the hallway telling me I needed to come to (Resident #8's) room because she had fallen." LVN B said when she got into Resident #8's room, she was lying on the floor face down, and "There was all this blood." LVN B then said there was so much blood, she was unable to really assess Resident #8, so she instructed the staff to stay in the room with the resident, and LVN B went to call 911. The surveyor queried LVN B concerning the type of care the staff assisted Resident #8 with on the night shift. LVN B said she knew Resident #8 could feed herself and she required two people to transfer her. LVN B said she had one person for all other ADLs. LVN B said she had recommended that Resident #8 might need to be a two person assist for dressing now. The surveyor queried if LVN B knew how the CNAs on the night shift assisted Resident #8. LVN B said the CNAs, who worked on the night shift, usually teamed-up and worked together. LVN B said CNA A never did ask her for any assistance with Resident #8 until she came running down the hall to get her (LVN B). Observation on 05/13/14 at 2:59 p.m. with LVN D revealed Resident #8 was lying in bed, her left eye was swollen shut, and there was approximately one cm of dark black and purple bruising surrounding the left eye. Located at the top of the forehead was a three cm laceration. LVN D had cleansed the laceration on Resident #8's forehead and applied addtional steri-strips. LVN D stated the laceration on the forehead had been "glued" at the emergency room , but the wound was still bleeding at times. Further observation of Resident #8's face revealed bruising and swelling between Resident #8's eyes at the bridge of the nose, and a 1.5 cm linear abrasion extending from the right of the [MEDICAL CONDITION], and a 2 cm linear abrasion extending from the left side of the [MEDICAL CONDITION]. Following the surveyor's interviews and observations, the DON initiated an in-service dated 05/13/14 at 2:00 p.m. concerning "providing care according to the level assist needed." The surveyor was informed by the Administrator at that time that CNA A was suspending during his investigation, concerning the fall Resident #8 had. Review of the facility's "Suspension Pending Investigation" dated 05/13/14 revealed CNA A had failed to provide proper assistance to a resident while providing care. CNA A was providing care alone when the resident was a two person assist for all ADLs. The form was signed by CNA A. Review of the "Corrective Action Form" dated 05/13/14 revealed CNA A would provide care as assigned by the nurse and receive 1:1 in-service education, which was also signed by CNA A. A facility In-service dated February 2014 revealed training regarding falls was conducted, which was attended by all staff, including CNA A. A facility in-service dated 03/13/14 reflected training in regard to abuse/neglect was conducted by the Administrator and all staff attended. CNA A was in attendance. An interview with the DON post survey on 05/16/14 at 10:00 a.m. revealed the facility used the "Silver Chair Program" for training on falls. The most recent training completed concerning abuse/neglect was done by the Administrator. The DON said when the facility did training concerning abuse/neglect, they used the handbook titled, "What You Need to Know." The DON said they had never used video tapes for training concerning abuse/neglect, but had given a post test. When the surveyor clarified what the facility's current Policy and Procedure for abuse/neglect was with the DON, she replied, "No. We use the handbook, What You Need To Know, and do a post test." The Abuse, Neglect and Misappropriation Policy and Procedure, dated October 2010 with a revision date of 04/26/12, was provided by the facility on 05/12/14 and reflected: "The facility's leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident... Procedures: ...Component II: Training 1. All new and present employees receive continuous education, training and reinforcement that identifies all aspects of abuse prohibition to include: 2. Education/training materials A. Facility-specific video: Keeping Nursing Home Facility Residents Safe: A training program of Abuse, Mistreatment and Neglect. 1) Module 1 a) Stressful Working environment b) Employees at risk c) Training and education d) Intentional and unintentional harm e) Pre-test 2) Module II a) Definitions and examples of abuse, mistreatment, and nelect b) Laws and regulations and the agencies the enforce them. ...d) Understanding stress... e) Understanding the patient's/residents perspective... f) Group stress relief exercise... ...Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding, unusual occurrences or patterns of trends of potential abuse or neglect. Types of abuse include but not limited to: ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness...." The facility's Form CMS-802, Roster/Sample Matrix provided on 05/12/14 by the DON reflected 17 residents had sustained falls out of the 59 residents identified as high risks for falls.

Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #8) of four residents reviewed for falls. CNA A, who was aware Resident #8 needed two person assistance with her ADLs, attempted to provide care for the resident without assistance, which resulted in the resident falling to the floor, hitting her head, resulting in a closed-head injury and a [MEDICAL CONDITION] requiring treatment at the emergency room . This failure could affect the 59 residents, including Resident #8, who were at high risk for falls and placed them at risk for falls, bruises, fractures, and/or more serious injuries. Findings included: The Abuse, Neglect and Misappropriation Policy and Procedure, dated October 2010 with a revision date of 04/26/12, was provided by the facility on 05/12/14 and reflected: "The facility's leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident... Procedures: ...Component II: Training 1. All new and present employees receive continuous education, training and reinforcement that identifies all aspects of abuse prohibition to include: 2. Education/training materials A. Facility-specific video: Keeping Nursing Home Facility Residents Safe: A training program of Abuse, Mistreatment and Neglect. 1) Module 1 a) Stressful Working environment b) Employees at risk c) Training and education d) Intentional and unintentional harm e) Pre-test 2) Module II a) Definitions and examples of abuse, mistreatment, and nelect b) Laws and regulations and the agencies the enforce them. ...d) Understanding stress... e) Understanding the patient's/residents perspective... f) Group stress relief exercise... ...Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding, unusual occurrences or patterns of trends of potential abuse or neglect. Types of abuse include but not limited to: ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness...." The facility's Resident Admission Record dated 09/05/13 reflected Resident #8 was a [AGE] year-old female admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. The facility's Nursing Data Collection Tool dated 03/11/14 reflected Resident #8 had short term memory problems and was severely impaired for decision-making. The Tool further reflected the areas of the resident's limitations was blank, prior falls in the past 180 days was blank, and how Resident #8 transferred between bed and chair was blank. The Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #8 had a Brief Interview Mental Status (BIMS) score of three, which indicated severe cognitife impairment. The MDS assessment reflected Resident #8 sometimes understood, with difficulty thinking and disorganized thinking that fluctuated. Resident #8 required extensive assistance of two staff members for transfers, dressing, bed mobility, and was totally dependent on staff for bathing. Resident #8 had fallen once since readmission to the facility on [DATE], with no injuries. Resident #8's Fall Risk assessment dated [DATE], and completed by LVN D, reflected a score of 14, which indicated she was a high risk for falls. The Care Area Assessment summary dated 03/13/14 reflected care plan decisions concerning ADLs and falls, to be care planned: "1. Dependent on staff for all grooming and all personal hygiene due to cognitive impairment... 2. Non ambulatory, uses a Geri chair, has history of falls, and fall risk assessment...." The Care Plan dated 03/20/14 reflected goals for Resident #8 included: "1. (Resident #8) was dependent upon staff for toileting, dressing, and mobility. Approaches included extensive assist of two for bed mobility, dressing, and total dependence for bathing, transfer with mechanical lift...." Further review of Resident #8's care plan dated 03/20/14 revealed no goals or approaches related to fall prevention or undetermined neurological movements. The facility's Point of Care History for CNAs (Activities of Daily Living Sheets for Certified Nurse Aides) reviewed for dates from 03/04/14 through 05/12/14 revealed Resident #8 required extensive to total assist of two staff members for bed mobility, and transferring on all three shifts. Resident #8 was totally dependent, and at times required extensive assistance with the mechanical lift. Resident #8 always required two staff members on all three shifts for dressing and was totally dependent on staff for all mobility. The monthly consolidated Physician order [REDACTED].