Every finding on record at North Hills Life Care and Rehab

Based on observations, interviews, facility document review, and facility policy review, the facility failed to write the open date on medications for 4 (Resident #5, #32, #33, and #35) and maintained pharmacy packaging of a medication card for 1(Resident #5) of 2 medication carts observed for medication labeling and storage standards. The facility also failed to maintain possession of medication cart/room keys with authorized personnel for all residents in the facility. Findings include: A review of a facility policy titled, Medication Labeling and Storage, revised in February of 2023, indicated medications should remain stored in the packaging it was received from the pharmacy, multi-dose medication should be dated with the date it was opened, and only authorized personnel should have access to keys. During an observation and interview on 08/21/2024 at 2:27 PM, Licensed Practical Nurse (LPN) #2 was asked to retrieve medication for labeling review from the 200-hall medication cart. On inspection of Resident #32's Anoro Ellipita 62.5-25mcg (microgram) inhaler, Resident #33's Symbicort inhaler, and Resident #35's bottle of liquid morphine there were no open dates written on those 3 items. LPN #2 stated all 3 medications had doses utilized from them and were currently in use. Resident #5's Citalopram 20mg (milligram) tab medication card was observed to no longer have intact pharmacy packaging for slots number 29 and 30 instead tape across the back of those slot was holding a pill in each slot. LPN #2 stated someone must have put them back in. During inspection of the medications a person in black scrubs told LPN #2 they needed in the medication room to check the refrigerator and LPN #2 gave the person the set of keys she had used to open the medication cart. The person in black scrubs was seen walking to the medication room, unlocking the door with the keys, and going in alone. The person returned in a couple of minutes and returned the keys to LPN #2. During an interview on 08/21/2024 at 2:55 PM, the Director of Nursing (DON) stated the facility utilized the 28-day rule with opened multi use medications and agreed without the open date written on the medication there would be no way to determine the proper time to throw the medication out. When asked about the pharmacy packaging of two slots on the citalopram medication card being opened and then the pill taped back in the Nurse Consultant #6 stated we have always done that. During a follow-up interview on 08/21/2024 at 3:49 PM, LPN #2 stated the person the key was given to was someone with lab. LPN #2 did not know the person's name, title, or who they worked for. When asked why the facility keys including the key for the medication carts and medication storeroom were handed over to the unidentified lab personnel, the response was it was the LPN #2's practice. During a follow-up interview on 08/21/2024 at 4:08 PM, the Director of Nursing (DON) stated the person in black scrubs was a phlebotomist from their contracted lab company. The DON stated they come in for lab draws and retrieve any specimens from the specimen refrigerator in the medication room, but should not be given the keys to let themselves in. The DON stated LPN #2 should have retrieved the specimens and brought them to the lab personnel and agreed giving the keys to unauthorized personnel was a security issue.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to date and maintain cold food temperature for pudding prepared in the facility's kitchen intended to be served to facility residents. Findings include: A review of a facility policy titled, Food Receiving and Storage, revised in October 2017, indicated all food items and snacks kept on the nursing units must be kept below 41 Fahrenheit and labeled with the use by date. During an observation on 08/20/2024 at 6:33 AM, a clear plastic container holding 20-25 vanilla and chocolate puddings in small plastic tubs with pop-on lids, was seen sitting at the central nurses' station. The container contained no ice and had no water to show where any ice had melted. The individual pudding tubs were not dated. During a concurrent observation and interview on 08/20/2024 at 6:59 AM, the pudding tubs were still sitting in the same location at the nurses' station. When touched they were room temperature. Licensed Practical Nurse (LPN) #3 stated they had been retrieved from the kitchen not long ago for use during medication pass and those not used were put in the refrigerator for resident snacks. LPN #3 stated they never come from the kitchen with a date and when LPN #3 put one on her medication cart the current date was written. Observation of the medication cart showed one vanilla and one chocolate pudding tub with some gone. The date of 08/20/2024 was written on the lid. LPN #3 was asked to take the container sitting at the nurses' station to the Dietary Manager (DM) #4 for information. During a concurrent observation and interview on 08/20/2024 at 7:07 AM, DM #4 stated the pudding tubs were prepared in the kitchen and placed in a storage container in the kitchen refrigerator. The storage container was dated with a sign with the date they were made, but not the individual tubs. DM #4 stated the pudding tubs were good for 7 days but was unaware LPN #3 was dating tubs with the current date. DM #4 stated the pudding tubs had been out too long to be at the correct temperature and would throw them away. During an interview on 08/20/2024 at 10:37, the DON stated the pudding cups should have been on ice but was unaware of the dating process the LPN #3 was using.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene during meal assistance; failed to utilize Enhanced Barrier Precautions (EBP), to maintain sterile and aseptic technique during a dressing removal and failed to maintain aseptic technique for IV tubing, specifically no cap was in place on the tubing to maintain a barrier from contamination for 1 (Resident #62) of 1 resident reviewed for dressing change. Findings include: 1. A review of a facility in-service titled, 400 Hall Certified Nursing Assistant (CNA) Meal Service, dated 08/16/2024, indicated, 1. Keep staff hands from crossing over cups/bowls (inf control). A review of Resident #26's Care Plan, revised on 05/28/2024, revealed the resident had an activity of daily living (ADL) related to muscle loss and had a potential for fluid deficit related to confusion. Interventions included providing care and assistance as needed and encouraging resident to drink fluids. During an observation on 08/19/2024 at 1:20 PM, CNA) #7 was sitting on a stool on the right side of Resident #26. CNA #7 grasped the rim of Resident #26's cup of water, by placing their index finger inside the cup and their thumb on the outside of the rim of the cup, pulled the cup toward the resident, then picked up the cup by placing their hand over the opening and their fingers around the top rim, and handed the cup to the resident, who drank from the cup. CNA #7 rested their hands on their lap, palms down. No hand hygiene was done during this observation. A review of Resident #68's Care Plan, revised on 05/07/2024, revealed the resident had an ADL self-care deficit related to generalized weakness and was dependent on staff to eat. Interventions included encouraging Resident #68 to participate to the extent possible. During an observation on 08/19/2024 at 1:26 PM, CNA #7 was sitting to left of Resident #68, lifted their hands above the table, from their lap and picked up a fork and placed chocolate pudding in Resident #68's mouth, returned the fork to the plate and picked up a biscuit and broke off piece with their hands and gave it to Resident #68 who took a bite. CNA #7 put their hands back in their lap, palms down. CNA #7 lifted hands from their lap, grasped the rim of a cup containing iced tea, by placing their hand over the opening of the cup with their fingers touching the rim, and assisted resident to drink from the cup. No hand hygiene was performed during this observation. A review of Resident #51's Care Plan, revised 03/13/2024, revealed the resident had a communication problem, had limited physical mobility, had the potential for a nutritional problem, had dehydration, had an ADL deficit and required assistance eating. Interventions included anticipating and meeting needs, encouraging resident to drink, setting up resident's meal, encouraging resident to eat, and encouraging resident to participate to the extent possible, On 08/19/2024 at 1:22 PM, CNA #8 was sitting to the right of Resident #51, grasped the resident's cup of water with the palm of their hand over the opening and their thumb, middle, ring and small finger grasping the rim of the cup and a straw was being held in place between their index finger the knuckle of their middle finger. Resident #51 drank from the straw. No hand sanitation was performed during this observation. During an interview on 08/19/2024 at 1:57 PM, CNA #7 stated they should not have grabbed the cup by the rim while assisting Resident #26 or Resident #68 and should not touch resident's food with their bare hands because it could cause germs to be passed to resident. CNA #7 stated they were used to doing that for their son and Just did not think about it and should have sanitized their hands between residents and did not do so because there was not enough sanitizer in the room. The sanitizing station was located on a wall in the assisted dining area. During an interview on 08/19/2024 at 2:18 PM, CNA #8 stated they should have sanitized hands prior to feeding Resident #51 after their hands were in their lap and should not have touched the rim of the cup and straw prior to providing a drink to the resident because something could have dropped into cup from their hands or germs on their hands could have gotten into resident's mouth and caused problems. During an interview on 08/22/2024 at 12:48 PM, the Director of Nursing (DON) stated some residents have compromised immune systems and staff should perform hand hygiene while assisting residents in the dining room, so they are not passing germs from one resident to another and making everyone sick. Staff should not be picking up cups by the rims or placing their fingers inside a resident's cup and giving it to the residents. They should be holding cup by the side (demonstrated on cup on their desk). The DON further stated contaminates on their hands could be transferred to the residents and you don't put your fingers where the resident places their lips. 2. A review of a facility policy titled, Enhanced Barrier Precautions, dated August 2022, indicated Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention. Under EBP, gowns and gloves are used during high contact resident care like device care of a central line. A review of a facility policy titled, Center Venous Catheter Dressing Changes, revised April 2017, indicated central line dressings should be done every 5-7 days. Removal of the old dressing is an aseptic technique. A review of a facility policy titled. Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014, indicated aseptic techniques should be observed at all times when working with intravenous (IV) equipment, IV administration set for IV medications should be discarded if found without a sterile cap at the end of the tubing. A review of the Admission Record, indicated the facility admitted Resident #62 with diagnoses that included bacteremia and sepsis, and that Resident #62 was admitted with a peripherally inserted central catheter (PICC) line, a type of central venous catheter, for long term IV medication administration. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #62's Admission Care Plan, dated 08/08/2024, revealed the resident had an infection of the right great toe. Interventions included EBP and IV medication administration through the right upper arm peripherally inserted central catheter, (PICC) line. Care of the PICC line included weekly dressing changes. During an observation on 08/20/2024 at 1:06 PM, Resident #62's cefazolin IV tubing was seen hanging on the IV pole. The end of the tubing was left but open to air without a cap. Resident #62's right upper arm PICC line dressing was dated 08/06/2024. During an interview on 08/20/2024 at 1:08 PM Registered Nurse (RN) #1 did not know the date on Resident #62's PICC line dressing and didn't not know the policy for how often dressings were changed. After accessing the Medication Administration Record (MAR), RN #1 stated it was due on Tuesdays. RN #1 stated no knowledge of a policy for IV tubing care. During a concurrent observation and interview on 08/20/2024 at 2:28 PM, the Assistant Director of Nursing (ADON) prepared setup for Resident #62's PICC line dressing without putting on a gown as required when utilizing EBP. The ADON stated the date on the PICC line dressing was 08/06/2024 and should have been changed a week ago. The ADON used gloved hands and touched Resident #62's face when applying a mask but did not remove the dirty gloves or perform hand hygiene prior to removing the old PICC line dressing. The ADON's left dirty gloved hand touched the PICC line insertion site while the right dirty gloved hand pulled the old dressing off. The ADON stated the IV medication tubing should have a cap on it to reduce infection risk from exposure and it now needed to be thrown away.

Based on observation, record review, and interview, it was determined the facility failed to ensure physician orders were followed for 1 (Resident #62) of 1 resident observed receiving medications from 1 (Licensed Practical Nurse (LPN) #9) of 3 nurses observed during medication pass. Findings include: A review of a facility in-service titled, 7 Rights of medication Administration, dated 08/15/2024, indicated, Must Check All Before Administering Any Medication: 1. Right Resident 2. Right Medication 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation 7. Right Reason. A review of the Admission Record, indicated the facility admitted Resident #62 with diagnoses that included local infection of the skin and subcutaneous tissue of the right toe. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and had an infection of the right toe and was receiving an antibiotic by intravenous (IV) route. A review of Resident #62's Care Plan, revised 07/24/2024, revealed the resident had IV (intravenous) medication (an antibiotic) related to an infection of the right great toe. Interventions included administering an antibiotic per MD (medical doctor) orders, an Inservice of nursing staff on 08/15/2924 due to resident receiving the wrong medication by IV. A review of the Order Summary, revealed Resident #62 had an antibiotic being administered through a peripherally inserted central catheter (PICC) line (an access used for different medical purposes such as delivering fluids containing medications into a person's vein), a saline flush intravenous solution, Flush PICC line with 10cc (cubic centimeters) normal saline (NS) before and after IV medication administration, and a standing order for the SASH (saline, antibiotic, saline, heparin) protocol was to be followed with IV administration of antibiotic, 10cc / administer medication/Saline 10cc/heparin 5cc. A review of the Standing Orders [Named Medical Doctor]as of 08/07/2024, indicated the SASH protocol was to be used for PICC lines with medication administration. SASH protocol included 10cc NS, medication administration, 10cc NS, and 5cc Heparin. During an observation on 08/21/2024 at 5:08 AM, LPN #9 entered Resident #62's room to administer an antibiotic. LPN #9 attached a 10cc syringe containing Normal Saline, to the PICC line, located in the resident's right arm, and administered a portion of the saline. LPN #9 attached the antibiotic to the PICC line and infused the antibiotic using a medication pump. LPN #9 stated 8 and a half milliliters (ml) of normal saline was placed in the IV line prior to starting the antibiotic. [Milliliters and cubic centimeters are the same measurement or volume of a substance and wording is interchangeable] During an observation on 08/21/2024 at 6:04 AM, LPN #9 returned to Resident #62's room, turned off the medication pump and removed IV medication line from PICC line, attached a 10cc syringe containing 10ml of NS flush to the PICC line and administered a portion of the fluid. LPN #9 removed the NS syringe and attached a syringe containing 5ml of Heparin lock to the PICC line and administered the heparin. LPN #9 was asked how much NS flush was used and stated 7ml and 5ml of Heparin. During an interview on 8/21/2024 at 7:54 AM, LPN #9 was asked how much NS is ordered to flush the PICC line prior to administering Resident #62's antibiotic. LPN #9 stated 10ml and only 8 and a half was used. LPN #9 was asked how much NS is ordered to flush the PICC line after administering the antibiotic. LPN #9 stated 10ml and 7ml was used. LPN #9 stated 10ml should have been used both times because that is what the doctor ordered, and physicians orders should be followed because the NS is used to flush all the medication from the line to ensure the resident receives all the medication. During an interview on 08/22/2024 at 12:46 PM, the Director of Nursing (DON) stated staff should follow physician orders for flushing a resident's PICC line because it is in the best interest of the patient. If it is not done it could cause a decline in the resident's health.

