Every finding on record at Midland Medical Lodge

Based on observation, interviews and record reviews, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 6 of 28 residents (#11, #37, #83, #87, #96 and #103) who were reviewed for call light response and within reach in that the facility. 1. The facility failed to place Residents #11, #87 and #96's call lights within reach. 2. The facility failed to deliver timely call light response for Residents #37, #83 and #103. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. Findings included: Resident #11 Record review of Resident #11's admission record dated 08/21/2025 indicated she was admitted to the facility on [DATE] with diagnoses of quadriplegia (partial or complete paralysis of both the arms and legs), chronic respiratory failure, tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe), gastrostomy (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression), muscle weakness, and seizures. She was [AGE] years of age. Record review of Resident #11's annual MDS assessment dated [DATE] revealed a Cognitive Skills for Daily Decision Making score of 3, Severely impaired - never/rarely made decisions. Record review of Resident #11's care plan revealed she had an ADL (activities of daily living) performance deficit related to quadriplegia and decreased movement to all extremities. It was revealed that staff were to encourage the resident to use bell to call for assistance and touch pad call light to keep at residents reach to call for assistance. In an observation on 08/21/25 at 09:11 AM, revealed Resident #11 was in bed, watching tv. The call pad was hanging off the left side rail. In an observation and interview on 08/21/2025 at 09:25 AM, revealed Resident #11 was in bed, watching tv. The call pad was hanging off the left side rail. The DON said Resident #11 would not be able to reach the call pad where it was. The DON placed the pad on Resident #11's chest, between her hands. The DON said sometimes the staff forgot to place call bells within reach of the residents after moving them or making the bed. Resident #87 Record review of Resident #87's admission record dated 08/21/2025 indicated he was admitted to the facility on [DATE] with diagnoses of dementia, reduced mobility, history of falling, and muscle weakness. He was [AGE] years of age. Record review of Resident #87's annual MDS assessment dated [DATE] revealed a BIMS score of 02, his cognitive ability was severely impaired. Mobility devices = Wheelchair. He needed substantial/maximal assistance for eating, oral hygiene, toileting, showering, and dressing. Bladder and bowel: Urinary/bowel continence = always incontinent. Record review of Resident #87's care plan dated 05/27/2025 revealed he had difficulty communicating related to a cerebral vascular accident (interruption of blood flow to the brain) with memory deficits. It said that staff needed to ensure and provide a safe environment with the call light in reach, adequate low glare light, bed in lowest position and wheels locked, and to avoid isolation. The care plan reflected that Resident #87 had a history of falling and was at risk for falls. The care plan reflected staff needed to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. said the care plan reflected the resident needed prompt response to all requests for assistance and the resident needed a safe environment with a working and reachable call light. In an observation and interview on 08/21/25 at 09:13 AM, revealed Resident #87 was sitting in his wheelchair on the right side of his bed. The resident was asked if he knew where his call light was, he answered no. The call light was at the head of the bed on the left side. In an observation and interview on 08/21/2025 at 09:25 AM, revealed Resident #87 was sitting in his wheelchair on the right side of the bed. The call light was on the bed. The DON asked Resident #87 if he wanted the call light on his chest. He said yes, the DON placed the light on his chest. The DON said sometimes the staff forget to place call bells within reach of the residents after moving them or making the bed. Resident #96 Record review of Resident #96's admission record dated 08/21/2025 indicated she was admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of conditions that affect movement and posture), reduced mobility, muscle weakness, muscle wasting and muscle atrophy. She was [AGE] years of age. Record review of Resident #96's annual MDS assessment dated [DATE] revealed a BIMS score of 03, her cognitive ability was severely impaired. Mobility devices = Wheelchair. She was dependent on staff for eating, oral hygiene, toileting, showering, and dressing. Bladder and bowel: Urinary/bowel continence = always incontinent. Record review of Resident #96's care plan dated 6/25/2025 revealed she was at risk for falls due to cerebral palsy. The care plan reflected the staff needed to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan reflected the resident needed prompt response to all requests for assistance. The care plan reflected the she had an ADL performance deficit related to cerebral palsy and limited range of motion. It was revealed that staff were to encourage the resident to use bell to call for assistance and touch pad call used for assistance. In an observation and interview on 08/20/25 at 10:31 AM, revealed a procedure on the roommate of Resident #96 was being observed by the surveyor. CNA D knocked on the door, entered, and asked LVN B if he needed something because the call light was on. LVN B responded no and asked if it was Resident #96's light. CNA D responded No, it is not in her hand. before exiting the room. Resident #96 was observed in her wheelchair on the left side of the bed and the call pad was hanging in between the seat and the right wheel of the wheelchair. At 10:48 AM LVN B exited the room. The call pad for Resident #96 was hanging in between the seat and the right wheel of the wheelchair. At 10:55 AM LVN B entered the room again to perform another procedure for the roommate of Resident #96. At 10:56 AM LVN B said he was not sure why the call light kept going off, then exited the room. Resident #96's call pad was hanging in between the seat and the right wheel of the wheelchair. In observations on 08/20/25 at 11:08 AM and 11:17 AM, revealed Resident #96 remained in her wheelchair and the call pad remained in between the seat and right wheel of her wheelchair. In an observation on 08/20/25 at 2:35 PM, revealed Resident #96 was in her wheelchair on the left side of the bed. The call pad was on the bed. In an interview on 08/20/25 at 2:37 PM with LVN B, he said Resident #96 could push the call pad if it was placed real close. In an observation on 08/20/25 at 2:47 PM, revealed Resident #96 remained in her wheelchair on the left side of the bed. The call pad remained on the bed. In an interview with the DON, she said Resident #96 could push the call pad if it was placed close to her hands. In observations on 08/20/25 at 4:15 PM and 4:42 PM, revealed Resident #96 was in bed on her left side. The call pad was placed on the right side of the head of the bed. In an observation and on 08/21/25 at 9:11 AM, revealed Resident #96 was in her wheelchair on the left side of the bed. The call pad was on the bed. In an observation and interview on 08/21/2025 at 09:25 AM, revealed Resident #96 was in her wheelchair on the left side of the bed. The call pad was on the bed. The DON said Resident #96 would not be able to reach the call pad where it was. The DON placed the pad on Resident #96's chest, between her hands. The DON said sometimes the staff forget to place call bells within reach of the residents after moving them or making the bed. Resident #37 Record review of Resident #37's admission record dated 08/21/2025 indicated he was admitted to the facility on [DATE] with diagnoses of shortness of breath, difficulty in walking and unsteadiness on feet. He was [AGE] years of age. Record review of Resident #37's quarterly MDS assessment dated [DATE] revealed a BIMS score of 08 indicating he was moderately impaired. Mobility devices = Wheelchair. Resident required supervision or touching assistance for chair/bed-to-chair transfer and toilet transfer. Record review of Resident #37's care plan dated 08/03/2025 revealed the resident is at risk for falls due to new environment and/or age. The resident will be free of falls through the review date. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a safe environment with: Clutter free, reachable call light, the bed in low position at night. In an interview on 08/19/25 at 11:58 AM Resident #37 said the night shift aides did not do their job and that they took a long time to answer the call lights. The resident said he clocked them when his roommate Resident # 87 pressed his call light and they took about an hour and half to answer it. Resident #37 said he had seen the lights on the hallway and the aides were just sitting elsewhere and not answering the lights. Resident #37 said he had voiced his complaints to the administration people but that nothing was done about it. In an interview on 8/19/25 at 4:01 p.m. Resident #37 stated there were nights when he could not sleep and he would get up to work puzzles in the day room and there would be 4 or 5 call lights going off. Resident #37 said there was no one on the hall whatsoever because the aides were all in the break room. Resident #37 stated he had been telling the DON and the Administrator for he didn't know how long but nothing was done about it. Resident #37 added Who did we not tell? Resident #83 Review of Resident #83's admission Record, dated 8/21/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of permanent disorders of the development of movement and posture, causing activity limitation including difficulty with holding things), feeding difficulties, hemiplegia (one side paralysis), and need for assistance with personal care. Review of Resident #83's Quarterly MDS assessment, dated 6/29/25, revealed:He had a mental status interview score of 15 of 15, indicating he was cognitively intact.Resident #83 was completely dependent on staff for all ADL care including eating and chair/bed-to-chair transfers. Resident #83 used a motorized wheelchair.Resident #83 was frequently incontinent of bowel and bladder. Review of Resident #83's Care Plan Report, saved 8/21/25, revealed problems:Dated 3/18/24 Problem: Resident requires assist with ADL's.Goal: Resident is able to perform self-care to optimal level and maintain strength and endurance for 90 days. Revised 7/26/25.Interventions included: Hoyer lift for all transfers.Problem 7/25/25 The resident has limited physical mobility related to cerebral palsy and poor trunk control. May have pancake call like to enable resident to utilize call light himself as desired.Goal: The resident will remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin break down, fall related injury through the next review date. Interventions included provide supportive care, assistance with mobility as needed. Problem 3/18/24:The resident is at risk for falls due to new environment end or age. No other indicators that would suggest high fall risk. Date initiated 03/18/2024Goal: the resident will be free of falls through the review dateinterventions included: the be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response for all requests for assistance. Interview on 8/19/25 at 4:01 PM Resident #83 revealed it could take up to an hour for the call light to be answered on the night shift. Resident #83 stated he had no idea why it took so long. Resident #83 stated it was some of the day rotations as well. Resident #83 shared that the only way to get help sometimes was to get his roommate to go get help. Resident #83's roommate was present and confirmed that happened. Resident #83 stated it made him angry because the staff were not paying attention, or he was told they were too busy. Resident #83 stated he knew the staff were doing the best they could, but their best could bet better. Resident #83 said on the days there were days when two aides could not handle his hall. Resident #83 stated he thought it took so long because he was a two-person assist for everything and if both people were working, there would be no one on the hall to help everyone else. Resident #83 stated he had aides tell him it was not their job to help him. Resident #83 said that was especially true when he had to eat in his room. Resident #103 Record review of Resident #103's admission record dated 08/20/2025 indicated she was admitted to the facility on [DATE] with diagnoses of quadriplegia (a pattern of paralysis which is when someone can't deliberately control or move their muscles that can affect someone from the neck down)and lack of coordination. She was [AGE] years of age. Record review of Resident #103's significant change MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident was cognitively intact. Mobility devices = Wheelchair. She was dependent Helper does ALL of the effort. Resident does none of the effort to complete the activity for . eating, oral hygiene, toileting, showering and dressing. Bladder and bowel: Urinary continence = resident had a catheter. Bowel continence = always incontinent. Record review of Resident #103's care plan dated 07/02/2025 revealed Resident has a history of falling. Anticipate and meet resident needs. Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. At risk for contractures- Reposition every two hours and prn. In an interview on 08/19/2025 at 3:20 PM Resident #103 said the staff would take a long time to answer her call light. She said that at times it was from breakfast time like 8am until lunchtime which was around noon time. Resident #103 said she had no complaints about the staff but that she felt bad that the staff would ignore her call light for such a long time. Resident #103 said she was totally dependent on staff to help her as she was paralyzed from the neck down and needed help with even getting a drink of water. Resident #103 said most of the times it was something minor that she needed help with such as repositioning her pillow so if the staff went in to help her with that it wouldn't take them that long. The resident said she believed the staff did not answer her call light was because they thought it was probably something minor that she needed help with which unfortunately was probably true, but she still needed their help. Resident #103 said that this would occur about every other day, and it would mostly occur on the day shift but sometimes also on the evening shift. In an interview on 08/20/2025 2:05 PM CNA A said she had been working at the facility since June 2024. The CNA said she and another CNA were working hall 200 and would both answer the call lights. CNA A said she normally answered a call light within 5 to 10 minutes which she considered a fair amount of time for the resident to wait for assistance. In an interview on 08/20/2025 2:10 PM CNA F said she had been working at the facility since February 2025. CNA F said she would try to answer the call light as soon as possible. CNA F said she considered 5 to 10 minutes a fair amount time to answer the call light. In an interview on 08/20/2025 at 6:22 PM with CNA H said that she worked the night shift which was from 6pm to 6am. CNA H said answering a call light within 5 minutes was what she considered a fair amount time for the resident to wait to be attended. CNA H said she believed she was answering the call lights timely. In an interview on 08/20/2025 at 6:25 PM with CNA I said that she worked the night shift which was from 6pm to 6am. CNA I said answering a call light within 5 to 10 minutes was what she considered a fair amount time for the resident to wait to be attended. CNA I said she believed that she was able to answer her call lights timely and not heard residents complain about left waiting too long for their light to be answered. In an interview on 08/21/2025 at 5:02 PM the DON and the Administrator said they considered a call light being answered timely within 15 minutes and that was depending on what staff were doing at the time the call light was on. The DON and Administrator said they would expect for staff to answer the call lights as soon as possible. They said they were not aware that the call lights were being left on for over an hour. Record review of the resident council meeting form dated June 26, 2025, indicated in part: Residents state some are not getting changed in a timely manner wait 30 minutes or more. Record review of the Call Lights policy (undated) read in part Answer call light promptly; especially if it involves the bathroom light. The call light must always be within resident's reach before you leave the room.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #11 and #71) of 5 residents reviewed for infection control in that: The facility failed to ensure LVN B used PPE during PEG tube (percutaneous endoscopic gastrostomy tube-a feeding tube inserted through the abdominal wall into the stomach) care for Resident #11 as the resident was on EBP (enhanced barrier precautions). The facility failed to ensure LVN B sanitized the glucometer with an appropriate sanitizing item after performing a blood sugar test on Resident #71. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: Resident #11 Record review of Resident #11's admission record dated 08/21/2025 indicated she was admitted to the facility on [DATE] with diagnoses of quadriplegia (partial or complete paralysis of both the arms and legs), chronic respiratory failure, tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe), gastrostomy (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression), muscle weakness, and seizures. She was [AGE] years of age. Record review of Resident #11's annual MDS assessment dated [DATE] revealed a Cognitive Skills for Daily Decision Making score of 3, Severely impaired - never/rarely made decisions. Record review of Resident #11's care plan revealed she required a PEG tube for adequate nutritional intake. It was revealed that EBP was implemented due to risk of infection. The care plan revealed she has a tracheostomy related to impaired breathing mechanics. It was revealed that EBP was implemented due to risk of infection. During an observation on 08/20/2025 at 10:48 AM, revealed LVN B entered Resident #11's room, washed his hands, and put gloves on. He performed the PEG tube placement check and residual check. He did not put on any type of PPE such as a gown except gloves during the process. There was an EBP posting outside the door for Resident #11. The EBP posting indicated to use a gown and gloves and the resident was on enhanced barrier precautions. During an interview on 08/20/2025 at 4:46 PM, LVN B stated he did not forget to put on a gown. He said he did not consider PEG tube placement and residual checks high-contact resident care. He said he does gown up when changing PEG tube dressings. During an interview on 08/20/2025 at 5:23 PM, the DON/Infection Preventionist (IP) said she did consider PEG tube placement and residual checks to be high-contact resident care. Record Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated in part: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (multi drug-resistant organisms) to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted (Centers of Disease Control) MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Resident #71 Record review of Resident #71's admission record dated 08/21/2025 indicated he was admitted to the facility on [DATE] with diagnosis of diabetes. He was [AGE] years of age. Record review of Resident #11's care plan dated 05/27/2025 revealed The resident has Diabetes Mellitus - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During an observation and interview on 08/21/2025 at 11:24 AM revealed LVN B performed a blood sugar check for Resident #71 using a glucometer. After the LVN had performed the blood sugar check he returned to his cart and cleaned the glucometer with an alcohol prep pad. The LVN was asked if he normally sanitized the glucometer with an alcohol pad and he replied yes. LVN B said as far as he knew that was an appropriate way to sanitize the glucometer. The LVN was in the process of entering another resident's room to perform a blood sugar check with the same glucometer he had just used on Resident #71 when the surveyor intervened and asked the LVN to stop. LVN B looked in his medication cart and found some germicidal bleach wipes and proceeded to sanitize the glucometer before proceeding to perform another blood sugar check. (A glucometer is a device used to test a person's sugar level by applying a drop of blood unto a test strip that is inserted in the glucometer). During an interview on 08/21/2025 at 5:05 PM the DON said the nurses were expected to use a germicidal wipe to sanitize the glucometers in between resident's blood sugar checks. The DON was made aware of a nurse using an alcohol pad to sanitize the glucometer. The DON said she believed the alcohol pad was an appropriate way to sanitize the glucometer. The DON said she was not sure what their policy indicated but that she would look. Record review of the facility's undated policy and titled Glucometer policy indicated in part: It is the policy of our facilities that the glucometer be cleaned after each use. This procedure will ensure that any area of the glucometer that could possibly come in contact with blood will be cleaned properly to avoid any possible chance of cross-contamination. Each glucometer will be cleaned with an alcohol-free cleaning product that is a germicidal, viricidal and anti-bacterial agent. After each use the glucometer is to be c leaned with an approved alcohol-free cleaning product. Sani-cloth is used in our facilities as the cleaning product of choice for our glucometers. Record review of the CDC's website on 08/21/2025, the website indicated in part: Do not share blood glucose meters. If you must share them in a healthcare or congregate setting, select a device designed for use in professional settings, not an over-the-counter device. Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions. These recommendations apply in: Long-term care settings (e.g., nursing homes and assisted living facilities). https://www.cdc.gov/injection-safety/hcp/infection-control/index.html. Record review of the glucometer's manufacturers recommendation indicated in part: Your EvenCare G2 Meter and lancing device are validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products are validated for disinfecting the EvenCare G2 meter and lancing device. Hospital Cleaner Disinfectant Towels with Bleach, Medline Micro-Kill + Disinfecting, Deodorizing, Cleaning Wipes with Alcohol, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes, Medline Micro-Kill Bleach Germicidal Bleach Wipes.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 nurse medication carts (Hall 200 cart) reviewed for medication storage and security. The 200-hall nurse medication cart was left unlocked while unsupervised. These failures could place clients at risk for drug diversion or accidental ingestion. The findings included: Record review of Resident #115's admission record dated 08/21/2025 indicated she was admitted to the facility on [DATE] with diagnosis of diabetes. She was [AGE] years of age. Record review of Resident #115's order summary report indicated in part: (Insulin Lispro) Inject as per sliding scale: if 60 - 200 = 0 No insulin; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 499 = 10 units Contact MD subcutaneously before meals for diabetes. Order date 07/25/2025. Record review of Resident #115's care plan dated 04/21/2025 revealed The resident has Diabetes Mellitus - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. During an observation on 08/21/2025 at 11:38 AM revealed RN G performed a blood sugar check for Resident #115 in her room. RN G took the items needed from his medication cart then entered the resident's room. The medication cart was left unlocked as the RN did not press the lock cylinder back into the medication cart. RN G entered the room and the cart was out of his sight as the cart was parked out to the side in the hallway. After checking the resident's blood sugar, the RN returned to the medication cart and obtained an insulin pen and went back into the resident's room and again left the cart unlocked and unattended. During an interview on 08/21/2025 at 11:42 AM RN G said that the medication carts were supposed to be locked when unattended. The RN was made aware that he had left the medication unlocked when he entered the resident's room. RN G said that he could see the cart from the room, but he was made aware that he had his back turned to the cart and had left it unlocked on 2 occasions. RN G said he should have locked the cart. During an interview on 08/21/2025 at 5:08 PM the DON said if a nursing staff stepped away from their medication cart then they were expected to lock it. The DON was made aware of RN G stepping away from the medication cart and leaving it unlocked and unsupervised. The DON said the nurse should have locked it as the cart had several medications in it. Record review of the facility's undated policy and titled Medication cart administration of drugs indicated in part: If the cart is left at any time during medication pass due to an emergency, it must be locked.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1of 7 residents reviewed for pharmacy services. (Resident #23) The facility failed to ensure Resident #23's ordered Rifampin (antimicrobial drug used to manage and treat diverse mycobacterial infections and gram-positive bacterial infections) medication was available for administration from 8/8/2025-8/20/25. The facility did not notify physician of unavailability until after resident missed 12 doses of Rifampin. These failures could place residents at risk for not receiving medications as prescribed and a decline in health status. Findings included: Record review of Resident #23's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of fracture of unspecified part of neck of left femur (hip fracture), presence of right artificial hip joint, need for assistance with personal care, muscle weakness, osteoarthritis, chronic respiratory failure, elevated white blood cell count. He discharged to the hospital on 7/31/2025 for infection of surgical wound. He readmitted to facility from hospital on [DATE] with diagnoses methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by Staphylococcus aureus bacteria that are sensitive to methicillin and similar antibiotics), methicillin resistant staphylococcus aureus infection (a type of staphylococcus bacteria resistant to many common antibiotics), unspecified Escherichia Coli (a type of bacteria commonly found in the intestines of humans). Record review of Resident #23's comprehensive care plan, dated 07/15/2025, revealed he had surgical wound to left hip. The goal was wound will heal without complications through review date. The interventions included: wound treatments per doctor's orders.Record review of Resident #23's admission MDS assessment, dated 07/21/2025, revealed:He had a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderate cognitive impairment. There were no behaviors or refusal of care. Record review of the order summary report for August 20, 2025, revealed Resident #23 had an order for Rifampin oral capsule 300milligrams to be given two times every day from 8/8/2025 to 9/15/2025 indicated for infection after surgical procedure. Record review of the Medication Administration Record for August 2025 reflected Resident #23 did not receive any doses of his Rifampin because the medication was on order. In an interview on 8/20/25 at 11:05AM LVN C stated the Rifampin medication not being available was out of her hands. She stated she was first notified of the medication not being available yesterday evening (8/19/25) but the pharmacy was already closed. LVN C stated she was unsure why the medications had not come into the facility yet. LVN C called the pharmacy on 8/20/25 and the pharmacy stated they would not be sending the medication due to a possible drug interaction. LVN C said she called to notify the Infection Specialist Doctor but was only able to leave a message. LVN C stated the medication not being available could lead to not being able to treat the residents' diseases appropriately. In an interview on 8/20/25 at 11:45AM the DON stated the medication aides should report all unavailable medications to the nurse and the nurse then would look for the medication. The DON said if it was a prescription medication the nurse would verify it was not delivered, check the order, and call the pharmacy. The DON stated the nurse would report all unavailable medications to the DON and doctor. The DON stated it was the ADON's duty to ensure all medications were delivered. The DON stated resident was taking the medication due to an infection after a hip surgery. The DON stated negative effects could include the resident not receiving what medications they needed leading to prolonged sickness. In an interview on 8/20/2025 at 1:30PM Resident #23 said he was not aware he was not receiving the Rifampin. In an interview on 8/21/2025 at 10:30AM the DON stated the medication was discontinued by Resident #23's primary physician until follow-up appointment with Infectious Disease Specialist on 9/3/2025. The DON said she was going to implement communication forms to notify her if a medication was unavailable. The DON stated she spoke with the pharmacy about notifying the facility if a medication was not going to be dispensed as ordered. The surveyor requested the policy on medication availability, and one was not provided.

Based on observation, interview and record review the facility failed to ensure resident equipment was maintained in a safe, operating condition for 1 of 7 residents reviewed for wheelchair safety. The facility failed to ensure that Resident #62's wheelchair brakes operated. This failure placed residents at risk for unsafe transfers and/or falls if wheelchair rolled out from under the resident during transfers. The findings included:Review of Resident #62's admission Record, dated 8/20/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included hemiplegia (one sided weakness or paralysis) following stroke affecting the right side, reduced mobility, and history of falling. Review of resident #62's quarterly MSDS assessment, dated 7/11/25, revealed:Resident #62 scored a three of 15 on his mental status exam (indicating severe cognitive impairment),Resident #62 had upper and lower range of motion impairment on one side and used a wheelchair.Resident #62 was totally dependent on staff for bed to chair transfers. Review of Resident #62's Care Plan revealed:Revised 4/28/21: Problem: Resident requires assist with Activities of Daily Living. Goal: Resident is able to perform self-care to optimal level and maintains strength and endurance for 90 days. Interventions included: Provide level of support to complete transferring needs each shift; Reinforce use of aides to mobility as indicated. Revised 5/1/25 Problem: The resident has had an actual fall with no injury 3/10/25 fall. The identified goal was the resident will not sustain serious injury through the review date. Interventions included: 3/10/25 CNA reported during transfer the wheelchair brakes did not lock due to being broken and wheelchair rolled out from underneath resident's bottom, resident was using transfer pole during staff assisted transfer. Intervention - two person transfer initiated 3/11/25. Observation on 08/20/2025 9:02 AM revealed the wheelchair specialist was working on fixing another resident's specialized wheelchair. Observation on 08/20/2025 11:12 AM revealed CNA J and CNA L prepared to do a Sit-to-Stand mechanical lift transfer with Resident #62. CNA J put the sling on Resident #62, locked the wheelchair and hooked the sling onto the machine while CNA L prepared the lift. The wheelchair brake on the left side was noted to not be engaging despite being put in place. CNA J noticed the left brake and braced the wheelchair from behind on the left side while the aides completed the rest of the transfer properly. Interview on 08/20/2025 at 4:00 PM CNA J stated he worked at the facility for 2.5 years and usually worked Resident #62's hall. CNA J stated Resident #62 used to use a transfer pole on another hall, but since moving to the current hall Resident #62 used the Sit-to-Stand lift. CNA J said he checked the wheels on the wheelchair during the transfer and realized the brake did not engage. CNA J said the brake had not worked, but he did not now for how long. CNA J felt with him behind the wheelchair bracing it, that the transfer was safe since there were two people performing the transfer. CNA J stated the other side was secure and he stood on the side that was not. CNA J said he did not report the wheelchair brake not working. Interview on 08/20/2025 at 4:24 PM CNA K stated Resident #62 was ok in his wheelchair. CNA K stated the wheelchair worked for her when she locked the wheelchair; but CNA K said the left side brake did not work since she started working about a month ago. CNA K said she told the physical therapy department because she learned maintenance could not work on the type of wheelchair Resident #62 had. Interview on 08/20/2025 at 4:32 PM CNA L said she was the lead aide and she worked everywhere in the building. CNA L said Resident #62 used the Sit-to-Stand lift. CNA L said she did not feel the observed transfer did not go so well because the lock on the custom wheelchair did not lock. CNA L said she knew the facility could not fix it at the facility because she had another resident's wheelchair fixed that morning. CNA L said Resident #62's wheelchair brake had not been working a while. CNA L said she believed therapy was responsible for monitoring if the specialized wheelchairs worked. CNA L said if the aides noticed the wheelchair brakes not working they would document it in the maintenance book. CNA L said she knew the brake did not work for a while because the last time it was fixed the person accidently put the brake on backwards. CNA L said the transfer she and CNA J completed was done safely because CNA J was behind the chair and holding it stead. CNA L said she was notified it was not working today. CNA L said since she moved hallways so much, she could not say how long Resident #62's wheelchair was not working. Interview on 08/20/2025 at 4:45 PM RN G stated he worked Resident #62's hall for the past two years. RN G stated he was not aware Resident #62's wheelchair was not working. RN G said he did not know if therapy would notice because Resident #62 did not do therapy. RN G stated it could take weeks for a specialized wheelchair to be fixed. RN G said the CNAs did not communicate that Resident #62's brakes were not working. RN G said he did expect the CNA to communicate that. RN G stated if the brakes did not engage ultimately it was not a safe transfer. At that time, RN G took the surveyor to the maintenance book and reviewed 8/12/25 through 8/20/25; RN G confirmed there was no documentation about Resident #62's wheelchair brakes not working. Interview and observation on 08/20/2025 at 5:25 PM the DON stated Resident #62 used the Sit-to-Stand lift. The DON said Resident #62 had a customized wheelchair that was maintained by the company that was at the facility earlier that day (8/20/25). The DON said it would depend on the use and wear and tear on the wheelchair brakes to determine how long it would take to go out. The DON said any staff that were assisting Resident #62 could put Resident #62's brakes were not working in the maintenance book and were responsible for monitoring the brakes were in working order. The DON said due to the brakes not working Resident #62's transfer was not safe, but the staff did what they could to make it as safe as they could. The DON stated she would have to get the wheelchair looked at and the wheelchair maintenance company was coming back on 6/21/25 and she would have the wheelchair looked out. The DON and surveyor checked Resident #62's brakes and she said, It looked like the mechanism was not engaging. The Administrator joined the conversation and was shown Resident #62's brakes. Interview and observation on 08/20/2025 at 5:54 PM the Administrator stated the repair company repaired Resident #62's wheelchair in June and July (2025). The Administrator looked at Resident #62's wheelchair and said it looked like the tread on the wheelchair was wearing out and also needed to be replaced. Interview and record review on 08/20/2025 at 6:03 PM the Administrator said he reviewed the maintenance log and showed the surveyor on 6/30/25 the charge nurse documented both wheelchair brakes were out and it was fixed on 7/2/25. Review of the facility's policy on Administrative Requirements for Durable Medical Equipment and Customized Manual Wheelchairs, undated, revealed:A modification, adjustment or repair to a Customized Manual Wheelchair, required in the first six months after delivery of the Customized Manual Wheelchair is the responsibility of the supplier. More than six months after delivery of a Customized Manual Wheelchair, the facility will maintain and repair all medically necessary equipment for a designated resident, including Customized Manual Wheelchairs.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of seven residents (Resident #23) reviewed for quality of care. The facility failed to provide wound care for Resident #23 using professional wound care standards and failed to follow the physician's treatment order. This failure could place residents at risk of improper wound management, deterioration in existing wounds, leading to infection and pain. Findings include: Record review of Resident #23's Face Sheet dated 7/14/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses of infection following a procedure, unspecified severe protein-calorie malnutrition, chronic respiratory failure, resistance to multiple antibiotics, systemic inflammatory response syndrome (a life threatening condition that occurs when the body overreacts to a stressor, causing severe inflammation throughout the body), methicillin resistant staphylococcus aureus infection (a type of staph bacteria resistant to many common antibiotics), chronic respiratory failure, methicillin susceptible staphylococcus aureus infection (a type of bacterial infection caused by staphylococcus aureus bacteria that are sensitive to methicillin and similar antibiotics), Escherichia Coli as the cause of diseases classified elsewhere (a type of bacteria commonly found in the intestines of humans), aftercare following joint replacement surgery. Record review of Resident #23's admission MDS dated [DATE] revealed he had a BIMS score of 10 of 15 indicating moderate cognitive impairment. Record review of Resident #23's Care Plan dated 07/15/2025 revealed the resident has a skin tear to his left outer forearm. Record review of Resident #23's Physician orders dated 8/08/2025 revealed skin tear left outer forearm: clean with wound cleanser, pat dry, apply xeroform (a fine mesh gauze dressing impregnated with petrolatum for use on low exudating wounds), cover with dry dressing, change Monday, Wednesday, Friday, and as needed. Observation on 08/20/2025 at 9:58 AM of wound care for Resident #23 revealed: LVN E donned (put on) gloves and opened a treatment cart drawer. LVN E used a small tray covered with wax paper to set up a clean field and place supplies in. LVN E knocked on Resident #23's door explained the procedure, washed her hands, applied PPE (personal protective equipment) required for EBP (enhanced barrier precautions), put on gloves, and removed the dressing from the resident's left forearm. LVN E removed her gloves and placed them as trash in the biohazard bag. LVN E washed her hands, put on gloves, cleansed the wound with normal saline from the inside outwards, and patted dry. LVN E washed her hands, put on new gloves, applied a hydrogel dressing (a type of dressing characterized by its high-water content) to Resident #23's left forearm, removed her gloves, and washed her hands. LVN E did not follow physicians orders for applying a xeroform dressing. In an interview on 08/20/2025 at 10:30 AM LVN E stated hydrogel and xeroform were the same dressings and she was going to call the supplier and tell the supplier if they were sending the wrong dressings. LVN E stated she was not wound-care certified but had completed the wound care competency check-off upon hire. In an interview on 8/20/2025 at 2:30PM LVN E stated she talked to the wound care supplier and the hydrogel dressing was to be used as a dry dressing and she should have applied the xeroform under the hydrogel dressing. In an interview on 08/21/2025 at 10:06 AM the DON stated the wound care procedure would be to follow physician's orders. She agreed that LVN E did not use the correct dressing. The DON said incorrect dressings could delay the healing of wounds. Review of the facility's undated wound care policy received from the DON revealed: 1. Treat wounds with the appropriate products. 2. Effectively heal wounds by using approved products 3. Get treatment order form physician 4. Treat wound until it is healed.

45411 Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 3 of 22 residents (Residents #33, #37, and #41) reviewed for MDS assessment accuracy. 1. The facility failed to accurately address Resident #33's tracheostomy status on her Quarterly MDS assessment. 2. The facility failed to accurately address Resident #37's use of insulin on her Quarterly MDS assessment. 3. The facility failed to accurately address Resident #41's dependence on dialysis on her Admission MDS assessment. The failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Resident #33 Review of Resident #33's Admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with admitting diagnoses which included quadriplegia (paralysis of all four limbs), tracheostomy status (an opening surgically created through the neck into the windpipe to allow air flow into the lungs), and chronic respiratory failure. Review of Resident #33's Order Summary Report dated 7/2/24 revealed the following: Change inner cannula Shiley #6 everyday (one time a day for Trach use) Order Date 3/23/21 Clean Trach Collar (at bedtime) Order Date 3/23/21 Trach - Change Inner Cannula = Change the disposable inner cannula of trach as needed, using sterile technique. Document any adverse reaction (as needed) Order Date 3/23/21 Clean Inner Cannula Every Shift & PRN (every shift AND every 8 hours as needed) Order Date 3/23/21 Trach Care: Change Nebulizer Tubing, Trach Collar Every Week (every night shift, every Sun) Order Date 3/28/21 Trach - Supply Check = Check every shift to ensure the following supplies are at bedside: Extra trach, suction machine, suction catheters, ambu-bag, humidified oxygen (every shift) Order Date 3/23/21 Trach -Suction PRN= May suction as needed, using sterile technique. Document character of secretions (as needed) Order Date 3/23/21 Trach Care: Trach care every shift and PRN using sterile technique (every shift AND as needed) Order Date 3/22/21 Trach Dressing Change = Change trach dressing every day and PRN, using sterile technique. Document any adverse conditions/reactions (every day shift AND as needed) Order Date 3/22/21 Review of Resident #33's Quarterly MDS assessment dated [DATE] revealed she was unable to complete a mental status evaluation due to her impaired cognition. She was dependent on staff for all ADL's. Her active diagnoses list included her tracheostomy status, however Section O - Special Treatments, Procedures, and Programs did not address Resident #33's tracheostomy care or suctioning. Review of Resident #33's Care Plan, most recent revision date 5/24/24, revealed the following: Problem - Trach Care: Resident has a history of infection of the trach R/T family touching trach area without gloves. Goal - The resident will be free from complications related to infection through the review date. Interventions - 3/22/2021 Change trach dressing every day and PRN, using sterile technique. Document any adverse conditions/reactions. 3/22/2021 Trach Care: Trach care every shift and PRN using sterile technique. 3/23/2021 Change Nebulizer Tubing, Trach collar every week (night shift, every Sunday). 3/23/2021 May suction as needed, using sterile technique. Document character of secretions. 4/13/2021 Clean trach collar at bedtime. Duo-neb solution four times a day r/t chronic respiratory failure. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Lung/Respiratory Assessments every shift. Record vitals and number for lung sounds present; along with total minutes spent with pt. during assessment. Maintain universal precautions when providing resident care. Monitor temperature/pulse per MD orders. Mucinex fast max dm liquid via peg two times a day. Repeat sputum culture with sensitivity CBC, CMP in a.m. Problem - resident has a tracheostomy r/t Impaired breathing mechanics. Goals - The resident will have clear and equal breath sounds bilaterally through the review date. The resident will have no s/sx of infection through the review date. The resident will have no abnormal drainage around trach site through the review date. Interventions - 3/22/2021 Flonase Suspension 50 MCG/ACT (Fluticasone Propionate) 1 spray in both nostrils one time a day related to OTHER SEASONAL ALLERGIC RHINITIS (J30.2). 3/22/2021 Lung/Respiratory Assessment- Assess Lungs &Sounds Present - Vital Signs - Check Time Prior to Assessment and Again After Completion to Track total Minutes Spent Performing Assessment. 3/22/2021 Mucinex Fast-Max DM Max Liquid 20-400 MG/20ML (Dextromethorphan-guaifenesin) Give 20 ml via PEG-Tube two times a day for Medical Diagnosis/Condition related to OTHER SEASONAL ALLERGIC RHINITIS (J30.2) CHANGED ON 8/23/2021 every 12 hours prn congestion. 4/04/22 Atropine Sulfate Solution 0.01 % Give 1 drop sublingually every 4 hours as needed for excess secretions related to ENCOUNTER FOR ATTENTION TO TRACHEOSTOMY (Z43.0) 4/04/22 Chest X-ray one time only for rule out aspiration/pneumonia related to CHRONIC RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA (J96.10) for 1 Day. 4/8/24 EBP implemented due to at risk for infection. 6/07/22 Refer to ENT for trach evaluation and replacement if needed. Resident to ER for bleeding noted when suctioning and resident told ER they had put in the wrong trach and ER referred her to ENT. Change inner cannula Shiley #4 every day one time a day for trach use change outer trach dressing every shift and PRN. Clean inner cannula every shift and prn. Clean trach collar one time a day. Duo-Neb Solution (Ipratropium-Albuterol) per MD orders. Elevate HOB at least 30 degrees every shift. Keep lips moist all the times every shift. Monitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia. Monitor/document level of consciousness, mental status, and lethargy PRN. Monitor/document respiratory rate, depth, and quality. Check and document every shift/as ordered. Nebulizer treatment of albuterol as ordered by MD. Document v/s, lung sounds, and minutes spent prior to and after administration. OXYGEN SETTINGS: 2-5 l/m via trach prn to keep sats >92%, check o2 sats every shift and as needed. Provide good oral care daily and PRN. RESPIRATORY THERAPY: Assess Shortness of Breath; Assess bed positioning related to SOB, specifically when lying flat(orthopnea); Assess for cough and sputum production and character; Assess for signs/symptoms of worsening lung function; Assess lung sounds and describe type and location of abnormal sounds; Assess vital signs and respiratory effort; Describe all breathing/respiratory exercises performed this shift; Describe all Education provided this shift; Document time spent with resident in respiratory assessment, monitoring and treatment. Suction as necessary. trach care every shift and PRN. May use trach mask prn. TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. Use UNIVERSAL PRECAUTIONS as appropriate. Resident #37 Review of Resident #37's Admission Record dated 7/3/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, end stage renal disease (kidney failure), right below the knee amputation, and peripheral vascular disease (condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident #37's Order Summary Report revealed the following: Insulin Regular Human Subcutaneous Solution 500 units/ml inject as per sliding scale: if 0-60 = 0 and notify MD; 61-200 = 0; 201-250 =4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401-999 = 10 and notify MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus (Order Date 2/21/24) Review of Resident #37's Quarterly MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. She used a wheelchair for mobility. She required partial to moderate assistance for most ADL's. Her insulin use was not documented on the MDS assessment. Review of Resident #37's Care Plan, most recent revision date 6/20/24, revealed the following: Focus - The resident has diabetes mellitus. Goals - The resident will be free from any s/sx of hyperglycemia through the review date. The resident will be free from any s/sx of hypoglycemia through the review date. Interventions - CBG before meals and at bedtime for DM (1/13/22). CBG two times a day for DM (2/10/22). Humulin R injection: inject as per sliding scale if 0-60 = 0units initiate hypoglycemic protocol and call MD if not resolved; 61-150 = 0units; 151 -200 = 2units; 201 - 250 = 4units; 251 - 300 = 6units; 301 - 350 = 8units; 351 - 400 = 10units; 400 or greater = notify physician - subcutaneously before meals and at bedtime for diabetes send pen needles as covered (4/4/23). Humulin R injection solution inject as per sliding scale: if 60 - 200 = 0units; 201 - 250 = 8units; 251 - 300 = 10units; 301 - 350 = 12units; 351 - 400 = 14units; 400 or greater notify physician; subcutaneously before meals and at bedtime for diabetes, send pen needles as covered (7/5/23). Novolin R injection solution 100 unit/ml inject 15units subcutaneously one time only for hyperglycemia (7/5/23). Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Monitor/document/report PRN any s/sx of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Resident #41 Review of Resident #41's Admission Record revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included end stage renal disease, type 2 diabetes mellitus, and pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and heart). Review of Resident #41's Order Summary Report dated 7/3/24 revealed the following: Dialysis - Access Site Check = Check dialysis access site for thrill and bruit, redness, swelling, drainage, temperature of skin surrounding site, peripheral pulses, bleeding and intact every shift. (Order Date 5/31/24) Dialysis - Order For = May go to dialysis three times a week on Tuesday, Thursday, Saturday at 3:15pm. (Order Date 5/31/24) Dialysis - Vital Sign Checks = Check vital signs before and after dialysis, document vital signs; two times a day every Tuesday, Thursday, and Saturday. (Order Date 5/31/24) Review of Resident #41's Admission MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 12 indicating she was cognitively intact. She required a walker for mobility. She required partial to moderate assistance for some ADL's. Her use of hemodialysis was not addressed on the MDS assessment. Review of Resident #41's Care Plan, most recent revision date 6/3/24, revealed the following: Focus - Renal Dialysis Goals - Resident will maintain optimal function/mobility x 90 days. Resident will not incur significant problems r/t dialysis/shunt x 90 days. Interventions - Administer all medications per doctor's orders. Assess resident for s/s of headaches, n/v, hypertension, tremors, confusion/agitation. Check shunt before leaving for dialysis and upon returning to nursing home. Edema (swelling caused by fluid buildup in the tissue) check daily. Monitor access area for redness, pain. Monitor for chest pain, elevated blood pressure, bleeding. Monitor for itchy skin. Monitor labs per doctor's orders. Obtain vital signs before dialysis and upon return to nursing home. Send snack to dialysis with resident. Weigh resident daily before leaving for dialysis and upon returning to nursing home. Focus - The resident needs hemodialysis. Goals - The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. The resident will have no s/sx of complications from dialysis through the review date. Interventions - 5/31/24 Dialysis Order: May go to dialysis three times a week on Tuesday - Thursday - Saturday at 3:15pm. Check and change dressing daily at access site and document. Do not draw blood or take blood pressure in arm with graft. Encourage resident to go for the scheduled dialysis appointments. Monitor for dry skin and apply lotion as needed. Monitor intake and output. Monitor labs and report to doctor as needed. In an interview on 7/3/24 at 7:25pm, MDS D stated she had been working at the facility for three years as the MDS coordinator for the skilled residents. She stated that she got her information to start the MDS assessment from hospital documentation, the resident and/or their family. She stated she was responsible for completing the BIMS and depression screening questions. She stated that Resident #41 was one of the residents she was responsible for. She stated that dialysis should have been included on her MDS and the only reason it would not have been was that she overlooked it when she completed the assessment. She stated that she received corrections from her corporate supervisor each month and they would catch a mistake like that. MDS D stated that once she received corrections from her supervisor, she would do modifications to the assessments that needed them before they were submitted. In an interview on 7/3/24 at 8:01pm, MDS E stated she started her position as long-term MDS Coordinator in November of 2023. She stated she got her information to complete the assessments by interviewing the resident and their family, reviewing hospital records or physician's records. She stated there was a form she had printed as well as a form in the electronic chart to complete the assessment. She stated that some information carried over from previous assessments and some did not, so she had to pay close attention to each box to make sure everything was checked correctly. She stated that was the reason for Resident #31's insulin not being checked and Resident #33's trach not being checked on their quarterly assessments. She stated that those areas were not carried over each time and she must have just missed the boxes. Review of undated facility policy titled Resident Assessment revealed, in part: Composition of the Comprehensive Resident Assessment: The facility will make a comprehensive assessment of a resident's need, strengths, goals, life history, and preferences, using the current Resident Assessment Instrument (RAI) process, including MDS, Care Area Assessment process, and the Utilization Guidelines specified by HHSC and approved by CMS. The current RAI process is found in the MDS 3.0 and posted by CMS on http://www.cms.gov.