#8 was to have her bed in the low position with a floor mat in place every shift. A specialty mattress with bolster sides was to be used at all times. The facility's Incident Reporting Logs dated from 03/01/14 through 05/07/14 reflected Resident #8's last fall was in January 2014. The facility's Incident/Accident Report dated 05/12/14 at 5:40 a.m. reflected Resident #8 had fallen from a sitting position on the side of the bed while awaiting transfer. The report reflected Resident #8 was assisted by CNA A when she began shaking. CNA A lost control of Resident #8, and she fell off the bed onto the floor. Resident #8 was assessed by LVN B, with a laceration to the forehead, bruising and a complaint of knee pain. Resident #8 was transferred to the hospital for evaluation. Further review revealed investigation findings and follow-up steps to prevent recurrence due to Resident #8's medical condition of involuntary movements: to continue with the low bed and mat. In addition, the Incident/Accident Report reflected Resident #8 was a two person transfer, but "may need to increase (Resident #8) to a two person assist when getting dressed. Nurses notes dated 03/01/14 through 05/12/14 reflected Resident #8 had fallen to the floor hitting her head and had a notable amount of bleeding from her head. Resident #8 was yelling and shaking, 911 was called and Resident #8 was transferred to the emergency room . On 05/12/14 at 10:00 a.m., Resident #8 returned from the emergency room with steri-strips to her forehead with a small amount of bleeding noted. Discharge instructions from the emergency room for Resident #8 dated 05/12/14 reflected, "(Resident #8) fell from a height, off furniture, approximately three feet earlier this morning. (Resident #8) sustained injury to the head, laceration, 3 cms (centimeters), of the forehead." A Cat Scan (CT) of the cervical spine was completed with results being negative for injury, and the results of a CT of the head reflected Resident #8 had a prominent left frontal scalp injury. Resident #8's final [DIAGNOSES REDACTED]." Observation on initial tour on 05/12/14 at 9:45 a.m. revealed Resident #8 was in her low bed with two staff members in the room. Resident #8 had notable dark bruising to the upper part of her forehead into her left eye, and a fresh laceration with 2-3 steri-strips noted on her forehead, which was oozing blood. An interview on 05/12/14 at 9:45 a.m. with CNA C revealed Resident #8 had just come back from the hospital from a fall during the night. CNA C said she had been told by the night shift CNA Resident #8 fell from sitting on the side of the bed, but that was all she knew. Observation on 05/12/14 at 12:20 p.m. revealed Resident #8 was eating lunch in bed. Resident #8 had a moderate amount of swelling and dark bruising to her forehead and her left eye was swollen and had dark bruising. The surveyor queried Resident #8 concerning her fall and trip to the hospital. Resident #8 said she did not remember falling, or going to the hospital, and she had no pain. An interview conducted on 05/12/14 at 1:50 p.m. with CNA C revealed Resident #8 could only assist herself to eat, everything else had to be done for her. CNA C said Resident #8 "shakes" even when she was in the bed, and if she was moved. CNA C two people were needed when they provided care for her, because Resident #8 had these "shaking" episodes, or "jerking" episodes, and "you" did not know when it was going to happen, but most of the time, it was when she was moved. CNA C said at times, "you" would think she was going to shake right out of the shower chair, even the shower bed. "When we get ready to transfer her, we use the stand-up lift. It is safer than using the Hoyer lift, because of the jerking and shaking." When the surveyor queried further whether CNA C could care for Resident #8 by herself, she replied, absolutely not. An interview was conducted on 05/12/14 at 2:05 p.m. with LVN D. LVN D stated Resident #8 was alert and confused at times. LVN D said one never knew when Resident #8 was going to be alert and understand what was needed, and when she would not, because it could change very quickly. LVN D said Resident #8 was a total care for all ADLs except for eating. In addition, LVN D said Resident #8 was a two person assist with all her ADLs. When the surveyor queried why Resident #8 was a total assist of two, LVN D said Resident #8 had this neurological condition in which she jerks and shakes. Resident #8 had this condition ever since she (LVN D) had been working in the facility, which was approximately five years. LVN D said, "You had better have a hold of (Resident #8) when she starts jerking, even with the mechanical lift, because she can be very difficult." LVN D said, "It is just like this morning. They said she just starting shaking and fell right off the bed." An interview on 05/12/14 at 2:15 p.m. with CNA E revealed Resident #8 was very difficult to move, dress, and transfer. CNA E stated she would never think about trying to take care of Resident #8 by herself. CNA E said Resident #8 had these jerking motions anytime you moved her, and sometimes the motions were worse than other times. An interview on 05/12/14 at 2:30 p.m. with CNA F revealed Resident #8 was very hard to shower and today, she (CNA F) was the shower aide. CNA F stated, "We rotate on who is the shower aide for the day. It takes me and sometimes two other people just to shower her (Resident #8) because we are afraid she is going to fall out of the shower chair or off the shower bed because of her movements. This morning I told somebody I could not believe that another nurse aide tried to care for (Resident #8) by herself. We