Based on observations, interviews, facility record review, it was determined that the facility failed to provide privacy during care for 1 (Resident #62) of 1 resident reviewed for privacy. Findings include: A review of the facility admission packet including the Resident Handbook, which provided the Arkansas Patient Rights Section 9, signed by the Resident #62 and Admission Director #5 on 07/20/2024, indicated, residents have the right to have privacy in treatment. A review of the Admission Record, indicated the facility admitted Resident #62 with diagnoses that included bacteremia and sepsis. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During an observation and interview on 08/20/2024 at 2:28 PM, the Assistant Director of Nursing (ADON) entered Resident #62's room to perform a peripherally inserted central catheter (PICC) line dressing change. Resident #62's roommate with two family members were also in the room, all had direct line of sight to Resident #62 and the ADON during the procedure. The ADON failed to pull the room's curtain or ask Resident #62 if the resident was comfortable with spectators during the procedure. During the sterile part of the dressing change the ADON looked at the curtain divider and stated they should have pulled the curtain before performing the procedure.

Based on observation, interview and record review, the facility failed to notify the Resident's representative of changes to medication for one (Resident #1) of three (Resident #1, #2, and #3) sampled residents. The findings are: Resident #1 with an admitted [DATE] had a diagnosis of Parkinson's disease. The Admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 8/18/23 documented a staff assessment of mental status [SAMS] of severely impaired. Physician Orders dated 08/11/2023 documented, Carbidopa Levodopa 25/250 mg [milligrams] take 3 tablets four times a day. A change made on 11/06/2023 showed, Carbidopa-Levodopa Oral Tablet 25-250 MG (Carbidopa-Levodopa) Give 2 tablet by mouth four times a day related to Parkinson's Disease . then on 12/08/2023 to, Carbidopa-Levodopa Oral Tablet 25-250 MG (Carbidopa-Levodopa) Give 1 tablet by mouth four times a day related to Parkinsonism for 7 Days, Decrease to 1 tablet four times a day [QID] x 7 days then discontinue .Amantadine HCl Oral Capsule 100 MGH. Give 1 capsule by mouth two times a day related to Parkinson's Disease give medication with breakfast and supper, which was changed to Amantadine HCl Oral Capsule 100 MG (Amantadine HCl) Give 1 capsule by mouth two times a day related to Parkinson's Disease . Interdisciplinary Team [IDT] progress note dated 12/07/2023 documented, .Current Care Plan [CP] Interventions and Effectiveness: Carbidopa-Levodopa decreased to one tablet QID (four times per day) x 7 days then dc (discontinue) . Physician Assistant-Certified [PA-C] #1 progress notes dated 09/05/23, documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #2 progress notes dated 09/29/23 documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #3 progress notes dated 10/23/2023 documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #4 progress notes dated 11/08/2023, 11/17/2023 and 12/05/2023 documented, .Neurologic: Coordination and Cerebellum: Resting tremor . PA-C #4 progress notes dated 12/11/2023 documented.Assessment Plan; 1. Parkinsons disease- Per Behavioral Medicine rec: resume gradual dose reduction [GDR]: (carbidopa Levodopa) 25-200 mg 1 tablet QID x 1 week discontinue (carbidopa levodopa) in 7 days . Unable to locate documentation in Resident #1's medical chart of notification to representative or responsible party of dosage decrease of carbidopa levodopa with intent to discontinue. On 05/06/2024 at 3:30 PM Resident 1's relative was interviewed on the phone. Relative stated the family was never made aware of decreasing or stopping Parkinson's medications. Also, said when PA-C #4 was asked by another relative why the medications were being stopped they were told it was due to Resident #1 not having tremors. Relative stated they were concerned due to Resident #1 being on this medication for over [AGE] years and having a deep brain stimulator that helps control Resident #1's tremors. On 05/07/2024 at 11:20 AM, PA-C #4 was interviewed by phone, and confirmed being familiar with Resident #1 and thinks the carbidopa levodopa was being decreased due to resident having a neurostimulator, to reduce side effects and to prevent the use of unnecessary medications. On 05/07/2024 at 4:42 PM, surveyor spoke with the Primary Care Physician [PCP]/ Medical Director, who said Resident #1's record is being reviewed at that time and confirmed being familiar with Resident #1's tremors and shuffling gait walk which is indicative of Parkinson Disease. They were not aware of Resident #1 having a deep brain stimulator and did not have record of a medication decrease in carbidopa levodopa.

Based on observation, interview and record review, the facility failed to ensure a complete surgical history was obtained and surgical diagnosis history forwarded from the pre-admission screen for one Resident #1 of three (Resident #1, #2 & #3) sampled resident. This failed practice had the potential to have an adverse effect on the resident due to medical staff not having all the information to make an informed decision concerning care. The findings are: The pre-admission screen completed on 08/10/2023 documented, .has deep brain stimulator . Review of the pre-admission screen document Resident #1 was admitted on [DATE] and had a diagnosis of Parkinson's disease. The Admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 8/18/23 documented a staff assessment of mental status [SAMS] of severely impaired. Under section J of the MDS (Health Conditions), under neurological surgery, Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or drainage devices question is marked no, indicating Resident does not have this device. Resident #1's Physician's orders date of 08/23/2023 showed, an order for Carbidopa- for Parkinson's disease with an order date of 08/23/2023. The medication order was changed on 11/06/2023 from 3 tablets four times a day to 2 tablets four times a day. The medication order was changed again on 12/07/2024 to give 1 tablet four times a day. Review of hospital discharge paperwork dated 11/31/2023 listed medication, .Carbadopa-Levodopa 25/250 MG 2 tabs QID (four times a day) . Review of the Provider Progress notes did not address the Carbidopa-Levodopa dosage decrease with the intent to discontinue nor was there any communication with resident's spouse. On 05/06/2024 at 3:30 PM, Resident #1's spouse was interviewed on the phone, and said the family was never made aware of decreasing or stopping Parkinson's medications, and were concerned about the medication adjustment, and that Resident #1 had a deep brain stimulator that was helping a lot with Parkinson's symptoms, but Resident #1 still needed the medication. The family member stated the fact that Resident #1 had a deep brain stimulator was in Resident #1's chart, that this helped control the tremors but that the medication was still needed. On 05/07/2024 at 11:20 AM, Certified Physician's Assistant (PA-C) #4 was interviewed by phone and confirmed being familiar with Resident #1 and thinks the carbidopa levodopa was being decreased due to resident having a neurostimulator, to reduce side effects and to prevent the use of unnecessary medications. On 05/07/2024 at 3:30 PM the surveyor interviewed Licensed Practical Nurse [LPN] #1, who worked the secure unit. The surveyor asked LPN #1 and she noticed Resident #1 having tremors. LPN #1 replied, Maybe a little. When asked if she was aware of Resident #1 having a deep brain stimulator to help control tremors, LPN #1 confirmed not being aware. The surveyor asked LPN #1 if Resident #1 was noted to have an increase in tremors with the decrease in carbidopa levodopa. LPN #1 said she did not notice an increase in tremors. During an interview on 05/07/2024 at 4:42 PM Primary Care Physician]/ Medical Director, confirmed Resident #1 had tremors and walked with a shuffling gait indicative of Parkinson Disease but was not aware of the Resident having a deep brain stimulator and did not have record of a medication decrease in Carbidopa levodopa.

Based on observation, record review, and interview, the facility failed to ensure food was served in a sanitary manner to prevent cross contamination for 2 (Residents #26 and #65) of 5 (Residents #22 #26, #52, #63 and #65) sampled residents who are served meals in the 400 Hall Dining Room. This failed practice had the potential to affect 19 residents (total census: 75) who are served meals in the 400 Hall Dining Room as documented on a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. On 05/30/23 at 12:35 PM, Certified Nursing Assistant (CNA) #1 removed plastic wrap from cups and served chocolate cake, water, and tea to Resident #26 with her fingers on the rim of the cups and bowl. 2. On 05/30/23 at 12:37 PM, CNA #2 removed plastic wrap from cups and served chocolate cake, water, and tea to Resident #65 with her fingers resting on the rim of the cups and bowl. 3. On 05/31/23 at 3:16 PM, the Surveyor asked CNA #1 to explain the purpose of plastic wrap covering glasses and food when serving residents, and the process for serving food to the residents. CNA #1 said, Well I guess contamination purposes. Nobody has really shown me a process or talked to me about it. CNA #1 held her hand up demonstrating setting a cup down and said, Oh, I touched the rim. The Surveyor asked what the possible outcome was from touching the rim. She said, Contamination, and we have COVID. 4. On 06/01/23 at 9:35 AM, the Surveyor asked CNA #2 why it is important to serve meals in a sanitary manner without touching the rims of cups and bowls. CNA #2 said, Residents drink from the cups and it would be cross contamination. The Surveyor asked what the possible outcome was from not serving meals in a sanitary manner. CNA #2 said, Residents are vulnerable and more prone to get sick. 5. On 06/01/23 at 10:20 AM, the Surveyor asked the DON who was responsible for serving meals and what type of training they received. The DON said, The CNAs serve meals, but anyone can assist. The CNAs are trained before they get here. The Surveyor asked why it would be important to serve meals using sanitary practices. The DON said, For infection control. The Surveyor asked what a possible outcome could be of serving meals not using sanitary practices. The DON said, Residents could get sick.

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for oxygen therapy for 1 (Resident #11) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents with Physician Orders for oxygen therapy per a list provided by the Administrator on 06/01/23 at 8:58 AM, and failed to ensure MDS assessments were accurately coded for Preadmission Screening and Resident Review (PASARR) II for 3 (Residents #1, #2 and #5) of 4 (Residents #1, #2, #5 and #24) sampled residents with serious mental health diagnoses per a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #1 had diagnoses of Paranoid Schizophrenia and Anxiety Disorder, Unspecified. The Annual MDS with Assessment Reference Date (ARD) of 04/03/23 documented the resident was not currently considered by the Level II PASARR process to have a serious mental illness. a. A State Designated Professional Associates Assessment/Letter dated 08/17/94 provided by the Administrator on 06/01/23 at 2:00 PM documented recommendations for placement and specialized services for Resident #1 serious mental illness. b. A Care Plan with a revision date of 04/24/13 documented, Resident has a current diagnosis of Anxiety, Paranoid Schizophrenia . Behavioral health consults as needed . 2. Resident #2 had a diagnosis of Bipolar Disorder, Unspecified. The Annual MDS with an ARD of 07/27/22 documented the resident was not currently considered by the Level II PASARR process to have serious mental illness. a. A State Designated Professional Associates Assessment/Letter dated 11/04/04, provided by the Administrator on 06/01/23 at 8:58 AM documented, .Section 3: Psychiatrist's Conclusions . 2. Has been identified as having the following serious mental illness . Bipolar Disorder . b. A Care Plan with a revision date of 08/14/20 documented, The resident uses psychotropic medications Abilify r/t [related to] Disease process - Bi-Polar . 3. Resident #5 had diagnoses of Bipolar Disorder, Anxiety Disorder, and Unspecified Dementia. The Annual MDS with an ARD of 7/12/22 documented the resident was not currently considered by the Level II PASARR process to have a serious mental illness. a. a State Designated Professional Associates Letter dated 01/26/17 provided by the Administrator on 05/31/23 at 11:43 AM documented, .You do not require specialized services for your mental illness (MI), intellectual disability, and/or developmental disability (ID/DD) beyond the capabilities of a nursing facility . Surveyor: [NAME], [NAME] L 4. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of Bronchus or Lung. The Admission MDS with an ARD of 04/14/23 documented the resident did not receive oxygen therapy. a. The (Nursing) Admit/Readmit Assessment and Care Plan dated 04/04/23 revealed the resident had oxygen at 3 liters via nasal cannula. b. On 05/31/23 at 02:34 PM, the Surveyor asked the MDS Coordinator if Resident #11's Baseline Care Plan had oxygen marked. The MDS Coordinator stated, Yes it does. The Surveyor asked if the Admission MDS had oxygen marked. The MDS Coordinator stated, I hope it does. It is not marked. No ma'am it is not. I need to do a correction to correct the coding. The Surveyor asked if that coding would impact the development of Resident #11's individualized Comprehensive Care Plan. The MDS Coordinator stated, Yes, it can. It pulls off the MDS. 5. On 06/02/23 at 7:57 AM, the Surveyor asked the MDS Coordinator if [Residents #1, #2 and #5] had diagnoses to require a PASSRR II. The MDS Coordinator stated, Looks like it yes for Resident #1 and Resident #5. I'm not seeing that it's [PASSRR] scanned, so I would not know for Resident #2. The Surveyor asked if the Annual MDS dated [DATE] was marked in Section A1500 for Resident #5, if the Annual MDS dated [DATE] was marked in Section A1500 for Resident #2, and if the Annual MDS dated [DATE] was marked in Section A1500 for Resident #1. The MDS Coordinator stated, I know [Resident #1] should be. It is marked No. For [Resident #5] it says No. That was the person before me. It should be marked Yes. For [Resident #2] it is marked No. I guess it should be marked Yes, but that one [PASARR] is not scanned in. The Surveyor asked if Resident #2's diagnoses would trigger a PASARR II. The MDS Coordinator stated, Probably with the psychotic disorder with delusions and Bipolar as well. We should have marked it Yes. The Surveyor asked what the possible outcomes could be for a PASRR not being marked accurately on the MDS. The MDS Coordinator stated, Um, honestly I am not 100% sure. I know it throws off our records with Medicaid and Medicare and obviously we are missing things that impact their care. 6. On 06/02/23 at 7:56 AM, the Surveyor asked the Director of Nursing (DON) if it is important that the MDS be coded correctly and why. The DON stated, Yes. To provide accurate care. The Surveyor asked what the outcome could be of not coding the MDS correctly for PASSAR. The DON stated, The resident may not get the services they need, and to provide the correct care. 7. The facility policy titled, Certifying Accuracy of the Resident Assessment, provided by the Administrator on 06/01/23 at 8:58 AM documented, Policy Statement All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and implementation . 2. All personnel who complete any portion of the MDS assessment .must sign assessment certifying the accuracy of that portion of the assessment . 46032