45411 Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 22 residents (Resident #85) reviewed for care plans. 1. The facility failed to have a care plan in place to accurately address Resident #85's code status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #85's Admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, stroke, and type 2 diabetes mellitus. Review of Resident #85's Quarterly MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 2 indicating severe cognitive impairment. She required maximum assistance or was dependent on staff for all ADL's except for eating. She required a wheelchair for mobility. Review of Resident #85's Care Plan, most recent revision date [DATE] revealed the following: Focus - Resident and family request NO CPR/DNR measures (date initiated [DATE]) Goal - Request for NO CPR will be respected. Will have a peaceful, pain free death. Will respect resident's wishes x 90 days. Interventions - [DATE] DNR Code Status. If cardiac arrest do not resuscitate. Offer reassurance and support to family. Resident code status reviewed with family and RP with each care plan review/care plan meeting. Focus - Resident request to be Full Code Status or Full Code due to no out of hospital form completed in place (date initiated [DATE]) Goal - Comply with resident and family wishes for next 90 days. Interventions - Call for emergency personnel and initiate CPR. Resident's code status reviewed family and RP with each care plan review/care plan meeting. Respect end of life decisions. Review of Resident #85's Order Summary Record dated [DATE] revealed the following: DNR (Order Date [DATE]) Review of Resident #85's Electronic Health Record on [DATE] at 4:47pm revealed scanned copy of Out of Hospital Do Not Resuscitate form signed by physician [DATE]. In an interview on [DATE] at 8:01pm, MDS E stated she was responsible for the long-term resident care plans. She stated that Resident #85 was a DNR and she did not understand why there were care plans for both Full Code and DNR status in her care plan. She stated she would have to look into that as it did not make sense and would be confusing to anyone reading it. Review of undated facility policy titled Comprehensive Person-Centered Resident Care Planning revealed, in part: A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights and will incorporate resident-centered goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accident hazards/supervision (Resident #23). The facility failed to ensure CNAs B and C demonstrated appropriate transfer techniques while using the mechanical lift for Resident #23. The failure could place residents at risk for injuries. Findings included: Review of Resident #23's Quarterly MDS Assessment, [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture, quadriplegia (paralysis of all four limbs), Parkinsonism (neurological disease causes thinking disorders, depression and emotional changes, swallowing problems, tremors, involuntary movement, painful muscle contractions and difficulty speaking), and muscle weakness. She scored a 6 of 15 on her mental status exam (indicating she was severely cognitively impaired). She used a wheelchair. She was dependent on staff for all activities of daily living including chair or bed-to-chair transfers. Observation on [DATE] at 10:35 AM revealed Resident #23 gave permission to watch her being transferred. CNA C lowered the boom (cross piece used to hook the sling to) to the shower bed and both CNA B and CNA C hooked up to the lift Resident #23. CNA B said she was unable to get the resident hooked up right and did not understand why. CNA C explained to the Resident #23 she slid down in the shower so they had to reposition the boom a little bit. The shower bed was not locked. Once they got the hooks on the boom secured, CNA C told Resident #23 they were going up (the lift was going up to prepare the resident that she would be dangling) while CNA B made sure the boom did not hit Resident #23 in the head. Through the whole process the two aides communicated with the resident. Once in position, CNA C lowered Resident #23 in the bed while CNA B positioned the sling in the bed. CNA B and CNA C removed the wet sling and got Resident #23 dressed. CNA B and CNA C again rolled Resident #23 side to side to place the dry sling under her while pulling Resident #23's dress down as far as it would go. The CNAs hooked the dry sling onto the lift, told Resident #23 they were going up and again, CNA C operated the lift while CNA B steadied Resident #23 and engaged her in conversation CNA C moved the lift to fit under the wheelchair, locked the lift, but did not lock the wheelchair while CNA B positioned Resident #23 in the sling in the wheelchair. The aides both unhooked the sling. CNA B pulled Resident #23's dress as far as it would go, while CNA C took the lift out of the room returned and washed her hands. CNA B made sure Resident #23 was satisfied and then also washed her hands. Interview on [DATE] at 10:57 AM with CNA B and CNA C CNA C asked how she did. She said she made sure the lift was locked before putting the resident down because she felt safer because Resident #23's wheelchair was specialized, and she had to approach it sideways. The Surveyor and CNA C read the lift instructions posted on the boom which reflected do not lock lift when lowering or lifting the resident. CNA C said she felt safter locking the lift when lowering the resident. CNA C said she had not asked therapy what she was supposed to do and had not received training from therapy about what she supposed to do. CNA C said she did not remember if Resident #23's wheelchair was locked and returned into Resident #23's room and checked. CNA C came back out of the room and said they did not lock the wheelchair. Interview on [DATE] at 09:08 AM the DON stated her expectation for a mechanical transfer was for the staff to position the sling under the resident comfortably, move the lift into position, hook the sling onto it, lift the patient up, and move the resident into the position. The DON said one staff would be maneuvering the lift while the other person was guiding the resident. The DON said the staff should put the person down, unhook and there you go. She said the staff should make sure the resident was aligned right in the chair and comfortable and unhook from the lift and take the lift away. The DON said the wheelchair needed to be locked and lift needed to be locked in place to keep the resident from falling and moving around. The DON explained if the lift of wheelchair could roll and move around, there was a possibility that it could tip and it's just not safe. The DON stated the staff were in-serviced on the mechanical lift once a year with proficiency, on hire, or if there was something that happened that was noticed. The DON said the facility did a skills brush up because their window opened in [DATE], but she would have to look. She said she knew her lead aide and staff educator had been working with the staff. Interview on [DATE] at 09:51 AM the Administrator stated he had not been trained on mechanical lifts but his understanding was the lift was lined up, get the resident ready sling under them, hook up the sling, lift the resident, make sure the space was clear, move the resident and put them where they need to go. The Administrator stated any general transfer from the bed to the wheelchair was the wheelchair be locked. He was informed it was not locked. Review of the Mechanical Lift Transfer Proficiency Checklist revealed: 11. Move lift into position. Open the leges of the lift to their widest position, the shifter handle locked in place and do not lock the rear [NAME]. Both CNA B and CNA C passed the proficiency check-off on [DATE]. Review of the facility's policy and procedure on Two Person Mechanical Lift. Procedure. 2. Position Wheelchair so you can maneuver the lift safely from the bed to over the chair. Lock wheels/brakes.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of two residents (Resident #74) reviewed for enteral feedings. The head of the bed was not kept elevated above 30 degrees for Resident #74 to prevent aspiration pneumonia. This failure could place residents who are fed by enteral means at an increased risk for complications including, but not limited to, aspiration pneumonia (pneumonia caused by breathing foreign objects breathed into the lungs). Findings include: Review of Resident #74's Admission Record, dated 7/2/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included stroke and Gastrostomy Status (feeding tube). Review of Resident #74's Significant Change MDS Assessment, dated 6/6/24, revealed: Resident #74 unable to respond to questions. Mental status was not assessed. She had a feeding tube while a resident but received 25% or less of total calories and fluid intake through the parenteral or tube feeding. Review of Resident #74's Care Plan, initiated 10/2/23, revealed she required a PEG tube for adequate national intake. The identified goal was she would not experience adverse effects from placement of a PEG tube. Identified goals included: Head of bed elevated 30 - 45 degrees at all times initiated 12/19/23. Sign above bed, every shift date initiated 3/21/24. Review of Resident #74'sCarePlan, initiated 5/3/24 revealed the resident required tube feeding. The identified goal included the resident would remain free of side effects or complications related to tube feeding through review date. Identified interventions included. The resident needed the head of bed elevated 45 degrees during and thirty minutes after tube feed. Review of Resident #74's Order Summary Report, printed 7/2/24, revealed orders dated 6/14/24: Enteral Feed Order every shift G-Tube- Head of bed elevated 30 - 45 degrees at all times. Observation on 7/1/24 at 1:17 PM revealed Resident #74 was in her bed. There was a sign posted above her bed that reflected to keep the head of the bed above 30 degrees. Resident #74 had a feeding tube, oxygen a wound vacuum, a collar for tracheostomy care, and a catheter. The head of her bed was raised at least 45 degrees, and she was gurgling. The Surveyor activated the call light and the aides came in and stated she needed suctioning due to increase secretions visible from tracheostomy, and went to get the nurse. The aides returned, put on PPE which included a gown and gloves. The aides lowered the head of the bed to 10 degrees, and checked to see if resident #74 needed incontinent care. At this time LVN A entered the room, donned gloves and a gown. LVN A suctioned Resident #74. He stated he suctioned Resident #74 around 12:30 p.m. but it did not take long for her to get full again (need suctioning again). LVN A said if Resident #74 had drainage she needed to be suctioned. At 1:48 PM LVN A was done with Resident #74 and doffed the PPE and left to get trash bags for the room. He left Resident #74 uncovered and lying flat at 10 degrees. Interview and observation on 7/1/24 at 1:53 PM revealed the Surveyor called LVN A to Resident #74's bed side. The Surveyor asked LVN A what as charge nurse he should be checking for. LVN A stated that Resident #74 was not covered and covered her up; that her call light was not within reach and that her tubing was a bit of a tangle. The Surveyor then asked LVN A if Resident #74 had a peg tube and if her bed was at the right angle. LVN A stopped and said Oh, no. It's not. and raised Resident #74's bed to the right angle. Interview on 07/03/24 at 4:44 PM LVN A stated he did tracheostomy care on Resident #74 and left to get trash bags, so it took him a minute to get what the surveyor was asking. He agreed the head of the bed needed to be elevated. He said it was the policy because Resident #74 had a peg tube and the facility did not want her to aspirate and for the feeding formula to go to her lungs or worse. LVN A said he made that mistake because he was nervous, and he did not know Resident #74 since he was covering the hall. Interview on 07/03/24 at 06:48 PM the DON was informed of the 7/1/24 observation. The DON said they did not want residents with a peg tube lying flat because they could get aspiration pneumonia which was when things could get into the resident's lungs and cause infection. She said it was posted as a picture behind the bed of all residents with a peg tube for all the staff, the aides, anyone, so families would not lay residents down flat. Review of the facility's policy and procedure on Care of Enteral Feeding Tube, undated, revealed: Position resident in semi-Fowler's position (an individual lies on their back on a bed with the head of the bed elevated between 30 - 45 degrees).

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. - There was 1 bag of frozen of pizza sausages located in the walk-in freezer that was removed from the original package and not dated or labeled with contents. -There was 1 sealed storage bag of approximately 10-12 pork chops removed from the original package without a label of its contents -There was 1 sealed storage bag of chopped carrots removed from the original package without a label of its contents. -There was 1 sealed storage bag of cooked bacon removed from the original package without a label of its contents. -Dietary Aide L not wearing a beard net while in the kitchen. Dietary Aide L's hair was not restrained and sticking out under the cap. These failures could place residents at risk of food-borne illness. Findings included: Observation on 03/21/2024 at 11:15 a.m., of the walk-in freezer revealed a gallon sized zipper storage bag of frozen pizza sausages removed from the original package without a label of contents or date food item was removed from the original package. Observation on 03/21/2024 at 11:17 a.m., of walk-in refrigerator revealed a gallon sized zipper storage bag of 10-12 pork chops dated 03/20, that were removed from the original package without a label of contents. Observation on 03/21/2024 at 11:17 a.m., of walk-in refrigerator revealed a gallon sized zipper storage bag of approximately 1-2 cups of chopped carrots dated 03/20 that was removed from the original package without label of contents. Observation on 03/21/2024 at 11:17 a.m., of walk-in refrigerator revealed a gallon sized zipper storage bag of approximately 20-25 pieces of cooked bacon dated 03/20 that was removed from the original package without label of contents. Observation on 03/21/2024 at 11:15 a.m., revealed Dietary Aide L with a beard sitting in the kitchen wrapping utensils in napkins. Dietary Aide L was not wearing a beard net. Dietary Aide L had on a baseball cap with hair sticking out all around the cap. During an interview on 03/21/2024 at 11:20 a.m., Dietary Aide K said anyone who enters the kitchen must be wearing a hair restraint and if they have facial hair, they should be wearing a beard restraint. Dietary Aide K said the risk of not wearing a hair and/or beard net was hair falling into food. During an observation and interview on 03/21/2024 at 11:29 a.m., Dietary Aide L said if he wears a hat/cap then he does not have to wear a hair restraint. It was noted that Dietary Aide L's hair was wavy and approximately 3 to 4 inches long. Dietary Aide L said he did not know if the hat/cap needed to cover all of his hair. Dietary Aide L was noted with facial hair to his chin without a beard net. Dietary Aide L said he had not received any instructions on having to wear a beard net while in the kitchen. During an interview on 03/21/2024 at 1:45 p.m., the DM said anyone who enters the kitchen must wear a hairnet if applicable and a beard net if they have facial hair. The DM said the risk of not wearing a hair restraint was that hair could fall in the food. The DM said when kitchen staff store food items removed from the original package, they use zip lock bags that can be sealed and labeled with the date. The DM said the date on the bag was the date the food item was put in the refrigerator. The DM said for the most part kitchen staff is able to see what the food item was in the storage bag and do not label the storage bag with content of food item. The DM said the risk of not labeling the contents of the storage bag on the storage bag was staff may not know what was being stored. Review of facility policy Food Safety in Receiving and Storage dated 2010, reads in part, potentially hazardous leftover food are properly covered, labeled, dated and refrigerated immediately Any foods removed from the shipped box must be labeled and dated. General food storage guidelines: The container/lid is labeled with name of contents and dated with the date it was transferred to the container. Review of facility policy Personnel Hygiene dated 2010, reads in part, Dietary personnel will practice good hygiene and will be free of illness that can be transmitted through food. Hair clean and worn in a manner that it can be completely covered by hair restraint. Hair nets and other hair restraint to be worn by employees at all times in the kitchen. Review of Food Code 2022 revealed: 2-402 Hair Restraints. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD.

Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored foods were properly labeled and dated. The facility failed to ensure that expired foods were discarded. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation of the dry storage on [DATE] at 11:05 AM revealed: 4, 46-ounce boxes of thickened apple juice with best by date of [DATE] 2, 32-ounce boxes of thickened dairy drink with best by date of [DATE] 5, 24-ounce packets of citrus gelatin mix with no expiration date 4, 6-pound bags of vanilla soft serve mix with no expiration date 17, 24-ounce packets of lemonade drink mix with no expiration date 2, 3-gallon boxes of orange juice blend 4 + 1 concentrate with no expiration date 3, 5-gallon boxes of nectar consistency thickened water with no expiration date 8, 6-pound 9-ounce cans of marinara sauce with no expiration date 6, 105-ounce cans of peeled apricot halves with no expiration date 1, 6-pound 10-ounce can of cream style corn with no expiration date 3, 112-ounce cans of chocolate pudding with no expiration date 2, 6-pound 10-ounce cans of tomato sauce with no expiration date 2, 6-pound 10-ounce cans of seasoned pizza sauce with no expiration date 2, 106-ounce cans of crushed pineapple in juice with no expiration date 7, 27-ounce cans of diced green chiles with no expiration date 1, 8-ounce packet of chicken and dumpling season mix with no expiration date 6, 14-ounce packets of roasted chicken gravy mix with no expiration date 26, 3.2-ounce packets of ranch salad dressing mix with no expiration date 4, 24-ounce packets of peppered gravy mix with no expiration date 8, 13-ounce packets of brown gravy mix with no expiration date 1, 32-ounce bag of thick and hearty tortilla chips with expiration date of [DATE] 1, 56-ounce open container (approximately 28-ounces remaining) of bacon flavored bits with no expiration date 1, 56-ounce container of bacon flavored bits with no expiration date 2, 1-gallon containers of balsamic vinegar with no expiration date 1, 4-pound open container (approximately 3-pounds remaining) maraschino cherries with no expiration date 1, 4-pound container of maraschino cherries with no expiration date 3, 1-gallon containers of imitation vanilla flavor with no expiration date 2, 1-gallon containers of soy sauce with no expiration date 1, 10-pound open container (approximately 8-pounds remaining) of baking powder with expiration date of [DATE] 1, 25-pound open bag (approximately 20-pounds remaining) of yellow corn meal with no expiration date and bag not sealed in any way, just folded over to keep closed 2, 5-pound bags of cornbread and muffin mix with no expiration date 4, 5-pound bags of yellow cake mix with no expiration date 3, 5-pound bags of chocolate cake mix with no expiration date 9, 16-ounce boxes of baking soda with expiration date of [DATE] 3, 12.6-ounce boxes of French vanilla nutritional drink mixes with expiration date of [DATE] In an interview on [DATE] at 12:15 PM, the Dietary Manager stated that most of the food that was ordered did not stay on her shelves very long because of the number of residents the facility had. She stated that food rarely had time to go bad in the facility. She stated that she did not know where to go to find expiration dates for food items if they were not on the labels. She stated that she made sure that the kitchen/dietary staff knew to label all food items with the date that it was received but she did not write expiration dates or use by dates on the items that did not already have those dates printed on the packaging. She acknowledged that she did need a better system for dating food due to ingredients and the manufacturer's packaged on dates. She stated she did not know how long certain food items would stay safe for in different storage settings and that she would have to investigate that to improve her process as well as speak with the supplier and her corporate dietician. Observation of the walk-in cooler on [DATE] at 12:25 PM revealed: Plastic tub on shelf with resealable plastic bag containing head of lettuce with no label and no date and second head of lettuce sitting in tub not in bag 1, 1-gallon container of lite Italian dressing with no expiration date 1, 1-gallon container of hamburger dill pickle slices with no expiration date 2, 1-gallon open containers (each with approximately 0.5-gallon remaining) of mayonnaise with no expiration date 1, 1-gallon open container (approximately 0.5-gallon remaining) of coleslaw dressing with no expiration date 8, 1-pound containers of chicken flavored base with no expiration date Observation of the refrigerator on [DATE] at 12:35 PM revealed: 6, 3.375-ounce gelatin snack cups with expiration date of [DATE] 2, 32-ounce opened (unable to tell how much remaining) boxes of thickened dairy drink with expiration date of [DATE] In an interview on [DATE] at 12:40 PM the Dietary Manager stated that kitchen staff should have been checking the dates on all items in the refrigerator daily. She had no explanation for the expired items in the refrigerator. In an interview on [DATE] at 9:50 AM, the DON stated that she was not aware that the food items in the kitchen did not have expiration dates. She stated that there should never be expired food in the facility. She stated she would have to speak with the Dietary Manager about the process for checking the kitchen for expired food items as well as how she determined when foods expired when they did not have an expiration date on the package. Review of facility policy Food Safety in Receiving and Storage revision date [DATE], revealed, in part: Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Receiving Guidelines: 5. Check expiration dates and use-by dates to assure the dates are within acceptable parameters.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 4 of 10 residents observed for infection control. MA C dropped Resident #77's medication on the medication cart then proceeded to pick it up with her bare hands and placed it in the medication cup to be administered to the resident. MA C failed to wash hands prior to administration of medications. MA C measured blood pressures on two consecutive residents (#60,#65), failing to wipe off the blood pressure cuff between residents. MA C administered nasal spray to Resident #60 with bare hands, failed to wash hands prior to or after procedure. CNA A double gloved during incontinent care for Resident #1 and did not sanitize her hands when going from dirty to clean. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #60's admission record dated 05/16/23 indicated she was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (Stroke), Type 2 diabetes, and dementia. She was [AGE] years of age. Record review of Resident #60's MDS dated [DATE] indicated in part: That resident's BIMS score was 07 which shows severely impaired daily decision making related to dementia. That resident received anti-anxiety medication, anti-depressant medication, anti-coagulant medication, and opioid medication. Record review of Resident #60's care plan dated 03/04/2023 indicated in part: Problem: The resident is At Risk for developing impaired cognitive function or impaired thought processes. BIMS showed moderately impaired daily decision making related to dementia. Goal: The resident will maintain current level of cognitive function through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #65's admission record dated 05/16/23 indicated she was admitted to the facility on [DATE]. Diagnosis included major depression and dementia. She was [AGE] years of age. Record review of Resident #65's MDS dated [DATE] indicated in part: That residents BIMS score was 07 which shows severely impaired daily decision making related to dementia. That resident received anti-depressant medication and anti-seizure medication. Record review of Resident #65's care plan dated 05/11/2023 indicated in part: Problem: The resident has a seizure disorder. Goal: The resident will remain free of seizure activity through review date. Intervention: Keppra tablet 500 mg, give 1 tablet by mouth, one time a day for seizures. Record review of Resident #77's admission record dated 05/16/23 indicated she was admitted to the facility on [DATE]. Diagnoses included major depression disorder, anxiety disorder, Parkinson's disease and dementia. She was [AGE] years of age. Record review of Resident #77's MDS dated [DATE] indicated in part: That residents BIMS score was 09 which shows moderately impaired daily decision making related to dementia. That resident received anti-anxiety medication, anti-depressant medication and opioid medication. Record review of Resident #77's care plan dated 04/23/2023 indicated in part: Problem: The resident uses anti-anxiety medications related to anxiety. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Intervention: Administer anti-anxiety medications as ordered by physician. Monitor/document for side effects and effectiveness every shift. During an observation on 05/16/23 at 09:48 AM of medication administration by MA C. MA C was attempting to drop a pill into med cup but it fell on the medication cart. MA C picked the pill up with bare hands and placed the pill in the medication cup. MA C administered the medication to Resident #77. MA C then proceeded to place the lidocaine patch on resident's lower leg with bare hands. MA C failed to wash her hands, use hand sanitizer or wear gloves prior to administration of medications and failed to wash her hands after contact with resident #77. During an observation on 05/16/23 at 10:00 AM MA C then proceeded to Resident #60's room and took her blood pressure with bare hands. MA C failed to wipe off the blood pressure cuff prior to contact with resident #60. MA C returned to the medication cart to prepare medications for resident #60. MA C failed to wash hands prior to preparing medications. MA C used hand sanitizer after all medications were placed in cup. MA C then poured a cup of water from a pitcher, and opened a straw, then lifted the lid with her hands to the trash receptacle to dispose of straw wrapper. MA C then administered PO (by mouth) medications to the resident. MA C then administered nasal spray to each nostril with bare hands and failed to wash her hands prior to administering nasal spray and after administering nasal spray. During an observation on 05/16/23 at 10:15 AM MA C then proceeded to Resident #65's room and took her blood pressure with bare hands. MA C failed to wipe off the blood pressure cuff prior to contact with resident #65. MA C returned to medication cart to prepare medications for resident #65. MA C failed to wash hands prior to preparing medications. MA C used hand sanitizer after all medications were placed in a cup. MA C then administered PO (by mouth) medications to resident. During an interview on 05/17/23 at 09:58 am. with MA C. When asked about her failure to wipe off the blood pressure cuff between residents and wash hands between resident contact, MA C stated that she usually uses bleach wipes or alcohol wipes to clean the blood pressure cuff between residents. MA C stated, I don't know why I forgot to do it, I know it is important because of cross contamination and I know residents can get sick. MC A stated she usually carries her hand sanitizer with her but she did not have it at the time. During an interview on 05/17/2023 at 1:10 pm the DON stated that her expectation is that all facility staff would be handwashing between residents and cleaning equipment between residents. The DON stated that after all the training and in-services the facility had during covid, all staff should know the importance of handwashing, transmission precautions, especially when dealing with bodily fluids. DON stated that ADON will be performing a competency on handwashing and medication administration with MA C. Record review of the facility's policy titled Medication: Administration of Drugs undated, indicated in part, Procedure: Properly wash hands prior to starting medication administration. Properly wash hands if contact has been made with the resident or any procedure that would cause infected hands, and leave resident who is to receive medications. Repeat procedure with each resident who is to receive medications. Record review of the facility's policy titled Blood Pressure section B, undated, indicated in part, Procedure: Properly clean hands before procedure as appropriate and measure blood pressure. Clean blood pressure cuff with sanitizing wipes or spray. Record review of the facility's medication administration proficiency checklist, undated, indicated in part, Licensed Nurse/ Medication Aide will perform proper hand washing technique/gloves at appropriate times. INCONTINENT CARE: Record review of Resident #1's admission record dated 05/18/23 indicated she was admitted to the facility on [DATE] with diagnoses which included cerebral palsy and lack of coordination. She was [AGE] years of age. Record review of Resident #1's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. Always incontinent (no episodes of continent voiding). Bowel Continence = Always incontinent (no episodes of continent bowel movements). Record review of Resident #1's care plan dated 08/15/2019 indicated in part: Problem: Resident has bladder incontinence- Resident has bowel incontinence. Goal: The resident will remain free from complications of urinary incontinence through the next review date. The resident will be continent during daytime through the review date Interventions: The resident uses disposable briefs. Check and change every 2-3 hours & PRN. Clean peri-area with each incontinence episode. Check @ least every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 05/16/23 at 11:44 AM CNA A performed incontinent care for Resident #1. CNA A removed the resident's pants and brief. CNA A wiped Resident #1's rectal area with some wet wipes. The wipes had some bowel movement on them. CNA A wiped the resident's rectal area again with wet wipes and more bowel movement was observed which also came in contact with the CNA's gloves. CNA A then removed the soiled gloves and under her soiled gloves, was another pair already on her hands. While wearing the second pair of gloves, CNA A applied the new brief and assisted the resident with putting her pants back on. During an interview on 05/16/23 at 5:32 PM CNA A said after she had wiped Resident #1's rectal area she had removed the first pair of gloves because she wanted to have clean gloves since they were considered contaminated. CNA A said she had learned to double glove at the previous facility she worked at. CNA A said she had been working at the facility for about a year now. CNA A said she was not sure if they could use double gloves at this facility. CNA A said she should have removed her second pair of gloves before she applied the new brief and assisted the resident with her pants. CNA A said she would usually wash her hands when she removed her gloves because her hands could possibly be contaminated. CNA A said the second gloves could possibly become contaminated and she should have not worn the second pair. CNA A said due to her not having changed her gloves that could lead to cross contamination and possibly urinary tract infections. During an interview on 05/17/23 at 5:44 PM the DON said staff were expected to put on gloves if they were going to provide care to a resident. The DON said staff were not allowed to double glove because it could lead to cross contamination and infections. The DON was made aware of the observation of staff wearing double gloves during resident care. The DON said that probably occurred because the staff was nervous and perhaps went to back to old practice because they did not teach that here. During an interview on 05/18/23 at 2:56 PM the staffing nurse said she trained staff regarding infection control procedures. The staffing nurse said if a CNA provided incontinent care and after they wiped bowel movement, they were supposed to change their gloves, wash their hands and apply clean gloves. The staffing nurse said it was considered cross contamination if they did not change their gloves as they were considered contaminated. The staffing nurse said the CNAs were supposed to wash their hands in between glove change because their hands could be dirty. The staffing nurse said if staff used the same gloves that could lead to an infection. The staffing nurse said staff were not allowed to double glove. The staffing nurse said she did not know why the CNA had done that as they did not teach that here. During an interview on 05/18/23 at 03:17 PM the Administrator was made aware of staff using double glove during resident personal care. The Administrator said the staff using double gloves was unacceptable. Record review of the facility's undated policy titled Incontinent care procedure and proficiency evaluation indicated in part: Knock on door identify yourself explain procedure. Perform hand hygiene, don (put on) gloves. Clean rectal area with new wash cloth/wipe using upward gentle strokes. Remove soiled pad and clothing and place in plastic bag. Remove gloves and discard, perform hand hygiene and don gloves.

Based on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 13 of 13 residents in the confidential group interview. Staff used cell phones in residents' presence causing residents to feel disrespected. Staff told residents to go to the bathroom on themselves and the residents would be changed later. This failure resulted in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation. The findings included: Interview on 05/16/23 at 10:19 AM during the confidential resident council meeting 13 alert, lucid residents stated unanimously that staff were on the phone while providing care. One resident said a Medication Aide or Nurse talked to their child while on their (the staff's) ear buds while pouring medications and it made the resident uneasy about their medication. Another resident stated one of the African Aides talked to whoever in that aide's native language for the entirety of the shower. The residents said it did not make a difference if it was day shift or night shift or weekends. The residents stated it made them feel lousy and disrespected. The residents reported because the staff were on the phone they had to wait forever for care. A resident said the staff told residents to go to the bathroom on themselves and the resident would be changed later. One resident said they saw this happen to a resident who asked to go to the bathroom but was unable to transfer without help. A resident who was present said an aide told her to urinate on themselves three evenings prior to the interview and it was gross. The residents were asked if surveyor could fix one thing in the building what would it be, and all 13 residents stated not having the staff on their phone and/or ear buds while providing care. Interview on 05/17/23 at 11:47 AM the DON stated the management staff would peek in the facility at nighttime every once in a while. She said she drove around the building, peeked in, and looked for if call lights were going off, staff bunching up (standing in a group together and not working) and being available. The DON stated once she got into the building for a check for smells, if snacks and ice were passed, and if rounds were done. The DON said it would be hard to watch for staff to resident interactions because staff would go on their best behavior when she (the DON) was present. The DON added that the ADONs had to cover the night shift once in a while and they could supervise the halls at that time. Interview on 05/18/23 at 11:57 AM the DON said her expectation on cell phone use was not to have the staff using the cell phone while in a resident room at all. The DON said if the staff had to take a call they could step into the 'cut out' (storage space on the hallway) or go to the break room. She said her expectation was staff not be on social media while on duty. The DON said she did not want staff on their phones while residents were in the shower, especially not hiding in the shower room having a long conversation. The DON said she monitored for cell phone use by making rounds which was usually every couple hours. The DON said she wouldn't like it if the staff were on the phone while they were taking care of her and it would make her upset and mad and sad, that the staff did not have their full attention on her during care. The DON said she was frustrated about the cell phone use because they had a major in-service about cell phone use in the bathrooms. She said it occurred because of one of the resident council meetings. Observation on 05/18/23 02:56 PM revealed NA J in front of the nurse's station standing behind Resident #32 on the phone. Review of the Resident Council Minutes, dated 4/11/23, revealed 21 residents attended and they informed the facility that the residents were not changed in a timely manner; and CNAs told residents to use restroom in pull -up or brief and the CNA would change the resident later. Review of the in-service dated 4/12/23 revealed: Residents are to be changed every 2 hours and as needed. The staff could not tell residents to use restroom on themselves. Review of the Resident Council Minutes, dated 5/3/23, revealed the residents communicated to the facility that CNAs were always on the phone and have their headphones in. Review of the in-services, dated 5/3/23, revealed phones are to only be used on break times and are to only be out in breakroom or outside of the facility. No phones in common areas or res areas. Ear pods /headphone are not to worn . We have to be able to focus on our jobs and be able to direct all of our attention to the residents. Review of the Complaint Book documented: On 2/2/23 Resident #21 reported staff were rude and left her in the bathroom alone. She also communicated the staff refused to change her when she was wet. On 4/12/23 Resident #4 told an aide Resident #4 needed to go use the bathroom. Resident #4 communicated the aide totally ignored Resident #4 and the aide said no, no go to the dining room. The complaint form documented Resident #4 got upset. The follow up documented the aide was counseled that if any resident asks to go to the restroom the aide needed to take the resident and not to ignore the resident. Review of In-services documented: 1/28/23 Ear buds - ear buds are not permitted inside of facility. 2/6/23 staff were in-serviced on Resident Rights and Statement of Resident Rights. 2/28/23 partially covered Statement of Resident Rights 3/6/23 partially covered the Statement of Resident Rights 3/9/23 Statement of Resident Rights 3/18/23 Both the Resident Bill of Rights and the Statement of Resident Rights 4/27/23 Phones: Do not be hiding in closets on phone Review of the Statement of Resident Rights posted in the facility and in staff orientation book documented: 4. Residents had the right to be treated with courtesy, consideration, and respect. Review of the Bill of Rights: the resident has a right to a dignified existence and self-determinization.

45411 Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #5 and #310) reviewed for accident/hazards/supervision, in that: - LVN E and CNA F transferred resident #310 from his wheelchair to his bed by hooking their arms under the resident's armpits and without the use of a gait belt. - CNA I and CNA H transferred Resident #5 from her bed to her wheelchair by hooking their arms under the resident's armpits and with the improper use of a gait belt. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. The findings included: Review of Resident #5's Admission Record, dated 5/17/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cellulitis of the right lower limb, arthritis, muscle weakness, hemiplegia (paralysis on one side), and stroke. Review of Resident #5's quarterly MDS Assessment, dated 4/10/23, revealed: Cognitive Ability was not assessed. She needed extensive assistance of two staff for transfers. She had range of motion impairment on one side of the lower extremity and used a wheelchair. Review of Resident #5's care plan, revised 2/12/19, revealed: Problem - Resident #5 has an ADL self-care performance deficit related to stroke. Goal - The resident will maintain current level of function through the review date. Interventions - Transfer - The resident needs extensive assistance with this task. Review of Resident #5's Care Plan, initiated 10/11/22 revealed: Problem - Resident Requires assist with ADLs. Goal - Resident is able to perform self-care to optimal level and maintains strength and endurance for 90 days. Interventions - provide level of support to complete transferring needs every shift. Review of Resident #5's ADL Flow Sheet on Transfers for 5/5/23 through 5/17/23 revealed Resident helped stand without plopping nine times and Resident #5 did not help with the transfer 19 times. Observation on 5/15/23 at 11:10 AM revealed Resident #5 needed help sitting up in bed. The aides helped her sit up and CNA I set the wheelchair up at the end of the bed and locked the wheels. CNA H put the gait belt around Resident #5. Both aides (CNA I and CNA H) hooked their arms under Resident #5's arms, grabbed the back of the gait belt and helped Resident #5 stand. The gait belt slid up to the bottom of Resident #5's shoulder blades. Resident #5 had difficulty staying in a standing position as her legs shook. The aides assisted Resident #5 in pivoting and sitting in the wheelchair. Review of Resident #310's Admission Record dated 5/16/23 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of unspecified lung, malignant neoplasm of bone, orthopedic aftercare, aftercare following surgery for neoplasm, unspecified fracture of T9-T10, neoplasm related pain, and stroke. Review of Resident #310's Admission MDS assessment dated [DATE], revealed: He scored a 15 on his mental status exam (indicating he was cognitively intact). He required extensive assistance with mobility ADLs and moderate assistance with all other ADLs. He used a wheelchair for mobility. He had spinal (involving lamina, discs, or facets) and other orthopedic (repair fractures of the pelvis, hip, leg, knee, or ankle) surgery in the 100 days prior to admission. Review of Resident #310's Baseline Care Plan initiated 5/11/23, revealed: Problem - Resident requires assist with ADLs Goal - Resident is able to perform self-care to optimal level and maintains strength and endurance for 90 days Interventions - Encourage independence in performance of self-care and mobility within limitations; Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs every shift; Therapy to evaluate and treat if indicated. Observation on 05/15/23 at 03:18 PM revealed Resident #310 required assistance getting into bed after incontinent care performed in his bathroom. LVN E positioned the resident's wheelchair at the bedside and locked both wheels. LVN E made sure that the footpath was clear of any trip hazards. LVN E came to Resident #310's right side and CNA F came to his left side. LVN E placed his arm under the resident's right armpit and CNA F placed her arm under the resident's left armpit and together they lifted Resident #310 out of the wheelchair by his arms and pivoted him in a half circle and placed him on his bed. LVN E and CNA F then repositioned Resident #310 until he was comfortable in the bed. There was no gait belt used during this transfer. In an iInterview on 05/17/23 at 11:47 AM, the DON was asked how staff is trained to perform a two-person transfer. She stated the resident must be weight bearing. The staff would sit the resident up, put a gait belt around them, and the resident's feet should be on the floor. She stated staff could hook their arm under the resident's arm if the staff's weight was on the gait belt and not used to pull someone up by their arm. She stated that any time staff used their arms to hook under a resident's arms to transfer, they should be using a gait belt for the transfer. The DON stated that all transfers should be done with a gait belt, so they had something to hold onto if the resident fell . Regarding Resident #5, DON was informed of the observed transfer in which the gait belt was not tight enough and the staff were pulling the resident by her arms, and the observation of the resident's leg shaking while trying to bear weight. DON stated I don't have her as a mechanical lift. I don't remember her being on a mechanical lift. She had been on therapy recently She gets physical therapy right now. In an interview on 05/17/23 at 12:00 PM, the DON stated that the facility determined the type of transfer by whether the resident was an unreliable weight-[NAME]. She explained that if the resident could stand but the staff knew the resident would drop in the middle of a transfer, they would assign the resident a mechanical lift. She stated most of time we have therapy come and they determine who uses a mechanical lift or sliding board, those kinds of things. If they come in with an order for non-weight bearing, we'll go by the order, then if we're unsure of that we'll contact therapy. In the mean time we'll use a mechanical lift. We have therapy assess them as needed. Surveyor requested the policy and any in-services on transfers completed in the previous three (3) months. In an interview on 05/17/23 at 01:08 PM, the DOR stated that regarding staff training she did transfers, any specific resident needs which could be positioning or equipment. She stated when she trained staff to do two-person transfers she wanted them to make sure the area was clear, use a gait belt, and make sure the wheels were locked on whatever transferring to and from (wheelchair/shower chair, mechanical lift). DOR stated she trained staff that during transfers the correct positioning for a two-person transfer was one person in front and the second person to assist on the side, one person grabbed both sides in back, while the other person grabbed in the middle of the back and the resident's open side. DOR stated she did not train staff to do a hug transfer because they were unsafe for the staff and the resident. She stated if the resident can hold the person's hug , it would prevent them from performing the task and if they were not able to take hold of the staff's arms, she would expect staff to put on a gait belt and the resident to hold onto the staff by their bicep . She stated that she did not like to transfer by the arms because the risk to the resident could be dislocation of shoulder, discomfort, and it was not safe. She stated that long term residents were reassessed at least quarterly and if something changed and nurses notified therapy her department would reassess as needed. She stated that if a resident was not able to reliably bear weight or not safe during a transfer (not able to follow commands or participate in transfer) they would be changed to a mechanical lift only transfer status. DOR stated that she taught the CNAs how to do transfers especially if it was a difficult transfer. She stated she thought her last staff in-service was in April or the week prior. She stated she did one-on-one teaching with new residents, usually the in the rehab hall. Regarding the two-person transfer with Resident #5 she stated she did not know where the staff would learn that kind of transfer, and it seems that the gait belt was too loose. She stated that a gait belt would be snug and if the resident did not like it the staff would need to explain that it would loosen when they stand. She stated Resident #5 has a history of wanting to bear weight on her toes. She stated that Resident #5's legs shaking could be a sign she was having trouble in therapy. DOR stated Resident #5 had been able to bear weight in therapy and take a few steps, but she had gone back and forth with her progress. In an interview on 05/17/23 at 4:50 PM regarding the transfer done with Resident #310 on 5/15/23, LVN E stated that Resident #310 was able to do sit to stand transfers with assistance. He stated after he (LVN E) and CNA F got the resident cleaned up in the bathroom and back over to the bed in his wheelchair, they got him some new non-slip socks and he had him use his arms and push himself up to standing and then helped him to pivot over to the bed and sit, then got him positioned comfortably on the bed. When he was advised of how the transfer was done from surveyor notes, he stated, oh no and shook his head. LVN E then stated, and with no gait belt and shook his head again. He stated that they should have used a gait belt and that a resident should never be lifted by their arms in that manner. He stated that he knew better than to transfer a resident in that way especially without a gait belt but that sometimes it did happen even though it shouldn't. He stated that he had received the most recent facility in-service on transfers in April which included two-person transfers. He stated that Resident #310 did have orders for non-weight bearing on his right leg due to his recent surgeries and he (LVN E) had been educating him about using his call light for assistance as well as the proper way to do transfers since he was admitted so he had no excuse for why he did the transfer incorrectly. In an interview on 5/18/23 at 8:40 AM, the DON and Corporate RN stated the facility's competency checklist on transfers for aides just had a line to address if the aide completed the appropriate transfer, not the steps involved in the transfer. Interview on 05/18/23 at 01:00 PM CNA H stated she did do the transfer with Resident #5 on Monday. She stated she remembered grabbing the gait belt in the front and back but denied hooking her arms under the resident's arms. When advised she did hook her arms under Resident #5's arms during the transfer, she raised her hands in a 'hands off not arguing motion' and stated Resident #5 bears weight, and she didn't notice her legs shaking. She stated that Resident #5 was able to push up from a seated position by herself. Review of undated facility procedure Two Person Pivot Transfer revealed: Purpose: To safely get resident from one surface to another by allowing resident to participate by weight bearing during transfer. Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot. Equipment: 1. Gait Belt 2. Two staff members Procedure: 1. Explain procedure to resident. 2. Clear obstacles. Lock wheels/brakes; remove leg rests and/or wheelchair arms if able. Position wheelchair next to bed. 3. Assist resident to get on nonslip footwear. 4. Assist resident to sit at bedside with feet on the floor. The resident's knees should be separated to provide a wide base of support. 5. Apply gait belt snugly around waist. 6. Stand in front of the resident. Each staff member places one hand under the front of the belt and one hand under the back of the belt, using an underhand grip. 7. The staff member closest to the chair stands in a position so that he or she can pivot and move away, allowing the resident unobstructed access to the chair. 8. On the count of three both nursing assistants will move the resident at the same time. Coordination of the movement is important. 9. Instruct the resident on the count of three to lean forward and push up from the bed with his/her hands while you assist bringing the resident's weight forward with the belt. Support the resident's knees and feet by placing your knees and feet firmly against them. 10. On the count of three, the resident is assisted to a standing position. The staff members pivot slowly and smoothly by moving their feet, legs and hips until the resident can feel the back of the wheelchair with his or her legs. 11. Both staff members bend their knees and assist the resident to lower him or herself into the chair. 12. Remove the transfer belt. 13. Adjust the wheelchair legs and footrests. 14. Reverse the procedure to return the resident to bed. No in-services were provided by the facility before the time of exit on 5/18/23 at 5:30 PM .

Based on observation, 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 3 of 10 residents reviewed for pharmacy services (Residents # 15, #34, #43) during review of medication carts. -Warfarin 6mg tab card expired 5/1/23, prescribed to resident #34 -Warfarin 10mg card expired 4/24/23, prescribed to resident #34 -Ondansetron 4mg expired 4/13/23, prescribed to resident #15 -Ondansetron 4mg expired 5/9/23, prescribed to resident #15 -Ondansetron 4mg expired 5/13/23, prescribed to resident #43 -Hydralazine 10mg expired 5/13/23, prescribed to resident #43 This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Record review of Resident #15's admission record dated 5/17/23 indicated she was admitted to the facility on [DATE] with diagnoses which included dementia, type 2 diabetes, and hypertension. She was [AGE] years of age. Record review of Resident #15's care plan dated 03/30/2023 indicated in part: Problem: Resident has history of nausea. Goal: The resident will have minimal or no emesis (vomit) through the review date. Interventions/tasks: Zofran Tablet 4 MG (Ondansetron HCl) Give 1 tablet by mouth every 6 hours as needed for Nausea/Vomiting. Record review of Resident #15's order summary report indicated in part: Ondansetron tablet 4mg, Give 1 tablet by mouth for nausea. Order date 05/10/2022. Record review of Resident #34's admission record dated 5/17/23 indicated she was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (Stroke), dysphagia (difficulty swallowing), aphasia (difficulty with speech), COPD, anxiety, depressive disorder. She was [AGE] years of age. Record review of Resident #34's care plan dated 03/04/2023 indicated in part: Problem: Resident was on anticoagulant therapy warfarin sodium r/t cerebral infarction due to occlusion of right cerebral artery. Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions/tasks: Administer anticoagulant medications as ordered by physician, monitor side effects and effectiveness every shift. Record review of Resident #34's order summary report indicated in part: Coumadin (warfarin sodium) tablet 6mg, Give 2 tablets by mouth one time a day related to cerebral infarction. Order date 05/03/2022. Coumadin (warfarin sodium) tablet 10mg, Give 1 tablet by mouth one time a day related to cerebral infarction. Order date 12/13/2022 Record review of Resident #43's admission record dated 5/17/23 indicated she was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, COPD, major depression, dementia, anxiety. She was [AGE] years of age. Record review of Resident #43's care plan dated 04/23/2023 indicated in part: Problem: Resident had potential nutritional problem. Goal: The resident will be free from problems through the review date. Interventions/tasks: Administer medications as ordered by physician, monitor side effects and effectiveness. Record review of Resident #43's order summary report indicated in part: Hydralazine tablet 10mg, Give 1 tablet by mouth every 8 hours as needed. Order date 02/27/23. Ondansetron 4mg, give 1 tablet by mouth every 6 hours as needed for nausea. Order date 4/04/2022. During an observation and interview on 05/17/2023 at 08:30am of medication cart #1, it was discovered that Warfarin 6mg tab card was expired on 5/1/23, prescribed to resident #34. Warfarin 10mg card was expired on 4/24/23, prescribed to resident #34. Ondansetron 4mg was expired on 4/13/23, prescribed to resident #15. Ondansetron 4mg was expired on 5/9/23, prescribed to resident #15. Ondansetron 4mg was expired on 5/13/23, prescribed to resident #43. Hydralazine 10mg was expired on 5/13/23, prescribed to resident #43. RN D stated that he did not who was in charge of checking medication carts for expired medications. During an interview on 05/17/2023 at 01:10 PM the DON was made aware of the discovery of the expired medications in medication cart #1. The DON stated that the ADON checked the carts for expired medications once a week. The DON stated that she is very surprised there were expired medications found in the cart. The DON stated that the charge nurses were responsible for checking the medication carts on a daily basis. Record review of the facility's policy titled Medications, ordering and receiving undated indicated in part: Medication orders are phoned or faxed to the pharmacy and written on a medication order form provided by the pharmacy for that purpose. The entry includes whether the order is a new or repeat order prescription number, patient's name and room number, medication name and straight, directions for use, if a new order or direction change to a previous order common name of pharmacy supplier, physicians name. Information concerning repeat medication or refills will be written on a medication order form provided by the pharmacy for that purpose. Transferred to the form on a peel off label and ordered as follows: order medication within 72 hours of the last dose available, the nurse who orders the medication is responsible for notifying the pharmacy of changes in directions for you., the refill order is called in faxed or otherwise transmitted to the pharmacy.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication (cart #3) of 4 medication carts reviewed and 1 of 1 treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #3 was locked when unattended. The facility failed to ensure that treatment cart 1 of 1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation on 05/15/23 at 10:39 am at nurses station revealed an unlocked treatment cart. The treatment cart revealed: 1 - 2 ounce tube of triple antibiotic 1- 4 ounce tube of desitin 2- 15 gram tubes of triamcinolone acetonide 0.1% 1 -60 gram tube of ketoconazole cream 2% 2- 1.5 fluid ounce tubes of silvasorb gel 2- 22 gram tube of muprocin ointment 2% 2- 30 gram tubes of Santyl collagenase ointment 250 U/gm During an observation on 5/17/23 beginning at 4:32 pm revealed the Hall 300 medication cart unlocked and unattended. At 4:37 pm, the RN passed the cart, looked at the surveyor and then locked the cart. Medication cart #3 had insulins, glucometers, lancets and alcohol swabs in the top drawer. Medication pouches were in the second drawer. Medication cards were in the third drawer and narcotics were in locked compartment. Medication bottles and liquid medications were in the fourth drawer. In an interview on 05/18/23 at 12:00 PM, the DON stated that her expectations were that all unattended medication carts and treatment carts be locked to ensure the safety of residents. Record review of the facility's medication administration proficiency checklist, undated, indicated in part, If the cart is left at any time during medication pass due to an emergency, it must be locked.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1of 2 residents (Resident #3) reviewed for infection control. CNA C and CNA D failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #3. This failure could place residents at risk for the spread of infection. Findings include: Record review of Resident #3's face sheet, dated 01/03/21, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, human immunodeficiency virus (HIV), Parkinson disease and muscle weakness. Record review of Resident #3's MDS assessment, dated 11/27/22, revealed Resident #3 required extensive assistance with most activity of daily living (ADLs) and two-person assist. Resident #3 was always incontinent of bowel and bladder. Record review of Resident #3's, undated, care plan revealed the resident was care planned for being incontinent of bladder and bowel related to physical/mental decline. Observation of incontinence care for Resident #3 on 01/03/22 at 10:10 a.m. revealed CNA C and CNA D did not wash their hands but donned gloves before the start of care. CNA C removed the resident's soiled brief. She wiped from front to back. Resident #3's brief was soiled with urine and fecal matter. Both staff repositioned Resident #3. CNA C continued to clean the resident's bottom area. CNA C's gloves were visibly soiled with urine. CNA C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #3's clean brief. She placed the clean brief on the resident and fastened it. CNA D assisted CNA C to provide care to Resident #3. CNA D wore the same gloves for repositioning the resident including touching the perineal area and fastened the clean brief to the resident. CNA C and CNA D did not wash their hands before exiting Resident #3's room. In an interview on 01/03/22 at 10:22 a.m. with CNA C she stated she had been employed at the facility since May 2022 and received infection control in-services 2 months ago. CNA C stated cross contamination meant mixing clean with dirty. CNA C stated she should have washed her hands and changed gloves before she retrieved the resident's clean brief. She stated Resident #3 could get an infection for not using good infection control practice. Interview with CNA D on 01/03/22 at 10:26 a.m. revealed she had been employed at the facility for about 1 year. CNA D received infection control training 4 months ago. She stated cross contamination was transferring germs from one place to another. CNA D stated she should have changed her gloves and washed her hands before fastening Resident #3 clean brief. She stated Resident #3 could get sick for not washing hands or changing gloves. During an interview with the DON on 01/03/22 at 10:33 a.m. revealed she was aware of some of the concerns raised about infection control. She stated the staff were expected to wash their hands and don gloves before starting care. She explained she was responsible for infection control and the staff were trained every three months with random checks on infection control practices. Record review of the facility's, undated, Hand washing policy reflected, Standard: Mechanical removal of pathogenic organisms from the skin is accomplished by hand washing. Policy: Hand washing is required before and after a procedure that involves direct and indirect contact with a resident, after contact with any wastes or contaminated materials, before handling any food or food receptacle, or at any time the hands are soiled.