all know better." An interview conducted on 05/12/14 at 3:30 p.m. with LVN G revealed Resident #8 was a total care resident except for eating, and she was confused in the evenings. LVN G said Resident #8 required the assistance of two staff for all ADLs due to her involuntary movements. LVN G said she had helped the CNAs with Resident #8 on the evening shift many times. An interview was conducted on 05/13/14 at 4:30 a.m. with LVN H. LVN H stated she had been performing neurological checks on Resident #8 for a fall. The surveyor queried LVN H if she was aware of Resident #8's jerking movements. LVN H said she had been a nurse in the facility for about three years, and Resident #8 had those movements for that length of time, sometimes worse than others. LVN H was aware there was supposed to be two staff members when Resident #8 had care given. An interview conducted on 05/13/14 at 4:40 a.m. with CNA A revealed the CNA normally worked on the evening shift, but had volunteered to work the night shift because they needed someone. CNA A said she went into Resident #8's room to get her up and get her ready for breakfast. CNA A said she knew she was supposed to have another staff member to help her, but she did not ask anyone. When the surveyor queried as to why she did not wait to get another staff member, CNA A said she thought she could just do it by herself. CNA A said "(Resident #8) has these jerking movements. That is why we use two people." CNA A said she got Resident #8 dressed and had her up on the side of the bed, and was reaching for the mechanical lift when Resident #8 started jerking really hard and, CNA A said she could not hold onto Resident #8, who fell off the side of the bed and "hit" the floor. CNA A said she felt really bad. She had cared for Resident #8 for a long time, and she knew she was supposed to have two people because of her jerking motions. "I just thought I could do this without somebody (helping)." An interview was conducted on 05/13/14 at 11:05 a.m. with the DON and the facility's only ADON. Both the DON and ADON were aware there was a problem. The DON said normally they took Incident/Accident Reports into the morning stand-up meeting and discuss them, but that morning, the Administrator was busy, so they did not have their morning stand up meeting. The DON said she had spoken to CNA A the day before and started counseling her, but needed to get with the Administrator for him to sign the paper work and talk about the accident. The DON said this was how they would normally handle this type of situation. The DON and ADON both said they were aware of Resident #8's involuntary movements and knew the resident had been a two person assist with all ADLs for a long time. The surveyor reviewed the Incident/Accident Report with the DON, who said she had not had time to look at the entire report. The surveyor brought to the DON's attention, the recommendations indicated to prevent recurrence. The DON said the CNA had not been working at the facility that long, and she did not know Resident #8 was a two person assist for all ADLs, and she needed to be educated. On 05/13/14 at 11:52 a.m., CNA C, CNA I, and CNA J were observed transferring Resident #8 from the Geri-chair to the bed using the stand-up mechanical lift. Incontinent care was performed, and Resident #8's clothing was changed. The surveyor observed during these tasks a large amount of involuntary jerking movements involving Resident #8's arms and legs. The three CNAs involved in the care of Resident #8 said, "You see how it would take two people to help her in order to keep her safe." An interview conducted on 05/13/14 at 12:04 p.m. with LVN B revealed, "(CNA A) came running down the hallway telling me I needed to come to (Resident #8's) room because she had fallen." LVN B said when she got into Resident #8's room, she was lying on the floor face down, and "There was all this blood." LVN B then said there was so much blood, she was unable to really assess Resident #8, so she instructed the staff to stay in the room with the resident, and LVN B went to call 911. The surveyor queried LVN B concerning the type of care the staff assisted Resident #8 with on the night shift. LVN B said she knew Resident #8 could feed herself and she required two people to transfer her. LVN B said she had one person for all other ADLs. LVN B said she had recommended that Resident #8 might need to be a two person assist for dressing now. The surveyor queried if LVN B knew how the CNAs on the night shift assisted Resident #8. LVN B said the CNAs, who worked on the night shift, usually teamed-up and worked together. LVN B said CNA A never did ask her for any assistance with Resident #8 until she came running down the hall to get her (LVN B). Observation on 05/13/14 at 2:59 p.m. with LVN D revealed Resident #8 was lying in bed, her left eye was swollen shut, and there was approximately one cm of dark black and purple bruising surrounding the left eye. Located at the top of the forehead was a three cm