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the Physician Ordered rate for 2 (Residents #11 and #227) and oxygen tubing was changed weekly for 1 (Resident #29) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents who received oxygen therapy and failed to ensure Continuous Positive Airway Pressure (CPAP) tubing was stored to prevent contamination for 1 (Resident #227) of 2 (Residents #8 and #227) sampled residents with Physician Orders for CPAP therapy as documented on lists provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Malignant Neoplasm of Bronchus or Lung. a. Physicians Orders dated 04/04/23 documented, Oxygen @ [at] 3 L [liters] as needed for shortness of breath 3 liters/min [minute] per nasal cannula PRN [as needed] . Oxygen @ 3 L every shift for shortness of breath . b. On 05/30/23 at 11:06 AM, Resident #11 was asleep in his wheelchair with oxygen (O2) via nasal cannula at 4 lpm [liters per minute]. c. On 05/30/23 at 12:17 PM, Resident #11 was sitting in his wheelchair in his room with O2 via nasal cannula at 4 lpm. d. On 05/30/23 at 12:19 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 what Resident #11's O2 flow rate was set at. She stated, It's at 4. The Surveyor asked what the Physician Orders were. LPN #2 stated, I am not sure I will have to look it up. I don't want to say the wrong thing. LPN #2 looked in the electronic records and stated, It should be at 3. The Surveyor asked what the outcome could be if it is at the wrong rate. LPN #2 stated, Well, he does have Neoplasm and shortness of breath. It's not at the right rate. It's one over. e. On 05/31/23 at 10:53 AM, the Surveyor asked the Interim Director of Nursing (DON) when the oxygen concentrator rates were checked. The DON stated, Every shift. The Surveyor asked what the possible outcomes were for the concentrator being at the wrong flow rate. The DON stated, I guess it depends. I don't really know. I guess if a diagnosis could cause COPD or if it's too low and they don't get enough oxygen. Lots of things I suppose. 2. Resident #29 had diagnoses of Acute Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Emphysema and Shortness of Breath. a. A Physicians Order dated 12/25/22 documented, Change and date O2 tubing and water bottle q [every] week every night shift every Sun [Sunday] . b. On 05/30/23 at 11:34 AM, Resident #29 was lying in bed receiving oxygen via nasal cannula. The O2 tubing and clear plastic storage bag were dated 05/21/23 and the humidifier bottle was not dated. c. On 05/30/23 at 12:35 PM, Resident #29 was lying in bed receiving oxygen via nasal cannula. The O2 tubing and clear plastic storage bag were dated 05/21/23 and the humidifier bottle was not dated. d. On 05/30/23 at 12:36 PM, the Surveyor asked LPN #2 what the date was on the oxygen tubing Resident #29 was currently using and the date on the storage bag. LPN #2 stated, 5/21. The Surveyor asked when the tubing was changed. LPN #2 stated, Weekly on Sundays. The Surveyor asked what the outcome could be if the tubing was not changed. LPN #2 stated, It's just dirty. She needs a clean one. They shouldn't be using dirty ones. e. On 05/30/23 at 12:44 PM, LPN #2 stated, I don't have an explanation for that. f. On 05/31/23 at 10:53 AM, the Surveyor asked the Interim DON when the oxygen tubing was changed. The DON stated, Weekly. The Surveyor asked what the possible outcomes were for the tubing not being changed. The DON stated, I guess it's infection control. That's the only thing I can think of. 3. Resident #227 had a diagnosis of Acute Respiratory Failure with Hypoxia. a. The Physician Orders dated 05/18/23 documented, Oxygen @ 2L/ Min via nasal cannula as needed for Shortness of Breath 2 Liters/min per nasal cannula PRN and every shift for Shortness of Breath . CPAP Per home settings at bedtime . Clean CPAP machine and tubing ensure it has water. in the morning . b. On 05/30/23 at 10:59 AM, the Surveyor asked Resident #227 how much oxygen she wears. Resident #227 said, 2-3 liters. Resident #227 had 1.5 liters oxygen. A nasal canula was in a bag, the oxygen tubing and humidifier bottle were dated 05/29/23. A CPAP mask was in a bag with no date. The oxygen tubing connected to the CPAP was dated 05/29/23. The open end was lying in the floor, between the window and the bed. Resident #227 said, That is not supposed to be there. I distinctly remember telling the new aide early this morning that it had to go into the bag, not the floor. c. On 05/30/23 at 2:20 PM, Resident #227 was resting in bed. The open end of the oxygen tubing dated 5/29, connected to CPAP, was lying in the floor under the bedside table. Resident #227 said, Staff has been in to check on me, but they still have not picked up that oxygen tubing. d. On 05/31/23 at 8:20 AM, Resident #227's CPAP hose was lying on the bedside table, unattached to the face mask and not in a bag. e. On 05/31/23 at 11:35 AM, the Surveyor asked LPN #1 to verify how much oxygen Resident #227 was receiving and the process for storing oxygen and CPAP tubing and supplies. LPN #1 said, She is on 1 liter of oxygen. LPN #1 picked up the tubing and hoses, some bagged and some not and said, It should be in a bag and dated. This CPAP hose is usually connected and stays in a bag. The Surveyor asked if it is acceptable for oxygen tubing to lay in the floor. LPN #1 said, No, it is not, and it should be thrown away. LPN #1 opened the top drawer of the bedside table and pulled out new tubing that was not in the original packaging. The Surveyor asked what the possible outcome of tubing and CPAP supplies not being stored properly could be. LPN #1 said, Introducing bacteria. f. On 05/31/23 at 12:38 PM, the Surveyor asked the DON who was responsible for the ongoing monitoring and storage of oxygen and CPAP equipment. The DON said, Nurses on the floor, Certified Nursing Assistants [CNA], or anyone that rounds. The Surveyor asked if it is appropriate for tubing to be on the floor. The DON said, It depends on if the resident is messing with it. The Surveyor asked what possible outcomes could come from the inappropriate storage of Oxygen/CPAP equipment and tubing on the floor. The DON said, Infection control probably. 4. A facility policy titled, CPAP/BiPAP [Bilevel Positive Airway Pressure] Support, provided by the Administrator on 06/01/23 at 8:58 AM documented, .Preparation l. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. 2. Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory and gastrointestinal status. 3. Review the physician's order to determine the oxygen concentration and flow . 4. Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery . The policy does not address the storage of the mask, hose and tubing when not in use. 5. A facility policy titled, Oxygen Administration, provided by the Administrator on 06/01/23 at 8:58 AM documented, .Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Steps in the Procedure . 8. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 47916

Based on interview, and record review, the facility failed to ensure generally accepted accounting principles were followed to ensure insurance premiums were paid timely for 1 (Resident #42) of 3 (Residents #2, #22 and #42) sampled residents whose personal funds were reviewed. The failed practice had the potential to affect 32 residents with resident trusts managed by the facility per a list provided by the Business Office Manager (BOM) on 06/01/23 at 10:08 AM. The findings are: 1. Resident #42's Annual Transaction Report provided by the BOM on 06/01/23 at 10:17 AM documented Dental Insurance Premiums of $111 - paid 02/28/23, 03/10/23 and 04/14/23. The Facility Notification dated 12/14/22 revealed the amount owed to Resident #42's dental insurance was $222 per month for the months of November 2022, December 2022, and January 2023, and the Facility Notification dated 05/05/23 revealed the amount owed to Resident #42's dental insurance was $111 per month from November 2022 through June 2023. 2. On 06/01/23 at 12:01 PM, the Surveyor asked the BOM if Resident #42's premium had been paid for November 2022 through January 2023. The BOM stated, [Resident #42] cancelled her insurance premium in June 2022 and kept dental. We contacted DHS [Department of Human Services] and they finally changed her liability. I don't know if it goes back to November. After reviewing the DHS notice, the BOM stated, [Insurance Provider] ended in June 2022 and her [Dental Provider] started in November. The Surveyor asked if payment of those premiums had occurred or if DHS had been notified of the dental premium starting later. The BOM stated, No, because I had not realized that. Maybe it did and we need to go back and pay for those months. I don't know on that one. 3. On 06/01/23 at 1:58 PM, the Surveyor asked the BOM what possible outcomes could occur if a resident's insurance premium was not paid. The BOM stated, They would lose their insurance. 4. On 06/01/23 at 2:00 PM, the Surveyor asked the Administrator what possible outcomes could occur if a resident's insurance premium was not paid. The Administrator stated, They could lose their insurance. 5. On 06/01/23 at 2:48 PM, the Consultant stated, We did not get the adjusted insurance premium until this month. The Surveyor asked if the insurance premium amount on the DHS Facility Notification should have been billed for November forward until the correction was received. The Consultant stated, We knew it was wrong, so we did not bill it. 6. On 06/01/23 at 3:28 PM, the Consultant stated, It is a verbal agreement with [Dental Insurance]. Sorry, I wish I had something in writing, but I don't. 7. The facility policy titled, Patient Trust, provided by the Administrator on 06/01/23 at 3:38 PM documented, .1. Trust accounts are the facility responsibility to maintain .2. Accurate ledger balances and individual resident trust accounting must be maintained at all times . i. Trust Draft authorization . allows the facility to make recurring deductions from the patient's trust monies . 11. Each month, the Patient Trust checkbook and individual ledgers . are reconciled .