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 and prevent infection for 1 of 8 residents (Resident #2) reviewed for pressure ulcers. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents at risk for the development or worsening of pressure ulcers, infection, pain, decreased quality of life, and/or hospitalization . The findings included: Resident #2 Record review of Resident #2's Admission Record dated 08/06/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Significant Change MDS assessment dated [DATE] documented: She scored a 7 of 15 on her mental status exam, indicating severe cognitive impairment, exhibited physical behaviors directed towards others for 1 - 3 days of the previous 7, was totally dependent on one or two staff for all Activities of Daily Living. She had upper and lower range of motion impairment on one side and used a wheelchair and was frequently incontinent of bladder and always incontinent of bowel. MDS indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS indicated Resident #2 had chronic pain, had a life expectancy of less than 6 months and was as at risk for the development of pressure ulcers. Review of Resident #2's Care Plan, revised 07/11/2022, indicated, in part: Resident #2 had an ADL self-care performance deficit related to unspecified dementia without behavioral disturbance. The Goal was: the resident will maintain current level of function in ADL's/ care daily through the review date. Identified Approaches included: a mechanical lift for all transfers, providing a sponge bath when a full bath or shower cannot be tolerated, the resident required assistance by staff to turn and reposition in bed per doctor's order and/or nursing home protocol. Notify doctor and responsible party of significant abnormalities and document findings. The resident required assistance by staff to eat; the resident required skin inspection during all ADL;'s/care per resident request and as necessary. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Review of Resident #2's Care Plan, revised on 6/21/22, indicated, in part: Problem: Resident #2 had a pathological bone fracture due to other specified disorders of bone density and structure. The identified goal was Resident #2 will be free from signs or symptoms of pain or will express/exhibit relief of pain after administration of ordered medications, alternative comfort measures. Identified interventions included: wound care: daily monitor [CONDITION(S)]/swelling right knee with immobilizer, one time a day. Remove immobilizer to right lower leg and assess skin every shift, then reapply immobilizer. Notify doctor if any changes to skin. In an interview on 8/6/22 at 12:15 PM, DON stated Resident #2 was admitted to the hospital on 8/4/22 after being taken to a follow up appointment with her orthopedic doctor. Record review of Resident #2's Emergency Department note, dated 8/4/22, revealed Chief Complaint: BIBA from skilled nursing facility after Resident #2 was seen for a follow up doctor appointment to check on dislocated knee. Resident #2 was sent by orthopedic doctor due to right knee being swollen, a 1-inch pressure ulcer and drainage., Physical Exam: Skin: circular 3 cm purulent ulcer to right knee, stage 1 erythematous ulcer to mid anterior right shin, Medical Decision-Making Process: [Resident #2] arrived via EMS. She has a chronic appearing wound of the right patellar region with obvious deformity . Orthopedic doctor would like the patient admitted to the hospital with infectious disease consultation and wound care until further plan has been established. In an interview on 8/6/22 at 12:15 PM DON stated that on 8/5/22, Resident #2's son came to the facility to meet with the Administrator and herself regarding a wound found on Resident #2's right knee during Orthopedic physician follow-up appointment yesterday (08/04/22). DON stated that Resident #2's son showed pictures of Resident #2's right knee which showed a round wound with pus and brown drainage and what appeared to be a 4-inch by 4-inch foam pad held in place by a single strip of tape above the right knee. DON stated the dressing showed drainage on it too. DON stated Resident #2's son told them the wound was discovered when the orthopedic doctor removed the immobilizer to examine her right knee. DON stated that the facility immediately began investigating the situation with the DON stating the Treatment Nurse had documented a head-to-toe skin assessment for Resident #2 on 8/1/22. DON stated that the only documented wound at the time of the skin assessment on 8/1/22 was an existing skin tear to Resident #2's left 2nd toe. DON stated that Resident #2 was on hospice, that her baths were done by hospice aides and the last bath was documented on 8/4/22, with no documentation of a wound to right knee noted. DON stated that no one from facility or Hospice had reported a wound or skin breakdown regarding Resident #2's right knee to her. DON stated that the Treatment Nurse did identify an abrasion to Resident #2's right shin immediately before Resident #2 left the facility for her Orthopedic appointment on 8/4/22 but the Treatment Nurse denied seeing any wounds or dressing on Resident #2's right knee. DON stated that she questioned the Treatment Nurse about the type of dressing shown in the pictures Resident #2's son showed. DON stated that the Treatment Nurse reported she did have that type of dressing (seen in photo), but Treatment nurse stated she did not use them and did not keep these dressings on her treatment cart. DON stated that the facility was continuing their investigation into the incident. In an interview with on 8/6/22 at 12:15 AM, Administrator stated that Resident #2's son came to the facility on [DATE] and requested to meet with him and the DON. Administrator stated they were shown the pictures of Resident #2's right knee by Resident #2's son. The Administrator stated he instructed the DON to report the incident to State Office and begin a facility investigation. Record review of Resident #2's, MAR's-TAR's revealed the documented physician orders: 9/14/21 (date order written by physician)-Remove immobilizer to right lower leg and assess skin every shift, then reapply immobilizer. Notify MD if any changes to skin. Every Shift. With review, day shift nurses and night shift nurses initialed they completed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/17/22 (date order written by physician) Resident #2 has a brace/splint to right knee remove and assess skin every day. Report any adverse findings. Resident is to be moved with extreme caution. Every shift to assess for knee joint dislocation. Instruct aides to use extreme caution while providing resident care. With review, day shift nurses and night shift nurses initialed they completed the order while resident was in the facility. Record review of Resident #2's, Order Summary dated 08/08/2022 revealed the following physician orders: 6/29/22-[MEDICATION(S)] (liquid vitamin supplement) two times a day for wound care protocol, 1 packet mixed in 4-6 ounces water. 5/13/22-Wound Care protocol: Pre-[MEDICATION(S)] every month. 4/24/19-May apply skin protectant/barrier cream to affected/reddened areas every shift and/or prn as preventative. 5/11/22-Protective tent to foot of bed to prevent pressure on feet every shift. 9/14/21 Remove immobilizer to left lower leg and assess skin every shift, then reapply immobilizer. Notify MD if any changes to skin. 6/17/22-Resident has a brace/splint to right knee, remove and assess skin every day, report any adverse findings. Resident to be moved with extreme caution. 4/24/19-Skin assessments: skin assessments on admission for three days and then weekly, weekly assessments for all identified wounds and Braden risk assessments on admission then weekly times three weeks and then quarterly. 6/20/22 Wound Care: daily monitor [CONDITION(S)]/swelling right knee with immobilizer. Record review of Resident #2's Skin Assessments, revealed the following documentation by Treatment nurse: 7/25/22 at 2:02 PM revealed no documented wounds. 8/1/22 at 6:22 PM revealed skin tear to left 2nd toe. Record review of Resident #2's Orthopedic Progress Note (during hospital admission), dated 8/5/22, revealed: Assessment/Plan: continued drainage; patient and family have 2 options, wound care, antibiotics for this wound over the anterior knee, I do not know if the TKA is septic but it may be, the other and really only reasonable surgical option is an above knee amputation which the family for good reason is hesitant; reduction with wound care is likely not a good answer as this was attempted in June, this knee has been unstable for at least 6 months and she does not ambulate, I attempted a reduction yesterday but the knee did not move, even if I was able to reduce it, we have no way to keep it reduced which is why the only surgical option would be AKA; recommend ID consult; Wound care consult Record review of Resident #2's Infectious Disease Consultation Note (during hospital admission), dated 8/6/22 revealed: Chief Complaint: BIBA from local skilled nursing facility after a doc appt to check on dislocated knee. Sent by Orthopedic physician d/t knee being swollen, a 1-inch pressure ulcer and drainage., History of Present Illness: ID consultation is requested for [AGE] year-old female with [CONDITION(S)] infection of the right knee and chronic dislocation. She has been non ambulatory for 3 years .Orthopedic physician could not reduce the dislocated knee. He recommended right AKA. Patient is on hospice at skilled nursing facility. She has been started on [MEDICATION(S)] and [MEDICATION(S)]., Physical Exam: Musculoskeletal: right knee with dislocation and quarter sized ulcer on right knee, the knee is not warm to touch or erythematous., Assessment/Plan: 1. Open knee wound: Patient has a [CONDITION(S)] infection of the knee, a prosthetic knee. I agree with Orthopedic physician and have recommended right AKA for cure. If the goal is chronic suppression, I would treat her with 4 weeks of [MEDICATION(S)] or [MEDICATION(S)] and then daily [MEDICATION(S)] for chronic suppression ([MEDICATION(S)] and [MEDICATION(S)] will not work for [CONDITION(S)]). I spoke to Resident #2's son and he said that he and his family would like a couple weeks to think about it. I told him that I could place a PICC line and send her to rehab while they decide; it wouldn't be an option to stay here for 2 weeks while they decide. Record review of Resident #2's Hospitalist Progress Note (during hospital admission), dated 8/7/22, revealed: Assessment /Plan: 1. Right knee infected wound/dislocation: continue IV [MEDICATION(S)] and [MEDICATION(S)]; wound culture grew out [CONDITION(S)]; Infectious Control physician in agreement with Orthopedic physician that AKA would be the correct treatment; Infectious Disease physician offered family that patient can be sent to SNF with IV antibiotics in the mean time until family makes decision about AKA; talked to patient's son who is in agreement with Infectious Control physician and wants IV antibiotics set up until family has come to a consensus about whether they want to pursue surgery or not In an interview on 8/8/22 at 12:28 PM, LVN A stated that Resident #2 had been fragile since she started working in the facility 4 months ago. LVN A stated that Resident #2 recently had a dislocation of her right knee and wore a brace to keep it straight. LVN A stated that she did not remember what the brace looked like exactly and that we did not touch her immobilizer at all. LVN A then stated that sometimes she would unstrap the immobilizer but not take it all the way off. LVN A stated that on the morning of 8/4/22 she saw the brace on Resident #2's leg and signed the order on the MAR's-TAR's but she did not remove the brace to visualize the leg. LVN A stated that she did not notice anything abnormal about the immobilizer on 8/4/22 before Resident #2 left for Orthopedic appointment. LVN A stated that she was not aware of any wounds to Resident #2's right knee/leg until after the Resident #2 was admitted to the hospital on 8/4/22. In an interview on 8/8/22 at 1:04 PM, RN B stated she had been the facility Treatment Nurse since February of 2022. RN B stated Resident #2 was very angry and resistant to care. RN B stated she did an unavoidable pressure ulcer risk assessment on Resident #2, but the physician was on vacation and had not signed it. RN B stated Resident #2 got the brace in June 2022 because she had [CONDITION(S)]. RN B described the brace as going approximately 6 inches above the right knee to right above the ankle. RN B stated the brace was a true immobilizer and would force the leg not to bend and the fabric holding it together was solid (no hole for the kneecap) with Velcro straps around it. RN B stated there were metal ridges on the sides covered in fabric preventing Resident #2 from bending her leg. RN B stated all she did was check for circulation at the top and bottom of the brace and make sure it was not too tight. RN B described the process as physically putting two fingers down the immobilizer to make sure it was not too tight (RN B showed surveyors by pantomiming). RN B stated she did not feel very far down the immobilizer to check for [CONDITION(S)] or to see if Resident #2's extremity was puffy. RN B stated she usually took the immobilizer off on Mondays when she did her full skin assessment, or when she noticed the immobilizer was too loose or too tight. She stated she did not usually take it off more than that. RN B stated she did Resident #2's skin assessment on 8/1/22 and did not find any new wounds when she removed immobilizer to perform weekly full skin assessment. RN B stated she remembered on 8/4/22 she got to the building around 1:45 p.m. and Resident #2 had not left for her Orthopedic physician appointment. RN B stated she did not realize Resident #2 did not have her wound care done that day until she saw the medical transport company going down Resident #2's hallway. RN B asked the personnel of the company who they were taking, and they told her Resident #2. RN B stated she asked them if she could do the wound care on Resident #2 really quick before they took Resident #2 to doctor appointment, transportation personnel waited while RN B provided wound care to Resident #2's left toe. RN B stated while she did the wound care to Resident #2's left toe she noticed the brace looked sloppy and tangled and did not want the orthopedic physician to see the brace looking this way. RN B stated she opened the bottom of Resident #2's brace and noted a new abrasion to the right shin that measured approximately 1.9 cm x 3 cm. RN B stated there was a dressing on the leg that was not one of hers. RN B stated she took off the dressing, cleaned the wound and put a xero-foam dressing on it and then wrapped the leg in the immobilizer and placed the Velcro correctly. RN B stated she did not open the part of the immobilizer that circled Resident #2's knee. RN B said she did not see any swelling over the top of the brace, and she did not have time to check for [CONDITION(S)]. RN B stated the transport company took Resident #2 to her appointment. RN B stated she expected Resident #2 to be back around 6 p.m. but the charge nurse told her (RN B) that Resident #2 was sent to the hospital. RN B stated she called the shin injury an abrasion but the corporate nurse told her it should be a Stage II pressure ulcer because of the location. RN B stated she initially thought Resident #2 went to the hospital because the knee was dislocated but the charge nurse told her it was because Resident #2 had a wound to the right knee, and it was infected. RN B stated, nothing was infected that I know of. RN B stated the charge nurse called Resident #2's hospice nurse and then put her on the phone with the treatment nurse (RN B). RN B stated the hospice nurse told her it was because of the wound being infected but did not say which wound. RN B stated she had more personal appointments and had to leave the facility and when she came back from her appointments, the administrator called her (RN B) into his office. RN B stated the DON asked the Hospice agency for the shower and skin sheets. RN B stated another nurse worked with Resident #2 and stated she put lotion on Resident #2's leg because the skin was scaly and flakey. RN B stated the family had pictures of the wound and when they showed the pictures to her, she asked what kind of dressing is that? RN B described the picture as showing a 4 cm x 4cm foam dressing that was taped across the wound at the top only. RN B clarified that the 4 cm x 4cm dressing was attached on one side but not the others. RN B stated the DON asked her if she had any dressings (like the ones that were seen in the photographs from son) and she said yes, but they were not in the cart because she did not like to use that type of dressing. RN B stated the dressing was just a non-adherent dressing because whoever put the dressing on used tape. RN B stated she had a hard time wrapping her head around why anyone would put a dressing on like that. RN B was asked to get a 4 cm by 4 cm dressing the facility used. RN B returned with the 4 cm x 4 cm dressing, and she ran her finger across the top, pointing. RN B stated, someone put tape just at the top. RN B stated the dressing absorbed drainage but held the drainage against the skin. RN B stated the only time she would use a 4 cm x 4 cm foam dressing like the one she showed surveyors was on a heal or as a protection of some kind, but not as a dressing. RN B stated the wound care company the facility used kept sending them to her, but she never used it. RN B stated there was a storage closet that held wound care supplies that anyone could get in because it was the same code as all the other doors in the facility. RN B stated the night nurses knew the code. RN B stated the aides should not know it because taking dressings on and off were outside their scope of practice. RN B described Resident #2's leg as the bone at the knee making a pyramid shape and the skin moved funny. RN B stated the new wound on Resident #2's knee appeared to be approximately quarter sized and round. She stated it looked like it might be a stage III wound. RN B stated the picture showed drainage on the foam pad that would match up where the knee was. RN B stated she did not know if there was eschar or drainage to the wound. RN B stated on 8/4/22 she did not notice any drainage. RN B stated she only slid her fingers on the inside at the top of the immobilizer because she was afraid of Resident #2 pulling her hair or something. RN B repeated there were no wounds on Resident #2's leg on Monday (8/1/22) when she opened the whole thing up. RN B stated the hospice company Resident #2 used had a shower aide who came in two or three times a week. RN B stated, a bath aide would be cleaning that leg. RN B stated the facility bath aides used shower sheets. RN B stated no one informed her Resident #2 had a wound on her knee. RN B stated, someone was supposed to let her know about the wound - the charge nurse or the DON. RN B stated, word of wounds traveled so it did not matter who was told first. RN B said she was guessing that when the hospice aides found a wound, they would notify their charge nurse and their charge nurse would notify the facility. RN B stated she never had anyone from that hospice company come to her and report there was a new wound. RN B stated: our facility policy is I look at new wounds. I let the DON know, I communicate with the hospice and the family and the doctor. RN B admitted the charge nurses were not removing Resident #2's immobilizer prior to the discovery of the wound. Surveyors read the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B stated, Really? Ok. I didn't know that. In an Interview on 8/8/22 at 2:48PM CNA C stated that Resident #2 could be resistant to care and that it would normally take 2 to 3 people to provide care. CNA C stated that she had never seen anyone remove or open the immobilizer. CNA C stated that she had seen the treatment nurse open the immobilizer one time when Resident #2 first came back to the facility after the dislocation was found (June 2022) and that the treatment nurse told her not to remove the immobilizer. CNA C stated that the CNAs were not supposed to open or remove the immobilizer. CNA C stated that since Resident #2 was on hospice the facility aides did basic care and the hospice aides did her bed bathes. CNA C stated that she did not know if the hospice aides removed the immobilizer during care. CNA C stated the hospice aides were last in the facility on 8/4/22 and they gave Resident #2 a bed bath that day. CNA C stated that she did not know if or how often the nurses were supposed to remove the immobilizer. CNA C stated she thought the staff had been in-serviced on proper care for the immobilizer. In an Interview on 8/8/22 at 7:57 PM, LVN D stated that she had been employed at the facility since March 2022. LVN D stated that since she started working in the facility Resident #2 had been confused and could be very aggressive. LVN D stated that if Resident #2 was resting she (LVN D) would not wake Resident #2 up for care because she did not want to disturb her or make her become agitated. LVN D stated that Resident #2 had a brace or protective thing on her right leg. LVN D stated she did not perform any type of care for it. LVN D stated that the last time she personally removed the brace to do a skin check was the last weekend of July 2022, but she could not remember what day. LVN D stated that at that time she did not see any wounds to Resident #2's right leg or knee. LVN D stated that she checked Resident #2's leg for abrasions or contusions by removing the brace as often as possible if the resident would allow it. LVN D stated she was not aware that she should document if the resident refused care, but she did know how to make a note in the chart to do so. LVN D stated that if there was an order to remove the brace and check the resident's skin, but the resident refused to allow her to do it she would not document that it had been done. LVN D stated that if she saw any dressing present, she would chart about the condition of the dressing, but she would never mess with it. In an Interview on 8/8/22 at 8:18 PM CNA E stated that she had worked in the facility for about one month. CNA E stated that she trained on Resident #2's hall when she started working with Resident #2. CNA E stated she had not worked with Resident #2 since training, but she did assist in providing care at some point the previous week because it took four staff to get Resident #2 cleaned up and the bed changed. CNA E stated the immobilizer was never removed from Resident #2's right leg and that she did not notice anything unusual about the immobilizer or the leg. CNA E stated that Resident #2 could be combative at times. CNA E stated that Resident #2's right leg had to be supported during care and it always took at least three staff to change her. In an Interview on 8/8/22 at 8:32 PM CNA F stated she had worked at the facility for 6 months and that she rotated the halls she worked. CNA F stated that Resident #2's mood was very unpredictable, and staff had to approach her in different ways to provide care depending on her mood. CNA F stated it always took 2 or 3 people to provide care for Resident #2. CNA F stated the last time she worked with Resident #2 was probably the last week of July 2022, but she was not certain. CNA F stated that Resident #2's right leg was sensitive. CNA F stated she had never seen the brace open or heard of anyone opening or removing the brace from Resident #2's right leg. CNA F said she could not remember seeing or being told about any sore/wound on the leg. CNA F stated the most important thing about caring for Resident #2 was that she was always a 2 person assist at least and one person could not provide care for her alone. In an Interview on 8/8/22 at 8:43 PM, CNA G stated that she started working at the facility on 8/1/22. CNA G stated she only worked with Resident #2 on 8/3/22 and she refused care and tried to hit her. CNA G stated she reported the refusal to the nurse. CNA G stated that Resident #2 had blankets covering her, so she did not see her legs. CNA G stated that she was not told that Resident #2 was fragile or that she had a brace on her leg. In an Interview on 8/9/22 at 9:42 AM, Hospice RN stated she last saw Resident #2 on 8/1/22. Hospice RN stated she only saw Resident #2 once a week on Mondays. Hospice RN stated that during her visits she checked vital signs, assessed pain and comfort levels, completed a head-to-toe skin assessment, made sure the resident had all the medications she needed, got any updates/changes from facility nurses, and spoke with the family to provide an update. Hospice RN stated that she did not ever remove the immobilizer from Resident #2's right leg because of the knee dislocation. Hospice RN stated that her skin assessment was done based on the skin surrounding the immobilizer and that she had never seen what Resident #2's leg looked like underneath the immobilizer. Hospice RN stated that she relied on the facility's treatment nurse to give her information regarding Resident #2's skin and that each time she came to the facility she would sit with the treatment nurse and go over the weekly skin assessments and any issues for all the hospice company's residents. In an interview on 8/9/22 at 10:00 AM, The Hospice Administrator stated that hospice staff based their care for residents on what they were told by the treatment nurse regarding skin issues or wounds. The Hospice Administrator stated that hospice nurses did not provide wound care supplies to the facility and hospice aides only brought wipes and briefs when they went to the facility. The Hospice Administrator stated that her aides went to the facility to do baths on Monday, Wednesday and Friday. The Hospice Administrator said recently the facility requested additional help with meals and basic care on Tuesday and Thursday as well but that they should have only been giving baths if it was necessary on those days. The Hospice Administrator stated the hospice aides did not remove Resident #2's immobilizer. The Hospice Administrator stated when the facility sent admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospice Administrator stated that they do not use the type of dressing that was seen in the pictures taken of Resident #2's right knee. Observation on 8/9/22 at 10:08 AM of pictures sent by the Hospice Administrator revealed box labeled [MEDICATION(S)] Gentle EX Silicone Faced Foam & Border dressing. Dressing was 4-inchx4-inch square in total size with 2.55-inchx2.55-inch square foam pad surrounded by adherent border. In an Interview on 8/9/22 at 10:55 AM, Hospice CNA 1 and Hospice CNA 2 both stated they had worked with Resident #2 since June 2022 and that she was funny and did not refuse care from them. Hospice CNA 1 stated that Resident #2 never complained of pain during care, only discomfort at being moved around. Hospice CNA 1 and Hospice CNA 2 stated that they last saw Resident #2 on 8/4/22 and provided basic care for her. Hospice CNA 1 stated Resident #2 required 2 staff for all care. Hospice CNA 1 stated they last bathed Resident #2 on 8/3/22. Hospice CNA 2 stated that they never removed Resident #2's immobilizer during care and that they were trained to clean around it when bathing her. Hospice CNA 1 and Hospice CNA 2 stated they had never seen the immobilizer removed or opened and both denied seeing any dressing on Resident #2's right leg. Hospice CNA 1 and Hospice CNA 2 denied seeing any drainage on the immobilizer or seeing any signs or symptoms of infection to the surrounding skin. Hospice CNA 2 stated there was a dressing on Resident #2's left foot that she first noticed a couple of weeks ago and that they had not been told about any other wounds. Hospice CNA 1 and Hospice CNA 2 both stated if they discovered a new wound or skin issue, they informed the hospice nurse and the facility nurse. Hospice CNA 1 and Hospice CNA 2 stated that they communicated with their nurse every day regarding the hospice residents and that they were notified of any changes with residents by their nurse. Hospice CNA 1 stated they had only found one new wound on a resident since she started work with the facility and it had been communicated to everyone. Hospice CNA 2 stated that when they brought supplies to the facility it was soap, wipes, briefs, lotions and that they do not carry wound care supplies. In an Interview on 8/9/22 at 11:30 AM, DON stated that the hospital sent Resident #2's records to the facility. DON stated wound cultures were done on Resident #2's right knee with admission to the hospital and revealed an [CONDITION(S)] infection. DON stated the hospital had started Resident #2 on IV antibiotics. The DON stated the orthopedic doctor recommended an above the knee amputation of the right leg due to the dislocation because it would never be stable again. DON stated that Resident #2's family planned to take some time to decide what course of action they wanted to take and that the hospital doctors agreed to do antibiotics to treat the infection until a decision was made. The DON stated she did not see anything in the hospital records to indicate if a wound care consultation was done. The DON stated the paperwork documented the wound to Resident #2's right knee was a 3-centimeter purulent (pus) ulcer. In an interview on 8/9/22 at 11:30 AM, The administrator stated that he could not say specifically say what caused the system breakdown regarding skin issues in the facility. The administrator stated that there has been quite a bit of turnover in staff and leadership, and they have been dealing with things as they come up. In an interview on 8/9/22 at 2:32 PM, DON stated that at the last skin meeting she thought there were around 40 treatments for wounds but was unable to say how many were pressure ulcers. DON stated that she thought the matrix the facility provided was not correct but that the MDS nurses are the ones responsible for that data. DON stated she did not know how the matrix was populated. The DON stated that when she first began working in the facility there were some issues with how skin issues were labeled such as red areas being called moisture associated skin damage when that was not an accurate description. She stated that she had discussed this with staff and explained the difference. Observation of wound care supply closet with Treatment Nurse on 8/9/22 at 3:10 PM revealed large box of individually packaged dressings labeled SiliGentle Self Adherent Silicone Foam Dressing. Upon opening single dressing, it was noted to be the same color and texture as the dressing shown in the photos sent by Resident #2's son. In an Interview on 8/9/22 at 3:30 PM, Resident #7 (Resident #2's roommate) stated that the day before Resident #2 was admitted to the hospital, Resident #2 and Resident #2's son was visiting in their shared room, when Resident #7 overheard the treatment nurse working with Resident #2 on the other side of the privacy curtain. Resident #7 stated Resident #2 kept sounding like she was in pain and telling the nurse to leave her alone and calling her a fool. Resident #7 stated that the treatment nurse apologized to Resident #

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 residents (Resident #83) reviewed for privacy, in that: RN A did not provide privacy for Resident #83 during the wound care she performed to his surgical wounds. This failure could place residents who received personal care at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #83's admission record dated 03/14/2022 indicated he was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He was [AGE] years of age. Record review of Resident #83's Order Summary Report for March 2022 indicated in part: Wound Care: Right Dorsum Surgical Wound, wound vac dressing 3 times weekly on. Remove old wound dressing. Cleanse with WC/NC. Pat dry with gauze. Bridge green foam to foot dorsum away from surgical incision. Windowpane wound with transparent drape. Seal 100 %. Set machine setting to 125 mmHg. Ensure wound vac dressing is sealed at all times. May redress if seal breaks and cannot reseal. one time a day every Mon, Wed, Fri for D/T Right Foot Dorsum Surgical Incision. Order date 03/14/2022. During an observation on 03/14/22 at 01:14 PM RN A performed surgical wound care to Resident #83's right foot. The nurse entered the resident's room and proceeded to remove the dressings from the resident's right foot. The resident had a partially amputated foot, and the nurse cleansed the surgical wounds. During the wound care the nurse failed to provide privacy by leaving the door open and not pulling the privacy curtain. During the wound care another resident's family member was observed standing outside the door looking into the room and observing the resident's foot. During an interview on 03/17/2022 at 11:24 AM RN A said she had forgotten to provide privacy during the wound care. She said she was sorry and that it would not happen again. She said she normally provided privacy during patient care but again she just forgot to. During an interview on 03/17/22 at 02:28 PM the DON was made aware of the wound care observation. The DON said the nurse should have provided privacy by closing the door and pulling the privacy curtain. The DON said she believed the failure occurred because the nurse probably got nervous and forgot to provide privacy. During an interview on 03/17/22 at 03:00 PM the Administrator was made aware of the wound care observation. He said staff were expected to provide privacy during resident care. He said the failure occurred because the nurse failed to provide privacy during the wound care. Review of the facility's undated admission agreement indicated in part: You the resident do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violations of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. You have a right to privacy, including privacy during visits and telephone calls. Record review of an undated document titled: Treatment nurse competency check-off indicated in part. Closed door and pulled privacy curtains. Maintained privacy and dignity during procedure.

Based on observation, interview and record review, the facility failed to ensure an effective infection control program was in place to prevent the transmission of communicable diseases was provided for the facility regarding COVID-19. A. The facility failed to follow contact isolation interventions to prevent the potential spread of COVID-19 after gaining knowledge of positive staff members and placed all residents in contact isolation. The following day the facility allowed CNA A, dressed in a rabbit suit, go room to room delivering plastic eggs from a plastic basket without appropriate PPE, handwashing, glove changes, sanitizing between resident rooms and did not social distance (hugging and putting her arms around the residents) when interacting with the residents. This affected 7 (Resident #1, #2, #3, #4, #5, #6 and #7) of 22 residents observed in photographs taken with CNA A. The residents were tested [DATE] and showed positive for COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/24/20. While the IJ was removed on 4/28/20 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. As the investigation continued the following failures were identified: B. The facility failed to follow their infection control procedures when the Maintenance Staff J was observed entering the (cold/not infected) side of the facility from the (hot/infected) Hall 300 COVID-19 hall when the procedure was to exit the back hall door. Maintenance Staff J did not follow infection control procedures upon entrance to Hall 300 COVID-19 hall which included full PPE. This failure reinstated the Immediate Jeopardy on 06/01/20. While the IJ was removed on 06/05/20 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could affect all residents and place the residents at risk for mental anguish, prolonged isolation time, coronavirus infections (COVID-19) and possible death. During the timeframe of the investigation from 4/17/20 until the exit on 6/05/20, 47 of 74 residents were confirmed positive with COVID-19 and 30 staff members confirmed positive with COVID-19. There were a total of 10 COVID-19 related resident deaths. Findings included: Review of a Provider Investigation Report dated 4/07/20 at 3:30 pm; indicated the facility had received confirmed positive [DIAGNOSES REDACTED]. Review of a Provider Investigation Report dated 4/10/20 at 7:30 pm; indicated there had been 5 facility staff tested and identified with COVID-19. The report stated the following; Since the first positive test result was confirmed, residents have been treated as if on contact isolation. Review of a Provider Investigation Report Addendum dated 4/16/20 indicated that three residents had been sent out to the local hospital on [DATE] and had been tested for COVID-19 and results had been confirmed as positive. During a telephone interview on 4/17/20 at 10:00 am; the Administrator stated all residents and staff at the facility would be tested for COVID-19. Review of a Provider Investigation Report Addendum dated 4/20/20 indicated there had been an additional 15 residents identified with COVID-19 positive diagnoses. Review of confidential complaint intake received 04/24/20 alleged the facility had posted pictures of staff in a bunny costume, with a plastic basket and plastic eggs with multiple residents. The complainant was concerned since there had been staff at the facility that tested positive for COVID-19. There were 22 residents identified in the pictures (Residents #1 - 7) were tested on [DATE] and showed positive for COVID-19 on 4/20/20. During an interview on 04/24/20 3:02 PM; the Administrator said the bunny was CNA A and had a rabbit costume on (4/12/20), said the plastic eggs were given to each resident to keep, said she did not know if the rabbit suit was being disinfected every time she went into each room, said CNA A had tested negative for [MEDICAL CONDITION], said they had contacted Dr. Y about the bunny thing and he said that due to brief interaction between bunny and the residents it was considered a low risk plus they did not know enough about [MEDICAL CONDITION], it was hard to tell when the residents were positive. Resident #1 Record review of Resident #1's admission record dated 09/18/19 indicated admission date of [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1's MDS assessment dated [DATE] indicated her BIMS score was 11 (moderately impaired cognition). Resident #1 required staff supervision with bed mobility, transfers, walking (used a walker), eating, toilet use, personal hygiene and limited staff assistance with dressing/bathing. Review of Resident #1's comprehensive care plans since admission 09/12/19 indicated: 03/20/20 Resident #1 at risk for infections, signs/symptoms of COVID-19. Resident #1 required use of continuous oxygen therapy as evidenced by shortness of breath related to [MEDICAL CONDITION], acute/chronic [MEDICAL CONDITION] with hypercapnia, & acute/chronic [MEDICAL CONDITION] with [MEDICAL CONDITION]. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was standing in direct contact/side-to-side with Resident #1. Resident #1 was observed to have an oxygen cannula in place to her nose, no mask and holding three plastic eggs in her right hand. Record review of Resident #1's Laboratory Report indicated on 04/17/20, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. During an observation and interview on 04/21/20 at 6:12 p.m. of the isolation hall, Resident #1 was resting in her bed with her eyes closed and appeared to be asleep. The resident did not appear to be in any distress and did not wake up when surveyor asked questions. Resident #2 Record review of Resident #2's admission record dated 06/17/19 indicated admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's MDS assessment dated [DATE] indicated her BIMS score was 13 (cognitively intact). Resident #2 required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Total assistance for transfers, locomotion and bathing. Review of Resident #2's comprehensive care plans since admission 06/12/19 indicated: 03/20/20 Resident #2 is at risk for infections, signs/symptoms of COVID-19. Resident #2 has oxygen therapy related to shortness of breath. Experiences sleep apnea, assist with [MEDICAL CONDITION]/[MEDICAL CONDITION] equipment each night. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was leaning over to be photographed with Resident #2 who was lying in bed. Resident #2 had no facemask and was observed to be holding a plastic egg. Record review of Resident #2's Laboratory Report indicated on 04/17/2020, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. Resident #3 Record review of Resident #3's admission record dated 07/05/19 indicated she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #3's MDS assessment dated [DATE] indicated BIMS score 9 (moderately impaired cognition). Resident #3 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Total assistance with locomotion and bathing. Review of Resident #3's comprehensive care plans since admission 07/03/19 indicated: 03/20/20 Resident #3 is at risk for infections, signs/symptoms of COVID-19. Resident #3 requires assist with ADL's/care daily. At risk for developing complications related to diabetes mellitus. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was observed to be leaned over toward the resident with her left arm over the resident's right wheelchair arm holding the plastic basket of plastic eggs over the resident's lap. Resident #3 had no facemask and was holding her cell phone up to her left ear. Record review of Resident #3's Laboratory Report indicated on 04/17/20, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. During an observation and interview on 04/21/20 at 6:18 p.m. of the isolation hall, Resident #3 was resting in her bed and voiced no complaints. Resident #4 Record review of Resident #4's admission record dated 08/26/19 indicated admitted [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident 4's MDS assessment dated [DATE] indicated BIMS score 6 (severe cognitive impairment). Resident #4 required extensive assist with bed mobility and transfers. Limited assistance with locomotion, dressing and personal hygiene. Review of Resident #4's comprehensive care plans since admission 08/20/19 indicated: 03/20/20 Resident #4 is at risk for infections, signs/symptoms of COVID-19. Requires assist with ADL's. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was leaning down with her arm around Resident #4. Resident #4 had no facemask and was seated in her wheelchair. Record review of Resident #4's Laboratory Report indicated on 04/17/20, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. During an observation and interview on 04/21/20 at 6:22 p.m. of the isolation hall, Resident #4 was resting in her bed and had no complaints. Resident #5 Record review of Resident #5's admission record dated 05/08/19 indicated admitted [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #5's MDS assessment dated [DATE] indicated Resident #5 required extensive assistance with bed mobility and toilet use. Required total assist with transfers, locomotion, dressing, eating, personal hygiene and bathing. Review of Resident #5's comprehensive care plans since admission 03/21/19 indicated: 03/20/20 Resident #5 is at risk for infections, signs/symptoms of COVID-19. Requires total assist with all ADL's/care daily related to [MEDICAL CONDITION]. Hoyer lift for all transfers. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was on the resident's right side, leaned over toward the resident, touching the bunny suit to the bedsheet, pink pillow and resident's right arm clothing. Resident #5 had a [MEDICAL CONDITION] to her neck and no facemask. Resident #5 was in bed, holding a pink pillow in her right arm; with a plastic basket full of plastic eggs sitting on the resident's blankets covering her legs. Record review of Resident #5's Laboratory Report indicated on 04/17/20, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. During an observation and interview on 04/21/20 at 6:02 p.m. of the isolation hall, Resident #5 was resting in her bed. The resident was not able to answer any questions. The resident did not appear to be in any distress. Resident #6 Record review of Resident #6's admission record dated 10/07/19 indicated original admitted [DATE]. [DIAGNOSES REDACTED]. with late onset. He was [AGE] years of age. Review of Resident #6's MDS assessment dated [DATE] indicated BIMS score 13 (cognitively intact). Resident #6 required limited assist with bed mobility, transfers, dressing, toilet use and personal hygiene. Required supervision with locomotion and eating. Review of Resident #6's comprehensive care plans since admission 06/08/19 indicated: 03/20/20 Resident #6 is at risk for infections, signs/symptoms of COVID-19. Requires assist with ADL's/care daily. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was sitting on Resident #6's bed. Resident #6 was sitting on his bed with an oxygen nasal cannula in place in his nose and had no facemask. Resident #6 was in close enough proximity to CNA A to have his left arm around the CNA's shoulders. Record review of Resident #6's Laboratory Report indicated on 04/17/20, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. During an observation and interview on 04/21/20 at 6:15 p.m. of the isolation hall, Resident #6 was resting in his bed and voiced no complaints. Resident #7 Record review of Resident #7's admission record dated 03/02/20 indicated admission 11/29/19. [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #7's MDS assessment dated [DATE] indicated BIMS score was 03 (severe cognitive impairment). Resident #7 required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Review of Resident #7's comprehensive care plans since admission 11/29/19 indicated: 03/20/20 Resident #7 is at risk for infections, signs/symptoms of COVID-19. Requires assist with ADLs. Review of a photograph later identified to have been taken on 4/12/20; CNA A was observed with a facemask, dressed in a hooded, onesie - bunny suit, with matching white mittens. CNA A was observed to be leaning down with her left arm over Resident #7's shoulder. Resident #7 had no facemask and was observed to be seated in her wheelchair holding a plastic yellow egg in her right hand. Record review of Resident #7's Laboratory Report indicated on 04/17/20, a nasopharyngeal swab was collected and tested for [DIAGNOSES REDACTED]-COV-2 (COVID19). On 04/20/20 the result showed positive for COVID-19. During an observation and interview on 04/21/20 at 6:06 p.m. of the isolation hall, Resident #7 was sitting up in her wheel chair. The resident said she was doing fine and had no complaints. Record review of the facility's Isolation Droplet policy/procedure, undated indicated the following, in part: Purpose: 1. To prevent the spread of infection. 2. To reduce the risk of transmission. Equipment: Gloves, gowns, mask. Procedure: - Place resident in isolation room or in an empty room or with another resident with the same type infection. - Wear gloves, gown and mask when coming into direct contact with resident, linens or body secretions. On 04/24/20 at 6:15 p.m., the Assistant Administrator was notified an IJ had been identified and a copy of the IJ template was provided. During an interview on 04/25/20 at 2:30 p.m., CNA A said on Easter Sunday 04/12/20 I put the plastic eggs together in the basket, sterilized eggs, I had clean eggs each time put in plastic day before, then placed in locked office, I got the rabbit suit out of the bag, I had gloves on under the suit, most of time I placed egg on beside table or laid them on the resident's chest then they picked it up, ADON (W) was with me and she handed the resident the eggs, I did get close to them and probably shouldn't have, we don't disinfectant the PPE gowns when go from to room ? We did not disinfect the suit, I could not wash hands due to suit on, I was wearing face mask. During an interview on 4/27/20 at 8:20 p.m. the Administrator was shown the photographs of the 22 residents with CNA A dressed in the bunny suit. The Administrator said the pictures were taken on 04/12/20. The Administrator said when those pictures were taken there weren't any positive (COVID-19) residents only staff. The Administrator said the DON had texted her and told her what they had planned. She said at the time they thought they were going to make it through the 14 days (CDC estimated incubation period for COVID-19). The Administrator said on 4/12/20 they only knew about the 4 staff and the last day worked was 3/27/20. During an interview on 5/08/20 at 3:08 p.m. ADON W said on 4/12/20 she went with CNA A that was dressed in a bunny costume, to all of residents room's on halls 1, 3 and 4. She said some of the resident's would motion CNA A to come into the room and want a picture taken. ADON W said she was the photographer. The facility provided an acceptable revised Plan of Removal on 04/25/20 at 8:18 p.m. and included the following: The facility's action Plan to Remove Immediate Jeopardy 04/24/20 Purpose: The purpose of this action plan is to take steps to remove the immediate jeopardy in failing to ensure that a system was in place to monitor staff interaction with residents related to infection control practices to prevent the spread of infectious diseases, especially respiratory diseases. This action plan will ensure proper infection control procedures are followed to ensure residents' health and safety regarding social distancing during individual resident activities is maintained and required infection control procedures are in place and being maintained. All facility staff will receive infection control in-service training. All facility staff will not be allowed to care for residents in the facility until they fully understand the infection control policy and procedures which will include attestation/competency as it relates to performing essential care tasks for residents in contact isolation that have been tested either positive or negative for COVID-19. This will prevent the spreading of infectious diseases, specifically, respiratory infections. The facility currently has 16 positive residents. On April 3, 2020 the facility reported its first COVID 19 positive test result related to a staff member. On April 10, 2020 the facility reported an additional 5 staff members as being positive and at that time residents were placed in contact isolation in their rooms and staff members were required to wear PPE. On April 12, 2020 the facility allowed a staff member (CNA A) to dress up in an Easter bunny suit and deliver Easter eggs to residents who were found to be COVID-19 positive on 04/20/20. Photographs were taken of the event and verified that social distancing by the CNA was not being done, proper PPE was not being worn, and hand hygiene was not complied with as required by CMS/CDC guidelines or facility infection control policies/procedures. Action Plan incorporated to ensure systems are in place to ensure correction and removal of the Immediate Jeopardy: 1. The facility CNA, who was the Bunny involved in this incident is one of the facility employees going through re-training and in-servicing concerning facility infection control policies and procedures to ensure that this does not reoccur. 2. Corporate RN and Corporate LVN, and another designee will in-service train, to include competency, all facility staff on the facility's policy concerning: visitation requirements to include [MEDICATION NAME] situations; the facility screening process for employees/residents and all essential personnel entering the facility to including first responders who do not have to be screened; who will do the screening and attesting to their competency as to what signs and symptoms to look for; the policy on tracking and responding to staff that work at jobs outside of the facility; PPE requirements; social distancing; and handwashing requirements. 3. An immediate in-service training was conducted and completed by RN Corporate nurse, LVN, Corporate nurse, and another designee to all facility staff on the following facility's infection control policy and procedures and guidelines implemented to reduce risk of transmission of COVID-19 on 04/24/20-04/26/20. All facility staff will not be allowed to work in the facility until their individual in-service training is done and the staff member attest to the understanding of the policies. The facilities goal is to protect our residents and staff from infectious diseases, and to maintain the highest level of care practicable by means of assessment and screening of residents, employees, and essential visitors. By these screenings and infection control practices, the risk of transmission of COVID-19 will be reduced. Preventing and ensuring that the spread of the COVID-19 virus is minimized will be obtained by team approaches, communication, and participation from our staff. The following policies and procedures will be in-service trained to all facility staff, with competency attested , to ensure staff are preforming essential care tasks for all residents in the facility to prevent any spread of infectious diseases, such as, respiratory infections. Employee Per CDC guidelines universal facemasks must be worn by all employees when confirmed case in the community. Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different residents with the same infectious diagnosis, without removing the facemask between resident encounters. Per CDC guidelines/recommendations: The facemask should be removed and discarded if soiled, damaged, or hard to breathe through Must take care not to touch facemask. If employee touches or adjusts facemask they must immediately perform hand hygiene Employees must leave resident care area if they need to remove the facemask Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during shortage The folded masks can be stored between uses in a clean sealable paper bag or breathable container Employee Screening All employees will complete the CMS/CDC guided screening directly upon entrance to the facility at the designated screening area, prior to clocking in for their scheduled shift, and then again mid-shift. Screening is completed by a facility designee that has completed the COVID-19 Screening Competency which deems that individual competent and proficient in the screening process. Screening/assessment to be documented on individual Employee Screening/Tracking Log, which includes; 1. Signs or symptoms: Fever (>100.0), Runny nose, Nausea/vomiting, Cough, Muscle aches, Confusion, Shortness of breath, Chest pain, Loss of smell (anosmia), Sore throat, Diarrhea, Loss of taste (ageusia). 2. Temperature (>100.0) 3. In the last 14 days, has had contact with someone with a confirmed [DIAGNOSES REDACTED]. 4. International travel within the last 14 days to countries with sustained community transmission Those employees who have signs and symptoms of a respiratory infection should not report to work. Any staff that develop signs and symptoms of a respiratory infection while on the job, should: o Immediately stop work and self-isolate at home o Inform the facilities DON/Administrator, include: - Information on individuals, equipment, and locations the person came in contact with. Employee Education - Staff educated and kept up to date on new information pertaining to COVID-19 virus - Education to staff, residents, and resident representatives of the following measures they can do to prevent the spread of infections o Avoid touching your eyes, nose, and mouth o Avoiding close contact with those who are sick outside of the facility o Cover your cough or sneeze with a tissue, then throw the tissue in the trash, and complete hand hygiene o Wash your hands often with soap and water for at least 20 seconds - Especially when blowing your nose, coughing or sneezing, going to the bathroom, or eating/preparing food o Hand hygiene before and after contact with residents, after contact with possibly contaminated surfaces or equipment, and after removing PPE o Use of ABHR (containing 60-95% alcohol) - facility is equipped with alcohol- based sanitizers at each entrance to the facility and on each wing of the building to include the kitchen, activity area and multiple common areas - In-services to all staff with competencies and return demonstrations to be completed on; o Standard precautions/universal precautions o Social distancing o Hand washing o Donning on and off PPE o Reuse/reprocess of PPE o N95 test/seal check o Proper cleaning of equipment and surfaces REPORT ALL SUSPECTED AND/OR CONFIRMED CASES TO THE 24/7 NUMBER FOR IMMEDIATELY REPORTABLE - [PHONE NUMBER] For the most up-to-date information, visit www.cdc.gov/covid19 Texas Department of State Services: https://dshs.texas.gov/regions/2019-nCoV-Local-Health-Entities/ For questions for the general public about COVID-19 call: [PHONE NUMBER] Staffing When achievable facility should ensure consistent staffing assignments - Enhances staff familiarity with their assigned residents, helps detect emerging condition changes - Decrease number of staff interacting with residents Facility administrators to keep an up-to-date roster of all staff who work at multiple healthcare facilities - Reduce or completely eliminate if possible - Employees who work at multiple healthcare facilities to report to Facility Administrator/DON when there is a suspected or positive case of COVID-19 at their other place of employment o Administrative team will utilize the CDC Epidemiologic Risk Classification Chart to guide in making a decision if employee can continue to work or is placed on a work restriction of isolating/excluding from work for x14-days after last exposure. Environment - Signage posted at front door entry informing of complete visitor restriction - Limit entry to facility to front door for essential personnel only - Increase the availability and accessibility of alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, and facemasks at healthcare facility entrances - Increase signage for vigilant infection prevention, such as hand hygiene and cough etiquette - Have adequate cleaning supplies that are appropriate for flu and [MEDICAL CONDITION] cleaning - Frequent cleaning of handrails, countertops, and any other high traffic contact area, common areas, furniture, and equipment on halls and in rooms - Increase cleaning of showers and shower equipment daily and PRN - Lysol or equivalent for disinfecting - Medication cart cleaning daily by nursing staff - Daily cleaning of resident's rooms - Linen barrels require daily disinfectant and cleaning - Ice carts and containers will be disinfected daily - Water pitchers will be cleaned daily by dietary staff and distributed to ensure hydration is maintained - Vital sign machines will be cleaned after each resident use - Daily (and as needed) cleaning of facility van after last resident transport Resident Assessment - Per Texas Health & Human Services, facilities are to utilize the Hospital to Post-Acute Care Transfer COVID-19 Assessment form when assessing a resident that is being admitted /readmitted from the hospital or returning from the emergency room . To ensure the facility can meet the residents' needs, an additional review is required and will be completed by the facility Director of Nurses along with the Director of Clinical Services or designee for any pending residents that are suspicious for [MEDICAL CONDITION] or have been diagnosed with [REDACTED]. - Residents in-house will have a focused assessment completed twice daily by charge nurse to screen for signs/symptoms associated to the COVID-19 virus. Assessment includes; o Temperature (fever, equal to or greater than 100 degrees Fahrenheit) o Does resident have new or worsening cough o Does resident have a new or worsening runny nose o Does resident have a new or worsening shortness of breath o Does resident have a new or worsening sore throat o Does resident have new or worsening muscle aches o Does resident have new or worsening tiredness/fatigue o Does resident have nausea o Does resident have diarrhea - Notification of Physician for symptoms and potential orders - Notification of resident and resident representative of symptoms and orders received - Assessment of resident every shift and PRN until 24hrs post symptoms - Essential communication from hospitals and other transfer facilities on signs/symptoms and infection - 24hr report review - Nurse practitioner assistance for assessments PRN as indicated Visitors All non-essential visitation is restricted with the exception of certain [MEDICATION NAME] care situations such as end of life. Essential Health Care Professionals Healthcare workers, such as Hospice, EMS personnel, or laboratory/radiology technicians that provide care/services to residents are permitted to come into the facility as long as they meet the CDC guidelines for health care workers. Permissible Essential healthcare personnel will complete screening/assessment per most recent CMS guidelines. To avoid potential risk of infection from outside, residents that require transportation to the hospital will be wheeled/brought to front lobby/entrance of the facility by employees if situation permits. EMS personnel are not required to be screened upon entrance into the facility in life threatening emergencies. Visitation in [MEDICATION NAME] Situations Decisions about visitation during [MEDICATION NAME] care situations (e.g., end-of-life care), will be made on a case-by-case basis in accordance with CMS guidelines. For individuals permitted entrance to the facility: - Must complete careful screening o Those with symptoms will not be granted access to the facility at any time (even in end-of-life situations): Fever (>100.0), Runny nose, Nausea/vomiting, Cough, Muscle aches, Confusion, Shortness of breath, Chest pain, Loss of smell (anosmia), Sore throat, Diarrhea, Loss of taste (ageusia) Required to perform witnessed hand hygiene Must use Personal Protective Equipment (PPE) Visitation restricted to resident's room, or other location designated by the facility Maximum of 2-visitors at a time Facility to set specific visitation hours, preferably between 7am-7pm Disinfect the area following a visitor's exit from the location Residents in-house will have a focused assessment completed twice daily to screen for signs/symptoms associated to the COVID-19 virus. Symptomatic/Suspected COVID-19 If a resident exhibits any suspicious symptoms: Immediately pla