laceration. LVN D had cleansed the laceration on Resident #8's forehead and applied addtional steri-strips. LVN D stated the laceration on the forehead had been "glued" at the emergency room , but the wound was still bleeding at times. Further observation of Resident #8's face revealed bruising and swelling between Resident #8's eyes at the bridge of the nose, and a 1.5 cm linear abrasion extending from the right of the [MEDICAL CONDITION], and a 2 cm linear abrasion extending from the left side of the [MEDICAL CONDITION]. Following the surveyor's interviews and observations, the DON initiated an in-service dated 05/13/14 at 2:00 p.m. concerning "providing care according to the level assist needed." The surveyor was informed by the Administrator at that time that CNA A was suspending during his investigation, concerning the fall Resident #8 had. Review of the facility's "Suspension Pending Investigation" dated 05/13/14 revealed CNA A had failed to provide proper assistance to a resident while providing care. CNA A was providing care alone when the resident was a two person assist for all ADLs. The form was signed by CNA A. Review of the "Corrective Action Form" dated 05/13/14 revealed CNA A would provide care as assigned by the nurse and receive 1:1 in-service education, which was also signed by CNA A. A facility In-service dated February 2014 revealed training regarding falls was conducted, which was attended by all staff, including CNA A. A facility in-service dated 03/13/14 reflected training in regard to abuse/neglect was conducted by the Administrator and all staff attended. CNA A was in attendance. An interview with the DON post survey on 05/16/14 at 10:00 a.m. revealed the facility used the "Silver Chair Program" for training on falls. The most recent training completed concerning abuse/neglect was done by the Administrator. The DON said when the facility did training concerning abuse/neglect, they used the handbook titled, "What You Need to Know." The DON said they had never used video tapes for training concerning abuse/neglect, but had given a post test. When the surveyor clarified what the facility's current Policy and Procedure for abuse/neglect was with the DON, she replied, "No. We use the handbook, What You Need To Know, and do a post test." The facility's Form CMS-802, Roster/Sample Matrix provided on 05/12/14 by the DON reflected 17 residents had sustained falls out of the 59 residents identified as high risks for falls.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #8) of four residents reviewed for falls. CNA A, who was aware Resident #8 needed two person assistance with her ADLs, attempted to provide care for the resident without assistance, which resulted in the resident falling to the floor, hitting her head, resulting in a closed-head injury and a forehead laceration requiring treatment at the emergency room . This failure could affect the 59 residents, including Resident #8, who were at high risk for falls and placed them at risk for falls, bruises, fractures, and/or more serious injuries. Findings included: The facility's Resident Admission Record dated 09/05/13 reflected Resident #8 was a [AGE] year-old female admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. The facility's Nursing Data Collection Tool dated 03/11/14 reflected Resident #8 had short term memory problems and was severely impaired for decision-making. The Tool further reflected the areas of the resident's limitations was blank, prior falls in the past 180 days was blank, and how Resident #8 transferred between bed and chair was blank. The Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #8 had a Brief Interview Mental Status (BIMS) score of three, which indicated severe cognitife impairment. The MDS assessment reflected Resident #8 sometimes understood, with difficulty thinking and disorganized thinking that fluctuated. Resident #8 required extensive assistance of two staff members for transfers, dressing, bed mobility, and was totally dependent on staff for bathing. Resident #8 had fallen once since readmission to the facility on [DATE], with no injuries. Resident #8's Fall Risk assessment dated [DATE], and completed by LVN D, reflected a score of 14, which indicated she was a high risk for falls. The Care Area Assessment summary dated 03/13/14 reflected care plan decisions concerning ADLs and falls, to be care planned: "1. Dependent on staff for all grooming and all personal hygiene due to cognitive impairment... 