Based on observation, record review and interview, the facility failed to develop and implement the plan of care for oxygen use for 2 (Residents #11 and #227) of 7 (Residents #5, #8, #9, #11, #22, #29 and #227) sampled residents who had Physician Orders for oxygen therapy as documented on a list provided by the Administrator on 06/01/23 at 8:58 AM. The findings are: 1. Resident #11 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Malignant Neoplasm of Bronchus or Lung. The Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 04/14/23 documented the resident did not receive oxygen therapy. a. The Physician Orders dated 04/04/23 documented, Oxygen @ [at] 3 L [liters] as needed for shortness of breath 3 liters/min [minute] per nasal cannula PRN [as needed] . Oxygen @ 3 L every shift for shortness of breath . b. The Nsg (Nursing) Admit/Readmit Assessment and Care Plan dated 04/04/23 revealed oxygen at 3 liters via nasal cannula. c. The comprehensive Care Plan with an initiated date of 04/04/23 and a revision date of 05/11/23 did not address care areas and/or interventions for oxygen therapy. d. On 05/30/23 at 11:06 AM, Resident #11 was asleep in his wheelchair with oxygen (O2) via nasal cannula at 4 lpm [liters per minute]. e. On 05/30/23 at 12:17 PM, Resident #11 was sitting in his wheelchair in his room with O2 via nasal cannula at 4 lpm. f. On 05/31/23 at 2:34 PM, the Surveyor asked the MDS Coordinator if Resident #11's Baseline Care Plan had oxygen marked. The MDS Coordinator stated, Yes it does. The Surveyor asked if the Admission MDS had oxygen marked. The MDS Coordinator stated, No ma'am it is not. The Surveyor asked if that coding would impact the development of Resident #11's individualized Comprehensive Care Plan. The MDS Coordinator stated, Yes, it can. It pulls off the MDS. It does not have anything about oxygen on the Closet Care Plan. It [Comprehensive Care Plan] was done on 5/30 [05/30/23]. I know I am reaching. It was missed on there until yesterday. g. On 06/02/23 at 7:58 AM, the Surveyor asked the Interim Director of Nursing (DON) if all services provided to residents are care planned. The DON stated, Yes. The Surveyor asked if Resident #11 had a Care Plan for oxygen prior to survey entry. The DON stated, No, it was not. The Surveyor asked what the potential outcomes of oxygen therapy not being on the Closet or Comprehensive Care Plans. The DON stated, The resident would not get accurate care or the care he needs. 47916 2. Resident #227 had diagnoses Acute Respiratory Failure with Hypoxia and Multiple Myeloma not having achieved Remission. a. The Physician Orders dated 05/18/23 documented Oxygen @ [at] 2L/Min [liters per minute] via nasal cannula as needed for Shortness of Breath 2 liters/min per Nasal Cannula PRN and every shift for Shortness of Breath . Clean CPAP machine and tubing ensure it has water in the morning . b. The Comprehensive Care Plan with an initiated date of 05/18/23 did not address oxygen therapy of CPAP care. c. On 06/02/23 at 7:50 AM, the Surveyor asked the MDS Coordinator to pull up the Care Plan for Resident #227 and explain the process for initiating the Baseline Care Plan and staff responsible for completing the Baseline Care Plan. The MDS Coordinator said, The nurses initially assess the resident and starts the Baseline Care Plan, and then I follow up on it. The nurses are initially responsible for the Baseline Care Plan, and we have 48 hours to get it done. The Surveyor asked if it was appropriate to not include respiratory therapy for oxygen and CPAP in the Baseline Care Plan for Resident #227. The MDS Coordinator said, It is not appropriate, and should be included in the Baseline Care Plan. The Surveyor asked what the possible outcomes were of leaving respiratory therapy, oxygen, and CPAP off the Baseline Care Plan. The MDS Coordinator said, It can cause a readmission, hypercapnia, hypoxia, lots of things. d. The facility policy titled, Care Plans - Baseline, provided by the DON on 06/01/23 at 1:33 PM documented, Policy Statement A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation . 2. The Interdisciplinary Team will review the healthcare practitioner's orders . and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician Orders; c. Dietary Orders; e. Social Services; and f. PASARR recommendation, if applicable. 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . 3. The facility policy titled, Care Plans, Comprehensive Person-Centered, provided by the Administrator on 06/01/23 at 8:58 AM documented, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . m. Aide in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident .

Based on observation, record review and interview, the facility failed to ensure a resident had on matching shoes to promote dignity for 1 (Resident #27) of 23 (Residents #22, #64, #49, #1, #57, #9, #50, #218, #52, #61, #33, #7, #121, #40, #60, #59, #27, #169, #28, #20, #11, #46 and #26) sampled residents who required assistance with dressing; failed to ensure staff sat at the resident's eye level and did not stand over them while assisting them with eating to promote dignity for 1 (Resident #28) of 3 (Resident #57, #169 and #28) sampled residents who required assistance with eating according to lists provided by the Director of Nursing (DON) on 3/17/22; failed to ensure housekeeping did not sweep the floor while the resident was eating to promote respect for 1 of 1 (Resident #60) who eating lunch in her room and failed to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag to promote dignity for 1 (Resident #169) of 1 sampled resident who had an indwelling catheter. The finds are: 1. Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/21 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision and setup with dressing. a. The Plan of Care with a revision date of 12/17/2021 documented, .Resident has an ADL [Activities of Daily Living] self-care deficit r/t [related to] acute fx [fracture] of lumbar spine . requires supervision by one staff to dress . b. On 03/14/22 at 1:20 PM, Resident #27 was ambulating up and down the Secured Unit hallway with a rolling walker wearing two different shoes. She had on a navy blue with a white sole shoe on the right foot and a black with black sole shoe on the left foot. c. On 03/16/22 at 9:00 AM, Certified Nursing Assistant (CNA) #3 was asked, Is [Resident #27] capable of choosing a matching pair of shoes to wear and putting them on herself? She stated, Sometimes. She was asked, Who is responsible for making sure she has on matching shoes while ambulating throughout the Secured Unit? She stated, We [CNA's] are? 2. Resident #28 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of 01/06/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Alzheimer's . EATING: The resident requires (EXTENSIVE assistance) by (X [times]1) staff to eat . b. On 03/15/22 at 8:44 AM, Licensed Practical Nurse (LPN) #1 served Resident #28 her breakfast tray in her room. LPN #1 was standing beside the bed bending over Resident #28 spoon feeding her. LPN #1 was asked, When feeding the resident should you stand over her? LPN #1 replied, No. LPN #1 was asked, Why? She replied, Its a dignity issue. c. On 03/16/22 at 12:40 PM, Certified Nursing Assistant (CNA) #1 served Resident #28 her lunch tray in her room. CNA #1 was standing beside the resident's bed bending over the resident spoon feeding her. CNA #1 was asked, When feeding the resident, should you stand over her? She replied, No, I would sit beside her, if I had a chair. d. The facility policy titled, Assistance with Meals, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity . Not standing over residents while assisting them with meals . 3. Resident #169 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) was not available for review at the time of the survey. a. The March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 03/17/22 . b. Care Plan with an initiated date of 03/10/22 documented, The resident has (SPECIFY: Indwelling Suprapubic) Catheter: . No interventions were addressed.The resident has (chronic) [CONDITION(S)] . Monitor for s/sx [signs/symptoms] of infection, [CONDITION(S)] [Urinary Tract Infection]. c. On 03/14/22 at 12:30 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #169 with the lift from her high back wheelchair to her bed. CNA #5 removed the resident's catheter bag from under the wheelchair and hung the catheter bag on the lift pad above the resident's bladder. The resident was lowered onto the bed without incident. CNA #5 hung the catheter bag on the right side of the bed. The catheter was not in a privacy bag. d. On 03/15/22 at 9:03 AM, Resident #169 was resting in bed, the catheter bag was hanging from the right side of bed with no privacy bag and was visible from the door entrance. e. On 03/15/22 at 1:33 PM, Licensed Practical Nurse (LPN) #1 was asked, To promote dignity should a catheter bag be in a privacy bag? She replied, Yes. f. On 3/15/22 at 1:42 PM, LPN #1 accompanied the surveyor to Resident #169's room. The resident was resting in bed, her catheter bag was hanging on the right side of the bed, no privacy bag noted. LPN #1 was asked, Should the resident's foley catheter be in a privacy bag? She replied, Yes. g. On 3/15/22 at 1:52 PM, the Director of Nursing (Don) was asked, To promote dignity should a catheter bag be in a privacy bag? The DON replied, Yes. 4. Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS with an ARD of 02/10/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required supervision and setup with eating. a. On 03/14/22 at 12:35 PM, Housekeeper #1 was sweeping Resident #60's floor while her lunch tray was in front of her. b. On 03/14/22 at 12:35 PM, the DON was asked, Should housekeeping be sweeping a resident ' s room while her lunch tray is in front of her? She stated, No.

Based on record review and interview, the facility failed to ensure residents who have authorized the facility to manage personal funds are given instructions on how to request their personal funds after hours and on weekends. This failed practice had the potential to affect 32 residents who have authorized the facility to manage their personal funds according to a list provided by the Business Office Manager on 03/17/22 at 8:20 AM. The findings are: 1. On 03/16/22 at 1:35 PM, during Resident Council Meeting, residents were asked, Do you have access to your personal funds? Two of the four residents said they can get their money Monday through Friday but not after hours or on weekends. 2. On 03/17/22 at 8:00 AM, the Administrator was asked, Who is responsible for the management of the Resident's Personal Funds? She stated, The Business Office Manager. 3. On 03/17/22 at 8:15 AM, the Business Office Manager (BOM) (with the Business Office Consultant present) was asked, Are you the one responsible for getting the residents their money when they ask for it? She said, Yes. She was asked, Do they have access to their money when you are not here? She said, Yes. She was told that during the Resident Council Meeting yesterday two of the four said they do not have access to their money after hours and on weekends. She said, After hours we put money in the Med [Medication] Carts, and they need to ask the LPNs [Licensed Practical Nurses] for their money when I'm not here. She was then asked, Who is responsible for making sure they know what the process is for requesting money after hours and on weekends? She stated, I think it is covered in their Admission Packet. 4. On 03/17/22 at 8:25 AM, the Admission Packet was reviewed and did not address how to access personal funds after hours or on weekends. 5. On 03/17/22 at 9:28 AM, the Admission Coordinator was asked, Is it covered in their Admission Packet how residents who have their funds managed by the facility can access their money after hours and on weekends? She stated, No. She was asked, Who is responsible for making sure residents who have their personal funds managed by the facility know how to access their money after hours and on weekends? She stated, I don't really know, maybe the Business Office. She was informed that the BOM told this Surveyor she thought it was covered in the Admission Packet. She was then asked, To your knowledge, does anyone at the facility make sure residents know how to access their money after hours or on weekends? She said, I guess not. 6. The facility policy and procedure titled, Policy and Procedure Patient Trust, provided by the Business Office Consultant on 03/18/22 at 8:15 AM documented, Policy: This facility manages patient personal funds as requested and in accordance with any and all applicable law. Procedure: The facility will manage patient personal funds via an interest-bearing account in the name of the facility with Patient Trust in the title. The following procedures are followed in managing patient trust accounts. Patient Trust Accounting: 10. Trust Cash-On-Hand must be available for patient cash requests.

Based on observation and interview, the facility failed to ensure the floors were clean, trash was emptied, the toilet was flushed and a leak was repaired for 1 (Resident #49) of 1 resident on the 400 Hall and soiled bed linens were changed promptly to maintain a clean and sanitary environment for 3 (Residents #24, #27 and #121) of 20 (Residents #53, #168, #22, #49, #9, #58, #8, #52, #24, #33, #7, #40, #60, #59, #27, #169, #50, #28, #11 and #218) sampled residents who were dependent on staff for linen changes. The findings are: 1. Resident #49 had diagnoses of Type 2 Diabetes and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons with toilet use and was frequently incontinent of urine and bowel. a. On 03/14/22 at 12:45 PM, in Resident #49's bathroom the toilet was full of a dark amber, cloudy, foul smelling liquid with the same colored liquid oozing approximately 1/8 inch out around the base of the toilet. Trash was overflowing out of the trash receptacle and there was a sticky substance on the entire floor of the bathroom. b. On 03/16/22 at 1:15 PM, in Resident #49's bathroom the toilet was full of a dark, cloudy, foul smelling liquid with a dark brown, semi soft, BM approximately 6 inches long with smears of a dark brown substance on the inside of the toilet, all over the seat of toilet, the raised seat and the poles and both arm rest of raised toilet seat. A brown liquid substance was oozing out around the base of the toilet approximately 4 inches and there was a sticky substance on the entire floor of bathroom. c. On 03/16/22 at 1:22 PM, Certified Nursing Assistant (CNA) #3 was asked to look at Resident #49's bathroom and was asked, Were you aware of the condition of this bathroom? She said, No, not until now, except I have been aware of the problem with this toilet not working [flushing] and that oozing out around the base for the last two months. She was asked, Have you made anyone aware of this? She said, Yes, maintenance. d. On 3/16/22 at 1:40 PM, Maintenance was asked to look at (Resident #49's) bathroom and as we approached the bathroom he said, Let me guess, the toilet? He was asked, You are aware of the condition of this toilet? He said, Yes, these two guys are constantly messing with this toilet, and I have worked on it off and on for last couple of months. He was asked, Have you made anyone aware that you have been unable to fix this toilet? He said, They are aware that I've been having issues with this toilet. I've had a couple of work orders to fix it. e. On 03/16/22 at 1:50 PM, the Administrator was asked to look at (Resident #49's) bathroom. She was asked, Who is responsible for fixing toilets that are not in good working order? She said, Maintenance. She was asked if she was aware that this toilet hasn't been working properly for a couple of months? She said, No. She was asked, Who is responsible for making sure that toilets and bathroom floors are clean? She said, Housekeeping. 2. Resident #121 had a diagnosis of Dementia. The Admission MDS with an ARD of 02/01/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with transfers and extensive physical assistance of one person with toilet use and personal hygiene use and was frequently incontinent of urine and always incontinent of bowel. a. On 03/14/22 at 12:48 PM, Resident #121's fitted bed sheet had three brown smears approximately 2 to 3 inches long. Resident #121 was in the Dining Room on the Secured Unit waiting on lunch to be served. 3. Resident #27 had diagnoses of Abnormalities of Gait and Mobility, [CONDITION(S)] and Cognitive Communication Deficit. The Quarterly MDS with an ARD of 12/25/21 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS. a. On 03/14/22 at 12:50 PM, Resident #27's bed spread had three dime sized areas of food particles and two blood drops bright red in color approximately 1 to 1½ inches was on the pillowcase. Resident #27 was asked where blood came from. She was unable to verbalize; but did reach and point to her nose. 4. On 03/17/22 at 1:36 PM, the Director of Nursing and the Nurse Consultant were asked, Who is responsible for making sure the residents on the Secured Unit bed linens are clean after being soiled with food, feces and blood? They both said, The aides are. 5. Resident #24 had a diagnosis of Cerebral Infarction. The Annual Minimum Data Set with an Assessment Reference Date of 12/19/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status and required supervision and setup with dressing and eating, limited physical assistance of one person with personal hygiene and totally dependent on one person's physical assistance with bathing. a. On 03/14/22 at 1:40 AM, Resident #24 was out of his room. There were four nickel size and five pea size blood stains on his sheet. b. On 03/15/22 at 10:10 AM, Resident #24 was resting in bed, he to have four nickel size and five pea size blood stains on sheet. c. On 03/15/22 at 1:28 PM, Certified Nursing Assistant (CNA) #1 was asked, When are the resident's beds changed? CNA #1 replied, On shower days and as needed if soiled. d. On 03/15/22 at 1:33 PM, Licensed Practical Nurse (LPN) #1 was asked, When are the resident's beds changed? She replied, On shower days and as needed if soiled. LPN #1 was asked, Who is responsible to ensure bed sheets are being changed as needed? She replied, The floor nurses. e. On 03/15/22 at 1:37 PM, LPN #1 accompanied the surveyor to Resident #24's room. Resident #24 was sitting on the side of his bed. LPN #1was asked, What is on his sheet? She replied, It looks like blood stains? LPN #1 was asked, Should his sheets be changed? She replied, Yes. f. On 03/15/22 at 1:52 PM, the Director of Nursing (DON) was asked, When are the resident's beds changed? She replied, Immediately, if soiled, and on shower days. She was asked, Who is responsible to ensure bed sheets are being changed as needed? The DON replied, The floor nurses, and me.