Based on interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 6 residents reviewed for quality of care. (Resident #15). Licensed Vocational Nurse (LVN) C did not administer Humalog (rapid acting) insulin according to physician orders [REDACTED].#15. Resident #15's blood sugar dropped to 32 mg/dl (milligrams per deciliter) requiring emergency intervention of [MEDICATION NAME] injection and oral glucose gel. This failure could place residents at risk of not having their physicians orders followed and causing a decline or decrease in their quality of life and quality of care. The findings included: Record review of Resident #15's electronic record indicated he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #15's admission Minimum Data Set (MDS) assessment dated [DATE] documented the following: - Brief Interview for Mental Status (BIMS) score 01 (1-15) which indicated severe cognitive impairment; - Required extensive assistance by 2+ persons for bed mobility, transfers and toilet use. Required extensive assistance by one person for locomotion (wheelchair), dressing, personal hygiene and bathing. Required supervision by one for eating. Record review of Resident #15's care plans dated 10/08/19 revealed the following: - Problem: Resident may require adjustment to insulin order. - Goal: My blood sugars will stabilize within next 90 days. - Interventions: Administer my insulin as ordered. Assess my response to the insulin changes and report to the physician. Assist me with good nutritional choices. Monitor my blood sugar as ordered. Obtain my FBS (fasting blood sugar) or HGBA1C (laboratory blood test) lab work as ordered. Record review of Resident #15's Physician order [REDACTED]. - [MEDICATION NAME] (long acting insulin) Inject 35 units subcutaneously at bedtime related to diabetes mellitus. - Humalog (rapid acting insulin) Inject 11 units subcutaneously with meals related to diabetes mellitus. - For BG (blood sugar) <60mg/dl or low and resident is alert: Administer one tube glucose gel (15-20mg). Recheck in 15 minutes. If still <70mg/dl administer another tube. Recheck in 15 minutes. If still low follow severe [DIAGNOSES REDACTED] orders. Provide regular meal or snack in ½ hour. - Severe [DIAGNOSES REDACTED]: For FSBS (finger stick blood sugar) reading below 60mg/dl or low reading and resident is unresponsive: Remove [MEDICATION NAME] kit from the emergency drug kit. Administer [MEDICATION NAME] as directed IM (intramuscular). Recheck FSBS in 30 minutes. If no response to [MEDICATION NAME] call 911 or begin IV (intravenous) administration of [MEDICATION NAME] 50%. Humalog starts acting fast, so give your injection within 15 minutes before or right after you eat a meal. Source researched on 11/12/19. http://uspl.lilly.com/humalog/humalog.html Record review of Resident #15's Nurse Administration Record for (MONTH) 2019 documented: - 10/28/19 blood sugar was 110 and Humalog insulin 11 units was administered at 6:12 a.m. by LVN C. Record review of Resident #15's electronic progress notes documented: - 10/29/19 at 9:44 AM Transfer Note - Vital signs: 132/64, 97.8, 76, 18, O2 (oxygen) sats 95%, CBG 212. Clinical Condition/Reason for Transfer: granddaughter concern TIA ([MEDICAL CONDITION]). Interventions attempted prior to DC (discharge): Lethargic, CBG (capillary blood glucose) 32, administered glucose injection and glucose gel, CBG increase to 212. Who transferred? 911. Granddaughter in facility aware. Physician notified. Record review of EMS notes dated 10/28/19 for Resident #15 documented the following, in part: - Arrived on scene 9:10 a.m., patient (Resident #15) in wheelchair, eyes responsive, confused and slow to respond, not following commands except when asked to smile. No facial droop was found. Skin hot to touch. Blood pressure at 9:15 a.m. 74/49, pulse 105, respirations 18, Oxygen saturation 100% and blood glucose 206. Departed at 9:19 a.m. Record review of Resident #15's hospital record dated 10/28/19 documented the following, in part: - Assessment/Plan: 1-Altered mental status likely to infection versus [DIAGNOSES REDACTED] versus dehydration. 2-Sepsis likely due to UTI (previously admitted for drug-resistant Urinary Tract Infection). 3-[MEDICAL CONDITION]. 4-Dehydration. 5-[MEDICAL CONDITION] status [REDACTED]. During an interview on 11/06/19 at 4:20 p.m., the Director of Nurses (DON) acknowledged Resident #15's Nurse MAR (medication administration record) looked like LVN C gave the Humalog insulin 11 units at 6:12 a.m. on 10/28/19. The DON said breakfast was not served until 7:30 a.m. in the dining room. The DON said the onset of Humalog was 15 minutes and peaked in 1-2 hours. The DON said LVN C should not have given the Humalog insulin at 6:12 a.m. The DON said, I would wait until I saw the resident eating or after he ate. During an interview on 11/06/19 at 5:15 p.m. LVN C acknowledged on 10/28/19 she checked Resident #15's blood sugar and it was 110. She verified she gave the Humalog insulin 11 units at 6:12 a.m. She said breakfast was about 7:30 a.m. She said the resident's blood sugar dropped before he went to breakfast. She said the Treatment Nurse checked his blood sugar and it was 32. She said she got the [MEDICATION NAME] injection from the medication machine. LVN C said she gave Resident #15 the injection in his abdomen. She said Resident #15 was awake, not talking, he mumbled and was still in his room. She said she also gave him some glucose gel. She said she told him he was going to go eat and he answered okay. LVN C said she rechecked his blood sugar and it was 212, then he was taken to eat. LVN C said Resident #15 was in the dining room, had his tray, he was eating and being assisted. She said she did not remember the aide who was assisting him. She said she saw the family come in and sit a bowl of fruit on the table, then left the dining room. LVN C said then Assistant Director of Nurses (ADON) A came in and told me they were sending Resident #15 to the hospital 911, so she printed out the face sheet and orders. LVN C said 911 picked resident up. LVN C said she did not know the onset of Humalog insulin. LVN C said, one hour, 30 minutes, I don't know. LVN C acknowledged when an order says with meals the medication needs to be given with food. LVN C said I should have given him juice or something. During an interview on 11/08/19 at 2:25 p.m., the Assistant Director of Nurses (ADON) said he came into the facility on [DATE] at 7:45 a.m. Resident #15 was at the nurse's station in his wheelchair and he looked pale. The ADON said he took Resident #15 to the dining room to an assisted table. The ADON said he went to his office. He said about 30 minutes later the social worker came and told him Resident #15's granddaughter was concerned. The ADON said he went to the dining room, Resident #15 had food in front of him and a Certified Nurse Aide (CNA) was trying to feed him. He said Resident #15's face was droopy, but his hand grips were good. The ADON said Resident #15's granddaughter thought it was his pacemaker. The ADON said they checked Resident #15's blood pressure, he didn't remember how low, but his pulse was high. The ADON said he asked the granddaughter if she wanted to send him out and she said yes 911. The ADON said he called 911, the doctor and passed the information to LVN C. The ADON said LVN C told him Resident #15's blood sugar was over 200 when he left. During an interview on 11/08/19 at 3:14 p.m., the Social Worker (SW) said on the morning of 10/28/19 she was in the dining room passing out drinks. She said a CNA called her over and told her Resident #15's granddaughter was upset. The SW said she brought Resident #15's granddaughter to her office. She said the granddaughter wanted to know what happened, she said she told her she didn't know and went to get the ADON. The SW said the ADON and granddaughter discussed that it might his pacemaker or a stroke because apparently the pacemaker malfunctioned in the hospital. The SW said she heard the ADON ask the granddaughter if she wanted to send Resident #15 to the hospital. The SW said she had seen Resident #15 in the dining room sitting in his chair. She said she wasn't focusing on the resident, she was focusing on the task she was doing. She said nothing stood out, he wasn't slouched over. During an interview on 11/08/19 at 4:05 p.m. the Treatment Nurse said on 10/28/19 about 7:00 a.m. she went in Resident #15's room. She said Resident #15 didn't seem himself. She said she checked his vitals Blood/Pressure 88/53, Pulse-125, Respirations-28, Temp forehead 97.3 and Oxygen saturation was 92%. She said she checked Resident #15's blood sugar and it showed 39. She said Resident #15's head was sweaty. The Treatment Nurse said she told LVN C what the vital signs were & CBG 39. She said she went with LVN C to the medication room. She said LVN C got the [MEDICATION NAME] injection out of the medication machine and took over. The Treatment Nurse said when ADON A came in to work, she told him what happened. She said she didn't see Resident #15 eat, because she wasn't in the dining room. Record review of the facility's Blood Glucose Monitoring (FSBS) policy/procedure, undated, documented the following, in part: - Verify Doctor's order. - Depending on your findings, interventions or further orders may need to be carried out. Notify Doctor of abnormal findings or according to orders, and notify family members of any new orders. Record review of the facility's Administration Of Insulin policy/procedure, undated, documented the following, in part: - Equipment - insulin as prescribed by doctor. - Complications to guard against: [DIAGNOSES REDACTED] (low blood sugar). - Signs/symptoms of [DIAGNOSES REDACTED] - perspiring or sweating excessively, weakness, dizziness or faintness, hunger or excessive eating, nervousness, irritability or changes in personality, blurred or impaired vision, numbness in the tongue and lips, [MEDICAL CONDITION] palpitations, tremors, headaches, appears to be in coma, unconscious. - treatment for [REDACTED]. Record review of the facility's Medication Errors and Drug Reactions policy/procedure, undated, revealed the following, in part: Purpose - To report when a drug is not given as ordered. - To report when a drug is not given at the correct time. Procedure - Note: All nurses administering medication should be familiar with drug reactions, effects and contraindications. If you are not sure, check the drug reference manuel before administering an unfamiliar drug.

Based on interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being for 1 of 6 residents reviewed for nursing services. (Residents #15) Licensed Vocational Nurse (LVN) C did not administer Humalog (rapid acting) insulin according to physician orders [REDACTED].#15. Resident #15's blood sugar dropped to 32 mg/dl (milligrams per deciliter) requiring emergency intervention of [MEDICATION NAME] injection and oral glucose gel. This failure could place residents at risk for serious illness, injury and death. Findings included: Record review of Resident #15's electronic record indicated he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #15's admission Minimum Data Set (MDS) assessment dated [DATE] documented the following: - Brief Interview for Mental Status (BIMS) score 01 (1-15) which indicated severe cognitive impairment; - Required extensive assistance by 2+ persons for bed mobility, transfers and toilet use. Required extensive assistance by one person for locomotion (wheelchair), dressing, personal hygiene and bathing. Required supervision by one for eating. Record review of Resident #15's care plans dated 10/08/19 revealed the following: - Problem: Resident may require adjustment to insulin order. - Goal: My blood sugars will stabilize within next 90 days. - Interventions: Administer my insulin as ordered. Assess my response to the insulin changes and report to the physician. Assist me with good nutritional choices. Monitor my blood sugar as ordered. Obtain my FBS (fasting blood sugar) or HGBA1C (laboratory blood test) lab work as ordered. Record review of Resident #15's Physician order [REDACTED]. - [MEDICATION NAME] (long acting insulin) Inject 35 units subcutaneously at bedtime related to diabetes mellitus. - Humalog (rapid acting insulin) Inject 11 units subcutaneously with meals related to diabetes mellitus. - For BG (blood sugar) <60mg/dl or low and resident is alert: Administer one tube glucose gel (15-20mg). Recheck in 15 minutes. If still <70mg/dl administer another tube. Recheck in 15 minutes. If still low follow severe [DIAGNOSES REDACTED] orders. Provide regular meal or snack in ½ hour. - Severe [DIAGNOSES REDACTED]: For FSBS (finger stick blood sugar) reading below 60mg/dl or low reading and resident is unresponsive: Remove [MEDICATION NAME] kit from the emergency drug kit. Administer [MEDICATION NAME] as directed IM (intramuscular). Recheck FSBS in 30 minutes. If no response to [MEDICATION NAME] call 911 or begin IV (intravenous) administration of [MEDICATION NAME] 50%. Humalog starts acting fast, so give your injection within 15 minutes before or right after you eat a meal. Source researched on 11/12/19. http://uspl.lilly.com/humalog/humalog.html Record review of Resident #15's Nurse Administration Record for (MONTH) 2019 documented: - 10/28/19 blood sugar was 110 and Humalog insulin 11 units was administered at 6:12 a.m. by LVN C. Record review of Resident #15's electronic progress notes documented: - 10/29/19 at 9:44 AM Transfer Note - Vital signs: 132/64, 97.8, 76, 18, O2 (oxygen) sats 95%, CBG 212. Clinical Condition/Reason for Transfer: granddaughter concern TIA ([MEDICAL CONDITION]). Interventions attempted prior to DC (discharge): Lethargic, CBG (capillary blood glucose) 32, administered glucose injection and glucose gel, CBG increase to 212. Who transferred? 911. Granddaughter in facility aware. Physician notified. Record review of EMS notes dated 10/28/19 for Resident #15 documented the following, in part: - Arrived on scene 9:10 a.m., patient (Resident #15) in wheelchair, eyes responsive, confused and slow to respond, not following commands except when asked to smile. No facial droop was found. Skin hot to touch. Blood pressure at 9:15 a.m. 74/49, pulse 105, respirations 18, Oxygen saturation 100% and blood glucose 206. Departed at 9:19 a.m. Record review of Resident #15's hospital record dated 10/28/19 documented the following, in part: - Assessment/Plan: 1-Altered mental status likely to infection versus [DIAGNOSES REDACTED] versus dehydration. 2-Sepsis likely due to UTI (previously admitted for drug-resistant Urinary Tract Infection). 3-[MEDICAL CONDITION]. 4-Dehydration. 5-[MEDICAL CONDITION] status [REDACTED]. During an interview on 11/06/19 at 4:20 p.m., the Director of Nurses (DON) acknowledged Resident #15's Nurse MAR (medication administration record) looked like LVN C gave the Humalog insulin 11 units at 6:12 a.m. on 10/28/19. The DON said breakfast was not served until 7:30 a.m. in the dining room. The DON said the onset of Humalog was 15 minutes and peaked in 1-2 hours. The DON said LVN C should not have given the Humalog insulin at 6:12 a.m. The DON said, I would wait until I saw the resident eating or after he ate. During an interview on 11/06/19 at 5:15 p.m. LVN C acknowledged on 10/28/19 she checked Resident #15's blood sugar and it was 110. She verified she gave the Humalog insulin 11 units at 6:12 a.m. She said breakfast was about 7:30 a.m. She said the resident's blood sugar dropped before he went to breakfast. She said the Treatment Nurse checked his blood sugar and it was 32. She said she got the [MEDICATION NAME] injection from the medication machine. LVN C said she gave Resident #15 the injection in his abdomen. She said Resident #15 was awake, not talking, he mumbled and was still in his room. She said she also gave him some glucose gel. She said she told him he was going to go eat and he answered okay. LVN C said she rechecked his blood sugar and it was 212, then he was taken to eat. LVN C said Resident #15 was in the dining room, had his tray, he was eating and being assisted. She said she did not remember the aide who was assisting him. She said she saw the family come in and sit a bowl of fruit on the table, then left the dining room. LVN C said then Assistant Director of Nurses (ADON) A came in and told me they were sending Resident #15 to the hospital 911, so she printed out the face sheet and orders. LVN C said 911 picked resident up. LVN C said she did not know the onset of Humalog insulin. LVN C said, one hour, 30 minutes, I don't know. LVN C acknowledged when an order says with meals the medication needs to be given with food. LVN C said I should have given him juice or something. During an interview on 11/08/19 at 2:25 p.m., the Assistant Director of Nurses (ADON) said he came into the facility on [DATE] at 7:45 a.m. Resident #15 was at the nurse's station in his wheelchair and he looked pale. The ADON said he took Resident #15 to the dining room to an assisted table. The ADON said he went to his office. He said about 30 minutes later the social worker came and told him Resident #15's granddaughter was concerned. The ADON said he went to the dining room, Resident #15 had food in front of him and a Certified Nurse Aide (CNA) was trying to feed him. He said Resident #15's face was droopy, but his hand grips were good. The ADON said Resident #15's granddaughter thought it was his pacemaker. The ADON said they checked Resident #15's blood pressure, he didn't remember how low, but his pulse was high. The ADON said he asked the granddaughter if she wanted to send him out and she said yes 911. The ADON said he called 911, the doctor and passed the information to LVN C. The ADON said LVN C told him Resident #15's blood sugar was over 200 when he left. During an interview on 11/08/19 at 3:14 p.m., the Social Worker (SW) said on the morning of 10/28/19 she was in the dining room passing out drinks. She said a CNA called her over and told her Resident #15's granddaughter was upset. The SW said she brought Resident #15's granddaughter to her office. She said the granddaughter wanted to know what happened, she said she told her she didn't know and went to get the ADON. The SW said the ADON and granddaughter discussed whether it was his pacemaker or a stroke because apparently the pacemaker malfunctioned in the hospital. The SW said she heard the ADON ask the granddaughter if she wanted to send Resident #15 to the hospital. The SW said she had seen Resident #15 in the dining room sitting in his chair. She said she wasn't focusing on the resident, she was focusing on the task she was doing. She said nothing stood out, he wasn't slouched over. During an interview on 11/08/19 at 4:05 p.m. the Treatment Nurse said on 10/28/19 about 7:00 a.m. she went in Resident #15's room. She said Resident #15 didn't seem himself. She said she checked his vitals Blood/Pressure 88/53, Pulse-125, Respirations-28, Temp forehead 97.3 and Oxygen saturation was 92%. She said she checked Resident #15's blood sugar and it showed 39. She said Resident #15's head was sweaty. The Treatment Nurse said she told LVN C what the vital signs were & CBG 39. She said she went with LVN C to the medication room. She said LVN C got the [MEDICATION NAME] injection out of the medication machine and took over. The Treatment Nurse said when ADON A came in to work, she told him what happened. She said she didn't see Resident #15 eat, because she wasn't in the dining room. Record review of the facility's Blood Glucose Monitoring (FSBS) policy/procedure, undated, documented the following, in part: - Verify Doctor's order. - Depending on your findings, interventions or further orders may need to be carried out. Notify Doctor of abnormal findings or according to orders, and notify family members of any new orders. Record review of the facility's Administration Of Insulin policy/procedure, undated, documented the following, in part: - Equipment - insulin as prescribed by doctor. - Complications to guard against: [DIAGNOSES REDACTED] (low blood sugar). - Signs/symptoms of [DIAGNOSES REDACTED] - perspiring or sweating excessively, weakness, dizziness or faintness, hunger or excessive eating, nervousness, irritability or changes in personality, blurred or impaired vision, numbness in the tongue and lips, [MEDICAL CONDITION] palpitations, tremors, headaches, appears to be in coma, unconscious. - treatment for [REDACTED]. Record review of the facility's Medication Errors and Drug Reactions policy/procedure, undated, revealed the following, in part: Purpose - To report when a drug is not given as ordered. - To report when a drug is not given at the correct time. Procedure - Note: All nurses administering medication should be familiar with drug reactions, effects and contraindications. If you are not sure, check the drug reference manuel before administering an unfamiliar drug.

Based on interview and record review, the facility failed to ensure the medication regimen was free from any significant medication error for 1 of 6 residents reviewed for medications. (Resident #15). Licensed Vocational Nurse (LVN) C did not administer Humalog (rapid acting) insulin according to physician orders [REDACTED].#15. Resident #15's blood sugar dropped to 32 mg/dl (milligrams per deciliter) requiring emergency intervention of [MEDICATION NAME] injection and oral glucose gel. This failure could place residents who received insulin at risk for having critically low blood sugar levels resulting in harm or death. Findings included: Record review of Resident #15's electronic record indicated he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #15's admission Minimum Data Set (MDS) assessment dated [DATE] documented the following: - Brief Interview for Mental Status (BIMS) score 01 (1-15) which indicated severe cognitive impairment; - Required extensive assistance by 2+ persons for bed mobility, transfers and toilet use. Required extensive assistance by one person for locomotion (wheelchair), dressing, personal hygiene and bathing. Required supervision by one for eating. Record review of Resident #15's care plans dated 10/08/19 revealed the following: - Problem: Resident may require adjustment to insulin order. - Goal: My blood sugars will stabilize within next 90 days. - Interventions: Administer my insulin as ordered. Assess my response to the insulin changes and report to the physician. Assist me with good nutritional choices. Monitor my blood sugar as ordered. Obtain my FBS (fasting blood sugar) or HGBA1C (laboratory blood test) lab work as ordered. Record review of Resident #15's Physician order [REDACTED]. - [MEDICATION NAME] (long acting insulin) Inject 35 units subcutaneously at bedtime related to diabetes mellitus. - Humalog (rapid acting insulin) Inject 11 units subcutaneously with meals related to diabetes mellitus. - For BG (blood sugar) <60mg/dl or low and resident is alert: Administer one tube glucose gel (15-20mg). Recheck in 15 minutes. If still <70mg/dl administer another tube. Recheck in 15 minutes. If still low follow severe [DIAGNOSES REDACTED] orders. Provide regular meal or snack in ½ hour. - Severe [DIAGNOSES REDACTED]: For FSBS (finger stick blood sugar) reading below 60mg/dl or low reading and resident is unresponsive: Remove [MEDICATION NAME] kit from the emergency drug kit. Administer [MEDICATION NAME] as directed IM (intramuscular). Recheck FSBS in 30 minutes. If no response to [MEDICATION NAME] call 911 or begin IV (intravenous) administration of [MEDICATION NAME] 50%. Humalog starts acting fast, so give your injection within 15 minutes before or right after you eat a meal. Source researched on 11/12/19. http://uspl.lilly.com/humalog/humalog.html Record review of Resident #15's Nurse Administration Record for (MONTH) 2019 documented: - 10/28/19 blood sugar was 110 and Humalog insulin 11 units was administered at 6:12 a.m. by LVN C. Record review of Resident #15's electronic progress notes documented: - 10/29/19 at 9:44 AM Transfer Note - Vital signs: 132/64, 97.8, 76, 18, O2 (oxygen) sats 95%, CBG 212. Clinical Condition/Reason for Transfer: granddaughter concern TIA ([MEDICAL CONDITION]). Interventions attempted prior to DC (discharge): Lethargic, CBG (capillary blood glucose) 32, administered glucose injection and glucose gel, CBG increase to 212. Who transferred? 911. Granddaughter in facility aware. Physician notified. Record review of EMS notes dated 10/28/19 for Resident #15 documented the following, in part: - Arrived on scene 9:10 a.m., patient (Resident #15) in wheelchair, eyes responsive, confused and slow to respond, not following commands except when asked to smile. No facial droop was found. Skin hot to touch. Blood pressure at 9:15 a.m. 74/49, pulse 105, respirations 18, Oxygen saturation 100% and blood glucose 206. Departed at 9:19 a.m. Record review of Resident #15's hospital record dated 10/28/19 documented the following, in part: - Assessment/Plan: 1-Altered mental status likely to infection versus [DIAGNOSES REDACTED] versus dehydration. 2-Sepsis likely due to UTI (previously admitted for drug-resistant Urinary Tract Infection). 3-[MEDICAL CONDITION]. 4-Dehydration. 5-[MEDICAL CONDITION] status [REDACTED]. During an interview on 11/06/19 at 4:20 p.m., the Director of Nurses (DON) acknowledged Resident #15's Nurse MAR (medication administration record) looked like LVN C gave the Humalog insulin 11 units at 6:12 a.m. on 10/28/19. The DON said breakfast was not served until 7:30 a.m. in the dining room. The DON said the onset of Humalog was 15 minutes and peaked in 1-2 hours. The DON said LVN C should not have given the Humalog insulin at 6:12 a.m. The DON said, I would wait until I saw the resident eating or after he ate. During an interview on 11/06/19 at 5:15 p.m. LVN C acknowledged on 10/28/19 she checked Resident #15's blood sugar and it was 110. She verified she gave the Humalog insulin 11 units at 6:12 a.m. She said breakfast was about 7:30 a.m. She said the resident's blood sugar dropped before he went to breakfast. She said the Treatment Nurse checked his blood sugar and it was 32. She said she got the [MEDICATION NAME] injection from the medication machine. LVN C said she gave Resident #15 the injection in his abdomen. She said Resident #15 was awake, not talking, he mumbled and was still in his room. She said she also gave him some glucose gel. She said she told him he was going to go eat and he answered okay. LVN C said she rechecked his blood sugar and it was 212, then he was taken to eat. LVN C said Resident #15 was in the dining room, had his tray, he was eating and being assisted. She said she did not remember the aide who was assisting him. She said she saw the family come in and sit a bowl of fruit on the table, then left the dining room. LVN C said then Assistant Director of Nurses (ADON) A came in and told me they were sending Resident #15 to the hospital 911, so she printed out the face sheet and orders. LVN C said 911 picked resident up. LVN C said she did not know the onset of Humalog insulin. LVN C said, one hour, 30 minutes, I don't know. LVN C acknowledged when an order says with meals the medication needs to be given with food. LVN C said I should have given him juice or something. During an interview on 11/08/19 at 2:25 p.m., the Assistant Director of Nurses (ADON) said he came into the facility on [DATE] at 7:45 a.m. Resident #15 was at the nurse's station in his wheelchair and he looked pale. The ADON said he took Resident #15 to the dining room to an assisted table. The ADON said he went to his office. He said about 30 minutes later the social worker came and told him Resident #15's granddaughter was concerned. The ADON said he went to the dining room, Resident #15 had food in front of him and a Certified Nurse Aide (CNA) was trying to feed him. He said Resident #15's face was droopy, but his hand grips were good. The ADON said Resident #15's granddaughter thought it was his pacemaker. The ADON said they checked Resident #15's blood pressure, he didn't remember how low, but his pulse was high. The ADON said he asked the granddaughter if she wanted to send him out and she said yes 911. The ADON said he called 911, the doctor and passed the information to LVN C. The ADON said LVN C told him Resident #15's blood sugar was over 200 when he left. During an interview on 11/08/19 at 3:14 p.m., the Social Worker (SW) said on the morning of 10/28/19 she was in the dining room passing out drinks. She said a CNA called her over and told her Resident #15's granddaughter was upset. The SW said she brought Resident #15's granddaughter to her office. She said the granddaughter wanted to know what happened, she said she told her she didn't know and went to get the ADON. The SW said the ADON and granddaughter discussed whether it was his pacemaker or a stroke because apparently the pacemaker malfunctioned in the hospital. The SW said she heard the ADON ask the granddaughter if she wanted to send Resident #15 to the hospital. The SW said she had seen Resident #15 in the dining room sitting in his chair. She said she wasn't focusing on the resident, she was focusing on the task she was doing. She said nothing stood out, he wasn't slouched over. During an interview on 11/08/19 at 4:05 p.m. the Treatment Nurse said on 10/28/19 about 7:00 a.m. she went in Resident #15's room. She said Resident #15 didn't seem himself. She said she checked his vitals Blood/Pressure 88/53, Pulse-125, Respirations-28, Temp forehead 97.3 and Oxygen saturation was 92%. She said she checked Resident #15's blood sugar and it showed 39. She said Resident #15's head was sweaty. The Treatment Nurse said she told LVN C what the vital signs were & CBG 39. She said she went with LVN C to the medication room. She said LVN C got the [MEDICATION NAME] injection out of the medication machine and took over. The Treatment Nurse said when ADON A came in to work, she told him what happened. She said she didn't see Resident #15 eat, because she wasn't in the dining room. Record review of the facility's Blood Glucose Monitoring (FSBS) policy/procedure, undated, documented the following, in part: - Verify Doctor's order. - Depending on your findings, interventions or further orders may need to be carried out. Notify Doctor of abnormal findings or according to orders, and notify family members of any new orders. Record review of the facility's Administration Of Insulin policy/procedure, undated, documented the following, in part: - Equipment - insulin as prescribed by doctor. - Complications to guard against: [DIAGNOSES REDACTED] (low blood sugar). - Signs/symptoms of [DIAGNOSES REDACTED] - perspiring or sweating excessively, weakness, dizziness or faintness, hunger or excessive eating, nervousness, irritability or changes in personality, blurred or impaired vision, numbness in the tongue and lips, [MEDICAL CONDITION] palpitations, tremors, headaches, appears to be in coma, unconscious. - treatment for [REDACTED]. Record review of the facility's Medication Errors and Drug Reactions policy/procedure, undated, revealed the following, in part: Purpose - To report when a drug is not given as ordered. - To report when a drug is not given at the correct time. Procedure - Note: All nurses administering medication should be familiar with drug reactions, effects and contraindications. If you are not sure, check the drug reference manuel before administering an unfamiliar drug.

Based on interview and record review the facility failed to ensure that residents had the right to refuse treatment for one (Resident #2) of six residents reviewed for advance directives. Resident #2 had both a completed Out of Hospital (OOH) Do-Not-Resuscitate Order form and a Do Not Resuscitate Order (DNR) in her chart. Resident #2 was sent to the hospital without the OOH and DNR documents. Resident #2 had a [MEDICAL CONDITION] and was placed on a ventilator for 2 days before being removed from the ventilator and passing away. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This deficiency could put residents with DNRs at risk of having CPR performed against their wishes. Findings include: Resident #2's closed record Record review of Resident #2's Face Sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility [DATE] with a readmission [DATE]. Her [DIAGNOSES REDACTED]. The Face Sheet included FULL CODE STATUS on the bottom. Review of Resident #2's Quarterly MDS dated [DATE] included a BIMS of 9, she needed extensive assistance for ADL's, received [MEDICAL TREATMENT], was continent of bowel, had frequent pain rated at 8 on a scale of ,[DATE], had one fall without major injury and used oxygen therapy. Review of Resident #2's care plan revealed she received [MEDICAL TREATMENT] Tuesday-Thursday-Saturday and had advanced care planning (dated [DATE]). Review of Resident #2's Nurse's Notes dated [DATE] at 9:25 p.m. revealed, Aide (CNA) (name) came calling that resident does not look right. Assessed resident- O2 (oxygen) between ,[DATE]% on 2 lt/min nc (liters per minute via nasal cannula), BP ,[DATE], Pulse 111, Temp 95.4 CBG-118. Resident has audible rales breathing sound, lethargic and altered mental status. SVN and inhalers given. Dr. (name) notified. Review of Resident #2's SBAR (Situation, Backround, Appearance and Review/Notify) dated [DATE] at 9:30 p.m. revealed .altered mental status, audible rales breathing, lethargic . Review of Resident #2's Nurse's Notes dated [DATE] at 9:35 p.m. revealed, Dr. (name) gave order to send resident to the E.R. Report given to (name) nurse in the E.R. Review of Resident #2's Nurse's Notes dated [DATE] at 9:55 p.m. revealed, resident out to the E.R. Review of the facility's internal investigation, Interview Record, dated [DATE] revealed Resident #2 was alert but confused. When she opened her eyes they bulged out as if she was very scared. She said she didn't know what was wrong. Her vitals were good. Her sugar had come up because not long before it was low and I gave her some O.J. (orange juice). It was in the 80's but @ this time it was 118. She was very confused and I'd never seen her like that. I called (name of physician) & no answer-I texted him- it's urgent. He called and gave order to transfer. She was making a gurgling sound that she hadn't made before. The EMS even asked me about it. I dialed 911 and from the rime I noticed problem to the time she was gone was probably less than 30 min (minutes). (Why did you not send DNR?) (This question was asked by the Administrator to RN A). RN A's answer was I was in a hurry to transfer her and I sent the face sheet. It didn't even cross my mind to look for DNR- I saw on face sheet full code . Review of RN A's Employee Counseling/Disciplinary Report dated [DATE] revealed a statement written by RN A in which she wrote, Proper paperwork was sent with Resident (#2) at time of discharge to hospital but unfortunately not all the paperwork was sent. Resident was full code on face sheet which is the 1st paperwork for resident identification to be given to EMS was sent out with resident. While printing the face sheet, I saw that resident was a full code and wanting to send her out in a timely manner I did not check to see if she also was a DNR. I called family immediately. Resident was taken outside the premises and left a voice message to be called back, hoping family (Resident #2's sister's name) would call back before my shift was over, but unfortunately she did not call back before I left. Review of Resident #2's hospital emergency room record dated [DATE] at 10:10 p.m. revealed, .Pre-arrival interventions .Assisted ventilation ambu bag (ambu bag A self-refilling bag-valve-mask unit, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. www.medicaldictionary.com accessed [DATE]) in progress .chief complaint-AMS (altered mental status), awake on arrival to (name of facility), cardiac/respiratory arrest in ambulance en (in) route .EMS (emergency medical staff) reports that shortly en route pt (patient) became unresponsive and CPR was initiated . Review of Resident #2's hospital emergency room record dated [DATE] at 10:15 p.m. revealed, Indication: cardiopulmonary arrest .Endotracheal intubation was performed under emergent conditions . In an interview with the DON [DATE] at 8:45 a.m., she said the nurse (RN A) who sent Resident #2 to the emergency room without her OOH DNR paperwork was out of the country, unable to be reached. In an interview [DATE] at 2:12 p.m., the DON and SW said after Resident #2 was sent to the hospital without her DNR OOH paperwork, they (including the Administrator) did a complete chart audit of all resident clinical records. The DON said some charts had a red sheet DNR and OOH form but did not have a written order, so the face sheet was incorrect. She said resident charts were corrected at that time. The DON said when a resident is admitted , the Admissions Coordinator discusses Full Code status and DNR OOH status with the resident/family. She said 48 hours after a resident is admitted , the SW discusses it again during a care plan meeting with the resident/family. Review of the facility's chart audit conducted [DATE] utilizing the former computer system revealed a census of 83. The audit list of residents revealed that there were 26 residents, not including Resident #2, on the form as not having a full code or DNR documented. In an interview on [DATE] at 4:10 p.m., Admission Coordinator B said she meets with resident and their responsible party prior to admission and explains code statuses and asks if the resident has an advanced directive. She said if the resident has an advanced directive but does not have it with them, she has them fill out another one to be sure it is on file with the facility, and the OOH DNR is downloaded into the computer system with a hard copy kept as backup. Review of the facility's admission packet, undated, revealed, in part, Competent adults may issue advance directives in accordance with applicable state laws. An advance directive has the meaning as defined in state law. The facility maintains policies and procedures implementing advance directives with respect to all adult residents. Acknowledgement of receipt advance directives/medical decisions-This is to acknowledge that I have been informed in writing in a language that I understand of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue Advance Directives to be followed should I become incapacitated. (Name of corporation) will honor legally executed Advance Directives in accordance with the Texas Natural Death Act) Directive to Physician/Living Will, Durable Power of Attorney for Healthcare, Physician/Family-Determined Treatment Decision, Out of Hospital DNR.) Review of the facility's policy, Transfer or Discharge, Emergency, dated 2001, revealed, Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare the transfer form to send with the resident; e. Notify the representative (sponsor) f. Assist in obtaining transportation; and g. Others as appropriate or as necessary . The facility took the following actions to correct the non-compliance on [DATE]: Review of the facility's form completed during the resident chart audit dated [DATE], completed at 3:18 p.m. revealed 26 of 81 residents did not have a Full Code or DNR status documented in their clinical record. Review of the facility's chart audit Advanced Directives, dated [DATE], revealed the Performance Improvement Committee reviewed records with 100% compliance for completed advanced directives and code status correctness. There were 38 residents with DNR OOH status. Review of an in-service dated [DATE] entitled Family Notification/Sending Proper Paperwork at time of DC (discharge) included sending a copy of the OOH document with the resident at the time. The in-service was signed by 16 licensed nurses. Interviews [DATE] with 3 LVN's and 2 RN's revealed they had recently been in-serviced and understood regarding sending residents to the hospital and sending all appropriate documentation for care and treatment.