2. Non ambulatory, uses a Geri chair, has history of falls, and fall risk assessment...." The Care Plan dated 03/20/14 reflected goals for Resident #8 included: "1. (Resident #8) was dependent upon staff for toileting, dressing, and mobility. Approaches included extensive assist of two for bed mobility, dressing, and total dependence for bathing, transfer with mechanical lift...." Further review of Resident #8's care plan dated 03/20/14 revealed no goals or approaches related to fall prevention or undetermined neurological movements. The facility's Point of Care History for CNAs (Activities of Daily Living Sheets for Certified Nurse Aides) reviewed for dates from 03/04/14 through 05/12/14 revealed Resident #8 required extensive to total assist of two staff members for bed mobility, and transferring on all three shifts. Resident #8 was totally dependent, and at times required extensive assistance with the mechanical lift. Resident #8 always required two staff members on all three shifts for dressing and was totally dependent on staff for all mobility. The monthly consolidated Physician order [REDACTED].#8 was to have her bed in the low position with a floor mat in place every shift. A specialty mattress with bolster sides was to be used at all times. The facility's Incident Reporting Logs dated from 03/01/14 through 05/07/14 reflected Resident #8's last fall was in January 2014. The facility's Incident/Accident Report dated 05/12/14 at 5:40 a.m. reflected Resident #8 had fallen from a sitting position on the side of the bed while awaiting transfer. The report reflected Resident #8 was assisted by CNA A when she began shaking. CNA A lost control of Resident #8, and she fell off the bed onto the floor. Resident #8 was assessed by LVN B, with a laceration to the forehead, bruising and a complaint of knee pain. Resident #8 was transferred to the hospital for evaluation. Further review revealed investigation findings and follow-up steps to prevent recurrence due to Resident #8's medical condition of involuntary movements: to continue with the low bed and mat. In addition, the Incident/Accident Report reflected Resident #8 was a two person transfer, but "may need to increase (Resident #8) to a two person assist when getting dressed. Nurses notes dated 03/01/14 through 05/12/14 reflected Resident #8 had fallen to the floor hitting her head and had a notable amount of bleeding from her head. Resident #8 was yelling and shaking, 911 was called and Resident #8 was transferred to the emergency room . On 05/12/14 at 10:00 a.m., Resident #8 returned from the emergency room with steri-strips to her forehead with a small amount of bleeding noted. Discharge instructions from the emergency room for Resident #8 dated 05/12/14 reflected, "(Resident #8) fell from a height, off furniture, approximately three feet earlier this morning. (Resident #8) sustained injury to the head, laceration, 3 cms (centimeters), of the forehead." A Cat Scan (CT) of the cervical spine was completed with results being negative for injury, and the results of a CT of the head reflected Resident #8 had a prominent left frontal scalp injury. Resident #8's final [DIAGNOSES REDACTED]." Observation on initial tour on 05/12/14 at 9:45 a.m. revealed Resident #8 was in her low bed with two staff members in the room. Resident #8 had notable dark bruising to the upper part of her forehead into her left eye, and a fresh laceration with 2-3 steri-strips noted on her forehead, which was oozing blood. An interview on 05/12/14 at 9:45 a.m. with CNA C revealed Resident #8 had just come back from the hospital from a fall during the night. CNA C said she had been told by the night shift CNA Resident #8 fell from sitting on the side of the bed, but that was all she knew. Observation on 05/12/14 at 12:20 p.m. revealed Resident #8 was eating lunch in bed. Resident #8 had a moderate amount of swelling and dark bruising to her forehead and her left eye was swollen and had dark bruising. The surveyor queried Resident #8 concerning her fall and trip to the hospital. Resident #8 said she did not remember falling, or going to the hospital, and she had no pain. An interview conducted on 05/12/14 at 1:50 p.m. with CNA C revealed Resident #8 could only assist herself to eat, everything else had to be done for her. CNA C said Resident #8 "shakes" even when she was in the bed, and if she was moved. CNA C two people were needed when they provided care for her, because Resident #8 had these "shaking" episodes, or "jerking" episodes, and "you" did not know when it was going to happen, but most of the time, it was when she was moved. CNA C said at times, "you" would think she was going to shake right out of the shower chair, even the shower bed. "When we get ready to transfer her, we use the stand-up lift. It is safer than using the Hoyer lift, because of the jerking and shaking." When the surveyor queried further whether CNA C could care for Resident #8 by herself, she replied, absolutely not. An interview was conducted on 05/12/14 at 2:05 p.m. with LVN D. LVN D stated Resident #8 was alert and confused at times. LVN D said one never knew when Resident #8 was going to be alert and understand what was needed, and when she would not, because it could change very quickly. LVN D said Resident #8 was a total care for all ADLs except for eating. In addition, LVN D said Resident #8 was a two person assist with all her ADLs. When the surveyor queried why Resident #8 was a total assist of two, LVN D said Resident #8 had this neurological condition in which she