Based on observation, record review and interview, the facility failed to ensure a person centered comprehensive care plan was developed and completed for 2 (Residents #49 and #53) of 18 (Residents #7, #8, #9, #20, #24, #27, #28, #33, #40, #43, #49, #50, #53, #58, #60, #168, #169 and #218) sampled residents whose care plans were reviewed. This failed practice had the potential to affect all 73 residents currently residing in the facility per the Residents Census and Condition of Residents dated 03/14/22, The findings are: 1. Resident #49 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/1/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of two plus persons with bed mobility, transfers and toilet use and extensive physical assistance of one person with dressing and personal hygiene. a. The Plan of Care with a revision date of 12/06/21 did not address activities of daily living (ADLs). b. The Plan of Care with a revision date of 03/10/22 was incomplete. The amount of assistance and the number of staff required for bathing/showering, bed mobility, dressing, personal hygiene, and toilet use was not addressed. 2. Resident #53 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 02/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS and received an antipsychotic medication 6 days of the 7 day look back period and requires extensive one physical assistance for dressing & personal hygiene and extensive two plus person physical assistance for toileting. a. The Plan of Care with a revision date of 02/28/22 did not address ADLs and was incomplete. Throughout the entire Plan of Care there were 25 areas that asked for: r/t (related to), SPECIFY, SPECIFY FREQ (Frequency) and FREQ that were not completed. 3. On 3/17/2022 at 2:06 PM, the DON was asked, Who is responsible for developing and updating the residents Plan of Care? She stated, The Minimum Data Set Coordinator (MDS) and she is off on Maternity Leave as she had her baby two days ago. The MDS Coordinator was unavailable for interview. 4. The facility policy titled, Care Plan, Comprehensive Person-Centered, provided by the Nurse Consultant on 03/17/22 at 2:18 PM documented, .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; .k. Reflect treatment goals, timetables, and objectives in measurable outcomes; .11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) .

Based on observation, record review and interview, the facility failed to ensure baths and/or showers were regularly provided to promote good personal hygiene and grooming for 1 (Residents #53) of 29 (Residents #1, #2, #7, #8, #9, #11, #20, #22, #24, #26, #27, #28, #33, #40, #46, #49, #50, #52, #53, #57, #58, #59, #60, #61, #64, #121, #168 and #169, #218); sampled residents; failed to ensure facial hair was removed for 4 (Residents #8, #49, #50 and #53) of 9 (Residents #8, #20, #40, #49, #50, #52, #53 #59, and #64) sampled residents; and failed to ensure fingernails were regularly trimmed and cleaned for 3 (Residents #28, #40 and #49) of 20 (Residents #1, #7, #9, #11, #20, #24, #26, #28, #33, #40, #46, #49, #50, #52, #57, #59, #60, #61, #64 and #169) sampled residents who were dependent for nail care, required assistance with shaving and with bathing. The findings are: 1. Resident #40 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on Brief Interview of Mental Status (BIMS) and required extensive physical assistance of two plus persons for personal hygiene and one person physical assistance in part of bathing and had functional limitation in range of motion one side of the upper extremities and both sides of the lower extremities. a. The Plan of Care with a revision date of 03/02/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] . Check nail length and trim and clean on bath day and as necessary, report any changes to the nurse . b. On 03/14/22 at 11:56 AM, Resident #40 was lying in bed. Her left hand had a contracture, the fingernails on that hand were approximately 1/8 inch out past the nail pad. d. On 03/16/22 at 1:17 PM, the Director of Nursing (DON) was asked, Who clips and cleans toenails and fingernails? She stated, The CNAs [Certified Nursing Assistants] when they give a bath, and our Treatment Nurse does a lot of the nail care. The DON accompanied the surveyor to Resident #40 was lying in bed. She was asked, Can you look at her left hand? Resident #40's left hand was contracted into a fist, her fingernails were approximately 1/8 inch past the nail pad. The DON stated, Oh those nails need to be cut. 2. Resident #53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS with an ARD of 02/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of one person with dressing and personal hygiene. Bathing activity itself did not occur or family and/or non-facility staff provided care 100% (percent) of the time during the 7 day look back look back period. a. The Plan of Care with a revision date of 02/07/22 did not address ADL's. b. On 03/15/22 at 9:12 AM, Resident #53's wife stated her husband is typically clean shaven and she has had to trim his mustache and beard that has grown here, as well as his roommates. The wife stated her husband was in a dirty shirt and she asked a CNA if he had been showered and was told he had but was unsure why he was then in a dirty shirt. The wife stated she had to bring cologne because her smells and does not ever smell fresh. The wife was asked when her husband typically showered. The wife stated he showered every morning at home first thing because they did not allow dirty in their home. The wife stated she was not sure when he gets his showers because she has not been here when he has ever received one. The wife was asked how often she visits, and she stated she thinks she should come every other day, but she has been coming almost daily because she does not know what to do with herself. c. The ADL-Bathing Schedule from 2/14/22 to 3/14/22 provided by the DON on 03/16/22 at 12:26 PM documented Resident #53's bathing schedule as .Tuesday, Friday EVE [evening] and PRN [as needed] . The schedule documented Resident #53 refused on 02/24/22 (Thursday) and on 03/14/22 (Monday). He received a shower on 02/17/22 (Thursday), 02/28/22 (Monday) at 20:29 (8:29 PM) and at 22:33 (10:33 PM), 03/9/22 (Wednesday), 03/10/22 (Thursday), Not applicable was documented on 02/14/22 (Monday), 02/21/22 (Monday), 03/3/22 (Thursday), 03/7/22 (Monday). Resident #53 received 5 showers in 29 days. 3. On 03/17/22 at 1:36 PM, the Administrator, the Nurse Consultant, and the DON were asked who was responsible for nailcare, beard trimming, shaving, and showers. The DON stated, The CNAs were responsible and should be included with showers. They were asked what not applicable meant on the bathing schedule and the Nurse Consultant stated, We hate that button. The DON stated, We do not know what that means. We have told the CNAs not to use it when the resident refuses or when the resident is unavailable because they are offsite . 4. Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 02/01/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of one with personal hygiene and one person physical assistance with bathing. a. The Plan of Care with a revision date of 03/10/22 was incomplete regarding his Activities of Daily Living (ADL) self-care deficit and the Plan of Care dated 12/05/21 did not address ADL's. b. On 03/16/22 at 9:02 AM, Resident #49 was sitting in a wheelchair at a dining table in the Secure Unit Dining Room. His fingernails were approximately 1/4 inch past the pads of his fingers and thumbs, jagged and had a brownish black substance under his fingernails. He had facial hair about his face. He was unable to answer questions regarding his personal care. c. On 03/16/22 at 9:45 AM, Resident #49 was sitting in a wheelchair in the hallway on the Secure Unit. He was asked to see his nails in the presence of CNA #3. She was asked, What does it look like under and on the sides of his nails? She said, Dirt and feces. She was asked, Who is responsible for making sure his nails are trimmed and cleaned? She did not answer but said to the resident, [Resident #49] I need to do your nail care! and left and returned and started nail care in the hallway. 5. Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 02/02/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a BIMS and required limited physical assistance of one person with personal hygiene. Bathing activity itself did not occur or family and/or non-facility staff provided care 100% (percent) of the time during the 7 day look back look back period. a. The Plan of Care with a revision date of 02/09/22 documented, .The resident has an ADL self-care performance deficit r/t [related to] Alzheimer's Dementia . DRESSING: The resident requires extensive assist [assistance] by 1 staff to dress. PERSONAL HYGIENE: The resident prefers to have a beard and mustache . The resident requires assist by 1 staff with personal hygiene and oral care. b. On 03/14/22 at 12:09 PM, Resident #50 was sitting in his room. His hair was uncombed, he had facial hair on the sides of his face approximately 1/16 of an inch long with a beard and mustache and food particles in his beard and on his t-shirt. c. On 03/16/22 at 9:21 AM, Resident #50 was sitting in his room. His hair was uncombed, and he had facial hair on both sides of face approximately 1/16 of an inch long and food particles in his beard. d. On 03/16/22 at 9:30 AM, CNA #3 was asked, Who is responsible for making sure [Resident #50] receives personal care such as shaving, and removing food particles from his beard and changing his food stained shirt? She stated, The CNAs are, but we've been off for two days and every time when we get back from being off this place, the residents are a mess. She was asked, Why has it not been taken care of this morning? She said, We've been slammed here this morning! We've been off the last two days and every time when we come back to this place, the residents are a mess! She was asked, Have you told anyone about this issue? She stated, Yes, they all know! e. On 03/17/22 at 1:36 PM, the DON and the Nurse Consultant were asked, Who is responsible for making sure residents on the Secured Unit nails are trimmed and cleaned, grooming and/or shaving men's beard's and making sure their clothes are clean after being soiled with food? They both said, The aides are. 5. Resident #8 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of 07/02/21 documented, The resident has an ADL self-care performance deficit r/t Dementia . BATHING/SHOWERING: The resident requires limited assistance) by (X [times]1) staff with (showering) (2X per week) and as necessary. PERSONAL HYGIENE/ORAL CARE: The resident is able to: Independently. Resident does like to grow a beard. He will let staff know when he wants to shave . b. On 03/14/22 at 11:44 AM, Resident #8 was sitting in his wheelchair, he had approximately ¼ inch facial stubble. He was asked if he liked having a beard. He stated, I wish they would shave me. I like to be clean shaven. He stated, I get shaved on shower day. c. On 03/15/22 at 8:36 AM, Resident #8 was sitting in his wheelchair at the entrance to his room. He had facial stubble approximately ¼ inch in length. d. On 03/15/22 at 1:28 PM, CNA #1 was asked, When are the residents shaved? She replied, On shower days. e. On 03/15/22 at 1:33 PM, LPN #1 was asked, When are the residents shaved? She replied, During their shower. LPN #1 was asked, Who is responsible to ensure the residents are shaved as scheduled and as needed? She replied, The floor nurses. f. On 03/15/22 at 1:35 PM, LPN #1 accompanied the surveyor to Resident #8's room and was asked, When was the last time the resident was shaved? She replied, On his shower day, and today is his shower day. Resident #8 stated, I got a shower yesterday and they didn't shave me. g. The ADL - Bathing Schedule provided by the Nurse Consultant on 03/15/22 at 2:12 PM documented Resident #8 received a shower on 3/14/22 at 10:38 AM. h. On 03/15/22 at 1:52 PM, the DON was asked, When are the residents shaved? She replied, On shower days and when requested. The DON was asked, Who is responsible to ensure the residents are shaved as scheduled and as needed and or requested? She replied, The floor nurses, and me. 6. Resident #28 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan with a revision date of 01/06/22 documented, The resident has an ADL self-care performance deficit r/t [related to] Alzheimer's . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 03/14/22 at 11:51 AM, Resident #28 was lying in bed, the fingernails on her right hand had a brown substance under nail tips. c. On 3/15/22 at 1:28 PM, CNA #1 was asked, How often are the residents showered? She replied, Twice a week. CNA #1 was asked, Who does the residents showers? She replied, One CNA on the hall is scheduled to do them. CNA #1 was asked, Who performs nail care on the residents? CNA #1 replied, The CNAs, the nurses if they are a diabetic. She was asked, When is nail care completed? She replied, On shower days and as needed. d. On 03/15/22 at 1:33 PM, LPN #1 was asked, How often are the residents showered? She replied, Twice a week. LPN #1 was asked, Who does the residents showers? She replied, The CNAs. LPN #1 was asked, Who performs nail care on the residents? She replied, The CNAs and the nurses if they're a diabetic. LPN #1 was asked, When is nail care completed? She replied, Shower days and as needed. She was asked, Who is responsible to ensure nail care is being completed as needed? LPN #1 replied, The floor nurses. e. On 03/15/22 at 1:38 PM, LPN #1 accompanied the surveyor to the resident's room. Resident #28 was lying in her bed, covered with a blanket. LPN #1 was asked to look at the resident's nails. All of Resident #28's fingernails had a brown substance under the nail tip. LPN #1 was asked, What is that brown substance under her nail tips? She stated, Dirt or feces, I'm not sure but they need to be cleaned. f. On 03/15/22 at 1:52 PM, the DON was asked, How often are the residents showered? She replied, Twice a week and as needed. The DON was asked, Who does the residents showers? She replied, The CNAs. The DON was asked, Who performs nail care on the residents? She replied, The CNAs, if diabetics, the nurses. She was asked, When is nail care completed? She replied, On shower days and when needed. The DON was asked, Who is responsible to ensure nail care is completed as needed? She replied, The floor nurses, and me. 7. The facility policy titled, Fingernail/Toenail, Care of, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed.Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