Based on interview and record review the facility failed to ensure that appropriate documentation was provided to ensure safe and orderly transfer from the facility when Resident #2 had a change in condition as evidenced by: Resident #2 had both a completed Out of Hospital (OOH) Do-Not-Resuscitate Order form and a Do Not Resuscitate Order (DNR) in her chart. Resident #2 was sent to the hospital without the OOH and DNR documents. Resident #2 had a [MEDICAL CONDITION] and was placed on a ventilator for 2 days before being removed from the ventilator and passing away. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This deficiency could put residents with DNRs at risk of having CPR performed against their wishes. Findings include: Resident #2's closed record Record review of Resident #2's Face Sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility [DATE] with a readmission [DATE]. Her [DIAGNOSES REDACTED]. The Face Sheet included FULL CODE STATUS on the bottom. Review of Resident #2's Quarterly MDS dated [DATE] included a BIMS of 9, she needed extensive assistance for ADL's, received [MEDICAL TREATMENT], was continent of bowel, had frequent pain rated at 8 on a scale of ,[DATE], had one fall without major injury and used oxygen therapy. Review of Resident #2's care plan revealed she received [MEDICAL TREATMENT] Tuesday-Thursday-Saturday and had advanced care planning (dated [DATE]). Review of Resident #2's Nurse's Notes dated [DATE] at 9:25 p.m. revealed, Aide (CNA) (name) came calling that resident does not look right. Assessed resident- O2 (oxygen) between ,[DATE]% on 2 lt/min nc (liters per minute via nasal cannula), BP ,[DATE], Pulse 111, Temp 95.4 CBG-118. Resident has audible rales breathing sound, lethargic and altered mental status. SVN and inhalers given. Dr. (name) notified. Review of Resident #2's SBAR (Situation, Backround, Appearance and Review/Notify) dated [DATE] at 9:30 p.m. revealed .altered mental status, audible rales breathing, lethargic . Review of Resident #2's Nurse's Notes dated [DATE] at 9:35 p.m. revealed, Dr. (name) gave order to send resident to the E.R. Report given to (name) nurse in the E.R. Review of Resident #2's Nurse's Notes dated [DATE] at 9:55 p.m. revealed, resident out to the E.R. Review of the facility's internal investigation, Interview Record, dated [DATE] revealed Resident #2 was alert but confused. When she opened her eyes they bulged out as if she was very scared. She said she didn't know what was wrong. Her vitals were good. Her sugar had come up because not long before it was low and I gave her some O.J. (orange juice). It was in the 80's but @ this time it was 118. She was very confused and I'd never seen her like that. I called (name of physician) & no answer-I texted him- it's urgent. He called and gave order to transfer. She was making a gurgling sound that she hadn't made before. The EMS even asked me about it. I dialed 911 and from the rime I noticed problem to the time she was gone was probably less than 30 min (minutes). (Why did you not send DNR?) (This question was asked by the Administrator to RN A). RN A's answer was I was in a hurry to transfer her and I sent the face sheet. It didn't even cross my mind to look for DNR- I saw on face sheet full code . Review of RN A's Employee Counseling/Disciplinary Report dated [DATE] revealed a statement written by RN A in which she wrote, Proper paperwork was sent with Resident (#2) at time of discharge to hospital but unfortunately not all the paperwork was sent. Resident was full code on face sheet which is the 1st paperwork for resident identification to be given to EMS was sent out with resident. While printing the face sheet, I saw that resident was a full code and wanting to send her out in a timely manner I did not check to see if she also was a DNR. I called family immediately. Resident was taken outside the premises and left a voice message to be called back, hoping family (Resident #2's sister's name) would call back before my shift was over, but unfortunately she did not call back before I left. Review of Resident #2's hospital emergency room record dated [DATE] at 10:10 p.m. revealed, .Pre-arrival interventions .Assisted ventilation ambu bag (ambu bag A self-refilling bag-valve-mask unit, used for artificial respiration which, while suboptimal for the non-intubated patient, is effective for ventilating and oxygenating intubated patients, allowing both spontaneous and artificial respiration. www.medicaldictionary.com accessed [DATE]) in progress .chief complaint-AMS (altered mental status), awake on arrival to (name of facility), cardiac/respiratory arrest in ambulance en (in) route .EMS (emergency medical staff) reports that shortly en route pt (patient) became unresponsive and CPR was initiated . Review of Resident #2's hospital emergency room record dated [DATE] at 10:15 p.m. revealed, Indication: cardiopulmonary arrest .Endotracheal intubation was performed under emergent conditions . In an interview with the DON [DATE] at 8:45 a.m., she said the nurse (RN A) who sent Resident #2 to the emergency room without her OOH DNR paperwork was out of the country, unable to be reached. In an interview [DATE] at 2:12 p.m., the DON and SW said after Resident #2 was sent to the hospital without her DNR OOH paperwork, they (including the Administrator) did a complete chart audit of all resident clinical records. The DON said some charts had a red sheet DNR and OOH form but did not have a written order, so the face sheet was incorrect. She said resident charts were corrected at that time. The DON said when a resident is admitted , the Admissions Coordinator discusses Full Code status and DNR OOH status with the resident/family. She said 48 hours after a resident is admitted , the SW discusses it again during a care plan meeting with the resident/family. Review of the facility's chart audit conducted [DATE] utilizing the former computer system revealed a census of 83. The audit list of residents revealed that there were 26 residents, not including Resident #2, on the form as not having a full code or DNR documented. In an interview on [DATE] at 4:10 p.m., Admission Coordinator B said she meets with resident and their responsible party prior to admission and explains code statuses and asks if the resident has an advanced directive. She said if the resident has an advanced directive but does not have it with them, she has them fill out another one to be sure it is on file with the facility, and the OOH DNR is downloaded into the computer system with a hard copy kept as backup. Review of the facility's admission packet, undated, revealed, in part, Competent adults may issue advance directives in accordance with applicable state laws. An advance directive has the meaning as defined in state law. The facility maintains policies and procedures implementing advance directives with respect to all adult residents. Acknowledgement of receipt advance directives/medical decisions-This is to acknowledge that I have been informed in writing in a language that I understand of my rights and all rules and regulations to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue Advance Directives to be followed should I become incapacitated. (Name of corporation) will honor legally executed Advance Directives in accordance with the Texas Natural Death Act) Directive to Physician/Living Will, Durable Power of Attorney for Healthcare, Physician/Family-Determined Treatment Decision, Out of Hospital DNR.) Review of the facility's policy, Transfer or Discharge, Emergency, dated 2001, revealed, Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare the transfer form to send with the resident; e. Notify the representative (sponsor) f. Assist in obtaining transportation; and g. Others as appropriate or as necessary . The facility took the following actions to correct the non-compliance on [DATE]: Review of the facility's form completed during the resident chart audit dated [DATE], completed at 3:18 p.m. revealed 26 of 81 residents did not have a Full Code or DNR status documented in their clinical record. Review of the facility's chart audit Advanced Directives, dated [DATE], revealed the Performance Improvement Committee reviewed records with 100% compliance for completed advanced directives and code status correctness. There were 38 residents with DNR OOH status. Review of an in-service dated [DATE] entitled Family Notification/Sending Proper Paperwork at time of DC (discharge) included sending a copy of the OOH document with the resident at the time. The in-service was signed by 16 licensed nurses. Interviews [DATE] with 3 LVN's and 2 RN's revealed they had recently been in-serviced and understood regarding sending residents to the hospital and sending all appropriate documentation for care and treatment.

Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 9 residents reviewed for pharmacy services. - The facility failed to transcribe Resident #1's Xarelto (anticoagulant medication) to the computer printout Medication Administration Record (MAR) which lead to the resident not receiving the medication from 01/28/18 through 04/05/18. Resident #1 was hosptalized on [DATE] and found to have a [MEDICAL CONDITION] Embolism (PE) and a [MEDICAL CONDITIONS]. - This was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. These failures could affect 24 residents on an anticoagulant, placing them at risk for not receiving therapeutic doses of their medications and an increased risk of developing blood clots leading to possible embolism, [MEDICAL CONDITION] and/or death. Findings Included: Record review of Resident #1's face sheet dated 04/05/18 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's physician orders [REDACTED]. - Xarelto 20mg tablet 1 tab PO with evening meal. Anticoagulant. Generic: Rivaroxaban. Order date 09/02/17. (mg = milligrams, PO=by mouth). According to their web-site, Xarelto is a prescription medicine used to reduce the risk of stroke and blood clots in people with [MEDICAL CONDITION], not caused by a heart valve problem. https://www.xarelto-us.com/about-xarelto/how-xarelto-works. Accessed on 04/20/18. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated in part: - Brief Interview Mental Status (BIMS) = 10. (8-12 moderately impaired). - Active [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan dated 10/10/17 indicated in part: - Problem/Need. Problem onset: 09/02/17. [MEDICAL CONDITIONS] - Resident takes anticoagulant. - Goal and target date: The [MEDICAL CONDITION] will dissolved within 30 days. - Approaches. Administer anticoagulants as ordered. Record review of Resident #1's facility admission orders [REDACTED] - Rivaroxaban 20mg PO qday (every day). Note: Resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #1's MARs for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) did not have Xarelto as one of the medications to be administered as ordered for a total of 67 missed doses. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's nurses notes indicated in part: - 0630 (6:30 a.m.) 04/05/18. When making rounds this morning Pt (patient) stated his right lower quad was hurting. Pain medication given [MEDICATION NAME]. @ 0645 (6:45 a.m.) Pt stated the pain had gotten worst V/S (vital signs) taken - Pt having SOB (shortness of breath) and was not able to breathe. Pt sent to local hospital to be evaluated. Record review of Resident #1's hospital records dated 04/05/18 indicated in part: - admitted : 04/05/18. Chief complaint abdominal pain. History of present illness. This morning he developed sudden onset of right upper quadrant pain that he described as 8 on a 0 to 10 scale. He also complained of right thigh pain. While in the emergency department a CT scan of the abdomen and pelvis with contrast was obtained with the following radiologist impression: Incidental [MEDICAL CONDITION] embolism with involvement of at least the right lower lobe. He was started on [MEDICATION NAME] for [MEDICAL CONDITION] protocol and hospitalist service was consulted to admit the patient. (CT=computed tomography) - Assessment 1. Acute [MEDICAL CONDITION] secondary PE. 2. [MEDICAL CONDITION] Embolism (PE). 5. [MEDICAL CONDITION] left lower extremity. A [MEDICAL CONDITION] embolism is a blockage in one of the [MEDICAL CONDITION] arteries in your lungs. In most cases, [MEDICAL CONDITION] embolism is caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body ([MEDICAL CONDITION]. https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc- 647 Sources accessed on 04/25/18. [MEDICAL CONDITIONS] occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. [MEDICAL CONDITION] can cause leg pain or swelling, but also can occur with no symptoms. https://www.mayoclinic.org/diseases-conditions/deep-vein-[MEDICAL CONDITION]/symptoms-causes/syc- 557 Sources accessed on 04/25/18. - PLAN: 1. We will admit the patient to the post-critical care unit with telemetry. 2. Regarding acute [MEDICAL CONDITION]: we will go ahead and treat for PE and early pneumonia. 3. Regarding [MEDICAL CONDITION] embolism: The patient was started on [MEDICAL CONDITION]. 5. Regarding [MEDICAL CONDITION]: [MEDICATION NAME] protocol. During an interview on 04/11/18 at 1:55 p.m. the Director of Nurses (DON) said Resident #1 had not received his Xarelto/Rivaroxaban medication from 01/28/18 through 04/05/18 due to it not being transcribed to the new (MONTH) (YEAR) MAR. The DON said according to the written admission order for (MONTH) (YEAR) it indicated Resident #1 received the Xarelto/Rivaroxaban on the 26th and 27th but after that it was dropped due to the new print out MAR no longer having the Xarelto/Rivaroxaban order on it. During an interview on 04/12/18 at 10:16 a.m. Medication Aide (MA) A said she was the medical records person. MA A said she would transcribe the written admission orders [REDACTED]=Treatment Administration Record). MA A said after she printed the MAR/TAR she would then go and place them in the medication aide's MARs book or the nurses TARs book. MA A said she would tell the MA or nurse to check the MAR/TAR and make sure it was correct after placing it in the MAR or TAR book. MA A said she was the one who had transcribed Resident #1's admission orders [REDACTED]. MA A said that she left out the medication Xarelto/Rivaroxaban when she did the transcription. MA A said sometimes she gets distracted while conducting the transcription and could have caused her to make that error. MA A said she acknowledged she had made an error. MA A said from now on once she transcribed the new orders and printed out the new MARs/TARs she would hand the printouts to the ADON/nurse to review it before being placed in the MARs/TARs book. (ADON = Assistant Director of Nurses) During an interview on 04/12/18 at 10:52 a.m. Resident #1 said he had gone to the hospital because he had developed a blood clot. Resident #1 said last week he had a lot of pain in his abdomen and had been transferred to the hospital and that was where it was determined he had a blood clot. During an interview on 04/12/18 at 12:12 p.m. MA B said it was her initials on Resident #1's admission orders [REDACTED]. MA B said the initials indicated she had administered Resident #1 his Xarelto/Rivaroxaban. MA B said she did not recall if she had obtained the medication from the resident's blister pack or had asked the nurse to pull it from the emergency kit. MA B said it was hard to notice that the resident's Xarelto/Rivaroxaban had been left out since the new MAR did not have that order on it anymore. During an interview on 04/13/18 at 11:59 a.m. the DON said after they had conducted the 100% audit of all the resident's orders on 04/05/18 and there had not been any other errors found. Record review of the facility's policy titled Medication orders dated 2001 indicated in part: - The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. - A current list of orders must be maintained in the clinical record of each resident. - Recording Orders. Medication orders - when recording orders for medications, specify the type, route, dosage, frequency and strength of the medication ordered. - Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation which continued from 01/28/18 to 04/05/18. The facility took the following action to correct the non-compliance: Review of the provider investigative report dated 04/05/18 indicated in part: - Family and physician were notified and patient sent to emergency room . Provider response when family reported Xarelto not given since readmission was as follows. 1) Immediate review of last 10 admissions for accuracy of transcription to MAR to computer order entry. 2) 100% audit of resident's physician orders [REDACTED]. 3) Head to toe skin assessments were completed on all residents receiving anticoagulants to check for any signs of redness, warmth, pain or tenderness. Record review of the facility' performance improvement plan dated 04/05/18. Observation: Order transcription. Goal/objective: To reduce the risk of order transcription errors. Actions: 1. Physician orders [REDACTED]. The 2nd nurse will review the physician orders [REDACTED]. The 2nd nurse will also verify that the medication has been ordered from the pharmacy and or the lab/x-ray has been ordered through the provider of service and that there is a notation on the 24 hour report book. The 2nd nurse will then cosign the order. In the event there is only one nurse on duty-the charge nurse will ask the oncoming nurse to review and co-sign. Responsible party: Chg nurse. (Chg = charge) Date completed: 4/5/18. Actions: 2. All new orders will be reviewed daily during clinical team to verify transcription accuracy, documentation on the 24 hour report, and follow through of order to completion. Any outstanding actions items related to new orders will be placed on the white board/flip chart to review until resolved. Responsible party: Adm/DON. (Adm = Administrator). Date completed: 4/5/18. Actions: 3. An afternoon stand down meeting will be held daily to review all items listed on white board/flip chart/daily clinical minutes - items will be erased/lined through when completed. Responsible party: DON. Date completed: 4/5/18. Actions: 4. Charge nurses will report to daily clinical and stand down meetings. They will bring their 24 hour report, all physician orders, incident reports, and x-ray/lab reports. They should report to meeting one at a time and not be in meeting more than 7-8 minutes. Responsible party: Chg nurse. Date completed: 4/5/18. Actions: 5. Nurse Management team will be in-serviced regarding process and expectations of follow up. Responsible party: DON. Date completed: 4/5/18. Actions: 6. Charge nurses will be in-serviced on new process now and as a part of new hire orientation. Responsible party: DON/Nurse managers. Date completed: 4/5/18. Record review of the facility's census list dated 04/05/18 indicated all physician orders [REDACTED]. (Note: this document was part of the 100% audit conducted by the facility). Record review of the facility's detail admission/Discharge report dated 04/05/18 indicated admit orders to med reconciled to MARS, printed checked and verified for accuracy. (Note: this document was part of the 100% audit conducted by the facility). Record on in-service dated 04/05/18 indicated in part: Admission/re-admission - all new orders from hospital will be checked to orders written for accuracy 2 nurses will sign off on transcription to validate accuracy, the 2nd nurse will also make sure /confirm meds have been ordered from Rx (pharmacy) and will note on 24H report book. (also ensure any labs required are completed filled out). - When MARS are printed it will be reviewed by a nurse for accuracy before placing in MAR book. - End of month reconciliation will review chart orders and MARS for any changes and note to ensure accuracy. - Night nurse will verify the orders and verify against MAR. - When transcribing new order on MAR initial date and write Dx (diagnosis) nurse that verifies order on MAR will also initial. Separate interviews were conducted with MA A on 04/12/18 at 10:16 a.m., RN C on 04/12/18 at 4:12 p.m., Licensed Vocational Nurse (LVN) D on 04/13/18 at 12:25 p.m., ADON E on 04/16/18 at 2:12 p.m., and LVN F on 04/16/18 at 3:40 p.m. Each staff member responded correctly to the following questions: What is the new process for transcribing new physician orders [REDACTED]. If it's a new telephone physician order [REDACTED]. The new physician order [REDACTED]. The night nurse will then check that order again and verify by looking in the MAR and initialing it. The new orders will be given to medical records who will then transcribe into the computer printout MAR. The medical records person will then printout the new MAR and have the ADON/charge nurse to check for verification before being placed in the MAR. The nurses from now on will be administering all the anticoagulant medications. Record review of the facility census report dated 04/16/18 provided by the DON indicated there were 24 residents in the facility that were on an anticoagulant medication.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #1) of nine residents reviewed for medication errors. - The facility failed to transcribe Resident #1's Xarelto (anticoagulant medication) to the computer printout Medication Administration Record (MAR) which lead to the resident not receiving the medication from 01/28/18 through 04/05/18. Resident #1 was hosptalized on [DATE] and found to have a [MEDICAL CONDITION] Embolism (PE) and a [MEDICAL CONDITIONS]. - This was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. These failures could affect 24 residents on an anticoagulant, placing them at risk for not receiving therapeutic doses of their medications and an increased risk of developing blood clots leading to possible embolism, [MEDICAL CONDITION] and/or death. Findings Included: Record review of Resident #1's face sheet dated 04/05/18 indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #1's physician orders [REDACTED]. - Xarelto 20mg tablet 1 tab PO with evening meal. Anticoagulant. Generic: Rivaroxaban. Order date 09/02/17. (mg = milligrams, PO=by mouth). According to their web-site, Xarelto is a prescription medicine used to reduce the risk of stroke and blood clots in people with [MEDICAL CONDITION], not caused by a heart valve problem. https://www.xarelto-us.com/about-xarelto/how-xarelto-works. Accessed on 04/20/18. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated in part: - Brief Interview Mental Status (BIMS) = 10. (8-12 moderately impaired). - Active [DIAGNOSES REDACTED]. Record review of Resident #1's Care Plan dated 10/10/17 indicated in part: - Problem/Need. Problem onset: 09/02/17. [MEDICAL CONDITIONS] - Resident takes anticoagulant. - Goal and target date: The [MEDICAL CONDITION] will dissolved within 30 days. - Approaches. Administer anticoagulants as ordered. Record review of Resident #1's facility admission orders [REDACTED] - Rivaroxaban 20mg PO qday (every day). Note: Resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident #1's MARs for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) did not have Xarelto as one of the medications to be administered as ordered for a total of 67 missed doses. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's nurses notes indicated in part: - 0630 (6:30 a.m.) 04/05/18. When making rounds this morning Pt (patient) stated his right lower quad was hurting. Pain medication given [MEDICATION NAME]. @ 0645 (6:45 a.m.) Pt stated the pain had gotten worst V/S (vital signs) taken - Pt having SOB (shortness of breath) and was not able to breathe. Pt sent to local hospital to be evaluated. Record review of Resident #1's hospital records dated 04/05/18 indicated in part: - admitted : 04/05/18. Chief complaint abdominal pain. History of present illness. This morning he developed sudden onset of right upper quadrant pain that he described as 8 on a 0 to 10 scale. He also complained of right thigh pain. While in the emergency department a CT scan of the abdomen and pelvis with contrast was obtained with the following radiologist impression: Incidental [MEDICAL CONDITION] embolism with involvement of at least the right lower lobe. He was started on [MEDICATION NAME] for [MEDICAL CONDITION] protocol and hospitalist service was consulted to admit the patient. (CT=computed tomography) - Assessment 1. Acute [MEDICAL CONDITION] secondary PE. 2. [MEDICAL CONDITION] Embolism (PE). 5. [MEDICAL CONDITION] left lower extremity. A [MEDICAL CONDITION] embolism is a blockage in one of the [MEDICAL CONDITION] arteries in your lungs. In most cases, [MEDICAL CONDITION] embolism is caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body ([MEDICAL CONDITION]. https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc- 647 Sources accessed on 04/25/18. A [MEDICAL CONDITIONS] occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. [MEDICAL CONDITION] can cause leg pain or swelling, but also can occur with no symptoms. https://www.mayoclinic.org/diseases-conditions/deep-vein-[MEDICAL CONDITION]/symptoms-causes/syc- 557 Sources accessed on 04/25/18. - PLAN: 1. We will admit the patient to the post-critical care unit with telemetry. 2. Regarding acute [MEDICAL CONDITION]: we will go ahead and treat for PE and early pneumonia. 3. Regarding [MEDICAL CONDITION] embolism: The patient was started on [MEDICAL CONDITION]. 5. Regarding [MEDICAL CONDITION]: [MEDICATION NAME] protocol. During an interview on 04/11/18 at 1:55 p.m. the Director of Nurses (DON) said Resident #1 had not received his Xarelto/Rivaroxaban medication from 01/28/18 through 04/05/18 due to it not being transcribed to the new (MONTH) (YEAR) MAR. The DON said according to the written admission order for (MONTH) (YEAR) it indicated Resident #1 received the Xarelto/Rivaroxaban on the 26th and 27th but after that it was dropped due to the new print out MAR no longer having the Xarelto/Rivaroxaban order on it. During an interview on 04/12/18 at 10:16 a.m. Medication Aide (MA) A said she was the medical records person. MA A said she would transcribe the written admission orders [REDACTED]=Treatment Administration Record). MA A said after she printed the MAR/TAR she would then go and place them in the medication aide's MARs book or the nurses TARs book. MA A said she would tell the MA or nurse to check the MAR/TAR and make sure it was correct after placing it in the MAR or TAR book. MA A said she was the one who had transcribed Resident #1's admission orders [REDACTED]. MA A said that she left out the medication Xarelto/Rivaroxaban when she did the transcription. MA A said sometimes she gets distracted while conducting the transcription and could have caused her to make that error. MA A said she acknowledged she had made an error. MA A said from now on once she transcribed the new orders and printed out the new MARs/TARs she would hand the printouts to the ADON/nurse to review it before being placed in the MARs/TARs book. (ADON = Assistant Director of Nurses) During an interview on 04/12/18 at 10:52 a.m. Resident #1 said he had gone to the hospital because he had developed a blood clot. Resident #1 said last week he had a lot of pain in his abdomen and had been transferred to the hospital and that was where it was determined he had a blood clot. During an interview on 04/12/18 at 12:12 p.m. MA B said it was her initials on Resident #1's admission orders [REDACTED]. MA B said the initials indicated she had administered Resident #1 his Xarelto/Rivaroxaban. MA B said she did not recall if she had obtained the medication from the resident's blister pack or had asked the nurse to pull it from the emergency kit. MA B said it was hard to notice that the resident's Xarelto/Rivaroxaban had been left out since the new MAR did not have that order on it anymore. During an interview on 04/13/18 at 11:59 a.m. the DON said after they had conducted the 100% audit of all the resident's orders on 04/05/18 and there had not been any other errors found. Record review of the facility's policy titled Medication orders dated 2001 indicated in part: - The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. - A current list of orders must be maintained in the clinical record of each resident. - Recording Orders. Medication orders - when recording orders for medications, specify the type, route, dosage, frequency and strength of the medication ordered. - Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation which continued from 01/28/18 to 04/05/18. The facility took the following action to correct the non-compliance: Review of the provider investigative report dated 04/05/18 indicated in part: - Family and physician were notified and patient sent to emergency room . Provider response when family reported Xarelto not given since readmission was as follows. 1) Immediate review of last 10 admissions for accuracy of transcription to MAR to computer order entry. 2) 100% audit of resident's physician orders [REDACTED]. 3) Head to toe skin assessments were completed on all residents receiving anticoagulants to check for any signs of redness, warmth, pain or tenderness. Record review of the facility' performance improvement plan dated 04/05/18. Observation: Order transcription. Goal/objective: To reduce the risk of order transcription errors. Actions: 1. Physician orders [REDACTED]. The 2nd nurse will review the physician orders [REDACTED]. The 2nd nurse will also verify that the medication has been ordered from the pharmacy and or the lab/x-ray has been ordered through the provider of service and that there is a notation on the 24 hour report book. The 2nd nurse will then cosign the order. In the event there is only one nurse on duty-the charge nurse will ask the oncoming nurse to review and co-sign. Responsible party: Chg nurse. (Chg = charge) Date completed: 4/5/18. Actions: 2. All new orders will be reviewed daily during clinical team to verify transcription accuracy, documentation on the 24 hour report, and follow through of order to completion. Any outstanding actions items related to new orders will be placed on the white board/flip chart to review until resolved. Responsible party: Adm/DON. (Adm = Administrator). Date completed: 4/5/18. Actions: 3. An afternoon stand down meeting will be held daily to review all items listed on white board/flip chart/daily clinical minutes - items will be erased/lined through when completed. Responsible party: DON. Date completed: 4/5/18. Actions: 4. Charge nurses will report to daily clinical and stand down meetings. They will bring their 24 hour report, all physician orders, incident reports, and x-ray/lab reports. They should report to meeting one at a time and not be in meeting more than 7-8 minutes. Responsible party: Chg nurse. Date completed: 4/5/18. Actions: 5. Nurse Management team will be in-serviced regarding process and expectations of follow up. Responsible party: DON. Date completed: 4/5/18. Actions: 6. Charge nurses will be in-serviced on new process now and as a part of new hire orientation. Responsible party: DON/Nurse managers. Date completed: 4/5/18. Record review of the facility's census list dated 04/05/18 indicated all physician orders [REDACTED]. (Note: this document was part of the 100% audit conducted by the facility). Record review of the facility's detail admission/Discharge report dated 04/05/18 indicated admit orders to med reconciled to MARS, printed checked and verified for accuracy. (Note: this document was part of the 100% audit conducted by the facility). Record on in-service dated 04/05/18 indicated in part: Admission/re-admission - all new orders from hospital will be checked to orders written for accuracy 2 nurses will sign off on transcription to validate accuracy, the 2nd nurse will also make sure /confirm meds have been ordered from Rx (pharmacy) and will note on 24H report book. (also ensure any labs required are completed filled out). - When MARS are printed it will be reviewed by a nurse for accuracy before placing in MAR book. - End of month reconciliation will review chart orders and MARS for any changes and note to ensure accuracy. - Night nurse will verify the orders and verify against MAR. - When transcribing new order on MAR initial date and write Dx (diagnosis) nurse that verifies order on MAR will also initial. Separate interviews were conducted with MA A on 04/12/18 at 10:16 a.m., RN C on 04/12/18 at 4:12 p.m., Licensed Vocational Nurse (LVN) D on 04/13/18 at 12:25 p.m., ADON E on 04/16/18 at 2:12 p.m., and LVN F on 04/16/18 at 3:40 p.m. Each staff member responded correctly to the following questions: What is the new process for transcribing new physician orders [REDACTED]. If it's a new telephone physician order [REDACTED]. The new physician order [REDACTED]. The night nurse will then check that order again and verify by looking in the MAR and initialing it. The new orders will be given to medical records who will then transcribe into the computer printout MAR. The medical records person will then printout the new MAR and have the ADON/charge nurse to check for verification before being placed in the MAR. The nurses from now on will be administering all the anticoagulant medications. Record review of the facility census report dated 04/16/18 provided by the DON indicated there were 24 residents in the facility that were on an anticoagulant medication.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for 2 of 5 (Resident #1 and #2) reviewed for falls. a). The facility failed to develop and implement interventions to prevent Resident #1, who was identified as a high fall risk, from falling. Resident #1 fell at least 6 times from February 2014 - July 2014 (2/03/14, 2/07/14, 2/10/14, 3/12/14, 7/04/14 and 7/16/14). Interventions were not put in place to prevent the likelihood of recurrence. b). The facility failed to develop and implement interventions to prevent Resident #2, who was identified as a high fall risk, from falling. Resident #2 fell a total of 5 times before interventions were put in place to prevent further falls. Resident #2 fell on [DATE], 06/14/14, 06/24/14, 06/25/14 and again on 06/27/14 and sustained a fractured hip. This failure could affect 63 residents that were identified as high fall risks for unwanted falls and injuries. Findings Include: RESIDENT #2 Record review of Resident #2's face sheet dated 07/22/14 indicated he was admitted to the facility on [DATE] and re-admited on 06/29/14 with [DIAGNOSES REDACTED]. Resident #2 was [AGE] years old. Record review of the Resident #2's Minimum Data Set ((MDS) dated [DATE] indicated in part: ? Type of assessment: Admission assessment. ? Brief Interview Mental Status (BIMS) = 4 (0-7 severe impairment). ? Functional status: Transfer = Extensive assistance-resident involved in activity, staff provide weight bearing support. Two person physical assist, non-ambulatory. ? Functional status: Balance moving from seated to standing position= Not steady, only able to stabilize with staff assistance. ? Health conditions: Fall history- fall during month before admission/reentry. Yes. Record review of the Resident #2's care plan indicated in part: ? 06/17/14: Resident at risk for falls. Resident will not experience falls or injuries from falls over the next 90 days. Encourage resident to ask for assistance of staff. Ensure call light is in reach, answer promptly. ? 06/17/14: Related to fall 6-14-14, Approach-Investigate incident to prevent any further incidents, resident stood up in dining room without assistance and fell to floor. Record review of the Resident #2's admission nursing evaluation dated 06/07/14 indicated in part: ? Cognitive: Alert, confused and oriented to self. ? History of falls: fell in the past 30 days. ? Comments: Patient very confused alert to person only. Record review of the Resident #2's fall risk evaluation dated 06/07/14 indicated in part: ? Total score: 18 ? A resident who scores a 10 or higher is at risk. Consider environmental risk factors in resident's interventions. Record review of Resident #2's nurses notes indicated in part: ? 06/09/14: Tries to lean forward and fall out of chair, will continue to monitor. ? 06/12/14: Very confused trying to get up from wheelchair constantly, oriented to surroundings several times. ? 06/15/14: Continuing to try and get out of bed and stand from chair, will continue to monitor call light in reach. ? 06/18/14: Patient continues to try and stand on own with weakness noted, encouraged to call for assist. ? 06/19/14: Patient tries to get out of bed frequently states needs to get up and go to store for some beer and cigarettes, encouraged patient to use call light and ask for assist. ? 06/20/14: Patient very confused, oriented to surroundings several times, patient trying to get out of wheelchair constantly. ? 06/22/14: Patient wanting to get up and walk without assistance, patient was encouraged to call for assistance, patient showed understanding at this time but unable to recall. ? 06/23/14: Patient constantly tries to get out of bed states going to town for beer will continue to monitor call light at reach. ? 06/27/14: Resident was observed by CNA standing up from wheelchair as CNA was trying to run to catch him he fell over and landed on his left side. 911 was called and doctor notified, family notified, resident admitted to hospital for left hip fracture. During an interview on 07/26/14 at 1:50 p.m., the ADON said Resident #2 needed 1 on 1 monitoring from admission to present. The ADON said Resident #2 was probably detoxing from alcohol abuse and was confused. The ADON said that when they had meetings they would go over the incident/accident reports and try to come up with interventions. During an interview on 07/26/14 at 2:15 p.m., LVN A said Resident #2 was probably going through alcohol withdrawals and was very confused. LVN A said Resident #2 wanted to go to the store and buy some beer. LVN A said she would keep Resident #2 at the nurse's station to monitor him but just could not keep up with him. LVN A said the Administrator and the DON wanted the facility to be an alarm free facility. LVN A said Resident #2 had gotten a bed and chair alarm after he had fractured his hip. During an interview on 07/26/14 at 2:42 p.m., LVN B said Resident #2 would not stay seated down on his wheelchair. LVN B said Resident #2 wanted to go to the store to buy some beer. LVN B said she had never been instructed to fill out the recommendations/interventions section on the falls investigation worksheet. LVN B said the administrator and DON had taken away all the bed/chair alarms. The alarams were put back in place afte Resident #2 fell and fractured his hip on 06/27/14. During an interview on 08/27/14 at 3:00 p.m., Resident # 2 said he had been at the facility several years now. Resident #2 said he had bought this property and had his house built here. During an interview on 08/27/14 at 4:02 p.m., the DON said Resident #2 was a 1 on 1 and you could not take your eyes off of him or he would try to get up. The DON said the nurses should have documented something on the recommendations/interventions section on the falls investigation worksheet. The DON said the nurses should have implemented the bed/chair alarms to prevent the injury. Record review of Resident #2's fall reports indicated in part: ? 06/11/14: Patient at dining room found on floor by CNA. Very confused. Fall investigation worksheet, recommendations/interventions section was left blank. ? 06/14/14: Patient was in dining room getting ready to eat at table when tried to stand and patient fell from chair and hit head on floor. Fall investigation worksheet, recommendations/interventions section was left blank. ? 06/24/14: Patient was in room on mat at side of bed. Fall investigation worksheet, recommendations/interventions section was left blank. ? 06/25/14: Patient at nurses station attempting to get up from wheelchair several times on one attempt patient got up and legs gave up and patient fell on floor. Fall investigation worksheet, recommendations/interventions: indicated labs drawn low potassium, Nurse Practioner (NP) to review labs. ? 06/27/14: Resident was observed getting out of wheelchair as soon as he went to take one step he fell over on left side. Progress note: Resident stood up out of wheelchair, CNA tried to run and catch him but as soon as resident tried to take a step he fell over landing on his left side. 911 and doctor notified, family notified, resident admitted for left hip fracture. Fall investigation worksheet, recommendations/interventions section was left blank. RESIDENT #1 Record review of Resident #1's face sheet dated 05/05/14 indicated she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was [AGE] years old. Record review of the Resident #1's Minimum Data Set (MDS) assessments dated 5/05/14 and 8/04/14 respectively, indicated in part: ? Type of assessments: Quarterly. ? Brief Interview Mental Status (BIMS) = 1 and 0 (0-7 severe impairment). ? Functional status: transfer = Extensive assistance-resident involved in activity, staff provide weight bearing support (both reviews). Two person physical assist and upgraded to one person assist. ? Functional status: toilet use= extensive assistance (both reviews). Two person physical assist and upgraded to one person assist. Bowel and bladder= always incontinent both reviews. Record review of the Resident #1's care plan indicated in part: ? 8/19/13: Resident at risk for falls related to cognitive impairment. Resident will be free of injury related to falls over the next 90 days. Assist with ambulation and transfers. Encourage resident to ask for assistance of staff. Undated, updated care plan on 2/03/14= "fall on 2/10/14 no injury. Intervention- inservice staff not to leave patient unattended while in bathroom." Other approaches: "Bed/chair alarm; toileting program." Updated care plan on 2/10/14= "cognitive impairment- scoop mattress and bedside commode." Updated care plan on 2/14/14= "Inservice Hospice aides to apply alarms." Care plan dated 8/19/13: Impaired ability to remain continent of bowel and bladder= Resident will be clean, dry and odor free for 90 days. Take to bathroom every 2 hours and after meals. Record review of the Resident #1's fall risk evaluation dated 8/29/13 indicated in part: ? Total score: 28 ? A resident who scores a 10 or higher is at risk. Consider environmental risk factors in resident's interventions. Review of physician telephone orders indicated in part: - 2/27/14- Discontinue bed and chair alarms. (The alarms were put into place on 2/03/14) - 7/29/14- Discharge from Hospice. Review of falls Resident #1 had: Fall #1-- 2/03/14= unwitnessed. Found by staff on floor in front of recliner. Resident alert and oriented X 1- confused. Denies pain. Notified Director of Nurses, and power of attorney. New order for bed and chair alarms. Fall #2-- 2/07/14= Pressure alarm going off. Patient found sitting on floor. Patient said she needed to go to bathroom. Patient very confused. Denies pain. No new orders. "Patient not using call light. Have patient use call light." Fall #3--2/10/14= Resident found on floor. No pain. Alert, oriented to name only. "Encouraged to use call light." Fall #4--3/12/14= Resident found sitting on floor. No pain. Skin tear to right thumb. "Encouraged to use call light. Bed with scoop mattress in lowest position." Fall #5--7/04/14= Resident found sitting on floor in dining room. Very confused, unable to explain what happened. No pain. No injury. No new orders. No interventions added to incident. Fall #6--7/16/14= Resident found on floor by bathroom door. Patient said she walked to bathroom but fell coming out. No pain. "Encouraged to call for assistance." No new orders. No interventions added to incident. During an interview on 8/27/14 at 4:15 p.m. Therapy Director C and Physical Therapist D said Resident #1 was not progressing so when the family suggested Hospice they discharged from therapy. They added the previous DON told them all alarms were going to be discontinued. The director added she was unaware Resident #1 had a [DIAGNOSES REDACTED]. (NOTE: therapy kept making recommendations for a bladder program as she was not suited for a therapy program.) When surveyor asked if Resident #1's falls were discussed in the morning meetings the director replied no. During an interview on 08/27/14 at 5:00 p.m. the surveyor and the DON reviewed Resident #1's falls, bladder status, cognitive status and functional status. The DON acknowledged Resident #1 was not oriented enough so "saying to remind her to use her call light was not an appropriate measure to prevent falls." The DON added since the resident was ambulatory the staff need to anticipate when she may need to go to the restroom and help her before she is incontinent and tries to go on her own. Record review of the facility's undated policy and procedure titled "Prohibit the mistreatment, neglect and abuse of residents and the misappropriation of resident property" indicated in part: ? Each resident has the right to be free from mistreatment, neglect and misappropriation of property. Record review of the facility's policy and procedure titled "Fall clinical protocol" and dated 4/2007 indicated in part: ? After more than one fall, the physician should review the resident's gait, balance and current medications that may be associated with dizziness or falling. ? The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Record review of the facility's policy and procedure titled "Falls and fall risk, managing" and dated 12/2007 indicated in part: ? Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of a document provided by the facility on 08/27/14 indicated there 63 residents in the facility that were considered a high fall risk.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of nine residents (ID#1 & #3) reviewed for falls, elopement and/or injury. The facility failed to: a) Provide supervision to prevent elopement. Resident #1 was able to exit the building through an unsecured door, traveled down the sidewalk and fell . b) Ensure bed and/or chair alarms were working and activated to alert staff when a resident attempted to stand. Staff failed to turn Resident #3's bed alarm on and subsequently the resident got out of bed and fell , fracturing her back. These failures could affect any of the 13 residents identified by the facility with dementia who were at risk for falls. Findings include: RESIDENT #1 Review or Resident #1's face sheet dated 09/27/13 indicated he was admitted on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years old. Review of Resident #1's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) completed by the Social Worker (SW) on 09/30/13 indicated in part: "Summary score: 9. BIMS score can be interpreted as follows: 8-12 = Moderately impaired." Review of Resident #1's care plan dated 09/25/13 did not include anything related to his wandering, blindness, elopement risks or behaviors. (Resident #1 was at the facility from 09/23/13 through 09/30/13). Review of Resident #1's resident data sheet dated 09/23/13 indicated in part: Cognition, communication and memory: Alert, confused, short term memory loss; Mobility: Fall risk, history of falls; Personal care: only sees shadows. Review of Resident #1's admission nursing evaluation dated 09/23/13 indicated in part: Cognitive: Alert, memory problem; Communication: Vision severely impaired right and left. Interview on 10/17/13 at 1:13 p.m. Certified Nursing Assistant (CNA) E said Resident #1 was no longer at the facility. CNA E said Resident #1 would wander in and out of other resident's rooms and they could not keep up with him. Interview on 10/17/13 at 3:01 p.m. the therapy supervisor said Resident #1 got out of the facility through the side door in the therapy room. The supervisor said a resident that was doing therapy saw Resident #1 go out the side door and told Physical Therapy Assistant (PTA) D about it. The supervisor said she ran out of her office to help PTA D with Resident #1. The supervisor said when she went outside to assist Resident #1, he was lying down on the street and a passerby had stopped to help. (Resident #1 wheels self on wheelchair and also stands up and walks while pushing the chair). Observation on 10/17/13 at 3:05 p.m. the side door in the therapy room was unlocked and there was no alarm on it. Interview on 10/17/13 at 3:40 p.m. the Administrator said he would like to place an alarm on the therapy room side door but had not been able to find one. Interview on 10/18/13 at 10:45 a.m. PTA D said Resident #1 would frequently wander into the therapy room and bump into stuff. PTA D said a resident she was working with that day told her he saw a resident go out the side door. PTA D said she was doing therapy with the resident that witnessed Resident #1 go out the door. PTA D said she got up to get something and when she returned the resident told her he saw a resident go out the side door. PTA D said when she went to see who went out she saw Resident #1 standing on the street. PTA D said there was a passerby whom had gotten off of their vehicle to assist Resident #1. PTA D said Resident #1 was "very impulsive and hazardous". PTA D said she used to ambulate Resident #1 up and down hallway and he would walk very fast and not understand directions. Interview on 10/18/13 at 11:30 a.m. Licensed Vocational Nurse (LVN) B said Resident #1 was very active and hard to redirect. LVN B said Resident #1 would get into other residents rooms. Interview on 10/18/13 at 2:55 p.m. the Assistant Director of Nurses (ADON) said she saw Resident #1 walk out the front door on 09/26/13. The ADON said the resident had figured out the wanderguard detector was attached to his wheelchair and if he went out without the wheelchair it would not trigger the wanderguard alarm. The ADON said Resident #1 was very confused. Interview on 10/18/13 at 3:19 p.m. LVN C said she worked the day Resident #1 got out of the facility. LVN C said that particular day Resident #1 was very irritated and trying to get out. LVN C said they put the resident in his room and next thing she knew therapy staff told her he was outside. LVN C said Resident #1's doctor (whom is also the facility ' s medical director) told Resident #1 if kept trying to get out he would send him to a psych ward. Telephone interview on 10/20/13 at 9:05 p.m. Resident #1's Daughter #2 said Resident #1's dementia and confusion had worsened while at the facility. Daughter #2 said Resident #1's blindness occurred after he had the second stroke and before that he could see fine. Daughter #2 said the Administrator told her they had checked resident and he was fine after they found him outside of the facility on 09/27/13. During an interview on 10/21/13 at 10:01 a.m. the treatment nurse said Resident #1 had short term memory and was very confused. The treatment nurse said Resident #1 would be wander in and out of other residents' rooms. Observation on 10/19/13 at 5:10 p.m. of the therapy room revealed it to be unlocked and unattended. Interview on 10/21/13 at 2:00 p.m. the ADON and Director of Nurses (DON) were made aware of observation made by surveyor on 10/19/13. The DON acknowledged that was a problem. The DON said they were trying to find an alarm for that back door. Interview on 10/22/13 at 10:50 a.m. PTA D said she worked 10/19/13 and did not lock the therapy room door. PTA D said she did not lock it because she was in the facility. Interview on 11/14/13 at 10:40 a.m. Resident #2 said he remembered Resident #1 because he was his roommate. Resident #2 said he remembered the staff redirecting Resident #1 over and over. Resident #2 said they would bring Resident #1 into his room and then he would go right back out. Interview on 11/14/13 at 11:30 a.m. the Administrator acknowledged the issue with the therapy room door observed unlocked at several times. Review of Resident #1's physical therapy plan of care dated 09/24/13 indicated in part: Precautions: Fall risk secondary to balance and visual deficits. Review of Resident #1's nurses notes indicated in part: 09/23/13-- Patient arrived via family to facility. Able to see images only, has had 3 strokes in 3 months and lost sight. Wants to get up and wander thinks he is in jail wants family here. He is blind, he continues to wander, short term memory, ask same question over and over. Short term memory problems (unable to recall after 5 minutes.) Difficulty seeing: severely impaired/blind. 09/24/13-- Patient ambulating around room without supervision and very confused. Gait very unsteady and unbalance. Continues wandering to other resident rooms. Short term memory problems (unable to recall after 5 minutes.) Difficulty seeing: severely impaired/blind. Behavior problems: Wanders. 09/25/13-- Patient trying to exit the building on foot and with wheelchair, only patient blind sees shadows, tried to redirect numerous times. Difficulty seeing: severely impaired/blind. 09/26/13-- Patient alert with confusion, continuously wanders hall trying to go home, patient redirected several times. Patient continues to wander around room and disturb roommate. Observed resident walking without assistance out back door states he was going home, redirected to wheelchair. Attempted to go out therapy door, "I am looking for my wallet" agitation noted. Difficulty seeing: severely impaired/blind. 09/27/13-- Was called by therapy stated patient was outside went to door and patient was on road next to sidewalk with bystanders. Doctor here as asked patient why he went out patient said he was going to a party. Doctor told him if he did not want to be here he would have to refer him to a psych hospital, patient stated he did not want that. Memory problems. Difficulty seeing: severely impaired/blind. Behavior problems: Wanders. Difficulty seeing: severely impaired/blind. 09/28/13-- Patient repeatedly tries to ambulate without assistance. Patient tries to leave facility via door. When asked where patient is going he states getting out of here, I don't want to stay here. Memory problems, Short term. Difficulty seeing: severely impaired/blind. Behavior problems: Wanders. 09/29/13-- Patient continually got up all shift and tried getting up out of wheelchair without assistance. Patient constantly going in other patients room and asked not to and that he couldn't, at this point I asked why he was behaving this way and he said because he does not want to stay here and wants to go wrong. I then guided patient to his room and told him that this behavior is inappropriate and will not be tolerated I told him since he knew he is doing wrong he needs to act like an adult and stop breaking the rules. Difficulty seeing: severely impaired/blind. Behavior problems: Wanders. 09/30/13-- Patient ambulating in hallway wandering around going into other patients rooms, gait very unsteady and unbalance, several times resident stating he's looking for exit door. Patient was transferred to psych hospital at 6:45 p.m. Memory problems, Short term. Difficulty seeing: severely impaired/blind. Behavior problems: Wanders. Review of the facility's undated policy and procedures "elopement" indicated in part: To safely and timely redirect patients/residents to a safe environment. Review of the facility's policy and procedures "Wandering, unsafe resident" dated 12/2008 indicated in part: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for resident who are at risk for elopement. RESIDENT #3 Review of Resident #3's face sheet dated 3/18/13 documented she was admitted [DATE] and was [AGE] years old. Her [DIAGNOSES REDACTED]. Review of Resident #3's admission fall risk evaluation dated 2/06/13 scored the resident at 22. A score of 10 or greater deems the resident high risk for falls. Review of Resident #3's Activity of Daily Living (ADL) assessment dated [DATE] showed the resident required extensive assistance of one person with her bed mobility and transfers and extensive assist of two people for her toileting needs. Review of Resident #3's Care Plan dated 2/13/13 documented she had short and long term memory problems and had impaired mobility and was a fall risk. Review of the facility's incident/accident reports for Resident #3 documented she had at least five falls- 7/14/13, 9/16/13, 9/19/13, 10/04/13 and 10/07/13: Fall #1) Unwitnessed fall on 7/14/13 at 5:35 p.m.- "Patient fell in room by bed rail looks- to be down. Ambulating without walker to get water. She didn't hit her head. She fall on her buttocks. Said she was in no pain." The conclusion noted, "Patient has dementia and does not use call light. Ambulatory without walker to get water and fell . No injury. Alarm sounding and alerted staff." Fall #2) Unwitnessed fall on 9/16/13 at 9:00 a.m.- "Resident complained of left knee and hip pain. Stated she fell last night. Stated she got herself up and went to bed. Moves all extremities without difficulty. Neuros ok." The conclusion noted, "Already on therapy. Had several medication changes over the weekend. Resident reported she fell but unable to tell when, just said last night and that she got herself up and back to bed. Resident is very confused and disoriented. X-ray ordered." The X-rays of the left knee and hip showed no fracture. Fall #3) Unwitnessed fall on 9/19/13 at 5:00 p.m.- "Patient was found on her buttocks when med aide found her. Patient assessed. No complaints of pain. Patient helped back in the chair." There were no recommendations/interventions documented. Fall #4) Unwitnessed fall on 10/04/13 at 6:00 a.m. - "Resident states she fell last night; about 15 minutes ago. Asked resident how she got up. Resident said she layed there awhile then got up. Complained of pain to knees, right thigh, lower back. Quarter size red area noted to bilateral knees, small bruise to right outer thigh 2 inches long. No injuries noted to lower back. Denies hitting head. Neuros started. Doctor ordered X-rays right knee, left knee, right femur, lumbar section. This nurse asked nurse aide if alarm was on and she stated I thought it was. This nurse found bed alarm off." The X-ray results (from mobile X-ray service) came back negative for fracture. The recommendations/interventions restated the description of the fall but had no new or modified interventions initiated. Fall #5) Unwitnessed fall on 10/07/13 at 11:30 p.m. - "Resident ambulated self to restroom. While attempting to use restroom, resident stated that her legs gave out and she fell lightly to the ground landing on her bottom. Resident complained of mild pain to her bottom area. X-ray of back and coccyx ordered." There were no recommendations/interventions documented. The results of the X-rays were documented as negative for fracture. Nurse's note dated 10/11/13 documented, "In bed. Complains of pain from previous fall. Unable to feed self this morning. Lethargic, more confused. Very unsteady gait. Dr. ___ ordered to send to the ER." Review of hospital Catscan performed 10/12/13 revealed Resident #3 had a fracture of her back at L4 level. The report documented, "There is an acute or subacute compression fracture of L4 with anterior wedging." Review of the facility's investigation report dated 10/16/13 and signed by the administrator documented Resident #3 was sent to the local hospital on [DATE] due to being "lethargic and confused. The resident complained of soreness to lower back. She was unable to perform ADL's in usual manner." The Investigation Summary portion noted: "Resident #3 suffered a fall on 10/07/13. X-rays by Mobil X did not show any fracture or injuries. On 10/11/13 she went out in the morning lethargic. The hospital found there was a compression fracture on her L4 vertebra. Once facility learned of the injury they called the state to self report. The patient suffers mild osteoarthritis of the lumbar spine with a multilevel disc disease. According to Dr. ___ it is hard to determine when the fracture could have occurred, but more likely the fall of 10/07/13 could have initiated it. The X-rays on 10/08/13 show no fracture and according to Dr. ___the fracture could have occurred anytime between 10/08/13 and 10/11/13. It is hard to determine due to her osteoarthritis. It is unconfirmed on how the fracture could have occurred. The resident had a fall on 10/04/13 and X-rays were negative and a fall on 10/07/13 and X-rays were negative." The Provider Action Taken Post-Investigation dated 10/16/13 noted: "Resident has bed and chair alarms. Bed wheels were taken off. Staff were educated on fall prevention and bed alarm position. Meet with Dr. ___to discuss possible causes of compression fracture. He agreed that she is very frail and that fall could very likely be the cause of the injury.Attempted to provide emotional support to the resident's daughter but she said she did not want to talk." In an interview on 10/17/13 at 3:20 p.m., Resident #3's physician acknowledged the resident had several falls and the last one she complained of back pain. The physician said the facility sent her to the hospital because of a "change in condition that presented like a stroke." He added, "She did have an X-ray and it showed osteoporosis." In an interview on 10/18/13 at 9:25 a.m., the DON said (in relation to Resident #3), "She still has her moments where she is oriented but she is mainly confused." In an interview on 10/18/13 at 12 noon (in the resident's room), Resident #3 was eating a hamburger with her daughter. The resident was alert but confused. The resident had a full back brace on. She said, "My back's broke." The daughter said, "I have X-ray's for you to show my mother has a fractured back at L4; the facility tries to say it was not broken." In an interview on 10/22/13 at 11:30 a.m. the DON and regional nurse consultant were made aware of the concern with Resident #3. They were informed of the facility failure to have a consist system in place to ensure alarms were in proper working condition and turned on. The DON acknowledged the problem. Review of the list provided by the DON on 10/21/13 indicated there were 5 wandering and confused residents residing at the facility and 13 residents with some form of dementia that were a fall risk.