jerks and shakes. Resident #8 had this condition ever since she (LVN D) had been working in the facility, which was approximately five years. LVN D said, "You had better have a hold of (Resident #8) when she starts jerking, even with the mechanical lift, because she can be very difficult." LVN D said, "It is just like this morning. They said she just starting shaking and fell right off the bed." An interview on 05/12/14 at 2:15 p.m. with CNA E revealed Resident #8 was very difficult to move, dress, and transfer. CNA E stated she would never think about trying to take care of Resident #8 by herself. CNA E said Resident #8 had these jerking motions anytime you moved her, and sometimes the motions were worse than other times. An interview on 05/12/14 at 2:30 p.m. with CNA F revealed Resident #8 was very hard to shower and today, she (CNA F) was the shower aide. CNA F stated, "We rotate on who is the shower aide for the day. It takes me and sometimes two other people just to shower her (Resident #8) because we are afraid she is going to fall out of the shower chair or off the shower bed because of her movements. This morning I told somebody I could not believe that another nurse aide tried to care for (Resident #8) by herself. We all know better." An interview conducted on 05/12/14 at 3:30 p.m. with LVN G revealed Resident #8 was a total care resident except for eating, and she was confused in the evenings. LVN G said Resident #8 required the assistance of two staff for all ADLs due to her involuntary movements. LVN G said she had helped the CNAs with Resident #8 on the evening shift many times. An interview was conducted on 05/13/14 at 4:30 a.m. with LVN H. LVN H stated she had been performing neurological checks on Resident #8 for a fall. The surveyor queried LVN H if she was aware of Resident #8's jerking movements. LVN H said she had been a nurse in the facility for about three years, and Resident #8 had those movements for that length of time, sometimes worse than others. LVN H was aware there was supposed to be two staff members when Resident #8 had care given. An interview conducted on 05/13/14 at 4:40 a.m. with CNA A revealed the CNA normally worked on the evening shift, but had volunteered to work the night shift because they needed someone. CNA A said she went into Resident #8's room to get her up and get her ready for breakfast. CNA A said she knew she was supposed to have another staff member to help her, but she did not ask anyone. When the surveyor queried as to why she did not wait to get another staff member, CNA A said she thought she could just do it by herself. CNA A said "(Resident #8) has these jerking movements. That is why we use two people." CNA A said she got Resident #8 dressed and had her up on the side of the bed, and was reaching for the mechanical lift when Resident #8 started jerking really hard and, CNA A said she could not hold onto Resident #8, who fell off the side of the bed and "hit" the floor. CNA A said she felt really bad. She had cared for Resident #8 for a long time, and she knew she was supposed to have two people because of her jerking motions. "I just thought I could do this without somebody (helping)." An interview was conducted on 05/13/14 at 11:05 a.m. with the DON and the facility's only ADON. Both the DON and ADON were aware there was a problem. The DON said normally they took Incident/Accident Reports into the morning stand-up meeting and discuss them, but that morning, the Administrator was busy, so they did not have their morning stand up meeting. The DON said she had spoken to CNA A the day before and started counseling her, but needed to get with the Administrator for him to sign the paper work and talk about the accident. The DON said this was how they would normally handle this type of situation. The DON and ADON both said they were aware of Resident #8's involuntary movements and knew the resident had been a two person assist with all ADLs for a long time. The surveyor reviewed the Incident/Accident Report with the DON, who said she had not had time to look at the entire report. The surveyor brought to the DON's attention, the recommendations indicated to prevent recurrence. The DON said the CNA had not been working at the facility that long, and she did not know Resident #8 was a two person assist for all ADLs, and she needed to be educated. On 05/13/14 at 11:52 a.m., CNA C, CNA I, and CNA J were observed transferring Resident #8 from the Geri-chair to the bed using the stand-up mechanical lift. Incontinent care was performed, and Resident #8's clothing was changed. The surveyor observed during these tasks a large amount of involuntary jerking movements involving Resident #8's arms and legs. The three CNAs involved in the care of Resident #8 said, "You see how it would take two people to help her in order to keep her safe." An interview conducted on 05/13/14 at 12:04 p.m. with LVN B revealed, "(CNA A) came running down the hallway telling me I needed to come to (Resident #8's) room because she