Based on observation, record review and interview, the facility failed to ensure the catheter bag remained below the bladder during a transfer to prevent potential infection for 1 (Resident #169) of 1 sampled resident who had an indwelling catheter. The findings are: Resident #169 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) was not available for review at the time of the survey. a. The March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 03/17/22 . MONITOR - Supra Pubic Cath drsg [dressing] for placement/excessive drainage; change PRN - Phys [Physician] to be notified if s/sx [signs and symptoms] of infection noted every evening and night shift for monitoring drsg/site .Order date 03/08/22 . b. Care Plan with an initiated date of 03/10/22 documented, The resident has (SPECIFY: Indwelling Suprapubic) Catheter: . No interventions were addressed.The resident has (chronic) [CONDITION(S)] . Monitor for s/sx [signs/symptoms] of infection, [CONDITION(S)] [Urinary Tract Infection]. c. On 03/14/22 at 12:30 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #169 with the lift from her high back wheelchair to her bed. CNA #5 removed the resident's catheter bag from under the wheelchair and hung the catheter bag on the lift pad above the resident's bladder. The resident was lowered onto the bed without incident. CNA #5 hung the catheter bag on the right side of the bed. The catheter was not in a privacy bag. d. On 03/15/22 at 1:33 PM, Licensed Practical Nurse (LPN) #1 was asked, When the CNAs transfer a resident with a lift, should they hang the catheter bag from the lift pad, above the bladder? She replied, No. e. On 3/15/22 at 1:52 PM, the Director of Nursing (Don) was asked, To promote dignity should a catheter bag be in a privacy bag? The DON replied, Yes. She was asked, When CNAs are performing a transfer with a lift, should the catheter bag be hung on the lift pad, above the bladder? She replied, No. f. The facility policy titled, Emptying a Urinary Drainage Bag, provided by the Nurse Consultant on 03/16/22 at 2:09 PM documented, . Keep the drainage bag below the level of the resident's bladder .

Based on observation, record review and interview, the facility failed to ensure foot care was regularly provided and toenails were clean, trimmed, and free of jagged edges to prevent potential complications for 2 (Residents #9 and #40) of 20 (Residents #1, #7, #9, #11, #20, #24, #26, #28, #33, #40, #46, #49, #50, #52, #57, #59, #60, #61, #64 and #169) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision and setup with personal hygiene, bathing activity itself did not occur or family and/or non-facility staff provided care 100% (percent) of the time during the 7 day look back look back period. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care with revision date of 03/05/22 documented, .Bathing/Showering: Check nail length and trim on bath day and as necessary. Report any changes to the nurse . c. On 03/14/22 at 11:53 AM, Resident #9 stated she needs a bath, wants nails clipped. I haven't had a bath in a couple of weeks. d. On 03/14/22 at 11:56 AM, Licensed Practical Nurse (LPN) #3 pulled Resident #9's socks off after the resident complained of not having nails trimmed. Resident #9's toenails were long 1/4 of an inch past the toe pad. The second toenail on the right foot was wrapped over the toe pad. LPN #3 was asked when the residents were to receive nail care. She stated, On their baths days. e. On 03/16/2022 at 1:04 PM, the Director of Nursing (DON) was asked, Do you have a Podiatrist that comes to the building? She stated, No. I really don't know. f. On 03/16/2022 at 1:17 PM the DON was asked, Who clips and cleans toenails and fingernails? She stated, The CNAs [Certified Nursing Assistants] when they bathe, and our Treatment Nurse does a lot of the nail care. She was asked, Does it appear that the nails have been clipped? She stated, No. She was asked, Should the resident's toenails be curved around the resident's toe pad? She stated, No. Resident #9 stated, I want my nails cut. The DON asked Resident #9, Have you told anybody? Resident #9 stated, No. The DON was asked, Is nail care part of the resident's ADLs? The DON stated, Yes. She was asked, When should nail care be done? She stated, On bath day, and if the CNA can't do it then they can tell the nurse. g. On 03/16/2022 at 1:25 PM, Resident #9 was with the DON in her room. Resident #9's toenails were 1/4 of an inch past the toe pad. The second toe on the right foot was ½ inch long and was wrapped around the toe pad. The DON asked Resident #9 if her toes hurt. Resident #9 stated, No, I want my nails cut. Resident #9 stuck out her hands when she stated she wanted nails cut. The DON asked Resident #9, Did you tell someone that you wanted your nails cut? Resident #9 stated, No. The DON was asked, Should a resident have to ask for nails to be cut? The DON stated, It should be done on bath days. 2. Resident #40 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 01/11/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons for personal hygiene and one person physical assistance in part of bathing and had functional limitation in range of motion one side of the upper extremities and both sides of the lower extremities. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care with a revision date of 03/02/22 documented, .The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] . Check nail length and trim and clean on bath day and as necessary, report any changes to the nurse . c. On 03/14/22 at 11:56 AM, Resident #40 was lying in bed. Resident #40 stated, They give me baths, but they don't cut my toenails. Licensed Practical Nurse (LPN) #3 pulled the sheet back from Resident #40's feet, her toenails were approximately ¼ inch long, thick, and jagged. d. On 03/16/22 at 1:04 PM, the Director of Nursing (DON) was asked, Do you have a Podiatrist that comes to the building? She stated, No. I really don't know. e. On 03/16/22 at 1:17 PM, the DON was asked, Who clips and cleans toenails and fingernails? She stated, The CNAs when they give a bath, and our Treatment Nurse does a lot of the nail care. The DON accompanied the surveyor to Resident #40's room. The DON was asked, Does it appear that the nails have been clipped? She stated, No. The DON asked Resident #40 if her toenails on the left great toe hurt. Resident #40 stated, Yes, if they move the covers over it. Residents #40's left great toenail extended up approximately 1/4 inch above the toenail bed. The toenails on the other four toes extended past the toe pad approximately ¼ inch. The great toenail on the right foot was thick. The other four toenails extended approximately ¼ inch past the toe pads. The DON stated, Her nails are long and need to be cut. 3. The facility policy titled, Fingernail/Toenail, Care of, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed.Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

Based on observation, record review and interview, the facility failed to ensure oxygen tubing was dated to facilitate timely change-out for 2 (Residents #168 and #169) residents; storage bags for oxygen tubing were changed out regularly to prevent potential infection for 4 (Residents #24, 33, 168 and #169) residents; oxygen was administered at the physician-ordered flow rate to prevent potential complications for 1 (Resident #7) resident; and updraft and [CONDITION(S)] (Continuous Positive Airway Pressure) masks were stored in a bag or other closed container when not in use to prevent potential contamination for 2 (Residents #24 and #218) of 11 (Residents #168, #33, #40, #60, #27, #218, #22, #9, #7, #24 and #169) sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/21 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. The Care Plan with a revision date of 01/04/22 documented, The resident has [CONDITION(S)]/[CONDITION(S)] . The resident will be free of s/sx [signs/symptoms] of respiratory infections through review date . b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 03/14/22 at 11:40 AM, Resident #24 was out of his room, an updraft machine was on bed side table and the updraft mask was hanging from drawer, not in a storage bag. d. On 03/15/22 at 10:10 AM, Resident #24 was resting in bed; the updraft machine was on bed side table and the updraft mask was hanging from drawer, not in a storage bag. e. On 3/15/22 at 1:37 PM, Licensed Practical Nurse (LPN) #1 accompanied the surveyor to Resident #24's room. Resident #24 was sitting on the side of his bed, his updraft mask was hanging from the bed side dresser drawer, not in a bag. LPN #1 was asked, Is his updraft mask stored properly? She replied, No it should be in a storage bag. 2. Resident #33 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 01/06/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS and required oxygen therapy. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen 2L[Liters]/min [per minute] per nasal cannula prn [as needed] to keep sats [saturations] above 90% [percent] every shift . b. The Care Plan with a revision date of 01/03/22 documented, .The resident has [CONDITION(S)]/[CONDITION(S)] . The resident will be free of s/sx of respiratory infections through review date . OXYGEN SETTINGS: O2 via [by way of] (nasal prongs) @ [at] (2)L (Continuous) . c. On 03/14/22 at 11:35 AM, Resident #33 was reclined in her recliner with oxygen at 2 liters per nasal cannula. Her wheelchair was beside the bed with an oxygen tank, the oxygen tubing was laying in seat of the chair, no storage bag present. d. On 03/15/22 at 8:28 PM, Resident #33 was out of her room, her oxygen tubing from the concentrator was lying on top of her made bed, not in a storage bag. e. On 3/15/22 at 1:45 PM, LPN #1 accompanied the surveyor to Resident #33's room. Resident #33 was reclined in her recliner. She had on oxygen at 2 liters per nasal cannula via oxygen concentrator. Her wheelchair was beside the bed with an oxygen tank, the oxygen tubing was laying in seat of the chair, no storage bag present. LPN #1 was asked, Is the oxygen tubing laying in the resident's wheelchair properly stored? She replied, No. She was asked, Should there be a storage bag on the oxygen tank to store the oxygen tubing? LPN #1 replied, Yes. 3. Resident #168 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 02/20/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and did not receive oxygen therapy. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen at 2L via NC [Nasal Cannula] as needed for SpO2 [Oxygen Saturation] lower than 90%/SOB . change and date oxygen tubing and water; clean filter weekly every night shift every Sun . b. The Care Plan with an initiated date of 03/08/22 documented, .The resident has Pneumonia r/t [related to] . The resident's pneumonia will be resolved without complications . OXYGEN SETTINGS: O2 via nasal cannula @ 2L. Humidified . c. On 03/14/22 at 12:02 PM, Resident #168 was lying in bed with oxygen via NC, the flow meter on the concentrator was at zero. The oxygen tubing connected to the oxygen tank on her wheelchair was looped around her wheelchair. The oxygen tubing on the concentrator and oxygen tank were not dated and there were no storage bags. d. On 3/15/22 at 8:53 AM, Resident #168 was sitting on side of the bed with oxygen at 2 Liters via NC. The oxygen tubing on the concentrator and oxygen tank were not dated and no storage bags were present. The oxygen tubing on the oxygen tank was looped around back of the wheelchair. e. On 3/15/22 at 1:33 PM, LPN #1 was asked, How often is oxygen tubing changed? She replied, Every Sunday. LPN #1 was asked, What is your policy on changing oxygen supplies? She replied, Change and date the humidity bottle, oxygen tubing and storage bag once weekly. She was asked, What is the proper way to store oxygen tubing when not in use? LPN #1 replied, The oxygen tubing needs to be placed in a storage bag. She was asked, Who is responsible to ensure oxygen is stored and labeled properly? She replied, The floor nurses. f. On 3/15/22 at 1:39 PM, LPN #1 accompanied the surveyor to Resident #168's room. Resident #168 was lying in her bed, she had on oxygen at 2 Liters via NC, a storage bag was on the floor. LPN #1 was asked, Is the oxygen tubing's or storage bag dated? LPN #1 stated, No. LPN #1 was asked, Is the oxygen tubing on the back of the wheelchair, that is coiled up and hanging from the oxygen tank, the proper way to store the oxygen tubing? LPN #1 replied, No. She was asked, Should the storage bag be lying on the floor? She replied, No. g. On 03/15/22 at 1:52 PM, the Director of Nursing (DON) was asked, How often is oxygen tubing changed? She replied, Once a week, on Sunday. She was asked, What is your policy on changing oxygen supplies? The DON replied, To change the filter, storage bag and oxygen tubing, and date everything. The DON was asked, What is the proper way to store oxygen tubing when not in use? She replied, In the plastic bag. She was asked, Who is responsible to ensure oxygen tubing is labeled and stored properly? She replied, The floor nurses, and me. 4. Resident #169 was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with an initiated date of 03/07/22 documented, .The resident has altered cardiovascular status . OXYGEN SETTINGS: O2 via nasal prongs @ 2L. Humidified . c. On 03/14/22 at 12:06 PM, Resident #169 was sitting in her high back wheelchair with oxygen at 2 liters via NC from an oxygen tank. The tubing was not dated and a plastic storage bag hanging from the concentrator was not dated. d. On 03/14/22 at 12:30 PM, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #169 with the lift from her high back wheelchair to her bed. CNA #5 removed the oxygen tubing from Resident #169 and draped the tubing over the handle of the resident's chair. e. On 03/15/22 at 9:03 AM, Resident #169 was resting in bed with oxygen at 2 Liters via NC from her concentrator. Her high back wheelchair was at the foot of her bed, with the oxygen tubing wrapped around the oxygen tank. f. On 03/15/22 at 1:42 PM, LPN #1 accompanied the surveyor to Resident #169's room. She was asked, Is the resident's oxygen tubing, or storage bag dated? She replied, No. She was asked, Is the resident's oxygen tubing that is coiled up and hanging from the oxygen tank, properly stored? She replied, No. 5. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change of Condition MDS with an ARD of 11/22/2021 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care with a revision date of 12/06/21 documented, .The resident uses oxygen therapy . Oxygen settings 02 via nasal cannula . c. On 03/14/22 at 12:24 PM, Resident #7 was lying in bed with 02 at 3 l/m (liters a minute) via nc. d. On 03/15/2022 at 9:23 AM, Resident #7 was lying in bed with 02 at 3 l/m via nc. e. On 03/16/2022 at 8:28 AM, Resident #7 was lying in bed with 02 at 3 l/m via nc. f. On 03/16/2022 at 1:00 PM, LPN #2 was asked, Can you tell me what the resident ' s oxygen concentrator is set on? She stated, It's on three. She was asked, Can you tell me if this is the correct setting? She stated, I will have to look it up. g. On 03/17/22 at 8:34 AM, Resident #7 was lying in bed with 02 at 3 l/m via nc. 6. Resident #218 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 02/8/22 documented resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and received oxygen therapy and did not use a [CONDITION(S)]. a. The Plan of Care with a revision date of 02/15/22 documented, .altered respiratory status C-pap titrated pressure via nasal pillow . b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 03/14/22 at 11:41 AM, Resident #218 was lying in bed with 02 at 2 l/m via nc. A [CONDITION(S)] mask was sitting on bedside table open to air not covered. d. On 03/15/22 at 8:34 AM, Resident #218 was lying in bed A [CONDITION(S)] mask was sitting on bedside table open to air, not cleaned. e. On 03/16/22 at 7:52 AM, Resident #218 was lying in bed A [CONDITION(S)] mask was sitting on bedside table open to air. A plastic bag dated, was lying on bedside table. f. On 03/16/22 at 1:25 PM, the DON was asked, Should a resident's [CONDITION(S)] mask be lying on a bedside table open to air? She stated, No, it should be bagged. At this time the mask was in a clear plastic bag. 7. The facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, provided by the Nurse Consultant on 03/15/22 at 2:27 PM documented, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks, and equipment . among residents and staff . Change the oxygen cannulae (sic) and tubing every seven (7) days, or as needed . Keep the oxygen cannulae (sic) and tubing used PRN in a plastic bag when not in use . 8. The facility policy titled, [CONDITION(S)]/[CONDITION(S)] Support', provided by the DON on 03/17/22 did not address storage when not in use.