Based on observations, interviews, and record reviews, the facility failed to thoroughly investigate 2 incidents of possible neglect for 2 of 3 residents reviewed for accidents (Resident #1 and 4) and failed to report an incident of possible neglect (an un-witnessed injury of a cognitively impaired resident) for Resident #4 as evidenced by: a) failure to thoroughly investigate an incident that resulted in Resident #1's leg fracture that occurred on 12/26/10 at 4:00 a.m. when CNA A transferred Resident #1 from her bed to a chair manually (picked her up) instead of using a two-person Hoyer lift as was recommended in her care plan; and CNAs A and B further injured Resident #1 by attempting to re-position her when her foot was caught in the chair foot rest; and b) failure to thoroughly investigate cognitively impaired Resident #4's injury (head injury/ laceration) that occurred 1/7/11 at 2:45 a.m. These failures resulted in an Immediate Jeopardy which was identified on 1/7/11 at 12:00 p.m. While the Immediate Jeopardy was removed on 1/10/11, the facility remained out of compliance at a level of actual harm as they had not yet monitored or measured the effectiveness of their action plan. The failure to thoroughly investigate incidents and accidents resulting in injury to residents could result in the facility not identifying neglect and taking the appropriate actions to prevent similar future occurrences. Findings included: 1. A record review of a medical record face sheet dated 12/27/10 revealed that Resident #1 was an [AGE] year-old female admitted to the facility 7/28/08 with [DIAGNOSES REDACTED]. A record review of a care plan conference summary sheet for Resident #1 dated 12/21/10 also documented contractures to bilateral lower extremities and scoliosis. The summary stated Resident #1 weighed 133.4 pounds. The care plan included a problem that stated Resident #1 was dependent on staff to meet all ADL needs. The approaches for this problem included, "Use appropriate adaptive device as RX'd." Another problem included in her plan was, "Limited range of motion to bilateral lower extremitites and contractures to BLE." The approaches for this problem included, "2-person transfer with Hoyer." A record review of a hospital ER report, dated 12/26/10 at 12:35 p.m. revealed the report stated, "The patient complains of left upper leg, pt. has been paralyzed in lower extremities for some time, nursing home staff was moving her and her foot got caught, states that fractured her femur." The ER reported her pain was assessed as "8" (on scale of 1-10). The report also stated, "She somehow got her left foot caught while nurses were transferring her from bed. She sustained a distal left thigh deforming injury." The report documented, "Four views obtained to show the entire left femur from the hip to the knee in AP and lateral projections show a comminuted and displaced [MEDICAL CONDITION] femoral shaft and metaphysis. The major distal fragments are displaced posteromedially and angled posteriorly relative to the femoral shaft." Impression: "Comminuted (A fracture in which bone is broken, splintered or crushed into a number of pieces)and displaced (when two ends of the bone are separated from one another) [MEDICAL CONDITION] femoral shaft and metaphysis (the wider part at the end of a long bone)." A record review of the facility's incident/accident report dated 12/26/10 at 4:23 a.m. revealed LVN A documented, "This nurse was notified by resident's aid that the resident was in extreme pain. This nurse asked resident where pain was located and its rating on a scale of 0-10. Resident stated that her posterior L (left) knee was in extreme pain and rated it at a 10." Under the section, "Was initial treatment provided?", LVN A documented, "pain medication." LVN A documented physician notification at 5:40 a.m., and under "action", "X-rays." During an interview on 1/6/11 at 11:25 a.m., the DON stated he received a report on 12/26/10 that Resident #1 was complaining of significant pain, "more than usual" and he came to the facility at approximately 9:30 a.m that morning (12/26/10). He stated he talked to the resident and she did not know why her leg was hurting, because she had not been dropped, hit, or fell . He said the resident's roommate could not tell him anything either. He stated he talked to the charge nurse who told him that one CNA said another CNA hurt the resident's leg during a transfer. He stated the charge nurse said he did not notice anything unusual about the resident's leg when he did a head-to-toe assessment on the resident, but only that the resident had alot of pain. The DON said he talked to the CNA A and B and CNA B said CNA A transferred the resident by herself when she should have had two people for the transfer. The DON said, "But these aides did not get along." The DON said the nurse was an "agency" nurse (not a full time employee of the facility), but the nurse contacted the doctor and the family as he should have. When discussing whether he interviewed or assessed any other residents that CNA A provided care for, he stated he did not do that in the course of the investigation, but he talked to his residents all the time. He then stated he did "some resident interviews" but did not document them. He stated he terminated CNA A for transferring the resident alone, stating, "She knew better" as the transfer needs for this resident were documented on a "data sheet" at the nurse's station. The DON failed to gather or failed to disclose pertinent facts that were evident in interviews and record reviews and evidence he was provided during his investigation as described below. During a telephone interview on 1/7/11 at 8:55 a.m., CNA B said that CNA A was recently transferred to work with her on her hall, and on 12/26/10 they were working together. She said that she had told CNA A not to transfer Resident #1 without waiting for her (CNA B ) to do it with her. She stated CNA A had transferred Resident #1 alone the night before, and she had told CNA A and the charge nurse about it. She stated that she was in a room near Resident #1's when she heard Resident #1 screaming "She broke my leg! I heard it pop!" She stated the resident was moaning and crying in pain. CNA B stated it was about 4:00 a.m. after they had started rounds. CNA B said CNA A was in the resident's room when she arrived and Resident #1 had been transferred into a chair from the bed. She stated there was no equipment in the room (no Hoyer lift). CNA B said when she looked at Resident #1's leg, she could tell that her leg was broken. She stated her leg was deformed and in a position that it would never be normally. She stated "It was horrible. It's hard to describe, it was like her knee was dipped in and turned to the side. Her leg was bent upwards at the knee." CNA B said that LVN A came in and looked at the resident and then told the two CNAs to put the resident back to bed. CNA B stated she kept telling the nurse that the resident's leg was broken and why didn't he call 9-1-1. CNA B stated she followed the nurse's directions to transfer the resident back to bed, but she stated the resident was protesting in pain and that she became tearful at seeing the resident in so much pain. CNA B stated that the nurse just gave the resident a pain pill and let her lie there in pain. CNA B stated Resident #1 was moaning and crying the rest of the morning and was still crying when she left her shift at 6:00 a.m. CNA B stated she never saw the nurse fully assess Resident #1. She stated that LVN A refused to help transfer Resident #1 back to bed because he said he had back problems. She stated that he never asked for her help to remove the resident's clothing or help him with completing an assessment, stating LVN A always had CNAs help him with anything that involved manually moving a resident. CNA B stated she talked to the DON on two separate occasions and told him this information in great detail. A record review of documentation of the DON's interview with CNA B, dated 12/26/10 revealed it contained only the following information: "(CNA B) stated she was asked to go to resident's room to help move resident up in chair. She said she observed resident's leg looked unusual so she went to get the charge nurse. The charge nurse stated the leg didn't look unusual. He stated he was going to get the resident something for pain. (CNA B) stated she did not help (CNA A) transfer her so (CNA A) must have done it alone. (CNA B) stated she help transfer resident back to bed using the Hoyer lift." During an interview on 1/7/11 at 12:00 noon (with the DON and Administrator), the DON stated he did not include all of CNA B's information in his investigation documentation. He stated, "She kept telling me things she could not have possibly known and I told her to only tell me what she knew for a fact." The DON also stated he did not give credibility to CNA B because he knew that CNA B and CNA A did not get along. He stated he did not get a witness statement from CNA B. The Administrator stated the facility did not gather witness statements because the corporate policy was not to get witness statements. During an interview on 1/10/11 at 9:00 a.m., CNA A stated she was new to the hall where Resident #1 resided and was not very familiar with the resident's needs. She stated she worked that hall only three shifts prior to 12/26/10. She stated she saw Resident #1 on rounds at 1:00 p.m. Resident #1 was complaining of leg pain, so she told the nurse. CNA A stated that CNA B told her to get Resident #1 up a little after 4:00 a.m. and so she went to the resident's room alone and transferred her from her bed to her chair. She stated that she did not use the mechanical lift for Resident #1, but she had been told by a charge nurse that if you were strong enough to lift a resident without the lift, that you could choose not to use the mechanical lift. She stated she "cradled" Resident #1 in her arms by putting one arm behind her back, and one arm under her thighs and moved her to the chair. CNA A stated the transfer went smoothly and the resident did not voice any discomfort. CNA A stated that after Resident #1 was in her chair, she needed to re-position her but could not do so by herself, so she went to get CNA B. She stated CNA B came in to help her, and when they pulled the resident back in the seat of her chair, the resident's ankle caught in the raised foot rest of the chair, and the resident yelled, "My leg! My leg!" CNA A stated that is when CNA B went to get the nurse. CNA A stated LVN A did not ask her any details about what happened at the time of the incident. She stated she wrote what happened on a nurse's note. She stated LVN A told her to put the resident back to bed, and finish her rounds. CNA A stated that the DON called her and just asked her if she had anything to add to her witness statement. She stated he did not ask her any questions about her statement or mention any other information he had gathered. A record review of the DON's interview with CNA A, documented 12/26/10 revealed it included only the following: "(CNA A) stated she transferred resident alone. Stated she knew information about resident and how to transfer was in the flow books. She could not give a reason why she did not ask for assistance with the transfer." During an interview on 1/7/11 at 4:37 p.m., CNA C stated she was working the night shift 12/26/10 on an opposite hall of the facility (from CNAs A and B). CNA C stated that CNA B came to her hall very upset ("shook up") telling her that she should go look at Resident #1 because her leg was broken. CNA C stated she went into Resident #1's room, and Resident #1 was "hollering" in pain, but stated, "I really didn't know what I was supposed to be looking for." CNA C stated she could not really say how the resident's leg appeared. A record review of documentation of the DON's investigation revealed there was no statement or interview with CNA C. During an interview on 1/7/11 at 9:30 a.m., LVN A stated that he was the charge nurse on duty on 12/26/10 night shift. He stated he first became aware of Resident #1's injury when CNA B approached him and told him that Resident #1's leg was "messed up." LVN A stated he went in the room and Resident #1 was in her wheelchair. He stated he did not notice anything "you know, outstanding" about the resident When discussing his assessment of Resident #1's leg, he first stated, "I touched them and stuff." When asked if there was any other assessment of the resident, he stated he removed the resident's pants and stated he did not notice any bruising or deformity of the leg. When discussing his documentation, which did not include a visual description of the resident, LVN A stated, "I was confused in the whole situation." LVN A stated he called the physician and told him the resident was complaining of pain on the left side and movement caused her pain. When discussing whether he told the physician that Resident #1 said she heard the bone pop, LVN A then stated he told the physician that information also. LVN A stated that Resident #1 was comfortable after he medicated her and he left his shift. He stated the mobile X-ray had not arrived prior to his leaving his shift at 6:30 a.m. A record review of LVN A's nurse's note dated 12/26/10 at 4:25 a.m. revealed LVN A documented an aide came to him and told him another aide had moved the resident from her bed to the wheelchair by herself and the resident's leg looked "messed up." LVN A documented the resident told him her left leg was hurt when she was moved from the bed to the wheelchair. He documented the resident then stated that she "felt and heard a snap and grinding." LVN A documented he administered [MEDICATION NAME] 7.5/500 mg. (pain medication) to relieve some of the pain. LVN A documented he had the nurse's aides put the resident in a Hoyer lift and move her to bed. He then documented, "nurse proceeded to monitor the pain level of the resident." He documented the physician's instructions to give another [MEDICATION NAME] and "send to ER if no improvement" and an order for [REDACTED]. A record review of the DON's investigation report revealed an interview with LVN A that documented "LVN A stated CNA (CNA not identified by name) reported resident was up in wheelchair she thought the resident leg looked unusual. LVN A stated he initially did not observe a difference that the other leg with her pants on. Upon removing the pants he assessed pain but leg only appeared a little swollen but he palpated it lightly and could not feel any gross displacement. He called and reported to MD and administered pain medication which was effective." The DON's investigation and interview did not address the significant differences between CNA B's observation of the resident's condition (level of pain that was reported as severe and constant through the shift; and description of Resident #1's leg being "obviously" broken), her allegation that LVN A did not properly assess the resident, and LVN A' description of the resident and assertion that he did a thorough assessment of the resident. During a telephone interview on 1/7/11 at 4:25 p.m., the physician who was on-call for the resident's physician on 12/26/10 stated that he received the call from LVN A about Resident #1. He stated LVN A told him the resident may have fallen and was complaining of pain in her left leg. The physician stated LVN A did not tell him that Resident #1 was in excrutiating pain, did not describe any abnormality to the appearance of the resident's leg, and did not tell the physician that the resident stated she had heard the bone break. The physician stated if he had been told any of those things, he would have ordered the resident sent to the emergency room immediately, and would not have waited for mobile X-ray. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed the physician's information was not included (there was no interview with the physician.) During a telephone interview on 1/8/11 at 5:55 a.m., LVN B stated he was on duty with LVN A on 12/26/10 when Resident #1 was injured. LVN B stated he did not know anything about the incident. He said he was on another hall passing medications when the incident occurred and was "shocked" that LVN A did not come and get him and ask him for assistance or tell him what was going on. He said he first heard about the incident when it was time to get off work that morning and saw LVN A writing an incident report. LVN B stated, "I was busy that night." When discussing whether the facility interviewed him regarding the incident, he stated that no one asked him anything until yesterday, and the DON asked him questions about it when he came to the facility for training. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed LVN B was not interviewed regarding the incident. A record review of a nurse's note dated 12/26/10 at 12:27 p.m., completed by the day shift charge nurse, revealed the nurse documented that "When I arrived pt. was yelling out about her leg...30 min later pt. pain decreased and pt. was settled... Pt. began to vomiting x2..." The charge nurse documented that X-ray results were received and she first attempted to contact the physician at 9:20 a.m. with the results. She documented that she spoke to the physician at 10:50. The nurse documented the resident left in an ambulance at 11:40 a.m. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed this charge nurse was not interviewed regarding her observations of Resident #1 on 12/26/10. A record review of the facility's Investigation report of Post investigation action taken, signed by the administrator on 12/30/10, revealed that the facility terminated CNA A, in-serviced staff on their transfer policies(the DON stated in 1/6/10 interview that CNAs were reminded to check the data sheets at the nurse's station which tells them what kind of transfer a resident requires), and in-serviced staff to reinfoce reporting procedure for unusual incidents and accidents. The actions taken did not address any re-training for safe handling of residents, CNA B's possible actions that may have contributed to Resident #1's injuries (re-positioning the resident and getting her leg caught in the footrest of her chair), or LVN A's lack of thorough assessment and post injury care for Resident #1, which were identified following a thorough investigation of the incident. 2. A record review revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of a nurse's note dated 1/7/11 at 2:45 a.m. stated Resident #4 was found lying supine on the floor next to bed with blood surrounding her. The note stated, "Pt. is confused." The writer documented that the resident had a cut 1/2 inch to the front of her head at the hair line, and was sent to the emergency room . The nurse's not did not describe how the resident came to be on the floor (such as whether the resident fell , rolled from bed, or had an accident during a transfer). A record review of an incident/accident report for Resident #4 dated 1/7/11 at 2:45 a.m. revealed, "Pt. found lying supine (lying on her back) on floor next to bed with blood everywhere." The incident/accident report did not describe injuries or observations of the resident other than this statement. The incident/accident report documented the resident was sent to the emergency room . A record review of an attached "Falls Investigation Worksheet" documented the resident had a laceration to her forehead. The writer documented the resident was confused and the accident not witnessed. The "Fall Investigation Worksheet" contained no information regarding contact with witnesses and no documentation to suggest the investigation led to any conclusions about how the fall occurred. A record review of a second attachment to the incident report, titled, "Incident/Accident Action Plan" documented under "Conclusion/Summary": "Incident and chart reviewed. Resident has a new order for pin alarm while in wc and in bed at all times. In-service to charge nurse about documenting acute information following incident." The "Conclusion/Summary" contained no conclusion that indicated a determination was made about the cause of the resident's injuries. ADON A signed as the individual completing the investigation on 1/8/11. During an interview on 1/9/11 at 3:25 p.m., the DON stated that he and the ADONs were responsible to complete post-accident investigations in the facility. When discussing the investigation of Resident #4's injury on 1/7, the DON stated, "I visited with the resident on the 7th (1/7/11)." When discussing that there were no interviews or witness statements documented, the DON hesitated, and stated, "Because she fell ." When discussing whether the incident was reported to the state authority due to there being a significant injury to the resident and no witnesses, he stated, "No it wasn't an injury of unknown origin because she fell ." He stated he did not investigate to rule out neglect because the resident told him she fell . During an interview on 1/11/11 at 1:00 p.m. for which the DON was also present and observed, Resident #4 was observed to be confused and disoriented. Resident #4 rambled incoherently through most of the 20 minute interview, making statements that were irrelevant to simple questions. She was unable to verbally complete a sentence that made sense, and when asked to repeat what she had just said, Resident #4 would begin talking about something else. She was unable to correctly answer orientation questions aside from her name. Resident #4 giggled and mumbled when asked what she had just eaten for lunch. Resident #4 was asked several times and could not recall what she had eaten for lunch just prior to coming to the interview. On one attempt, Resident #4 stated, "ice." At one time in the interview Resident #4 pointed to her head and stated "I fell ." Resident #4 could not give any additional information about the incident or her care at the facility. During an interview on 1/10/11 at 10:55 a.m., ADON A stated she talked to the nurse and two CNAs on duty who were working together as her investigation but did not document the conversations or take any witness statements. She stated she learned from her discussions with them that the resident was laying on her back with the covers on top of her when she was found, so she concluded that the resident must have fallen from bed. She did not conclude how the resident sustained [REDACTED]." When discussing Resident #4, ADON A stated Resident #4 was too confused to recall any events or to be able to tell what happened to her. She did not attempt to verify the CNAs statements regarding the care and supervision of Resident #4 by talking with any other residents about care by the CNAs, the second LVN on duty the night of the incident, or the roommate or neighboring residents to determine if they heard or saw anything, or whether they had any information regarding the care and supervision on that shift. ADON A had no evidence that she completed these interviews prior to the investigator's request for them on 1/9/11. A record review of the facility's policy titled, "Abuse Implementation Program" dated January 2005, with the most recent revision date of June 2009 revealed it stated that an investigation included signed and dated witness statements from all staff on duty at the time the incident occurred. During an interview on 1/7/11 at 12:00 p.m., the Administrator was notified of an Immediate Jeopardy. The following Action Plan was accepted on 1/10/11 to remove the immediacy: 1. RNs and LVNs were re-educated regarding reporting of incidents, assessing residents for injury, the documentation of their assessments, reporting information to the attending physician and responsible party, and interviewing staff when an incident occurs. A competency based test was required to complete the education. The DON will monitor by review of incident reports. Completed 1/8/11. 2. All nursing staff have been re-educated regarding the policy and procedure for interviewing staff members to obtain information to assist in the investigation process. The DON will monitor to ensure this practice continues and will report to the performance improvement committee. Completed 1/8/11. 3. The Administrator and DON were re-educated by corporate staff to follow current policy and procedures regarding abuse and neglect investigations and reporting. In the event of a report of abuse or neglect, the administrator, who is the abuse prevention coordinator, will direct the investigation and perform a second interview with all key personnel involved in the incident and will add her interview witness statements to the completed investigation. If the statements provided conflicting information, the Administrator will make a report of the variance in statements and include with the completed investigation. The Administrator and DON participated in a competency evaluation by the corporate nurse, utilizing a mock scenario. Completed: 1/8/11 4. The incident regarding Resident #4's injury was reported to the the State Authority. Completed 1/10/11 by the Administrator. 5. Investigation of Resident #4's incident was completed and neglect not substantiated. Corrective measures to prevent future incidents for Resident #4 were implemented. Completed 1/10/11. 6. Nursing Policy and Procedures were made accessible to nursing staff through the computer in the facility lobby. Completed 1/10/11. The Action plan of removal of immediacy was verified on 1/10/11. All In-service documentation was reviewed and complete with staff signatures. Interviews were conducted with nursing staff to verify information received during in-services and to confirm the staff's understanding. The Administrator verified an intake number of the report made to the state authority of the incident 1/7/11 and the investigation of that incident and corrective measures verified through observation of the personal alarm in place for Resident #4. The immediacy was verified as removed and the IJ lifted on 1/10/11 at 4:30 p.m., but the facility remained out of compliance at a level of actual harm, because the facility had not yet monitored or evaluated the effectiveness of the Action Plan.

Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to thoroughly investigate 2 incidents of possible neglect for 2 of 3 residents reviewed for accidents (Resident #1 and 4) and failed to follow their policy and procedures to report an incident of possible neglect for Resident #4 as evidenced by: a) failure to thoroughly investigate an incident that resulted in Resident #1's leg fracture that occurred on 12/26/10 at 4:00 a.m. when CNA A transferred Resident #1 from her bed to a chair manually (picked her up) instead of using a two-person Hoyer lift as was recommended in her care plan; and CNAs A and B further injured Resident #1 by attempting to re-position her when her foot was caught in the chair foot rest; and b) failure to thoroughly investigate Resident #4's fall and [MEDICAL CONDITION] that occurred 1/7/11 at 2:45 a.m. These failures resulted in an Immediate Jeopardy which was identified on 1/7/11 at 12:00 p.m. While the Immediate Jeopardy was removed on 1/10/11, the facility remained out of compliance at a level of actual harm because the facility had not yet monitored to evaluate the effectiveness of the action plan. The failure to thoroughly investigate incidents and accidents resulting in injury to residents could result in the facility not identifying neglect and taking the appropriate actions to prevent similar future occurrences. This failure could affect any of the 88 residents of the facility. Findings included: 1) A record review of the facility's policy titled, "Abuse Implementation Program" dated January 2005, with the most recent revision date of June 2009 revealed it included the following: Under the subtitle "Investigation": "1. The licensed nurse or physician will immediately a) examine the patient and b) document the results on the accident/incident report form and in the patient clinical record. 2. The involved employee's supervisor will a) interview and obtain handwritten, signed and dated statements from the following: employees, patients, witnesses, all staff on unit at the time that the alleged incident occurred, patients who receive care from the alleged abuser, and the person making the abuse allegation. b) Document all interviews even if the individual claims to have no knowledge of the incident. c) Keep witnesses' statements confidential. Statements will not be given to or discussed with patients, responsible parties, or other employees. 3. The Administrator or designee will: a) Report conclusions of the investiation per state and local requirements; b) Notify the patient and responsible party of the investiation results... c) Analyze all occurrences to determine if changes to policies and procedures are needed to prevent further occurrences... 4. The Administrator, or designee will a) immediately suspend the employee until the investigation is completed... b) Reinstate the employee with back pay if the claim is unsubstantiated; c) Consult with Human Resources... d) Terminate the employee if substantiated... e) If substantiated the Administrator or designee must report to other officials in accordance with state laws within five working days of the incident... 2) A record review of policies and procedures revealed forms titled, "Facility Investigation, Policy and Procedure, Forms" which included the following forms: a. Form entitled, "Investigation Go-By". This form contained prompts to document the allegation, date of occurrence, report date, reported by, reported to, involved resident name(s), involved staff name(s), Interim findings and/or preliminary statements; action taken to date; notification to the State at what date and time; Name of DADS intake person; Comments; and a signature line for the Reporter/and their title. b. Form titled "Investigation". This form contained prompts to document the investigation begin date; under the direction of whom; the allegation; lodged by whom; the reporting route; whether an incident report was completed; involved resident(s) neames; involved staff name(s); physical assessment and the assessor's name; environmental findings and the reviewer's name; a chart review and the reviewer's name, staffing review for each shift; documentation of an interview with the attending physician and the date and time this was accomplished; an interview with the involved resident(s); Any additional residents interviewed with attached results; staff members interviewed with attached results; Personnel record reviews of staff members reviewed; A statement of the conclusion of the investigation; and a statement of the Action taken. c. Form titled "Resident Interview". This form contained the Name, room number, site of interview, and time and date of interview. The form prompted the writer to document the question asked and the answers given, with a section at the end of the form for comments/conclusions and the interviewers signature and title. d. Form titled, "Staff Interview Form." This form contained a section for the name of the staff, interview site, date and time of interview, and documentation of others attending the interview with a blank space for documenting the interview and a signature line for the interviewer. e. Form titled, "Staff member's statement." This form contained a space prompting the writer to print the name of the staff member at the top; a blank space for the written statement; a signature, date, and time space, and space for a witness to sign. 3) A record review of a medical record face sheet dated 12/27/10 revealed that Resident #1 was an [AGE] year-old female admitted to the facility 7/28/08 with [DIAGNOSES REDACTED]. A record review of a hospital ER report, dated 12/26/10 at 12:35 p.m. revealed the report stated that nursing home staff reported they were moving her and her foot got caught, states that fractured her femur. The ER reported her pain was assessed as "8" (on scale of 1-10). The report also stated, "She somehow got her left foot caught while nurses were transferring her from bed. She sustained a distal left thigh deforming injury." The report documented, "Four views obtained to show the entire left femur from the hip to the knee in AP and lateral projections show a comminuted and displaced [MEDICAL CONDITION] femoral shaft and metaphysis. The major distal fragments are displaced posteromedially and angled posteriorly relative to the femoral shaft." Impression: "Comminuted (A fracture in which bone is broken, splintered or crushed into a number of pieces)and displaced (when two ends of the bone are separated from one another) [MEDICAL CONDITION] femoral shaft and metaphysis (the wider part at the end of a long bone)." A record review of the facility's incident/accident report dated 12/26/10 at 4:23 a.m. revealed LVN A documented, "This nurse was notified by resident's aid (sic) that the resident was in extreme pain. This nurse asked resident where pain was located and its rating on a scale of 0-10. Resident stated that her posterior L (left) knee was in extreme pain and rated it at a 10." Under the section, "Was initial treatment provided?", LVN A documented, "pain medication." LVN A documented physician notification at 5:40 a.m., and under "action", "X-rays." During an interview on 1/6/11 at 11:25 a.m., the DON stated he received a report on 12/26/10 that Resident #1 was complaining of significant pain, "more than usual" and he came to the facility at approximately 9:30 a.m that morning (12/26/10). He stated he talked to the resident and she did not know why her leg was hurting, because she had not been dropped, hit, or fell . He said the resident's roommate could not tell him anything either. He stated he talked to the charge nurse who told him that one CNA said another CNA hurt the resident's leg during a transfer. He stated the charge nurse said he did not notice anything unusual about the resident's leg when he did a head-to-toe assessment on the resident, but only that the resident had alot of pain. The DON said he talked to CNA A and B and CNA B said CNA A transferred the resident by herself when she should have had two people for the transfer. The DON said, "But these aides did not get along." The DON said the nurse on duty that night was an "agency" nurse (not a full time employee of the facility), and he contacted the doctor and the family as he should have. When discussing whether he interviewed or assessed any other residents that CNA A for whom CNA A or B provided care, he stated he did not do that in the course of the investigation, but he talked to his residents all the time "and nobody's complained". He then stated he did "some" resident interviews but did not document them. He stated he terminated CNA A for transferring the resident alone, stating, "She knew better" as the transfer needs for this resident were documented on a "data sheet" at the nurse's station and she had admitted to him she knew about the data sheet. The DON failed to gather or failed to disclose pertinent facts that were evident in interviews and record reviews, and information that was offered to him by witnesses (CNAs A and B) as described below. During a telephone interview on 1/7/11 at 8:55 a.m., CNA B said that CNA A was recently transferred to work with her on her hall, and on 12/26/10 they were working together. She said that she had told CNA A not to transfer Resident #1 without waiting for her (CNA B) to do it with her. She stated CNA A had transferred Resident #1 alone the night before, and she had told CNA A and the charge nurse about it. She stated that she was in a room near Resident #1's when she heard Resident #1 screaming "She broke my leg! I heard it pop!" She stated the resident was moaning and crying in pain. CNA B stated it was about 4:00 a.m. after they had started rounds. CNA B said CNA A was in the resident's room when she arrived and Resident #1 had been transferred into a chair from the bed. She stated there was no equipment in the room (no Hoyer lift). CNA B said when she looked at Resident #1's leg, she could tell that her leg was broken. She stated her leg was deformed and in a position that it would never be normally. She stated "It was horrible. It's hard to describe, it was like her knee was dipped in and turned to the side. Her leg was bent upwards at the knee." CNA B said that LVN A came in and looked at the resident and then told the two CNAs to put the resident back to bed. CNA B stated she kept telling the nurse that the resident's leg was broken and why didn't he call 9-1-1. CNA B stated she followed the nurse's directions to transfer the resident back to bed, but she stated the resident was protesting in pain and that she became tearful at seeing the resident in so much pain. CNA B stated that the nurse just gave the resident a pain pill and let her lie there in pain for the rest of the shift. She stated that Resident #1's pain did not seem to get much better as Resident #1 was still crying when she left her shift at 6:00 a.m. CNA B stated she never saw the nurse fully assess Resident #1. She stated that LVN A refused to help transfer Resident #1 back to bed because he said he had back problems. She stated that he never asked for her help to remove the resident's clothing or help him with completing an assessment, stating LVN A always had CNAs help him with anything that involved manually moving a resident. CNA B stated she talked to the DON on two separate occasions and told him this information in great detail. A record review of documentation of the DON's interview with CNA B, dated 12/26/10 revealed it contained only the following information: "(CNA B) stated she was asked to go to resident's room to help move resident up in chair. She said she observed resident's leg looked unusual so she went to get the charge nurse. The charge nurse stated the leg didn't look unusual. He stated he was going to get the resident something for pain. (CNA B) stated she did not help (CNA A) transfer her so (CNA A) must have done it alone. (CNA B) stated she help transfer resident back to bed using the Hoyer lift." During an interview on 1/7/11 at 12:00 noon (with the DON and Administrator), the DON stated he did not include all of CNA B's information in his investigation documentation. He stated, "She kept telling me things she could not have possibly known and I told her to only tell me what she knew for a fact." The DON also stated he did not give credibility to CNA B because he knew that CNA B and CNA A did not get along. He stated he did not get a witness statement from CNA B. The Administrator stated the facility did not gather witness statements because the corporate policy was not to get witness statements. Record review revealed there was no written statement from CNA B, as stated in the facility's abuse and neglect and facility investigation policies, above. The facility investigation forms were not utilized. During an interview on 1/10/11 at 9:00 a.m., CNA A stated she was new to the hall where Resident #1 resided and was not very familiar with the resident's needs. She stated she worked that hall only three shifts prior to 12/26/10. She stated she saw Resident #1 on rounds at 1:00 p.m. Resident #1 was complaining of leg pain, so she told the nurse. CNA A stated that CNA B told her to get Resident #1 up a little after 4:00 a.m. and so she went to the resident's room alone and transferred her from her bed to her chair. She stated that she did not use the mechanical lift for Resident #1, but she had been told by a charge nurse that if you were strong enough to lift a resident without the lift, that you could choose not to use the mechanical lift. She stated she "cradled" Resident #1 in her arms by putting one arm behind her back, and one arm under her thighs and moved her to the chair. CNA A stated the transfer went smoothly and the resident did not voice any discomfort. CNA A stated that after Resident #1 was in her chair, she needed to re-position her but could not do so by herself, so she went to get CNA B. She stated CNA B came in to help her, and when they pulled the resident back in the seat of her chair, the resident's ankle caught in the raised foot rest of the chair, and the resident yelled, "My leg! My leg!" CNA A stated that is when CNA B went to get the nurse. CNA A stated LVN A did not ask her any details about what happened at the time of the incident. She stated she wrote what happened on a nurse's note. She stated LVN A told her to put the resident back to bed, and finish her rounds. CNA A stated that the DON called her and just asked her if she had anything to add to her witness statement. She stated he did not ask her any questions about her statement or mention any other information he had gathered. A record review of the DON's interview with CNA A, documented 12/26/10 revealed it included only the following: "(CNA A) stated she transferred resident alone. Stated she knew information about resident and how to transfer was in the flow books. She could not give a reason why she did not ask for assistance with the transfer." During an interview on 1/7/11 at 4:37 p.m., CNA C stated she was working the night shift 12/26/10 on an opposite hall of the facility (from CNAs A and B). CNA C stated that CNA B came to her hall very upset ("shook up") telling her that she should go look at Resident #1 because her leg was broken. CNA C stated she went into Resident #1's room, and Resident #1 was "hollering" in pain, but stated, "I really didn't know what I was supposed to be looking for." CNA C stated she could not really say how the resident's leg appeared. A record review of documentation of the DON's investigation revealed there was no statement from, or interview with CNA C. During an interview on 1/7/11 at 9:30 a.m., LVN A stated that he was the charge nurse on duty on 12/26/10 night shift. He stated he first became aware of Resident #1's injury when CNA B approached him and told him that Resident #1's leg was "messed up." LVN A stated he went in the room and Resident #1 was in her wheelchair. He stated he did not notice anything "you know, outstanding" about the resident When discussing his assessment of Resident #1's leg, he first stated, "I touched them and stuff." When asked if there was any other assessment of the resident, he stated he removed the resident's pants and stated he did not notice any bruising or deformity of the leg. When discussing his documentation, which did not include a visual description of the resident, LVN A stated, "I was confused in the whole situation." LVN A stated he called the physician and told him the resident was complaining of pain on the left side and movement caused her pain. When discussing whether he told the physician that Resident #1 said she heard the bone pop, LVN A then stated he told the physician that information also. LVN A stated that Resident #1 was comfortable after he medicated her and he left his shift. He stated the mobile X-ray had not arrived prior to his leaving his shift at 6:30 a.m. A record review of LVN A's nurse's note dated 12/26/10 at 4:25 a.m. revealed LVN A documented an aide came to him and told him another aide had moved the resident from her bed to the wheelchair by herself and the resident's leg looked "messed up." LVN A documented the resident told him her left leg was hurt when she was moved from the bed to the wheelchair. He documented the resident then stated that she "felt and heard a snap and grinding." LVN A documented he administered [MEDICATION NAME] 7.5/500 mg. (pain medication) to relieve some of the pain. LVN A documented he had the nurse's aides put the resident in a Hoyer lift and move her to bed. He then documented, "nurse proceeded to monitor the pain level of the resident." He documented the physician's instructions to give another [MEDICATION NAME] and "send to ER if no improvement" and an order for [REDACTED]. A record review of the DON's investigation report revealed an interview with LVN A that documented only the following: "LVN A stated CNA (CNA not identified by name) reported resident was up in wheelchair she thought the resident leg looked unusual. LVN A stated he initially did not observe a difference that the other leg with her pants on. Upon removing the pants he assessed pain but leg only appeared a little swollen but he palpated it lightly and could not feel any gross displacement. He called and reported to MD and administered pain medication which was effective." (The DON's investigation and interview did not address the significant differences between CNA B's observation of the resident's level of pain and description of her leg, her allegation that LVN A did not properly assess the resident, and LVN A' description of the resident and assertion that he did a thorough assessment of the resident.) A review of the facility's investigation 12/26/10 through 12/27/10 revealed the facility did not obtain a written witness statment from LVN A as per the facility policy. During a telephone interview on 1/7/11 at 4:25 p.m., the physician who was on-call for the resident's physician on 12/26/10 stated that he received the call from LVN A about Resident #1. He stated LVN A told him the resident may have fallen and was complaining of pain in her left leg. The physician stated LVN A did not tell him that Resident #1 was in excruciating or severe pain, did not describe any abnormality to the appearance of the resident's leg, did not inform him that Resident #1 said she was hurt during a transfer, and did not tell the physician that the resident stated she had heard the bone break. The physician stated if he had been told any of those things, he would have ordered the resident sent to the emergency room immediately, and would not have waited for mobile X-ray. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed the physician's information was not included (there was no interview with the physician) as instructed in the facility's policy above. During a telephone interview on 1/8/11 at 5:55 a.m., LVN B stated he was on duty with LVN A on 12/26/10 when Resident #1 was injured. LVN B stated he did not know anything about the incident. He said he was on another hall passing medications when the incident occurred and was "shocked" that LVN A did not come and get him and ask him for assistance or tell him what was going on. He said he first heard about the incident when it was time to get off work that morning and saw LVN A writing an incident report. LVN B stated, "I was busy that night." When discussing whether the facility interviewed him regarding the incident, he stated that no one asked him anything until yesterday, and the DON asked him questions about it when he came to the facility for training. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed LVN B was not interviewed regarding the incident. A record review of a nurse's note dated 12/26/10 at 12:27 p.m., completed by the day shift charge nurse, revealed the nurse documented that "When I arrived pt. was yelling out about her leg...30 min later pt. pain decreased and pt. was settled... Pt. began to vomiting x2..." The charge nurse documented that X-ray results were received and she first attempted to contact the physician at 9:20 a.m. with the results. She documented that she spoke to the physician at 10:50. The nurse documented the resident left in an ambulance at 11:40 a.m. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed this charge nurse was not interviewed regarding her observations of Resident #1 on 12/26/10. A record review of the facility's investigation of Resident #1's incident on 12/26/10 in its entirety revealed it did not include interviews and/or handwritten statements from all potential employee witnesses (including LVN B and CNA C), or other residents for whom CNA A and B provided care; and the investigation report did not accurately document all pertinent information offered by witnesses, as described above. It was noted the investigator (DON) did not use the facility's forms that prompted the investigator to obtain this information. A record review of the facility's Investigation report of Post investigation action taken, signed by the administrator on 12/30/10, revealed that the facility terminated CNA A, in-serviced staff on their transfer policies(the DON stated in 1/6/10 interview that CNAs were reminded to check the data sheets at the nurse's station which tells them what kind of transfer a resident requires), and in-serviced staff to reinforce reporting procedure for unusual incidents and accidents. The actions taken did not address any corrective actions for re-training staff to ensure safe handling of residents, CNA B's possible actions that may have contributed to Resident #1's injuries (re-positioning the resident while her leg was caught in the raised foot rest of her chair), or LVN A's lack of thorough assessment and post injury care for Resident #1. 4. A record review revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of a nurse's note dated 1/7/11 at 2:45 a.m. stated Resident #4 was found lying supine on the floor next to bed with blood surrounding her. The note stated, "Pt. is confused." The writer documented that the resident had a cut 1/2 inch to the front of her head at the hair line, and was sent to the emergency room . The nurse's not did not describe how the resident came to be on the floor (such as whether the resident fell , rolled from bed, or had an accident during a transfer). A record review of an incident/accident report for Resident #4 dated 1/7/11 at 2:45 a.m. revealed, "Pt. found lying supine (lying on her back) on floor next to bed with blood everywhere." The incident/accident report did not describe injuries or observations of the resident other than this statement. The incident/accident report documented the resident was sent to the emergency room . A record review of an attached "Falls Investigation Worksheet" documented the resident had a laceration to her forehead. The writer documented the resident was confused and the accident not witnessed. The "Fall Investigation Worksheet" contained no information regarding contact with witnesses and no documentation to suggest the investigation led to any conclusions about how the fall occurred. A record review of a second attachment to the incident report, titled, "Incident/Accident Action Plan" documented under "Conclusion/Summary": "Incident and chart reviewed. Resident has a new order for pin alarm while in wc and in bed at all times. In-service to charge nurse about documenting acute information following incident." The "Conclusion/Summary" contained no conclusion that indicated a determination was made about the cause of the resident's injuries. ADON A signed as the individual completing the investigation on 1/8/11. During an interview on 1/9/11 at 3:25 p.m., the DON stated that he and the ADONs were responsible to complete post-accident investigations in the facility. When discussing the investigation of Resident #4's injury on 1/7, the DON stated, "I visited with the resident on the 7th (1/7/11)." When discussing that there were no interviews or witness statements documented, the DON hesitated, and stated, "Because she fell ." When discussing whether the incident was reported to the state authority due to there being a significant injury to the resident and no witnesses, he stated, "No it wasn't an injury of unknown origin because she fell ." He stated he did not investigate to rule out neglect because the resident told him she fell . During an interview on 1/11/11 at 1:00 p.m. for which the DON was also present and observed, Resident #4 was observed to be confused and disoriented. Resident #4 rambled incoherently through most of the 20 minute interview, making statements that were irrelevant to simple questions. She was unable to correctly answer orientation questions aside from her name. Resident #4 giggled and mumbled when asked what she had just eaten for lunch. Resident #4 was asked several times and could not recall what she had eaten for lunch just prior to coming to the interview. At one time in the interview Resident #4 pointed to her head and stated "I fell ." Resident #4 could not give any additional information about the incident or her care at the facility. During an interview on 1/10/11 at 10:55 a.m., ADON A stated she talked to the nurse and two CNAs on duty who were working together as her investigation but did not document the conversations or take any witness statements. She stated she learned from her discussions with them that the resident was laying on her back with the covers on top of her when she was found, so she concluded that the resident must have fallen from bed. She did not conclude how the resident sustained [REDACTED]." When discussing Resident #4, ADON A stated Resident #4 was too confused to recall any events or to be able to tell what happened to her. She did not attempt to verify the CNAs statements regarding the care and supervision of Resident #4 by talking with any other residents about care by the CNAs, the second LVN on duty the night of the incident, or the roommate or neighboring residents to determine if they heard or saw anything, or whether they had any information regarding the care and supervision on that shift. During an interview on 1/7/11 at 12:00 p.m., the Administrator was notified of an Immediate Jeopardy. The following Action Plan was accepted on 1/10/11 to remove the immediacy: 1. RNs and LVNs were re-educated regarding reporting of incidents, assessing residents for injury, the documentation of their assessments, reporting information to the attending physician and responsible party, and interviewing staff when an incident occurs. A competency based test was required to complete the education. The DON will monitor by review of incident reports. Completed 1/8/11. 2. All nursing staff have been re-educated regarding the policy and procedure for interviewing staff members to obtain information to assist in the investigation process. The DON will monitor to ensure this practice continues and will report to the performance improvement committee. Completed 1/8/11. 3. The Administrator and DON were re-educated by corporate staff to follow current policy and procedures regarding abuse and neglect investigations and reporting. In the event of a report of abuse or neglect, the administrator, who is the abuse prevention coordinator, will direct the investigation and perform a second interview with all key personnel involved in the incident and will add her interview witness statements to the completed investigation. If the statements provided conflicting information, the Administrator will make a report of the variance in statements and include with the completed investigation. The Administrator and DON participated in a competency evaluation by the corporate nurse, utilizing a mock scenario. Completed: 1/8/11 4. Investigation of Resident #4's incident was completed and neglect not substantiated. Corrective measures to prevent future incidents for Resident #4 were implemented. Completed 1/10/11. 5. Nursing Policy and Procedures were made accessible to nursing staff through the computer in the facility lobby. Completed 1/10/11. The Action plan of removal of immediacy was verified on 1/10/11. All In-service documentation was reviewed and complete with staff signatures. Interviews were conducted with nursing staff to verify information received during in-services and to confirm the staff's understanding. The Administrator verified an intake number of the report made to the state authority of the incident 1/7/11 and the investigation of that incident verified. The immediacy was verified as removed and the IJ lifted on 1/10/11 at 4:30 p.m., but the facility remained out of compliance at a level of actual harm, because the facility had not yet monitored or evaluated the effectiveness of the Action Plan.