had fallen." LVN B said when she got into Resident #8's room, she was lying on the floor face down, and "There was all this blood." LVN B then said there was so much blood, she was unable to really assess Resident #8, so she instructed the staff to stay in the room with the resident, and LVN B went to call 911. The surveyor queried LVN B concerning the type of care the staff assisted Resident #8 with on the night shift. LVN B said she knew Resident #8 could feed herself and she required two people to transfer her. LVN B said she had one person for all other ADLs. LVN B said she had recommended that Resident #8 might need to be a two person assist for dressing now. The surveyor queried if LVN B knew how the CNAs on the night shift assisted Resident #8. LVN B said the CNAs, who worked on the night shift, usually teamed-up and worked together. LVN B said CNA A never did ask her for any assistance with Resident #8 until she came running down the hall to get her (LVN B). Observation on 05/13/14 at 2:59 p.m. with LVN D revealed Resident #8 was lying in bed, her left eye was swollen shut, and there was approximately one cm of dark black and purple bruising surrounding the left eye. Located at the top of the forehead was a three cm laceration. LVN D had cleansed the laceration on Resident #8's forehead and applied addtional steri-strips. LVN D stated the laceration on the forehead had been "glued" at the emergency room , but the wound was still bleeding at times. Further observation of Resident #8's face revealed bruising and swelling between Resident #8's eyes at the bridge of the nose, and a 1.5 cm linear abrasion extending from the right of the forehead laceration, and a 2 cm linear abrasion extending from the left side of the forehead laceration. Following the surveyor's interviews and observations, the DON initiated an in-service dated 05/13/14 at 2:00 p.m. concerning "providing care according to the level assist needed." The surveyor was informed by the Administrator at that time that CNA A was suspending during his investigation, concerning the fall Resident #8 had. Review of the facility's "Suspension Pending Investigation" dated 05/13/14 revealed CNA A had failed to provide proper assistance to a resident while providing care. CNA A was providing care alone when the resident was a two person assist for all ADLs. The form was signed by CNA A. Review of the "Corrective Action Form" dated 05/13/14 revealed CNA A would provide care as assigned by the nurse and receive 1:1 in-service education, which was also signed by CNA A. A facility In-service dated February 2014 revealed training regarding falls was conducted, which was attended by all staff, including CNA A. A facility in-service dated 03/13/14 reflected training in regard to abuse/neglect was conducted by the Administrator and all staff attended. CNA A was in attendance. An interview with the DON post survey on 05/16/14 at 10:00 a.m. revealed the facility used the "Silver Chair Program" for training on falls. The most recent training completed concerning abuse/neglect was done by the Administrator. The DON said when the facility did training concerning abuse/neglect, they used the handbook titled, "What You Need to Know." The DON said they had never used video tapes for training concerning abuse/neglect, but had given a post test. When the surveyor clarified what the facility's current Policy and Procedure for abuse/neglect was with the DON, she replied, "No. We use the handbook, What You Need To Know, and do a post test." The Abuse, Neglect and Misappropriation Policy and Procedure, dated October 2010 with a revision date of 04/26/12, was provided by the facility on 05/12/14 and reflected: "The facility's leadership will implement appropriate and necessary guidelines, which prohibit the mistreatment, neglect, and abuse of the patient/resident... Procedures: ...Component II: Training 1. All new and present employees receive continuous education, training and reinforcement that identifies all aspects of abuse prohibition to include: 2. Education/training materials A. Facility-specific video: Keeping Nursing Home Facility Residents Safe: A training program of Abuse, Mistreatment and Neglect. 1) Module 1 a) Stressful Working environment b) Employees at risk c) Training and education d) Intentional and unintentional harm e) Pre-test 2) Module II a) Definitions and examples of abuse, mistreatment, and nelect b) Laws and regulations and the agencies the enforce them. ...d) Understanding stress... e) Understanding the patient's/residents perspective... f) Group stress relief exercise... ...Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding, unusual occurrences or patterns of trends of potential abuse or neglect. Types of abuse include but not limited to: ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness...." The facility's Form CMS-802, Roster/Sample Matrix provided on 05/12/14 by the DON reflected 17 residents had sustained falls out of the 59 residents identified as high risks for falls.