Complaint # (AR 045) was substantiated, (all or in part), with these findings: A. Based on record review and interview, the facility failed to ensure Resident #15 was provided the necessary care and services to address acute changes in condition after a fall, as evidenced by failure to conduct and document a thorough assessment of the resident ' s extremities prior to getting the resident up from the floor to prevent further potential injury; failure to consistently conduct and document complete neurological (neuro) checks and vital signs; failure to promptly consult with nursing administration and/or the Medical Director when the resident's physician did not respond to attempts to contact; and failure to ensure transfers and movement of the resident were limited to the extent possible while awaiting medical attention to address the fall-related injuries and new onset hip / leg pain for 1 (Resident #15) of 3 (Residents #4, #5 and #15) case mix residents who experienced falls with injury in the last 6 months. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #15, who experienced acute changes in condition after a fall, including a head contusion and right [MEDICAL CONDITION], and did not receive medical attention for a period of 3 hours after the incident occurred. The failed practices also had the potential to cause more than minimal harm to 4 residents who experienced falls with subsequent fractures in the last 6 months, according to a list provided by the Director of Nursing (DON) on 3/3/16 at 4:45 p.m. The facility was notified of the Immediate Jeopardy condition on 3/4/16 at 9:40 a.m. The findings are: 1. Resident #15 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/16 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS); required extensive assistance with transfers and toileting needs and had a urinary catheter. a. Progress Notes (Nursing Admission Summary) dated 12/31/15 13:50 (1:50 p.m.) documented, Patient arrive to facility in wheelchair via (name) EMS (Emergency Medical Services) with 1 attendant. Placed into room (Room Number) on skilled care for therapy rehab services due to Dx. (Diagnosis): left hip fx (fracture), S/P (status [REDACTED]. Progress Notes (Nursing-General Note) dated 1/11/16 at 13:15 (1:15 p.m.) documented, .Patient sent (Name of facility) ER (emergency room ) for EVAL (evaluation) for poss (possible)[MEDICAL CONDITION]. Presented with altered mental status, right side ADL (activities of daily living) deficit, Slurred speech and inability to follow simple commands Progress Notes (Nursing-Admission Summary) dated 1/19/16 at 14:30 (2:30 p.m.) documented, .Patient arrived to facility via (name) EMS on stretcher .Place on strict isolation for C - dif ([MEDICAL CONDITION]) and VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) to rectum .Assessment: Noted speech deficit and right side functional deficit, decreased right grasp and ROM (range of motion) Progress Notes (physician progress notes [REDACTED].o. (year old) .with a history [MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] .[MEDICAL CONDITIONS] and Dementia is receiving skilled therapy at (facility) after a fall resulting in a closed [MEDICAL CONDITION]. Patient was readmitted to the hospital due to [MEDICAL CONDITION] .Diagnosis: [REDACTED].[MEDICAL CONDITION] . Progress Notes (Nursing - I&A (incident/accident)) dated 2/5/16 at 22:00 (10:00 p.m.) documented, . Note . Physician Contact (Who/When): Notified After hours (Nurse on Call) (phone number) (Name) RN (Registered Nurse) for (Physician). Family Contact (who/when): (name) - daughter. Incident Description: CNA (Certified Nursing Assistant) entered room to empty Foley catheter, found resident on floor next to bed, leaning against alarm pad and bed. Resident is confused and cannot give a statement. Resident is noted to have been incontinent of bowel. Resident was checked head to toe per visualization / palpation . Immediate Intervention: Resident given incontinent care and sheet and alarm replaced in appropriate location on bed. Notified (DON), Notified (Administrator) . b. Progress Notes (Nursing - I&A (incident/accident)) dated 2/6/16 at 15:30 (3:30 p.m.) documented, . Physician Contact (Who/When): On call nurse per (Physician #1-resident primary physician) - (Name) . Family Contact (Who/When): - (Daughter) . Incident Description: Aide was walking past resident's room to get gloves when aide heard wheelchair alarm going off and when aide walked into resident's room, resident was observed lying in the floor in between the bathroom door and wheelchair lying on her RIGHT side in front of bathroom floor. Resident too confused to make a statement. Resident was observed to have a ping pong ball sized knot to forehead - Bluish/Purple. Resident c/o (complains of) RIGHT side hip pain. Neuros (neurological checks) started at 15:30 (3:30 p.m.). Neuros within normal limits - resident continues to be confused. Immediate Intervention: Resident was oriented and instructed to use call light when needing assist and was immediately put in recliner with foot rest up for better positioning . Vitals (BP) (blood pressure) 122/62 (P) (pulse) 68 (R) (respiration) 16 .Author: (LPN #1) The progress note did not contain a documented assessment for possible [MEDICAL CONDITION] prior to getting resident up in recliner. 1) On 3/3/16 at 1:06 p.m., Licensed Practical Nurse (LPN) #1 was asked to describe the circumstances regarding Resident #15's fall on 2/5/16. LPN #1 stated, It happened right around shift change, between 3:00 p.m. to 3:15 p.m. I was at the nurses' desk. One of the CNAs (certified nursing assistants) came and got me. I assessed her and log rolled her. When I assessed her, I already had seen a tiny, tiny knot, but it got bigger. I tried to see if she was alert and oriented. I think she asked me for a pain pill. When I got her up, it took two people with a gait belt. We first put her in her wheelchair, and then we put her in her recliner. She was able to bear weight on her right leg a little. I think I gave her Tylenol. Her blood pressure kept getting higher and higher in between trying to get the doctor on the phone. I was waiting on the doctor to call me back. I guess the family had come in while I was doing other stuff. She kept saying, 'it hurts, it hurts', when I would rub her right leg. I didn't try calling a family member at all, because the family was here when I sent her out (to the hospital). 2) On 3/3/16 at 2:15 p.m., Certified Nursing Assistant (CNA) #1 was asked to describe the events that occurred on 2/5/16 when Resident #15 fell . CNA #1 stated, She might've been in the wheelchair; she might've fallen out. I want to say her left side; we got her off the floor. There was no bleeding, no marks. The nurse assessed her before we got her off the floor. Yes, we did neuro checks; the other CNA (CNA #2) did. The other CNA heard the alarm and went into the room first. I can't remember if she had a bump on her head; she did seem like she was in pain. 3) On 3/3/16 at 2:31 p.m., CNA #2 was asked to describe the events that occurred on 2/5/16 when Resident #15 fell . CNA #2 stated, It was during shift change; her chair alarm was going off. I was out in the hall when I seen her on the floor. We got her back in her wheelchair. It was the first time in a month that I worked that hall. We didn't have a blood pressure machine; we were both doing vital signs, me and the other CNA (CNA #1). I couldn't get her blood pressure - I notified the nurse. She was close to her wheelchair, because her catheter was still on her wheelchair. She was on her bottom, leaning back. I was trying to keep her from hitting her back on the floor . I didn't notice anything wrong, no bleeding or bruising. We transferred her from the wheelchair to her recliner - two people using a gait belt. When asked if the resident was able to bear weight during the transfer, the CNA stated, No, not really able to bear any weight. The CNA also stated, I don't know the nurse's name. She (resident) was talking a little; I'm sure she was having some discomfort. I didn't know. Did neuro checks. I got a few blood pressures. I don't think I wrote them down. c. The Nursing Neurological Assessment form dated 2/6/16 did not consistently document thorough assessment of resident ' s condition (no recorded blood pressure after the first 30 minutes and no recorded vital signs, orientation, level of consciousness, pupil assessment, or pain assessment after 2 hours and 15 minutes). The entries from time of incident to time of transfer to emergency room are as follows: 1) First Fifteen Minute Assessment . Enter the date and time of this assessment 2/6/16 15:30 (3:30 p.m.) . Temperature 98.4 . Axilla . Pulse 68 .Apical . Respirations 16 . Blood Pressure 122/62 . Position at time of blood pressure . Sitting . Orientation . Resident is oriented to the following: Person . Is this a change from the resident's baseline orientation? . No. Level of Consciousness . Confused . Is this a change from the resident's baseline level of consciousness? . No. Pupils . Are Pupils Equal? Yes . Pain . Verbal expressions of pain? Yes . Nonverbal expressions of pain? (blank) . Level of Pain 6 . Extremities . Movement and sensation intact to right leg? Yes . Notes or Comments: Resident has a ping pong ball on forehead mid middle - Purple/Blue area . This entry was signed by LPN #1. 2) Second 15 Minute Assessment . 2/6/16 15:45 (3:45 p.m.) . Blood Pressure 130/74 .Verbal expression of pain? Yes . Indicate level of pain - 10 . Notes and Comments: Continues to c/o (complain of) RIGHT hip pain and knot to for head (forehead) . This entry was signed by LPN #1. 3) Third 15 Minute Assessment . 2/6/16 16:00 (4:00 p.m.) . Blood Pressure 132/74 . Verbal expressions of pain? Yes. Nonverbal expressions of pain? Yes. Indicate level of pain - 5 . Notes and Comments: Continues to c/o severe pain to RIGHT HIP and continues to have hematoma to for head (forehead). This entry was signed by LPN #1. 4) Fourth 15 Minute Assessment . 2/6/16 16:15 (4:15 p.m.) . Blood Pressure (blank) . Pain . 10. Note and Comments: Continues to have severe pain to RIGHT HIP . This entry was signed by LPN #1. 5) First 30 Minute Assessment .2/6/16 16:45 (4:45 p.m.) . Blood Pressure (blank) .Indicate level of pain 10. Notes or Comments: Continues to have severe pain to RIGHT HIP . 6) Second 30 Minute Assessment . 2/6/16 17:15 (5:15 p.m.) . Blood Pressure (blank) Pain Scale 10 .11c. Movement and sensation intact to right leg? 0. Yes 12. Notes or Comments: continues to have increasing pain to RIGHT HIP . 7) Third 30 Minute Assessment . 2/6/16 17:45 (5:45 p.m.) . This neurological assessment was blank 8) Fourth 30 Minute Assessment . 2/6/16 18:15 (6:15 p.m.) . Is this a change from resident's baseline orientation? 0. Yes . No other information (no vital signs, orientation, and level of consciousness, pupil assessment, or pain assessment) was documented with this assessment. On 3/3/16 at 4:40 p.m., LPN #1 was asked, When you did your assessment (after the fall on 2/5/16), what did you assess? LPN #1 stated, I checked her extremities and first made sure her hip wasn't broken; made sure everything was in line. LPN #1 was asked, What time did you notify the Medical Doctor of the fall? LPN #1 stated, Initially, somewhere around 4:15 to 4:30 (p.m.), somewhere in there. No, no, no, not the doctor himself; (I) called the answering service. LPN #1 was asked, How many times did you attempt to call him? LPN #1 stated, Two times, around 4:15 to 4:30; about an hour after that. LPN #1 was asked, Why didn't you keep trying to call the MD (Medical Doctor) when he had not responded? Was the doctor you were calling the Medical Director? Why didn't you call the Medical Director, if you were not getting any response from the answering service? LPN #1 stated, I don't know; I called so many doctors, I honestly don't remember. LPN #1 was asked, Did the CNAs tell you they couldn't get the blood pressure? LPN #1 stated, No, they didn ' t. They said it was too high. LPN #1 was asked, Did you attempt to get the blood pressure? LPN #1 stated, Not right away, I can ' t remember. LPN #1 was asked, Did you document any blood pressures? LPN #1 stated, The ones on the neuro checks. LPN #1 was asked, How many times did you assess Resident #15 after she had fallen? LPN #1 stated, Just once right after she had fallen. I kept going back in there doing neuro checks and checking on her She (Resident #15) told me she was in pain, squeezing her right leg, kept saying ' right, right ' , that was her way of telling me. The Progress Notes signed by LPN #1 only documented calls to Physician #1, there was no documentation that the Medical Director (Physician #2) was called. d. Progress Notes dated 2/6/16 at 6:30 p.m. documented, Type: Nsg - General Note . VTO (verbal telephone order) per (Physician #1) on call Dr to send resident to (hospital) to eval (evaluate) and tx (treat) if necessary r/t (related to) chronic pain to right hip from previous fall this evening and hematoma to forehead. Author: (LPN #1) . This was a period of at least 3 hours after the incident which injury occurred. e. The hospital Emergency Record dated 2/6/16 documented, .Emergency Documentation . Ambulance: Ambulance: Sat (Saturday) [DATE] 18:42 (6:42 p.m.) . BP (blood pressure) 18:55 (6:55 p.m.) 210/88 Pulse 107 . 2/6/16 20:41 (8:41 p.m.) 172/95 Pulse 101 . Head: Head exam included findings of, Contusion to frontal, normocephalic .Right Lower Extremity: Inspection findings includes signs of trauma to right hip, leg, shortening or right leg, bruising of knee . X-ray of the right hip shows right intertrochanteric [MEDICAL CONDITION] . CT (computerized tomography) of the head has been obtained and has been read as generalized atrophy and chronic small vessel ischemic disease . 2. The Immediate Jeopardy was removed and the scope / severity reduced to G on 3/4/16 at 1:30 p.m., when the facility implemented the following Plan of Removal: a. On 3/4/16, it was identified that resident was not assessed properly and accurately after a resident fall. Beginning on 3/4/16, any resident who had had a Significant Change in condition and/or Incident and Accident within the last 7 days or going forward will be reviewed by DON/RN Supervisor daily to ensure proper and accurate assessments were completed including any Neuro checks initiated. Any issues identified will be addressed immediately and corrected. DON will review and monitor daily times next 30 days. b. DON/RN Supervisor will review all Significant Changes in condition and/or Incident and Accidents since 2/1/16 to ensure proper and accurate assessments were completed and ongoing with any additional occurrences. Any issues identified will be addressed immediately and retraining completed with nursing staff as needed by the DON. DON will review and monitor daily times 30 days. c. Starting on 3/4/16 the DON/Administrator/RN Supervisor will review all Significant Change in condition and/or Incident and Accidents to ensure proper notifications and accuracy of assessments to include and Neuro Checks initiated daily times 4 weeks, then weekly thereafter until compliance is achieved. Any issues identified will be addressed and retraining will be completed with nursing staff as needed. DON will review and monitor daily times 30 days. d. Starting immediately on 3/4/16 the DON/RN Supervisor will In-service all Licensed Nursing Staff to ensure proper and accurate assessments and notifications are complete with any change in resident condition and/or Incident and Accidents. Any nurse not currently working will be in serviced prior to the beginning of their shift. e. Starting immediately on 3/4/16 DON/RN Supervisor will In-service all Nursing Staff prior to their shift regarding in the event the resident's MD cannot be notified of an Significant Change in condition and/or Incident and Accident requiring immediate attention i.e. possible fall with injury, severe vital sign changes etc. resident will be sent to ER via 911. DON/RN Supervisor will review and monitor daily times 30 days. f. Starting 3/4/16 the DON/RN Supervisor will review resident's nursing/progress notes and assessments daily times 2 weeks then weekly thereafter to ensure any resident with Significant Changes in condition and/or Incident and Accidents have been assessed appropriately and accurately. Any issues identified will be addressed immediately and nursing staff will be retrained as needed. DON/RN Supervisor will review and monitor daily times 30 days. B. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided for urinary catheter maintenance, by failing to ensure the catheter drainage bag was not lying on the floor and the urinary catheter tubing was secured with a device to prevent potential tension and trauma to the urinary structure and to decrease the risk of urinary tract infection for 1 (Resident # 2) of 3 (Resident #1, #2 and #7) case mix residents who had indwelling catheters. This failed practice had the potential to cause more than minimal harm 8 residents who had indwelling catheters as identified on a list provided by the Administrator on 3/3/16 at 1:30 p.m. The findings are: Resident # 2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/16 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS) required limited assistance of 2 plus person for toileting and is continent of bladder. a. The resident was admitted to the facility on [DATE]. A physician's orders [REDACTED]. b. The Plan of Care documented, Toilet Use: The resident requires assistance x (time) 1 staff for toileting. Resident prefers to stand up to use the urinal. Date initiated: 2/16/16. The resident has indwelling catheter due to [MEDICAL CONDITION]. Date initiated: 2/22/16. Catheter: Resident removes leg strap staff continues to encourage to leave in place for protection and pulling of catheter tubing. Date initiated: 3/2/16. c. On 2/29/16 at 2:21 p.m., the resident's catheter drainage bag was lying on the floor beside the recliner the resident was sitting in. d. On 3/1/16 at 9:35 a.m., the resident was sitting on the toilet. The Foley catheter tubing was not secured to his leg and the tubing was stretched taut. Certified Nursing Assistant (CNA) # 5 assisted the resident with toileting and changed the disposable brief (pull up). She changed the resident's clothing and assisted him to the wheelchair. She did not secure the catheter tubing with a device to prevent tautness and/or trauma to the urinary meatus. e. On 3/2/16 at 3:20 p.m., CNA # 6 and # 7 entered the resident's room to perform catheter care. When CNA # 6 removed the resident's pajama bottoms the Foley catheter tubing was not secured. During the care, the catheter tubing kept falling down the side of the resident's leg, causing tautness to the tubing. CNA #6 would reposition the tubing between the resident's legs and it would fall down the outside of the leg causing tautness. After several times of the tubing becoming taut, CNA #6 secured the tubing with her left hand and completed the catheter care. f. After the catheter care was completed, CNA #6 was asked, What are you going to do now? She stated, There is a leg band in the drawer there (she retrieved the band out of the drawer), I am going to put it on the resident. He should have had one on while I was doing the care. It made it difficult for me to clean him because it kept falling down. g. On 3/3/16 at 1:15 p.m., this surveyor pointed to the leg band and asked the resident, Do they put this (touched leg band to indicate what referring to) on you all the time? He stated, I don't know, haven't had one before, they cleaned me up down there last night and put it on. He was asked; Do you take it off when they put it on? He stated, I don't know, first time I've had one. h. The Policy and Procedure for Urinary Catheter Care, provided by the Administrator on 3/3/16 at 1:40 p.m. documented, Changing catheters: 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.). Steps in the procedure: 17. Secure catheter utilizing a leg band.