Based on interviews and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for accidents (Resident #1) as evidenced by: a) failure of LVN A (a contracted agency nurse) to appropriately assess, provide emergency treatment, and document assessment and treatment according to facility policies for Resident #1's fracture on 12/26/10; and b) failure of LVN A to communicate accurate assessment information, including Resident #1's pain level, an accurate physical description of the injury (that Resident #1's leg was in an abnormal position), and the resident's report of hearing her bone break, to the physician when Resident #1 sustained a leg fracture on 12/26/10. This failure resulted in a delay in medical treatment and sustained pain for the resident. Resident #1 sustained a fractured leg at 4:00 a.m. and did not receive treatment (physician assessment, immobilization and increased pain management) at the hospital until 12:35 p.m. (8.5 hours after her leg was fractured). These failures resulted in an Immediate Jeopardy which was identified on 1/7/11 at 12:00 p.m. While the Immediate Jeopardy was removed on 1/10/11, the facility remained out of compliance at a level of actual harm because the facility had not yet monitored to evaluate the effectiveness of the action plan. These failures could result in 88 residents not receiving emergency medical care when warranted. Findings included: 1) A record review of a medical record face sheet dated 12/27/10 revealed that Resident #1 was an [AGE] year-old female admitted to the facility 7/28/08 with [DIAGNOSES REDACTED]. A record review of a care plan conference summary sheet for Resident #1 dated 12/21/10 also documented contractures to bilateral lower extremities and scoliosis. The care plan included a problem that stated Resident #1 was dependent on staff to meet all ADL needs. Resident #1's plan also documented, "Limited range of motion to bilateral lower extremitites and contractures to BLE." The approaches for this problem included, "2-person transfer with Hoyer." A record review of a hospital ER report, dated 12/26/10 at 12:35 p.m. revealed the report stated, "The patient complains of left upper leg, pt. has been paralyzed in lower extremities for some time, nursing home staff was moving her and her foot got caught, states that fractured her femur." The ER reported her pain was assessed as "8" (on scale of 1-10). The report also stated, "She somehow got her left foot caught while nurses were transferring her from bed. She sustained a distal left thigh deforming injury." The report documented, "Four views obtained to show the entire left femur from the hip to the knee in AP and lateral projections show a comminuted and displaced [MEDICAL CONDITION] femoral shaft and metaphysis. The major distal fragments are displaced posteromedially and angled posteriorly relative to the femoral shaft." Impression: "Comminuted (A fracture in which bone is broken, splintered or crushed into a number of pieces)and displaced (when two ends of the bone are separated from one another) [MEDICAL CONDITION] femoral shaft and metaphysis (the wider part at the end of a long bone)." A record review of the facility's incident/accident report dated 12/26/10 at 4:23 a.m. revealed LVN A documented, "This nurse was notified by resident's aid (sic) that the resident was in extreme pain. This nurse asked resident where pain was located and its rating on a scale of 0-10. Resident stated that her posterior L (left) knee was in extreme pain and rated it at a 10." Under the section, "Was initial treatment provided?", LVN A documented, "pain medication." LVN A documented physician notification at 5:40 a.m., and under "action", "X-rays." During an interview on 1/6/11 at 11:25 a.m., the DON stated he received a report on 12/26/10 that Resident #1 was complaining of significant pain, "more than usual" and he came to the facility at approximately 9:30 a.m that morning (12/26/10). He stated he talked to the resident and she did not know why her leg was hurting, because she had not been dropped, hit, or had not fallen. He said the resident's roommate could not tell him anything either. He stated he talked to the charge nurse who told him that one CNA said another CNA hurt the resident's leg during a transfer. He stated the charge nurse said he did not notice anything unusual about the resident's leg when he did a head-to-toe assessment on the resident, but only that the resident had alot of pain. The DON said he talked to CNAs A and B and CNA B said CNA A transferred the resident by herself when she should have had two people for the transfer. The DON said, "But these aides did not get along." The DON said the nurse was an "agency" nurse (not a full time employee of the facility), but the nurse contacted the doctor and the family as he should have. During a telephone interview on 1/7/11 at 8:55 a.m., CNA B said that CNA A had transferred Resident #1 without a Hoyer lift and injured the resident. She stated that she was in a room near Resident #1's when she heard Resident #1 screaming "She broke my leg! I heard it pop!" She stated the resident was moaning and crying in pain. CNA B stated it was about 4:00 a.m. after they had started rounds. CNA B said CNA A was in the resident's room when she arrived and Resident #1 had been transferred into a chair from the bed. She stated there was no equipment in the room (no Hoyer lift). CNA B said when she looked at Resident #1's leg, she could tell that her leg was broken. She stated her leg was deformed and in a position that it would never be normally. She stated "It was horrible. It's hard to describe, it was like her knee was dipped in and turned to the side. Her leg was bent upwards at the knee." CNA B said that LVN A came in and looked at the resident and then told the two CNAs to put the resident back to bed. CNA B stated she kept telling the nurse that the resident's leg was broken and why didn't he call 9-1-1. She stated that she did not think the resident should have been moved at all, but she followed the nurse's directions to transfer the resident back to bed. She stated the resident was protesting in pain and that she became tearful at seeing the resident in so much pain. CNA B stated that the nurse just gave the resident a pain pill and let her lie there in pain. CNA B stated Resident #1 was moaning and crying the rest of the morning and was still crying when she left her shift at 6:00 a.m. CNA B stated she never saw the nurse fully assess Resident #1. She stated that LVN A refused to help transfer Resident #1 back to bed because he said he had back problems. She stated that he never asked for her help to remove the resident's clothing or help him with completing an assessment, stating LVN A always had CNAs help him with anything that involved manually moving a resident. CNA B stated she talked to the DON on two separate occasions since the incident and told him this information in great detail. A record review of documentation of the DON's interview with CNA B, dated 12/26/10 revealed it described CNA B's comments about CNA A's transfer of the resident, but did not include concerns expressed about LVN A's care of the resident. During an interview on 1/7/11 at 12:00 noon (with the DON and Administrator), the DON stated he did not include all of CNA B's information in his documentation. He stated, "She kept telling me things she could not have possibly known and I told her to only tell me what she knew for a fact." The DON also stated he did not consider CNA B very credible. During an interview on 1/10/11 at 9:00 a.m., CNA A stated she did not use the mechanical lift for Resident #1, but she had "cradled" Resident #1 in her arms by putting one arm behind her back, and one arm under her thighs and moved her to the chair. CNA A stated the transfer went smoothly and the resident did not voice any discomfort. CNA A stated that after Resident #1 was in her chair, she needed to re-position her but could not do so by herself, so she went to get CNA B. She stated CNA B came in to help her, and when they pulled the resident back in the seat of her chair, the resident's ankle caught in the raised foot rest of the chair, and the resident yelled, "My leg! My leg!" CNA A stated that is when CNA B went to get the nurse. CNA A also stated that the resident said that her leg was injured when she was put to bed the night before. CNA A stated LVN A did not ask her any details about what happened at the time of the incident. She stated LVN A told her to put the resident back to bed, and finish her rounds. CNA A said that after the resident was put to bed, she pulled Resident #1's pants down so LVN A could look at the resident's leg. She said Resident #1's leg looked very unusual from above the knee to the calf. She stated the deformity was obvious. CNA A stated that LVN A seemed "completely uncomfortable... completely!" during the management of the incident. During an interview on 1/7/11 at 9:30 a.m., LVN A stated that he was the charge nurse on duty on 12/26/10 night shift. He stated he first became aware of Resident #1's injury when CNA B approached him and told him that Resident #1's leg was "messed up." LVN A stated he went in the room and Resident #1 was in her wheelchair. He stated he did not notice anything "you know, outstanding" about the resident When discussing his assessment of Resident #1's leg, he first stated, "I touched them and stuff." When asked if there was any other assessment of the resident, he stated he removed the resident's pants and stated he did not notice any bruising or deformity of the leg. When discussing his documentation, which did not include a visual description of the resident, LVN A stated, "I was confused in the whole situation." LVN A stated he called the physician and told him the resident was complaining of pain on the left side and movement caused her pain. When discussing whether he told the physician that Resident #1 said she heard the bone pop, LVN A then stated he told the physician that information also. LVN A stated that Resident #1 was comfortable after he medicated her and he left his shift. He stated the mobile X-ray had not arrived prior to his leaving his shift at 6:30 a.m. A record review of LVN A's nurse's note dated 12/26/10 at 4:25 a.m. revealed LVN A documented an aide came to him and told him another aide had moved the resident from her bed to the wheelchair by herself and the resident's leg looked "messed up." LVN A documented the resident told him her left leg was hurt when she was moved from the bed to the wheelchair. He documented the resident then stated that she "felt and heard a snap and grinding." LVN A documented he administered [MEDICATION NAME] 7.5/500 mg. (pain medication) to relieve some of the pain. LVN A documented he had the nurse's aides put the resident in a Hoyer lift and move her to bed. He then documented, "nurse proceeded to monitor the pain level of the resident." He documented the physician's instructions to give another [MEDICATION NAME] and "send to ER if no improvement" and an order for [REDACTED]. LVN A's nurse's note at 4:25 a.m. stated, "This nurse then followed up with the resident about the effectiveness of the prescribed pain med. Resident stated that it was helping but still in alot of pain. This nurse recommended to the aids involved to write a statement of this event." LVN A did not document (in his nurse's note) any observations of Resident #1's affected limb, or assessment of her over-all condition, such as peripheral pulses, monitoring of vital signs, or immobilization of the affected limb. LVN A did not document rating of the resident's pain level after the initial assessment (when it was at a "10" on a scale of 1-10) to accurately describe her pain and measure effectiveness of medication. A record review of the DON's investigation report revealed an interview with LVN A that documented "LVN A stated CNA (CNA not identified by name) reported resident was up in wheelchair she thought the resident leg looked unusual. LVN A stated he initially did not observe a difference that the other leg with her pants on. Upon removing the pants he assessed pain but leg only appeared a little swollen but he palpated it lightly and could not feel any gross displacement. He called and reported to MD and administered pain medication which was effective." During a telephone interview on 1/7/11 at 4:25 p.m., the physician who was on-call for the resident's physician on 12/26/10 stated that he received the call from LVN A about Resident #1. He stated LVN A told him the resident may have fallen and was complaining of pain in her left leg. The physician stated LVN A did not tell him that Resident #1 was in extreme pain, did not describe any abnormality to the appearance of the resident's leg, and did not tell the physician that the resident stated she had heard the bone break. The physician stated if he had been told any of those things, he would have ordered the resident sent to the emergency room immediately, and would not have waited for mobile X-ray. During a telephone interview on 1/8/11 at 5:55 a.m., LVN B stated he was on duty with LVN A on 12/26/10 when Resident #1 was injured. LVN B stated he did not know anything about the incident. He said he was on another hall passing medications when the incident occurred and was "shocked" that LVN A did not come and get him and ask him for assistance or tell him what was going on. He said he first heard about the incident when it was time to get off work that morning and saw LVN A writing an incident report. LVN B stated, "I was busy that night." A record review of a nurse's note dated 12/26/10 at 12:27 p.m., completed by the day shift charge nurse, revealed the nurse documented that "When I arrived pt. was yelling out about her leg...30 min later pt. pain decreased and pt. was settled... Pt. began to vomiting x2..." The charge nurse documented that X-ray results were received and she first attempted to contact the physician at 9:20 a.m. with the results. She documented that she spoke to the physician at 10:50. The nurse documented the resident left in an ambulance at 11:40 a.m. A record review of the facility's Investigation report of Post investigation action taken regarding Resident #1's injury and care signed by the administrator on 12/30/10, revealed the facility did not identify or address any concerns related to LVN A's post-injury care for Resident #1. The facility's action was only to terminate CNA A and in-service staff regarding transfer policies and reporting policies. During an interview on 1/9/11 at 9:05 a.m., the DON stated that the facility used two separate contract agencies to provide staff when the facility did not have enough staff. He stated LVN A was an agency nurse and the shift on 12/26/10 was only LVN A's second or third shift at the facility. When discussing how agency staff received orientation to residents' needs and facility policies and procedures, the DON stated there was no process for that. He stated that the agency nurse could ask the other nurse on duty or call him at home if they had questions. During an observation and interview on 1/9/11 at 9:45 a.m., all of the facility's policy and procedures were observed to be on the computer, accessible from the DON's office. The DON stated there was not a hard copy of the nursing policies and procedures in the building and they were not accessible to charge nurses on the floor when he was not in the building. The DON stated, "They can call me at home if they have a question." 2) A record review of an undated facility policy and procedure titled, "Emergency Treatment-Fractures" revealed it contained the following: "1. Give immediate attention to the patient's overall condition and treat accordingly... 2. Evaluate the fractured parts. 3. Assess for signs and symptoms that may indicate injury to the blood supply: a. coolness b. blanching c. decreased sensation and motor function d. weak or absent pulse. 4. Assess all peripheral pulses 5. Handle the injured part as gently and as little as possible. 6. Before moving the patient, apply the splint 7. The fracture site and the joint above and below are immobilized 8. If the limb is in an abnormal position, it is splinted in that position. 16. For fracture of legs: a. Apply splint from hip to ankle 22. Stay with the patient until ambulance arrives and ready patient for transfer to hospital. 23. Chart in detail all observations and treatments." 3) A record review of an undated facility policy and procedure titled, "Emergency Treatment-Falls First Aid" revealed it included the following: "If resident has painful areas, bumps, limbs in unnatural position, permit them to stay on the floor. Do not move or leave an injured person..." 4) During an interview on 1/7/11 at 12:00 p.m., the Administrator was notified of an Immediate Jeopardy. 5) The following Action Plan was accepted on 1/10/11 to remove the immediacy: -RNs and LVNs were re-educated regarding the importance of following up on information provided them regarding care and/or change of resident condition. Completed 1/9/11. -LVN A will no longer be allowed to work at the facility. Agency contacted 1/7/11. -Any future use of Agency staff will require a facility orientation by facility staff prior to start of the contracted shift and will include assessment, documentation, and notification. Implemented 1/9/11. -The DON or designee will monitor to ensure reports of resident changes of condition are assessed, documented, and reported. The Performance Improvement Committee will receive a report weekly during the next quarter. Management Staff will review the 24-hour reports for changes of condition and will discuss them in the daily clinical meeting. Implemented 1/9/11. -Nursing Policies and Procedures were made accessible to nursing staff through the lobby staff computer. Completed 1/10/11. The implementation of the action plan was verified through interviews with nursing staff and record reviews of completed in-services. The immediacy was removed and the IJ lifted on 1/10/11 at 4:30 p.m., but the facility remained out of compliance at a level of actual harm, because the facility had not yet monitored or evaluated the effectiveness of the Action Plan.

Based on observations, interviews, and record reviews, the facility failed to ensure that 2 of 8 residents reviewed for falls and accidents (Residents #1 and 4) received adequate supervision and assistance devices to prevent accidents evidenced by: a) failure to ensure adequate supervision and the use of assistance devices for Resident #1. Resident #1 sustained a leg fracture when CNA B transferred her manually instead of using a Hoyer lift as prescribed in the resident's plan of care and after CNA A and CNA B got the resident's leg caught in the raised foot rest of her wheelchair when they were re-positioning her; b) failure to intervene after CNA B reported an inappropriate transfer of Resident #1 by CNA A (transferring her manually instead of with a Hoyer lift) on 12/25/10; c) failure to implement fall prevention measures for Resident #4, who was cognitively impaired and at risk for falls. Resident #4's pin alarm was discontinued in October 2010 with no valid clinical justification. Resident #4 fell again on 11/17/10; d) failure to determine factors that contributed to the un-witnessed fall for Resident #4 on 11/17/10 or implement preventive measures following the fall. Resident #4 fell again on 1/7/11 and sustained a concussion and laceration to her forehead; and e) failure to implement the pin alarm ordered by the physician for Resident #4 on 1/7/11 after her fall and injury on 1/7/11. The facility did not implement the alarm until 1/9/11 when brought the their attention by the investigator. These failures resulted in an Immediate Jeopardy which was identified on 1/7/11 at 12:00 p.m. While the Immediate Jeopardy was removed on 1/10/11, the facility remained out of compliance at a level of actual harm because the facility had not yet monitored the effectiveness of their action plan. The failure to determine factors that contribute to accidents and falls and failure to implement preventive measures to prevent falls could result in accidents and injuries that result in significant decline in mobility and independence, or even death, for any of the 58 residents identified as being at high risk for falls. Findings included: 1. A record review of a medical record face sheet dated 12/27/10 revealed that Resident #1 was an [AGE] year-old female admitted to the facility 7/28/08 with [DIAGNOSES REDACTED]. A record review of a care plan conference summary sheet for Resident #1 dated 12/21/10 also documented contractures to bilateral lower extremities and scoliosis. The summary stated Resident #1 weighed 133.4 pounds. The care plan included a problem that stated Resident #1 was dependent on staff to meet all ADL needs. The approaches for this problem included, "Use appropriate adaptive device as RX'd." Another problem included in her plan was, "Limited range of motion to bilateral lower extremitites and contractures to BLE." The approaches for this problem included, "2-person transfer with Hoyer." During an observation and attempted interview with Resident #1 on 1/6/11 at 11:15 a.m., Resident #1 was noted to be sitting up in bed with her left leg in a brace. Resident #1 was moaning continuously, touching the brace on her leg, and stating, "Oh my God, terrible pain, Mija (spanish term of endearment) I can't stand it." Resident #1 stated her pain was at an unbearable level and requested pain medication from the staff. Resident #1 placed her hand together and stated, "Take the pain away dear Lord!". Resident #1 was not interviewed at this time due to her pain level. During a second observation and interview on 1/6/11 at 12:15 p.m., Resident #1 was observed to be hard of hearing and stated, "Huh?" repeatedly during the conversation. Resident #1 stated her pain was getting better, after asked several times and gestures added to convey the question. Resident #1 stated she could not remember how her leg was injured. She was unable to recall any details about the night or morning that her injury was identified. A record review of a hospital ER report, dated 12/26/10 at 12:35 p.m. revealed the report stated, "The patient complains of left upper leg, pt. has been paralyzed in lower extremities for some time, nursing home staff was moving her and her foot got caught, states that fractured her femur." The ER reported her pain was assessed as "8" (on scale of 1-10). The report also stated, "She somehow got her left foot caught while nurses were transferring her from bed. She sustained a distal left thigh deforming injury." The report documented, "Four views obtained to show the entire left femur from the hip to the knee in AP and lateral projections show a comminuted and displaced fracture of the distal femoral shaft and metaphysis. The major distal fragments are displaced posteromedially and angled posteriorly relative to the femoral shaft." Impression: "Comminuted (A fracture in which bone is broken, splintered or crushed into a number of pieces)and displaced (when two ends of the bone are separated from one another) fracture of the distal femoral shaft and metaphysis (the wider part at the end of a long bone)." A record review of the facility's incident/accident report dated 12/26/10 at 4:23 a.m. revealed LVN A documented, "This nurse was notified by resident's aid (sic) that the resident was in extreme pain. This nurse asked resident where pain was located and its rating on a scale of 0-10. Resident stated that her posterior L (left) knee was in extreme pain and rated it at a 10." Under the section, "Was initial treatment provided?", LVN A documented, "pain medication." LVN A documented physician notification at 5:40 a.m., and under "action", "X-rays." During an interview on 1/6/11 at 11:25 a.m., the DON stated he received a report on 12/26/10 that Resident #1 was complaining of significant pain, "more than usual" and he came to the facility at approximately 9:30 a.m. He stated he talked to the resident and she did not know why her leg was hurting, because she stated she had not been dropped, hit, or fallen. He said the resident's roommate could not tell him anything either. He stated he talked to the charge nurse who told him that one CNA said another CNA hurt the resident's leg during a transfer. He stated the charge nurse said he did not notice anything unusual about the resident's leg when he did a head-to-toe assessment of the resident, but only that the resident had alot of pain. The DON said he talked to CNAs A and B and CNA B said CNA A transferred the resident by herself when she should have had two people for the transfer. The DON stated that transfer skills were evaluated for each CNA when they were hired, during orientation. He stated he fired CNA A and in-serviced all other CNAs on being sure they looked at the data sheet at the desk so they knew which type of transfer each resident required. A record review of CNA A's personnel file revealed she was hired 11/5/10. Included was a list of subjects covered during orientation, dated 11/5/10. At the end of the list the form stated, "Received orientation and information listed above..." and it was signed by CNA A. There was no documentation of a tranfer/lifting competency evaluation. The only items relative to the subject of lifting, transferring, or falls, was "Reporting incidents", "Body Mechanics", and "Breaking a resident's fall. There was no lifting/transferring competency evaluation in CNA A's personnel file. During a telephone interview on 1/7/11 at 8:55 a.m., CNA B said that CNA A was recently transferred to work with her on her hall, and on 12/26/10 they were working together. She said that she had told CNA A not to transfer Resident #1 without waiting for her (CNA A) to do it with her. She stated CNA A had transferred Resident #1 alone the night before, and she had told CNA A and the charge nurse about it. She stated that she was in a room near Resident #1's when she heard Resident #1 screaming "She broke my leg! I heard it pop!" She stated the resident was moaning and crying in pain. CNA B stated it was about 4:00 a.m. after they had started rounds. CNA B said CNA A was in the resident's room when she arrived just seconds after hearing the resident scream, and saw that Resident #1 had been transferred into a chair from the bed. She stated there was no equipment in the room (no Hoyer lift). CNA B said when she looked at Resident #1's leg, she could tell that her leg was broken. She stated her leg was deformed and in a position that it would never be normally. She stated "It was horrible. It's hard to describe, it was like her knee was dipped in and turned to the side. Her leg was bent upwards at the knee." A record review of documentation of the DON's interview with CNA B, dated 12/26/10 revealed it contained only the following information: "(CNA B) stated she was asked to go to resident's room to help move resident up in chair. She said she observed resident's leg looked unusual so she went to get the charge nurse. The charge nurse stated the leg didn't look unusual. He stated he was going to get the resident something for pain. (CNA B) stated she did not help (CNA A) transfer her so (CNA A) must have done it alone. (CNA B) stated she help transfer resident back to bed using the Hoyer lift." During an interview on 1/10/11 at 9:00 a.m., CNA A stated she was new to the hall where Resident #1 resided and was not very familiar with the resident's needs. She stated that the only way a CNA learned about resident's needs were "word of mouth, from another CNA." She stated she was never told about Data Sheets at the nursing station that described this information regarding a resident. She stated she worked that hall only three shifts prior to 12/26/10. She stated she saw Resident #1 on rounds at 1:00 a.m. Resident #1 was complaining of leg pain, so she told the nurse. CNA A said the nurse went and checked with Resident #1 and told CNA A that the resident declined any pain medication. CNA A stated, "He (LVN A) lied when he was interviewed and said that didn't happen." CNA A stated that CNA B told her to get Resident #1 up a little after 4:00 a.m. and so she went to the resident's room alone and transferred her from her bed to her chair. She stated that she did not use the mechanical lift for Resident #1, but she had been told by a charge nurse that if you were strong enough to lift a resident without the mechanical lift, that you could choose not to use the mechanical lift. She stated she "cradled" Resident #1 in her arms by putting one arm behind her back and one arm under her thighs, and then she moved her to the chair. CNA A stated, "I'm very strong." CNA A stated the transfer went smoothly and the resident did not voice any discomfort. CNA A stated that after Resident #1 was in her chair, she needed to re-position her (scoot her back in her wheelchair) but could not do so by herself, so she went to get CNA B. She stated CNA B came in to help her, and when they pulled the resident back in the seat of her chair, the resident's ankle caught in the raised foot rest of the chair, and the resident yelled, "My leg! My leg!" CNA A stated that is when CNA B went to get the nurse. CNA A stated that the resident told her that the night shift had hurt her leg when they put her to bed the previous night. CNA A stated the facility had never completed a competency evaluation of her lifting or transferring skills. A record review of CNA A's hand written (undated) statement at 4:23 a.m. revealed she documented that Resident #1 said she was sore and her left leg hurting some, but she did not ask for anyting for pain "ever." She documented, "Upon transferring resident this a.m., she began to yell about her left leg. When asked resident about leg she said 'the girl put me in bed last night and I heard a snap, I think its broken." CNA A's written statement did not include any information regarding CNA B assisting her to re-position the resident in her chair and getting the resident's leg caught in the foot rest of the chair as stated in her interview. A record review of the DON's interview with CNA A, documented 12/26/10 revealed it included only the following: "(CNA A) stated she transferred resident alone. Stated she knew information about resident and how to transfer was in the flow books. She could not give a reason why she did not ask for assistance with the transfer." During an interview on 1/7/11 at 4:37 p.m., CNA C stated she was working the night shift 12/26/10 on an opposite hall of the facility (from CNAs A and B). CNA C stated that CNA B came to her hall very upset ("shook up") telling her that she should go look at Resident #1 because her leg was broken. CNA C stated she went into Resident #1's room, and Resident #1 was "hollering" in pain, but stated, "I really didn't know what I was supposed to be looking for." CNA C stated she could not really say how the resident's leg appeared. During an interview on 1/7/11 at 9:30 a.m., LVN A stated that he was the charge nurse on duty on 12/26/10 night shift. He stated he first became aware of Resident #1's injury when CNA B approached him and told him that Resident #1's leg was "messed up." LVN A stated he went in the room and Resident #1 was in her wheelchair and stated she was hurt while being moved, but he did not know how it occurred. A record review of LVN A's nurse's note dated 12/26/10 at 4:25 a.m. revealed LVN A documented an aide came to him and told him another aide had moved the resident from her bed to the wheelchair by herself and the resident's leg looked "messed up." LVN A documented the resident told him her left leg was hurt when she was moved from the bed to the wheelchair. He documented the resident then stated that she "felt and heard a snap and grinding." A record review of the DON's investigation report revealed an interview with LVN A that documented "LVN A stated CNA (CNA not identified by name) reported resident was up in wheelchair she thought the resident leg looked unusual. LVN A stated he initially did not observe a difference that the other leg with her pants on. Upon removing the pants he assessed pain but leg only appeared a little swollen but he palpated it lightly (touched with palms and/or fingers) and could not feel any gross displacement. He called and reported to MD and administered pain medication which was effective." During a telephone interview on 1/7/11 at 4:25 p.m., the physician who was on-call for the resident's physician on 12/26/10 stated that he received the call from LVN A about Resident #1. He stated LVN A told him the resident may have fallen and was complaining of pain in her left leg. A record review of a nurse's note dated 12/26/10 at 12:27 p.m., completed by the day shift charge nurse, revealed the nurse documented that "When I arrived pt. was yelling out about her leg...30 min later pt. pain decreased and pt. was settled... Pt. began to vomiting x2..." The charge nurse documented that X-ray results were received and she first attempted to contact the physician at 9:20 a.m. with the results. She documented that she spoke to the physician at 10:50. The nurse documented the resident left in an ambulance at 11:40 a.m. A record review of the facility's Investigation report of Post investigation action taken, signed by the administrator on 12/30/10, revealed that the facility terminated CNA A, in-serviced staff on their transfer policies(the DON stated in 1/6/10 interview that CNAs were reminded to check the data sheets at the nurse's station which tells them what kind of transfer a resident requires), and in-serviced staff to reinfoce reporting procedure for unusual incidents and accidents. The actions taken did not address any re-training for safe handling of residents or CNA B's possible actions that may have contributed to Resident #1's injuries. 2. A record review revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of an MDS assessment for Resident #4, signed by the RN as complete on 11/29/10 revealed that during the brief interview for mental status, Resident #4 could recall only one word after given three words and asked to repeat them. She was unable to state the correct day of the week, month of the year, or the correct year. The MDS documented Resident #4 needed extensive assistance to transfer, dress, use the toilet, and to maintain hygeine. The assessment documented she used a wheelchair for mobility. The assessment documented one fall since her prior assessment with an injury that was not major. A record review of Resident #4's care plan dated 12/7/10 revealed Resident #4 required one-person extensive assistance with bed mobility and one-person assist with all transfers. The care plan included a problem that Resident #4 was at risk for falls and had poor safety awareness. Interventions included to assist her with all ambulation, remind her to ask for assistance with ambulation, monitor for changes in her condition that may warrant increased supervision, refer her to the restorative nursing program (record review revealed the restorative nursing care plan was added to the record and dated 1/7/11), and the use of a wheelchair for long distance mobilility. Another problem statement with the same date documented that Resident #4 had fluctuating and unstable blood pressure and should be monitored for headaches and dizziness. There were no care plan interventions in place to minimize the risk of injury for Resident #4 if she fell such as a low bed or a mat by her bed and no preventive measures such as an alarm to alert staff should she arise without assistance. A record review of a nurse's note dated 1/7/11 at 2:45 a.m. stated Resident #4 was found lying supine (on her back) on the floor next to bed with blood surrounding her. The note stated, "Pt. is confused." The writer documented that the resident had a cut 1/2 inch to the front of her head at the hair line, and was sent to the emergency room . The nurse's note did not include any assessment of the possibilities of how the resident may have come to be on the floor (such as whether the staff thought the resident fell , rolled from bed, or had an accident during a transfer, etc). A record review of hospital emergency department discharge instructions for Resident #4 dated 1/7/11 revealed it included: "Your [DIAGNOSES REDACTED]. A record review of an incident/accident report for Resident #4 dated 1/7/11 at 2:45 a.m. revealed, "Pt. found lying supine on floor next to bed with blood everywhere." The incident/accident report documented the resident was sent to the emergency room . A record review of an attached "Falls Investigation Worksheet" documented the resident had a laceration to her forehead. The writer documented the resident was confused and the incident not witnessed. There was no investigation information or conclusions documented. A record review of a second attachment to the incident report, titled, "Incident/Accident Action Plan" documented under "Conclusion/Summary": "Incident and chart reviewed. Resident has a new order for pin alarm while in wc and in bed at all times. In-service to charge nurse about documenting acute information following incident." The "Conclusion/Summary" contained no conclusion that indicated a determination was made about the events that led to the resident's fall or exactly how the resident's injuries were sustained. ADON A signed as the individual completing the investigation on 1/8/11. A record review of physician's telephone orders for Resident #4 revealed there were two physician's orders [REDACTED]. A second telephone order immediately following that one, which was undated, read, "May DC sensor alarm. May have pin alarm." (A pull-pin alarm has an adjustable length pull cord that attaches to patients clothing with strong metal clip. The alarm can be easily be attached to the bed, wheelchair or side chair. When the resident rises, the pull cord disengages the pull-pin from the alarm box, activating the alarm.) During an observation of Resident #4 (and interview) in a common area of the facility on 1/9/11 at 2:40 p.m., Resident #4 was sitting in her wheelchair in front of the television. Resident #4 was smiling and pleasant, but she was confused and much of what she said was unintelligible. She pointed to a male visitor and mumbled about "3 babies" and then she stated she wanted to call her daughter and "tell her what they did to me." When asked what she meant, Resident #4 began incoherently mumbling and when asked what she said again, she said, "I used to work for the railroad." The question was re-phrased, but Resident #4 could not follow the conversation. Resident #4 was observed not to have any type of alarm attached to her person or wheelchair (no sensor or pin alarm). During an interview on 1/9/11 at 3:45 p.m., when discussing the pin alarm that was ordered for the resident, the DON telephoned ADON A, and then stated ADON A told him Resident #4 had on a pin alarm this morning. The DON stated, "She must have taken the pin alarm off herself, because she has done that before." When discussing the 11/17/10 incident report, the DON stated there was no follow-up of the incident. He stated, "That's before we implemented what we're doing now." The Administrator was also present for this interview regarding the resident's pin alarm. During an observation on 1/9/11 at 3:30 p.m., the Administrator and investigator went to Resident #4's room together. A thorough look through the resident's room revealed there was no pin or sensor alarm there. A record review of previous nurse's notes revealed a nurse's note dated 10/28/10 at 1050 that stated, "N/O (new order) DC (discontinue) sensor alarm r/t (related to) resident exhibiting increased safety awareness." A record review of a nurse's note dated 11/17/10 at 1430 (which was observed to be documented on the same page as the above 10/28/10 note) read, "Pt. calling for help to available staff members d/t pt. fall. Pt. found on both hands c (with) R hip to floor and legs crossed. Pt. states she tried to get out of wheelchair into bed but slipped out." The nurse documented the resident had no pain or bruising. The nurse documented, "Pt. educated to call for assistance when needing to get to bed." A record review of the 11/17/10 incident revealed no further attempt to determine what led to the resident falling from her wheelchair and no documentation or follow-up of the incident, including no preventive measures documented. During an interview on 1/11/11 at 2:00 p.m., CNA I stated she had seen the resident about 30 minutes prior to hearing Resident #4 screaming (1/7/11). She stated Resident #4 was not screaming any words, just screaming out, like someone hurt and in pain. She stated she and the CNA working with her entered the room finding Resident #4 on the floor with covers on top of her. She stated, "She was bleeding alot." She then stated that she did not think the resident was trying to go to the bathroom, "Because she was not wet or anything." She stated that she was "pulling a double" that night, having worked the evening shift as well. CNA I stated that Resident #4 had a history of [REDACTED]. doing that awhile." During an interview on 1/11/11 at 2:30 p.m., LVN D stated she was on duty on 1/7/11 when Resident #4 was injured. She stated that when she went to assess Resident #4, she observed that her sheets were "thrown back" on the bed, and the resident was lying face up on the floor with the blanket half on the bed. LVN D stated she assumed Resident #4 fell from bed because the CNAs told her they were in a nearby room when they heard the resident scream. She said she did not think Resident #4 was trying to go to the bathroom, because she was not wet when they found her. LVN D stated, "She's confused all the time anyway." During an interview on 1/9/11 at 3:25 p.m., the DON stated that he and the ADONs were responsible to complete post-accident investigations in the facility (to determine factors leading to the accident and rule out neglect). When discussing the investigation of Resident #4's injury on 1/7, the DON stated, "I visited with the resident on the 7th (1/7/11)." When discussing that there were no interviews or witness statements documented, the DON hesitated, and stated, "Because she fell ." During an interview on 1/10/11 at 10:15 a.m. with the Administrator and DON, the Adminstrator stated she did not understand why Resident #4's incident should have been investigated further or reported. She stated, "It was just a fall." The Administrator stated that Resident #4 takes her pin alarm off sometimes and she was sure that is why it was not on her during the observation on 1/9/11, because several staff have said she had it on after it was ordered on [DATE]. During an interview on 1/10/11 at 10:55 a.m., ADON A stated she talked to the nurse and two CNAs on duty who were working together as her investigation into Resident #4's incident, but did not document the conversations or take any witness statements. She stated she learned from her discussions with them that the resident was laying on her back with the covers on top of her when she was found, so she concluded that the resident must have fallen from bed. She did not conclude how the resident sustained [REDACTED]." When discussing Resident #4, ADON A stated Resident #4 was too confused to recall any events or to be able to tell what happened to her. When discussing the documentation that Resident #4's pin alarm was previously discontinued in October 2010, ADON A stated that it was discontinued because Resident #4's daughter requested the alarm be removed because she thought the noise of the alarm bothered the resident. ADON A stated, "But she hasn't had any falls since then, until this fall." When discussing an incident report of a subsequent fall that Resident #4 had on 11/17/10, ADON A stated, "Oh, she did?" ADON A could not identify any intervention considered after the 11/17/10 or why the pin alarm was not reconsidered at that time. When discussing the observation of Resident #4 on 1/9/11 without the pin alarm as ordered on [DATE], ADON A stated she did not apply the pin alarm, and stated that the investigator should talk to LVN C because LVN C is the one who initially applied the pin alarm to Resident #4. During an interview on 1/10/11 at 11:30 a.m., LVN C stated, "No, I didn't write the order and I didn't put the pin alarm on her (Resident #4)." LVN C stated, "They put it on her yesterday." During an interview on 1/11/11 at 1:00 p.m. for which the DON was also present and observed, Resident #4 was observed to be confused and disoriented. Resident #4 rambled incoherently through most of the 20 minute interview, making statements that were irrelevant to simple questions. She was unable to correctly answer orientation questions aside from her name. Resident #4 giggled and mumbled when asked what she had just eaten for lunch. Resident #4 was asked several times and could not recall what she had eaten for lunch just prior to coming to the interview. At one time in the interview Resident #4 pointed to her head and stated "I fell ." Resident #4 could not give any additional information about the incident or her care at the facility. During this interview, Resident #4 was asked to remove the metal clip on her shirt (pin alarm). The investigator pointed to the clip and asked her to take it off. Resident #4 fumbled with the string of the alarm, moving it a few inches over, and put it under her elbow and then back again. Resident #4 was asked again to remove the clip from her shirt. Resident #4 could not remove the clip even after showing her where it was and prompting her several times to do so. Resident #4 was then told that the base of her alarm was attached to the back of her wheelchair and she was asked to remove that. The alarm base (box) was attached by a strap to the handle on the back of the resident's wheelchair. Resident #4 rotated to her left at the waist but appeared not to be able to turn around enough to see the base of the alarm attached to the arm of the back of her wheelchair. Resident #4 did not appear to have the ability to twist backwards enough to reach the alarm on the back of the wheelchair. This assessment of Resident #4's ability to remove her pin alarm suggested she was not cognitively or physically able to remove the pin alarm. When discussing this with the DON who also observed this, he did not comment. A record review of a care plan 12/14/10 revealed it did not address Resident #4's fall in November 2010 or discontinuation of the alarm in October 2010. 3. The facility was asked to provide evidence of trending and tracking falls and incidents. The DON provided an Incident/Accident Summary Report dated 11/1/10 through 11/30/10. The tracking data documented 25 falls in November 2010 with only 4 resident care plan revisions and 1 staff training. 4. According to the Centers for Disease control: (at http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html) ? About 1,800 people living in nursing homes die each year from falls. ? About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures. ? Falls result in disability, functional decline and reduced quality of life. Fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation. 5. A record review of a list provided by the facility revealed the facility identified 58 residents as being at high risk for falls. 6. During an interview on 1/7/11 at 12:00 p.m., the Administrator was notified of an Immediate Jeopardy. 7. The following Action Plan was accepted on 1/10/11 to remove the immediacy: -RNs and LVNs were re-educated regarding reporting of incidents, assessing residents for injury, the documentation of their assessments, reporting information to the attending physician and responsible party, and interviewing staff when an incident occurs. A competency based test was required to complete the education. The DON will monitor by review of incident reports. Completed 1/8/11. -All nursing staff have been re-educated regarding the policy and procedure for interviewing staff members to obtain information to assist in the investigation process. The DON will monitor to ensure this practice continues and will report to the performance improvement committee. Completed 1/8/11. -The Administrator and DON were re-educated by corporate staff to follow current policy and procedures regarding abuse and neglect investigations and reporting. In the event of a report of abuse or neglect, the administrator, who is the abuse prevention coordinator, will direct the investigation and perform a second interview with all key personnel involved in the incident and will add her interview witness statements to the completed investigation. If the statements provided conflicting information, the Administrator will make a report of the variance in statements and include with the completed investigation. The Administrator and DON participated in a competency evaluation by the corporate nurse, utilizing a mock scenario. Completed: 1/8/11 -Investigation of Resident #4's incident was completed and neglect not substantiated. Corrective measures including pin alarm, low bed, and scoop mattress to prevent future incidents for Resident #4 were implemented. Nurse's aides will monitor pin alarm during care and notify charge nurse to ensure it is in place. Completed 1/10/11. -Nursing Policy and Procedures were made accessible to nursing staff through the computer in the facility lobby. Completed 1/10/11. -All CNAs were required to show transfer competency through return demonstration including correct use of the Hoyer lift. newly hired CNAs will not be allowed to work until they have been deemed competent through demonstration of safe transfer techniques. A quarterly sample (of staff) of contin

Based on observation, interviews, and record reviews, the Administrator and DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for seven of eight residents sampled (Residents #1, 2, 3, 4, 6, 7, and 8) as evidenced by: a) The DON and Administrator failed to follow facility policies and procedures to thoroughly investigate incidents and accidents to rule out neglect and determine causes of accidents for Resident #1 (fractured leg) on 12/26/10 and #4 ([MEDICAL CONDITION]) on 1/7/11; b) The Administrator, who was the Abuse and Neglect Coordinator, failed to report an incident with injury to Resident #4, a cognitively impaired resident who sustained an un-witnessed injury ([MEDICAL CONDITION]) requiring emergency room treatment on 1/7/11; c) The DON failed to ensure LVN A responded appropriately and according to facility policies to thoroughly assess, monitor, communicate with the physician, and document when Resident #1 sustained a fractured leg on 12/26/10; d) The DON failed to ensure nursing staff followed physician's orders [REDACTED].#4 following her [MEDICAL CONDITION] on 1/7/11. The pin alarm had not been attached at observation of resident 1/9/11. e) The DON failed to ensure CNAs followed the resident's care plan for transferring of Resident #1 which resulted in a fracture for Resident #1; failed to complete annual CNA proficiency evaluations in lifting and transferring per the facility's policy; and failed to monitor and ensure CNA proficiency in completing safe transfers of residents and safe use of mechanical lifts according to the manufacturer's recommendations. These failures resulted in an Immediate Jeopardy which was identified on 1/7/11 at 12:00 p.m. While the Immediate Jeopardy was removed on 1/10/11, the facility remained out of compliance at a level of actual harm because the facility had not yet monitored to evaluate the effectiveness of the action plan. Findings included: 1. Resident #1: A record review of a medical record face sheet dated 12/27/10 revealed that Resident #1 was an [AGE] year-old female admitted to the facility 7/28/08 with [DIAGNOSES REDACTED]. A record review of a care plan conference summary sheet for Resident #1 dated 12/21/10 also documented contractures to bilateral lower extremities and scoliosis. The summary stated Resident #1 weighed 133.4 pounds. The care plan included a problem of, "Limited range of motion to bilateral lower extremitites and contractures to BLE." The approaches for this problem included, "2-person transfer with Hoyer." A record review of a hospital ER report, dated 12/26/10 at 12:35 p.m. revealed the report stated, "The patient complains of left upper leg, pt. has been paralyzed in lower extremities for some time, nursing home staff was moving her and her foot got caught, states that fractured her femur." The ER reported her pain was assessed as "8" (on scale of 1-10). The report also stated, "She somehow got her left foot caught while nurses were transferring her from bed. She sustained a distal left thigh deforming injury." The report documented, "Four views obtained to show the entire left femur from the hip to the knee in AP and lateral projections show a comminuted and displaced [MEDICAL CONDITION] femoral shaft and metaphysis. The major distal fragments are displaced posteromedially and angled posteriorly relative to the femoral shaft." Impression: "Comminuted (A fracture in which bone is broken, splintered or crushed into a number of pieces)and displaced (when two ends of the bone are separated from one another) [MEDICAL CONDITION] femoral shaft and metaphysis (the wider part at the end of a long bone)." A record review of the facility's incident/accident report dated 12/26/10 at 4:23 a.m. revealed LVN A documented, "This nurse was notified by resident's aid that the resident was in extreme pain. This nurse asked resident where pain was located and its rating on a scale of 0-10. Resident stated that her posterior L (left) knee was in extreme pain and rated it at a 10." Under the section, "Was initial treatment provided?", LVN A documented, "pain medication." LVN A documented physician notification at 5:40 a.m., and under "action", "X-rays." During an interview on 1/6/11 at 11:25 a.m., the DON stated he received a report on 12/26/10 that Resident #1 was complaining of significant pain, "more than usual" and he came to the facility at approximately 9:30 a.m. He stated he talked to the resident and she did not know why her leg was hurting, because she had not been dropped, hit, or fell . He said the resident's roommate could not tell him anything either. He stated he talked to the charge nurse who told him that one CNA said another CNA hurt the resident's leg during a transfer. He stated the charge nurse said he did not notice anything unusual about the resident's leg when he did a head-to-toe assessment on the resident, but only that the resident had alot of pain. The DON said he talked to the CNA A and B and CNA B said CNA A transferred the resident by herself when she should have had two people for the transfer. The DON said, "But these aides did not get along." The DON said the nurse was an "agency" nurse (not a full time employee of the facility), but the nurse contacted the doctor and the family as he should have. When discussing whether he interviewed or assessed any other residents that CNA A provided care for, he stated he did not do that in the course of the investigation, but he talked to his residents all the time. He then stated he did "some resident interviews" but did not document them. He stated he terminated CNA A for transferring the resident alone, stating, "She knew better" as the transfer needs for this resident were documented on a "data sheet" at the nurse's station. The DON failed to gather or failed to disclose pertinent facts that were evident in interviews and record reviews as described below. During a telephone interview on 1/7/11 at 8:55 a.m., CNA B said that CNA A was recently transferred to work with her on her hall, and on 12/26/10 they were working together. She said that she had told CNA A not to transfer Resident #1 without waiting for her (CNA B) to do it with her. She stated CNA A had transferred Resident #1 alone the night before, and she had told CNA A and the charge nurse about it. She stated that she was in a room near Resident #1's when she heard Resident #1 screaming "She broke my leg! I heard it pop!" She stated the resident was moaning and crying in pain. CNA B stated it was about 4:00 a.m. after they had started rounds. CNA B said CNA A was in the resident's room when she arrived and Resident #1 had been transferred into a chair from the bed. She stated there was no equipment in the room (no Hoyer lift). CNA B said when she looked at Resident #1's leg, she could tell that her leg was broken. She stated her leg was deformed and in a position that it would never be normally. She stated "It was horrible. It's hard to describe, it was like her knee was dipped in and turned to the side. Her leg was bent upwards at the knee." CNA B said that LVN A came in and looked at the resident and then told the two CNAs to put the resident back to bed. CNA B stated she kept telling the nurse that the resident's leg was broken and why didn't he call 9-1-1. CNA B stated she followed the nurse's directions to transfer the resident back to bed, but she stated the resident was protesting in pain and that she became tearful at seeing the resident in so much pain. CNA B stated that the nurse just gave the resident a pain pill and let her lie there in pain. CNA B stated Resident #1 was moaning and crying the rest of the morning and was still crying when she left her shift at 6:00 a.m. CNA B stated she never saw the nurse fully assess Resident #1. She stated that LVN A refused to help transfer Resident #1 back to bed because he said he had back problems. She stated that he never asked for her help to remove the resident's clothing or help him with completing an assessment, stating LVN A always had CNAs help him with anything that involved manually moving a resident. CNA B stated she talked to the DON on two separate occasions and told him this information in great detail. A record review of documentation of the DON's interview with CNA B, dated 12/26/10 revealed it contained only the following information: "(CNA B) stated she was asked to to to resident's room to help move resident up in chair. She said she observed resident's leg looked unusual so she went to get the charge nurse. The charge nurse stated the leg didn't look unusual. He stated he was going to get the resident something for pain. (CNA B) stated she did not help (CNA A) transfer her so (CNA A) must have done it alone. (CNA B) stated she help transfer resident back to bed using the Hoyer lift." During an interview on 1/7/11 at 12:00 noon (with the DON and Administrator), the DON stated he did not include all of CNA B's information in his investigation documentation. He stated, "She kept telling me things she could not have possibly known and I told her to only tell me what she knew for a fact." The DON also stated he did not give credibility to CNA B because he knew that CNA B and CNA A did not get along. He stated he did not get a witness statement from CNA B. The Administrator stated the facility did not gather witness statements because the corporate policy was not to get witness statements. During an interview on 1/10/11 at 9:00 a.m., CNA A stated she was new to the hall where Resident #1 resided and was not very familiar with the resident's needs. She stated she worked that hall only three shifts prior to 12/26/10. She stated she saw Resident #1 on rounds at 1:00 p.m. Resident #1 was complaining of leg pain, so she told the nurse. CNA A stated that CNA B told her to get Resident #1 up a little after 4:00 a.m. and so she went to the resident's room alone and transferred her from her bed to her chair. She stated that she did not use the mechanical lift for Resident #1, but she had been told by a charge nurse that if you were strong enough to lift a resident without the lift, that you could choose not to use the mechanical lift. She stated she "cradled" Resident #1 in her arms by putting one arm behind her back, and one arm under her thighs and moved her to the chair. CNA A stated the transfer went smoothly and the resident did not voice any discomfort. CNA A stated that after Resident #1 was in her chair, she needed to re-position her but could not do so by herself, so she went to get CNA B. She stated CNA B came in to help her, and when they pulled the resident back in the seat of her chair, the resident's ankle caught in the raised foot rest of the chair, and the resident yelled, "My leg! My leg!" CNA A stated that is when CNA B went to get the nurse. CNA A stated LVN A did not ask her any details about what happened at the time of the incident. She stated she wrote what happened on a nurse's note. She stated LVN A told her to put the resident back to bed, and finish her rounds. CNA A stated that the DON called her and just asked her if she had anything to add to her witness statement. She stated he did not ask her any questions about her statement or mention any other information he had gathered. A record review of the DON's interview with CNA A, documented 12/26/10 revealed it included only the following: "(CNA A) stated she transferred resident alone. Stated she knew information about resident and how to transfer was in the flow books. She could not give a reason why she did not ask for assistance with the transfer." During an interview on 1/7/11 at 4:37 p.m., CNA C stated she was working the night shift 12/26/10 on an opposite hall of the facility (from CNAs A and B). CNA C stated that CNA B came to her hall very upset ("shook up") telling her that she should go look at Resident #1 because her leg was broken. CNA C stated she went into Resident #1's room, and Resident #1 was "hollering" in pain, but stated, "I really didn't know what I was supposed to be looking for." CNA C stated she could not really say how the resident's leg appeared. A record review of documentation of the DON's investigation revealed there was no statement or interview with CNA C. During an interview on 1/7/11 at 9:30 a.m., LVN A stated that he was the charge nurse on duty on 12/26/10 night shift. He stated he first became aware of Resident #1's injury when CNA B approached him and told him that Resident #1's leg was "messed up." LVN A stated he went in the room and Resident #1 was in her wheelchair. He stated he did not notice anything "you know, outstanding" about the resident When discussing his assessment of Resident #1's leg, he first stated, "I touched them and stuff." When asked if there was any other assessment of the resident, he stated he removed the resident's pants and stated he did not notice any bruising or deformity of the leg. When discussing his documentation, which did not include a visual description of the resident, LVN A stated, "I was confused in the whole situation." LVN A stated he called the physician and told him the resident was complaining of pain on the left side and movement caused her pain. When discussing whether he told the physician that Resident #1 said she heard the bone pop, LVN A then stated he told the physician that information also. LVN A stated that Resident #1 was comfortable after he medicated her and he left his shift. He stated the mobile X-ray had not arrived prior to his leaving his shift at 6:30 a.m. A record review of LVN A's nurse's note dated 12/26/10 at 4:25 a.m. revealed LVN A documented an aide came to him and told him another aide had moved the resident from her bed to the wheelchair by herself and the resident's leg looked "messed up." LVN A documented the resident told him her left leg was hurt when she was moved from the bed to the wheelchair. He documented the resident then stated that she "felt and heard a snap and grinding." LVN A documented he administered [MEDICATION NAME] 7.5/500 mg. (pain medication) to relieve some of the pain. LVN A documented he had the nurse's aides put the resident in a Hoyer lift and move her to bed. He then documented, "nurse proceeded to monitgor the pain level of the resident." He documented the physician's instructions to give another [MEDICATION NAME] and "send to ER if no improvement" and an order for [REDACTED]. LVN A's nurse's note at 4:25 a.m. stated, "This nurse then followed up with the resident about the effectiveness of the prescribed pain med. Resident stated that it was helping but still in alot of pain. This nurse recommended to the aids involved to write a statement of this event." LVN A did not document (in his nurse's note) any observations of Resident #1's affected limb, or assessment of her over-all condition, such as peripheral pulses, monitoring of vital signs, or immobilization of the affected limb. LVN A did not document rating of the resident's pain level after the initial assessment (when it was at a "10" on a scale of 1-10) to accurately describe her pain and measure effectiveness of medication. A record review of the DON's investigation report revealed an interview with LVN A that documented "LVN A stated CNA (CNA not identified by name) reported resident was up in wheelchair she thought the resident leg looked unusual. LVN A stated he initially did not observe a difference that the other leg with her pants on. Upon removing the pants he assessed pain but leg only appeared a little swollen but he palpated it lightly and could not feel any gross displacement. He called and reported to MD and administered pain medication which was effective." The DON's investigation and interview did not address the significant differences between CNA B's observation of the resident's condition (level of pain and description of her leg) and CNA B's allegation that LVN A did not properly assess the resident; and LVN A' description of the resident and assertion that he did a thorough assessment of the resident. During a telephone interview on 1/7/11 at 4:25 p.m., the physician who was on-call for the resident's physician on 12/26/10 stated that he received the call from LVN A about Resident #1. He stated LVN A told him the resident may have fallen and was complaining of pain in her left leg. The physician stated LVN A did not tell him that Resident #1 was in excrutiating pain, did not describe any abnormality to the appearance of the resident's leg, and did not tell the physician that the resident stated she had heard the bone break. The physician stated if he had been told any of those things, he would have ordered the resident sent to the emergency room immediately, and would not have waited for mobile X-ray. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed the physician's information was not included (there was no interview with the physician.) During a telephone interview on 1/8/11 at 5:55 a.m., LVN B stated he was on duty with LVN A on 12/26/10 when Resident #1 was injured. LVN B stated he did not know anything about the incident. He said he was on another hall passing medications when the incident occurred and was "shocked" that LVN A did not come and get him and ask him for assistance or tell him what was going on. He said he first heard about the incident when it was time to get off work that morning and saw LVN A writing an incident report. LVN B stated, "I was busy that night." When discussing whether the facility interviewed him regarding the incident, he stated that no one asked him anything until yesterday, and the DON asked him questions about it when he came to the facility for training. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed LVN B was not interviewed regarding the incident. A record review of a nurse's note dated 12/26/10 at 12:27 p.m., completed by the day shift charge nurse, revealed the nurse documented that "When I arrived pt. was yelling out about her leg...30 min later pt. pain decreased and pt. was settled... Pt. began to vomiting x2..." The charge nurse documented that X-ray results were received and she first attempted to contact the physician at 9:20 a.m. with the results. She documented that she spoke to the physician at 10:50. The nurse documented the resident left in an ambulance at 11:40 a.m. A record review of the facility's investigation dated 12/26/10 through 12/27/10 revealed this charge nurse was not interviewed regarding her observations of Resident #1 on 12/26/10. A record review of the facility's Investigation report of Post investigation action taken, signed by the administrator on 12/30/10, revealed that the facility terminated CNA A, in-serviced staff on their transfer policies(the DON stated in 1/6/10 interview that CNAs were reminded to check the data sheets at the nurse's station which tells them what kind of transfer a resident requires), and in-serviced staff to reinforce reporting procedure for unusual incidents and accidents. The actions taken did not address any re-training for safe handling of residents, CNA B's possible actions that may have contributed to Resident #1's injuries (getting the resident's leg caught in the raised foot rest of the wheelchair), or LVN A's lack of thorough assessment and post injury care for Resident #1, which were identified following a thorough investigation of the incident. SEE F226 and F309 for the facility's policies and procedures regarding Abuse and neglect investigations (F226) and Emergency Care for Fractures (F309). 2. Resident #4: A record review revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of a nurse's note dated 1/7/11 at 2:45 a.m. stated Resident #4 was found lying supine (lying on her back) on the floor next to bed with blood surrounding her. The note stated, "Pt. is confused." The writer documented that the resident had a cut 1/2 inch to the front of her head at the hair line, and was sent to the emergency room . The nurse's note did not describe how the resident came to be on the floor (such as whether the resident fell , rolled from bed, or had an accident during a transfer). A record review of an incident/accident report for Resident #4 dated 1/7/11 at 2:45 a.m. revealed, "Pt. found lying supine on floor next to bed with blood everywhere." The incident/accident report did not describe injuries or observations of the resident other than this statement. The incident/accident report documented the resident was sent to the emergency room . A record review of an attached "Falls Investigation Worksheet" documented the resident had a laceration to her forehead. The writer documented the resident was confused and the accident not witnessed. The "Fall Investigation Worksheet" contained no information regarding contact with witnesses and no documentation to indicate conclusions of an investigation about how the fall occurred. A record review of a second attachment to the incident report, titled, "Incident/Accident Action Plan" documented under "Conclusion/Summary": "Incident and chart reviewed. Resident has a new order for pin alarm while in wc and in bed at all times. In-service to charge nurse about documenting acute information following incident." The "Conclusion/Summary" contained no conclusion that indicated a determination was made about the cause of the resident's injuries. ADON A signed as the individual completing the investigation on 1/8/11. During an interview on 1/9/11 at 3:25 p.m., the DON stated that he and the ADONs were responsible to complete post-accident investigations in the facility. When discussing the investigation of Resident #4's injury on 1/7/11, the DON stated, "I visited with the resident on the 7th (1/7/11)." When discussing that there were no interviews or witness statements documented, the DON hesitated, and stated, "Because she fell ." When discussing whether the incident was reported to the state authority due to there being a significant injury to the resident that required an emergency room visit and no witnesses, he stated, "No it wasn't an injury of unknown origin because she fell ." He stated he did not investigate to rule out neglect because the resident told him she fell . During an interview on 1/10/11 at 10:55 a.m., ADON A stated she talked to the nurse and two CNAs on duty who were working together as her investigation but did not document the conversations or take any witness statements. She stated she learned from her discussions with them that the resident was laying on her back with the covers on top of her when she was found, so she concluded that the resident must have fallen from bed. She did not conclude how the resident sustained [REDACTED]." When discussing Resident #4, ADON A stated Resident #4 was too confused to recall any events or to be able to tell what happened to her. She did not attempt to verify the CNAs statements regarding the care and supervision of Resident #4 by talking with any other residents about care by the CNAs, the second LVN on duty the night of the incident, or the roommate or neighboring residents to determine if they heard or saw anything, or whether they had any information regarding the care and supervision on that shift. ADON A had no evidence that she completed these interviews prior to the investigator's request for them on 1/9/11. A record review of physician's telephone orders for Resident #4 revealed there were two physician's orders [REDACTED]. A second telephone order immediately following that one, which was undated, read, "May DC sensor alarm. May have pin alarm." (A pull-pin alarm has an adjustable length pull cord that attaches to patients clothing with strong metal clip. The alarm can be easily be attached to the bed, wheelchair or side chair. When the resident rises, the pull cord disengages the pull-pin from the alarm box, activating the alarm.) During an observation of Resident #4 (and interview) in a common area of the facility on 1/9/11 at 2:40 p.m., Resident #4 was sitting in her wheelchair in front of the television. Resident #4 was smiling and pleasant, but she was confused and much of what she said was unintelligible. She pointed to a male visitor and mumbled about "3 babies" and then she stated she wanted to call her daughter and "tell her what they did to me." When asked what she meant, Resident #4 began incoherently mumbling and when asked what she said again, she said, "I used to work for the railroad." The question was re-phrased, but Resident #4 could not follow the conversation. Resident #4 was observed not to have any type of alarm attached to her person or wheelchair (no sensor or pin alarm). During an interview on 1/9/11 at 3:45 p.m., when discussing the pin alarm that was ordered for the resident, the DON telephoned ADON A, and then stated ADON A told him Resident #4 had on a pin alarm this morning. The DON stated, "She must have taken the pin alarm off herself, because she has done that before." When discussing the 11/17/10 incident report, the DON stated there was no follow-up of the incident. He stated, "That's before we implemented what we're doing now." The Administrator was also present for this interview regarding the resident's pin alarm. During an observation on 1/9/11 at 3:30 p.m., the Administrator and investigator went to Resident #4's room together. A thorough look through the resident's room revealed there was no pin or sensor alarm there. A record review of previous nurse's notes revealed a nurse's note dated 10/28/10 at 1050 that stated, "N/O (new order) DC (discontinue) sensor alarm r/t (related to) resident exhibiting increased safety awareness." A record review of a nurse's note dated 11/17/10 at 1430 (which was observed to be documented on the same page as the above 10/28/10 note) read, "Pt. calling for help to available staff members d/t pt. fall. Pt. found on both hands c (with) R hip to floor and legs crossed. Pt. states she tried to get out of wheelchair into bed but slipped out." The nurse documented the resident had no pain or bruising. The nurse documented, "Pt. educated to call for assistance when needing to get to bed." A record review of the 11/17/10 incident revealed no further attempt to determine what led to the resident falling from her wheelchair and no documentation or follow-up of the incident, including no preventive measures documented. During an interview on 1/10/11 at 10:55 a.m., ADON A stated that Resident #4's pin alarm was previously discontinued in October 2010 because Resident #4's daughter requested the alarm be removed. ADON A stated, "But she hasn't had any falls since then, until this fall." When discussing an incident report of a subsequent fall that Resident #4 had on 11/17/10, ADON A stated, "Oh, she did?" ADON A could not identify any intervention considered after the 11/17/10 or why the pin alarm was not reconsidered at that time. When discussing the observation of Resident #4 on 1/9/11 without the pin alarm as ordered on [DATE], ADON A stated she did not apply the pin alarm, and stated that LVN C is the one who initially applied the pin alarm to Resident #4. During an interview on 1/10/11 at 11:30 a.m., LVN C stated, "No, I didn't write the order and I didn't put the pin alarm on her (Resident #4)." LVN C stated, "They put it on her yesterday." During an interview on 1/11/11 at 1:00 p.m. for which the DON was also present and observed, Resident #4 was observed to be confused and disoriented. Resident #4 rambled incoherently through most of the 20 minute interview, making statements that were irrelevant to simple questions. She was unable to correctly answer orientation questions aside from her name. Resident #4 giggled and mumbled when asked what she had just eaten for lunch. Resident #4 was asked several times and could not recall what she had eaten for lunch just prior to coming to the interview. At one time in the interview Resident #4 pointed to her head and stated "I fell ." Resident #4 could not give any additional information about the incident or her care at the facility. During this interview, Resident #4 was asked to remove the metal clip on her shirt (pin alarm). The investigator pointed to the clip and asked her to take it off. Resident #4 fumbled with the string of the alarm, moving it a few inches over, and put it under her elbow and then back again. Resident #4 was asked again to remove the clip from her shirt. Resident #4 could not remove the clip even after showing her where it was and prompting her several times to do so. Resident #4 was then told that the base of her alarm was attached to the back of her wheelchair and she was asked to remove that. The alarm base (box) was attached by a strap to the handle on the back of the resident's wheelchair. Resident #4 rotated to her left at the waist but appeared not to be able to turn around enough to see the base of the alarm attached to the arm of the back of her wheelchair. Resident #4 did not appear to have the ability to twist backwards enough to reach the alarm on the back of the wheelchair. This assessment of Resident #4's ability to remove her pin alarm suggested she was not cognitively or physically able to remove the pin alarm. When discussing this with the DON who also observed this, he did not comment. A record review of a care plan 12/14/10 revealed it did not address Resident #4's fall in November 2010 or discontinuation of the alarm in October 2010. 3. CNA Proficiency: a) A record review revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of physician's orders [REDACTED]. A record review of Resident #2's care plans dated 5/18/10 and 12/17/10 revealed Resident #2 had a [MEDICAL CONDITION] right side hemilegia, was dependent on staff to meet all activities of daily living, and required the assistance of two staff and a Hoyer lift for transfers. An MDS for Resident #2 revealed her cognitive skills were modified independent, and she had good recall (could recall current season, location of her room, staff names and faces) but she had no speech (her speech was rarely/never understood). During an interview on 1/8/11 at 2:50 p.m., RN A stated that Resident #2 was very fragile because of her potential for chest pain, breathing/respiratory difficulties, and the fact that the resident has some difficulty communicating due to speech. RN A stated that she had learned to communicate with the resident very well, though, because if you take time to ask enough questions, Resident #2 communicated very well using facial expressions, nodding her head yes and no, and using gestures. For example, she stated that Resident #2 pats her chest with an open hand if she is having trouble breathing. She states Resident #2 has been observed to cry when something is wrong or she is in pain. During an observation on 1/6/11 at 1:39 p.m., CNAs D and E were observed to transfer Resident #2 by mechanical (Hoyer) lift from her wheelchair to her bed in her room. CNA D was operating the Hoyer, which was a motorized lift and CNA E was standing by to assist. CNA D positioned the resident's wheelchair with the back of it against the wall and facing the foot of the bed, then both CNAs attached the resident's sling, which was already positioned beneath her in the wheelchair, to the lift. CNA D then began the motor of the lift and as soon as t

Based on observation, interviews, and record reviews, the facility failed to ensure nurse aides were able to demonstrate competency in transfer and lifting skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for one of three residents reviewed for accidents with injuries (Resident #1) and five of eight residents observed during lifting and transfer (Residents 2, 3, 6, 7, and 8) by CNAs A, B, D, E, F, G, and J as evidenced by: a) failure to use a Hoyer lift per the care plan for transfer of Resident #1; and failure to re-position Resident #1 properly. Resident #1 sustained a leg fracture on 12/26/10 during a manual transfer by CNA A and/or during re-positioning by CNAs A and B when they caught her foot in the leg rest of her wheelchair on 12/26/10 immediately after the transfer; b) failure of CNAs D, E, F, and G to operate the Hoyer lift according to manufacturer's instructions during lift/transfers for Residents #2 and 3; and c) failure of CNAs D, J, F, and G to perform transfer with gait belt according to facility policies and recommended guidelines for Residents #6, 7, and 8. These failures resulted in an Immediate Jeopardy which was identified on 1/7/11 at 12:00 p.m. While the Immediate Jeopardy was removed on 1/10/11, the facility remained out of compliance at a level of actual harm because the facility had not yet monitored the effectiveness of their action plan. The failure to use safe lifting and transferring techniques could result in discomfort and mental anguish or could result in accidents, serious injuries, or even death for a resident. These failures could affect the 49 residents that required assistance with transferring. Findings included: 1.A record review of a medical record face sheet dated 12/27/10 revealed that Resident #1 was an [AGE] year-old female admitted to the facility 7/28/08 with [DIAGNOSES REDACTED]. A record review of a care plan conference summary sheet for Resident #1 dated 12/21/10 also documented contractures to bilateral lower extremities and scoliosis. The summary stated Resident #1 weighed 133.4 pounds. The care plan included a problem that stated Resident #1 was dependent on staff to meet all ADL needs. The approaches for this problem included, "Use appropriate adaptive device as RX'd." Another problem included in her plan was, "Limited range of motion to bilateral lower extremitites and contractures to BLE." The approaches for this problem included, "2-person transfer with Hoyer." A record review of a hospital ER report, dated 12/26/10 at 12:35 p.m. revealed the report stated, "The patient complains of left upper leg, pt. has been paralyzed in lower extremities for some time, nursing home staff was moving her and her foot got caught, states that fractured her femur." The ER reported her pain was assessed as "8" (on scale of 1-10). The report also stated, "She somehow got her left foot caught while nurses were transferring her from bed. She sustained a distal left thigh deforming injury." Impression: "Comminuted (A fracture in which bone is broken, splintered or crushed into a number of pieces)and displaced (when two ends of the bone are separated from one another) [MEDICAL CONDITION] femoral shaft and metaphysis (the wider part at the end of a long bone)." A record review of the facility's incident/accident report dated 12/26/10 at 4:23 a.m. revealed the incident report did not document how the injury occurred. During an interview on 1/6/11 at 11:25 a.m., the DON stated the he stated he talked to the resident and she did not know how she was injured. LVN A told him that CNA B said CNA A hurt the resident's leg during a transfer. The DON said he talked to CNA A and B and CNA B said CNA A transferred the resident by herself when she should have had two people for the transfer. He stated he terminated CNA A for transferring the resident alone, stating, "She knew better" as the transfer needs for this resident were documented on a "data sheet" at the nurse's station. The DON stated the facility had three working mechanical lifts available for staff use in the facility. During a telephone interview on 1/7/11 at 8:55 a.m., CNA B said that CNA A was recently transferred to work with her on her hall, and on 12/26/10 they were working together. She said that she had told CNA A not to transfer Resident #1 without waiting for her (CNA A) to do it with her. She stated CNA A had transferred Resident #1 alone the night before, and she had told CNA A and the charge nurse about it. She stated that she was in a room near Resident #1's when she heard Resident #1 screaming "She broke my leg! I heard it pop!" She stated the resident was moaning and crying in pain. CNA B stated it was about 4:00 a.m. after they had started rounds. CNA B said CNA A was in the resident's room when she arrived and Resident #1 had been transferred into a chair from the bed. She stated there was no equipment in the room (no Hoyer lift). CNA B said when she looked at Resident #1's leg, she could tell that her leg was broken. During an interview on 1/10/11 at 9:00 a.m., CNA A stated she was new to the hall where Resident #1 resided and was not very familiar with the resident's needs. She stated she worked that hall only three shifts prior to 12/26/10. CNA A stated that CNA B told her to get Resident #1 up a little after 4:00 a.m. and so she went to the resident's room alone and transferred her from her bed to her chair. She stated that she did not use the mechanical lift for Resident #1, but she had been told by a charge nurse that if you were strong enough to lift a resident without the mechanical lift, that you could choose not to use the mechanical lift. She stated that she had seen other CNAs do this and it was common practice. She stated she "cradled" Resident #1 in her arms by putting one arm behind her back, and one arm under her thighs and moved her to the chair. CNA A stated the transfer went smoothly and the resident did not voice any discomfort. CNA A stated that after Resident #1 was in her wheelchair, she needed to re-position her but could not do so by herself, so she went to get CNA B. She stated CNA B came in to help her, and when they pulled the resident back in the seat of her chair, the resident's ankle caught in the raised foot rest of the chair, and the resident yelled, "My leg! My leg!" CNA A stated that is when CNA B went to get the nurse. CNA A stated she was aware that a Hoyer lift was recommended for Resident #1. A record review of LVN A's nurse's note dated 12/26/10 at 4:25 a.m. revealed LVN A documented an aide came to him and told him another aide had moved the resident from her bed to the wheelchair by herself and the resident's leg looked "messed up." LVN A documented the resident told him her left leg was hurt when she was moved from the bed to the wheelchair. He documented the resident then stated that she "felt and heard a snap and grinding." A record review of a nurse's note dated 12/26/10 at 12:27 p.m. revealed the nurse documented the resident left in an ambulance at 11:40 a.m. A record review of the facility's Investigation report of Post investigation action taken, signed by the administrator on 12/30/10, revealed that the facility terminated CNA A, in-serviced staff on their transfer policies(the DON stated in 1/6/10 interview that CNAs were reminded to check the data sheets at the nurse's station which tells them what kind of transfer a resident requires), and in-serviced staff to reinforce reporting procedure for unusual incidents and accidents. The actions taken did not address any re-training for safe handling of residents (safe transfers). During an interview on 1/8/11 at 2:00 p.m., CNA G stated that he worked with Resident #1 and she required a Hoyer lift for transfer as she could not bear weight or help in the transfer process. He stated that she was heavy as she was "like dead weight." He stated he would never attempt to transfer Resident #1 by himself. He stated that they have done a sheet transfer with two people for her before. 2. A record review revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of physician's orders [REDACTED]. A record review of Resident #2's care plans dated 5/18/10 and 12/17/10 revealed Resident #2 had a [MEDICAL CONDITION] right side hemilegia, was dependent on staff to meet all activities of daily living, and required the assistance of two staff and a Hoyer lift for transfers. An MDS for Resident #2 revealed her cognitive skills were modified independent, and she had good recall (could recall current season, location of her room, staff names and faces) but she had no speech (her speech was rarely/never understood). During an interview on 1/8/11 at 2:50 p.m., RN A stated that Resident #2 was very fragile because of her potential for chest pain, breathing/respiratory difficulties, and the fact that the resident has some difficulty communicating due to speech. RN A stated that she had learned to communicate with the resident very well, though, because if you take time to ask enough questions, Resident #2 communicated very well using facial expressions, nodding her head yes and no, and using gestures. For example, she stated that Resident #2 pats her chest with an open hand if she is having trouble breathing. She states Resident #2 has been observed to cry when something is wrong or she is in pain. During an observation on 1/6/11 at 1:39 p.m., CNAs D and E were observed to transfer Resident #2 by mechanical (Hoyer) lift from her wheelchair to her bed in her room. CNA D was operating the Hoyer, which was a motorized lift and CNA E was standing by to assist. CNA D positioned the resident's wheelchair with the back of it against the wall and facing the foot of the bed, then both CNAs attached the resident's sling, which was already positioned beneath her in the wheelchair, to the lift. CNA D then began the motor of the lift and as soon as the resident began to be lifted, the resident's wheelchair began to rise off the ground on one side as well. CNA D stopped the motor and lowered the chair and resident back down. She looked at the wheelchair to find a strap of the sling had become wrapped around the handle on the back of the wheelchair. CNA D then began to try and remove the strap that was hung on the wheelchair, but the resident's weight on the sling resulted in not enough slack to loosen the stap enough to pull it off the chair. CNA D struggled and began "yanking" the strap backwards in order to get it off, pulling the sling up each time she yanked on it. CNA E did not attempt to assist, but stood to the side and watched CNA D. Because the resident was sitting on the sling, each "yanking" motion also jostled the resident considerably, bouncing her up and down and back and forth in the wheelchair. Resident #1 was visibly shaken, holding her hands under her chin and making "whimpering" like noises. CNA D repeated this motion five or six times before the strap of the sling finally came off the back of the wheelchair. After pulling the sling upwards so many times, the sling was no longer in place (appropriately) under the resident. The CNAs did not re-position the sling under the resident, but immediately engaged the motor and lifted the resident with the sling as it was. When suspended, it was observed that the top of the sling was way over the resident's head and the bottom of the sling positioned under just her upper thighs, not supporting her legs to the knee as appropriate. Resident #1 began crying more loudly during the transfer. The CNAs guided the sling over the bed and lowered her to the bed. Resident #1 continued to cry. CNA D asked Resident #1 after she was on the bed, "Are you okay?" Resident #1 was non-verbal, but shook her head back and forth, "No." 3. A record review of a medical record face sheet for Resident #3 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital report dated 11/18/10 also documented a history of diabetic [MEDICAL CONDITION] and depression. A review of an MDS assessment dated [DATE] revealed Resident #3 revealed the assessment documented that Resident #3 was totally dependent on the assistance of one staff to transfer, but the nurses documented in nursing notes on 1/5/11 that Resident #3 required maximum assistance of two persons and a Hoyer lift for transfers. During an observation on 1/6/11 at 1:45 p.m., CNAs F and G were observed to transfer Resident #3 by mechanical (Hoyer) lift from her wheelchair to her bed in her room. CNA F engaged the Hoyer lift's brake prior to lifting the resident, which prevented the Hoyer base from adjusting itself during the lift of the resident. When the resident began lifting from the chair, the wheelchair also began to come off the ground and was suspended by one arm. A portion of the sling had hung on the arm of the wheelchair. The resident and chair were lowered back to the ground and the sling released from the wheelchair without difficulty. The resident was then lifted again, facing the base of the Hoyer lift. The CNA assisting was able to move the resident's feet just in time to keep them from hitting the metal base of the Hoyer, but the CNA assisting did not help to guide the resident well once she was suspended, allowing her to "rock" in the air and almost hit her feet on the base of the Hoyer. 4. During an interview on 1/8/11 at 10:45 a.m., LVN E stated she had worked at the facility for almost a year. She stated she had never received training on use of the Hoyer lift and could not assist CNAs if they had a question or monitor whether they were using the Hoyer lift correctly. 5. During an interview on 1/8/11 at 2:00 p.m., CNA G stated that the first time he had ever used a Hoyer lift was when he began working at this facility. He stated he was taught to use the Hoyer lift by another CNA that worked here when he started (and is no longer here.) 6. According to the Texas Curriculum for Nurse Aides in Long Term Care Facilities, the operation of mechanical lifts are not covered as part of the curriculum. 7. During an interview on 1/6/11 at 4:30 p.m., the DON stated that he was not aware that the Hoyer lift brake should not be applied during the lifting of a resident. When discussing the manufacturer's instructions for the facility's lifts, the DON stated he did not have the instructions because they were lost prior to him coming to work there last April. He stated he would try to get instructions. 8. During an interview on 1/7/11 at 10:00 a.m., the DON stated, "You were right. The instructions said not to lock the Hoyer before lifting." The DON stated that he obtained the instructions for the lift. 9. A review of the Owner's Operator and Maintenance Manual for the manual/electric portable patient lift that the DON obtained and provided during this visit, the manual included the following instructions: "-Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object... -When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem-otherwise, injury or damage may occur. -Before transferring a patient from a stationary object (wheelchair, commode, or bed) slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again. -Does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Recommend that rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed, or any stationary object. -Adjustments for safety and comfort should be made before moving the patient..." 10. A record review of a medical record face sheet for Resident #7 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] revealed she was dependent on the assistance of two persons for transfers. During an observation on 1/6/11 at 1:35 p.m., CNAs F and G were observed to transfer Resident #7 from wheelchair to bed and back to wheelchair. Resident #7 was able to assist some with the transfer. The CNA placed the gait belt too high on the resident's waist, under the resident's breasts and around her ribcage, prior to transfer. 11. A record review of a medical record face sheet for Resident #8 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment for Resident #8 dated 12/22/10 revealed she required extensive assistance from one person for transfers. During an observation on 1/7/11 at 11:05 a.m., CNA D was observed to transfer Resident #8 from her recliner to her wheelchair, using a gait belt. CNA D placed the gait belt around the resident and then removed it because she had it on backwards. She then placed the gait belt high around the resident's waist, near her breasts. CNA D then lifted the resident using the gait belt and the gait belt slid over the chest/breasts of the resident. CNA D did not make sure the gait belt was snug enough not to slide up during the transfer. 12. A record review revealed Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan for Resident #6 with no date documented he was unable to feed himself, had poor safety awareness, had a history of [REDACTED]. An MDS assessment for Resident #6 with a date of completion as 1/4/11 documented that Resident #6 had unclear speech and sometimes understood others. His vision was moderately impaired. His cognitive skills were severely impaired. The assessment documented that he required the extensive assistance of one person for transfers, toilet use, and to complete activities of daily living such as dressing. He used a wheelchair for mobility. During an observation on 1/10/11 at 1:30 p.m., CNA J was observed to transfer Resident #6 from his wheelchair to his bed. CNA J was observed to tell Resident #6 that she was going to put a gait belt on him and transfer him, but Resident #6 did not respond. CNA J gave instructions rapidly, stood above him while she talked to him (talking while she applied the gait belt), and did not give him adequate time to respond, given his sensory and cognitive deficits. CNA J told the observer that Resident #6 could bear some weight during the transfer. She placed the gait belt on his waist, and then, without assisting or instructing the resident to move from the back of the chair, CNA J placed her hands on each side of the gait belt, rocked into the resident, and jerked backwards to lift the resident from the chair. Resident #6 did not bear any weight on his feet during the transfer and CNA J carried the resident to the bed by the gait belt. Resident #6 whined as if in pain, during the transfer. CNA J told the resident, "Don't get mad. Don't get mad." When discussing that she had to carry him by the gait belt, CNA J stated, "Oh its no problem, I've been doing this a long time." During an interview on 1/10/11 at 1:35 p.m., the O.T. stated that she had recently completed an evaluation on Resident #6 and stated that he could not bear weight. When discussing the above observation, the O.T., stated that based on her previous evaluation, a one-person transfer would not be recommended for Resident #6. She stated she would re-evaluate the resident and speak to the facility about a two-person transfer for Resident #6. During an observation on 1/10/11 at 3:30 p.m., the O.T. and DON were observed working with Resident #6 in the hallway. They were attempting to get Resident #6 to stand from his wheelchair with their support, and while holding on to the hand-rails. Resident #6 would not stand and bear weight. 13. During a record review of facility incidents and accidents dated from 12/17/10 through 1/6/11 there were two minor injuries reported as a result of transfers. One resident complained of pain in the left clavicle after a CNA admitted ly transferred the resident by raising her underneath her arms, and another resident received a skin tear on her leg during a transfer. 14. During an interview on 1/6/11 at 4:30 p.m., the DON stated that only the restorative staff had been checked off by Therapy for transfer competency demonstation in the last year. He stated that he had planned to do it soon for all the staff. 15. A record review of a form the DON identified as the most recent competency evaluation of CNAs for lifting and transferring revealed it had been completed more than a year ago, in November 2009. It was a list of staff names with dates beside them, that he stated was the date each received a competency check. 16. During an interview on1/10/11 at 4:05 p.m., CNA H stated he had worked at the facility several years. He stated the facility used to have a better system of keeping CNAs informed of resident's transfer needs compared to the recent past, where CNAs are not always informed. He stated he was aware of the data sheets that the facility had instructed the CNAs to look at, but he stated those data sheets had not always been kept current, and CNAs not kept informed. He stated this had been especially true when a new admission came in to the facility. 17. During an interview on 1/10/11 at 1:35 p.m., the Rehabilitation Director said that she provided the staff training and required return demonstration of them to confirm their skills in lifting and transferring, but the staff had not had that training in a little over a year. When discussing raising a resident from the back of a chair or not having the resident moved to the edge of the chair or bed prior to transferring, the Rehabilitation Director stated that moving the resident to the front of the chair prior to the lift was an important step in proper transferring. She stated that lifting the resident from the back of a chair puts more strain on both the staff and the resident, and places both at higher risk of injury. 18. A record review of the most recent facility trainings regarding transfers revealed: In-service sheet dated 12/30/10 that stated in full, "When transferring a pt. be aware of pt. extremities and other surroundings or objects that can be in the way, causing pt. to bump an arm or leg in turn causing harm to the pt. Take your time and be careful." In-service sheet dated 12/26/10 stating in full, "Information about how to assist a specific resident with ADLs can be found on resident Data Sheets which are kept in the flow books. If you are not sure, check these forms or contact DON." 19. A record review of a facility procedure titled, "Transfer of Patient" (undated) revealed it contained the following: "Purpose: To safely move resident from one place to another. Equipment: 1. Gait belt 2. Wheelchair. Procedure: Check physician's orders [REDACTED]. Explain to resident what you are going to do. Position wheelchair at a 45 degree angle. Help resident to sit on edge of the bed with legs and feet hanging over the edge. Stand in front of the resident with a firm grasp on gait belt that has been secured around the waist. Help resident to stand Pivot your body helping resident to pivot towards chair. Bend your knees, keep back straight, and help resident to sit. 20. A record review of a facility procedure titled, "Nurse Aide Proficiency" revealed it included the following: "Procedure: 1. All nurse aides will have a proficiency check done during new employee orientation and yearly at the time of their performance evaluation. 2. The proficiency check is to be done by the In-service Coordinator... 3. Any areas identified as needing additional training will be noted and additional in-service provided as needed. 4. The Nurse Aide Proficiency checklist will be kept in the employee folder and a copy in a separate binder maintained by the In-service Coordinator if desired. 5. The Nurse Aide Proficiency checklist may be updated with new areas to be assessed at any time by the Director of Nurses or other individuals designated." The proficiency checklist form included a list of areas, date, "S" or "U" (satisfactory, unsatisfactory), a column titled "in-serviced" and nurse's initials. The proficiency checklist areas were [MEDICAL CONDITION] and [MEDICAL CONDITION], falls and suspected fractures, [MEDICAL CONDITION], cold packs to strains/fractures, [MEDICAL CONDITION], vomiting and aspiration, clearing obstructed airway, handwhashing, clearing obstructed airway, personal protective equipment, standard precautions, transmission based precautions, communications/interpersonal skills, decubitus prevention, restraints- securing and releasing, termperature/pulse/respirations/blood pressure. The nurse aide proficiency policy did not address competency evaluation for lifting residents. 21. The facility provided a list of 49 residents in the facility that required assistance with transfers. 22. During an interview on 1/7/11 at 12:00 p.m., the Administrator was notified of an Immediate Jeopardy. The following Action Plan was accepted on 1/10/11 to remove the immediacy: -All nursing staff were re-educated on the use of the Resident Data Sheet which provides individual care instructions based on the residents' care plan, including appropriate and safe transfer information. The DON will monitor to ensure this practice continues. Completed 1/8/11. -All CNAs were required to show transfer competency through return demonstration, including the correct use of the Hoyer lift. Newly hired CNAs will not be allowed to work until they have been deemed competent through return demonstration of safe transfer techniques. A quarterly sample of continued transfer safety will be performed and an annual proficiency skills check off will be performed. The date of completion of training was 1/8/11. The action plan implementation was verified through record review of staff training, interviews with staff to verify knowledge, and observations of resident lifting and transfer techniques. The immediacy was removed and the IJ lifted on 1/10/11 at 4:30 p.m., but the facility remained out of compliance at a level of actual harm, because the facility had not yet monitored or evaluated the effectiveness of the Action Plan.