Complaint # , substantiated, all or in part, in these findings. A. Based on record review and interview, the facility failed to ensure staff were adequately supervised to prevent resident injury during staff assisted transfers as evidenced by the facility failure to ensure Certified Nursing Assistants were competent in the use of mechanical lifts to prevent resident injury for 1 (Resident #2) of 4 (Resident #2, 4, 5 & 6) case-mix residents who were transferred with a mechanical lift. This failed practice resulted in an Immediate Jeopardy that caused or could have caused serious harm or death to Resident #2, who suffered a fractured femur as a result of a fall from a mechanical lift, and had the potential to affect 23 residents who required the use of a mechanical lift for transfers according to a list received from the Director of Nursing (DON) on [DATE]. The Immediate Jeopardy was removed by the facility prior to the survey entrance date, however the underlying deficient practices were not fully corrected. The facility was notified of the Immediate Jeopardy removed on [DATE]. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status and was totally dependent on 2 plus persons for transfers. a. The Standard Care Plan documented, "... Provide 2 person assist with transfers to and from bed and Hoyer lift (blue sling) ... Review Dates: ... [DATE]..." b. Nurses Note dated [DATE] at 8:15 p.m. documented, "This nurse entered (resident) room observed (resident) lying on floor (with) shower sling underneath (resident) (no) visible injury-3 aids standing next to (resident)." An Unusual Occurrence Report dated [DATE] at 8:15 p.m. documented, "... This nurse entered the res (resident's) room observed res lying on floor with shower sling underneath res (no) visible injury - 3 aids next to res ..." An Unusual Occurrence Investigation Report documented, "... Contributing Factors: Unsafe position transfer (checked) ... Summarize factors that contributed to this unusual occurrence: Based on the gathered facts, what may have caused the event to occur? ... Res positioning in shower sling ... What immediate interventions have you initiated to prevent this event from occurring again: Inservice Discussion Positioning Res in Sling." A form titled DON (Director of Nursing)/Designee to complete investigation of event within 5 days documented, "... Describe the corrective actions taken to prevent recurrence of this event. Employee training or re-orientation (checked) ... Describe those items checked: Inservice staff on correct positioning of (resident) on Hoyer Shower Sling Reassessed/measured (resident) for appropriate size of sling..." 1) OLTC Witness Statement Form dated [DATE] at 8:15 p.m. and signed by Certified Nursing Assistant (CNA) #1 documented, "... Resident was positioned in sling being lifted out of the wheelchair after being showered, and the resident slipped out of the sling and landed on her bottom. The sling was crossed at the bottom." 2) OLTC Witness Statement Form dated [DATE] at 8:15 p.m. and signed by CNA #2 documented, "(Resident) was being lifted by Maxi-lift from wheelchair to bed when lifting (resident) she slipped out of the sling into floor falling on her bottom. Sling was crossed on the bottom." 3) OLTC Witness Statement Form dated [DATE] no time and signed by CNA #3 documented, "Resident was done with shower. We hooked her to the lift. As she was being lifted, resident slipped out of sling, hitting her bottom on the floor..." c. Nurses Note dated [DATE] at 6:30 p.m. documented, "... (temperature) 101 Tylenol Suppository 650 mg (milligrams) per rectum inserted (no) (signs/symptoms) pain emesis (times) 1..." Nurses Note dated [DATE] at 10:15 p.m. documented, "(New Order) X-Ray chest, X-Ray pelvis, coccyx ... Aspiration-fall 101 (temperature) ... X-Ray called." A Nurses Note dated [DATE] at 11:50 p.m. documented, "X-Ray to residents (room) for (chest x-ray), x-ray of pelvis (and) coccyx..." 1) The radiology Patient Report dated [DATE] did not document any fractures of the sacrum, coccyx, or pelvis. d. A Nurses Note dated [DATE] at 12:20 a.m. documented, "receive results of x-rays (and) (doctor) on call for (doctor) notified (and) (new order) noted to transfer resident to (hospital) for evaluation (and) treatment..." A Nurses Note dated [DATE] at 0450 (4:50 am) documented, " (Resident) returned from (hospital) via (by way of) ambulance ... Report from (hospital) (Registered Nurse) said (resident) had bacterial pneumonia ... (New Order) Levaquin 500 mg once a day (times) 10 days via peg (percutaneous endoscopic gastrostomy) tube. ..." e. Nurses Note dated [DATE] at 4:30 p.m. documented, "... (New Order) x-ray left knee and femur..." On [DATE] at 2:50 p.m., the Director of Nursing (DON) was interviewed regarding this resident's fall on [DATE]. She was asked why the initial x-ray on [DATE] had pelvis and coccyx and not the femur too. She stated, "The way she fell was how it was determined that was why the pelvis and coccyx x-ray was ordered on 6th. She did not have another fall on the 11th. The X-ray was ordered on the 11th because of swelling in her leg." f. The radiology Patient Report dated [DATE] documented, "Clinical Information: swelling/fall... Impressions: 1. Markedly displaced fracture of distal shaft of femur with angulation..." Nurses Note dated [DATE] at 8:45 p.m. documented, "Results of left knee and left femur x-ray reported to (doctor) on call for (doctor) (New Order) send to (hospital) to eval (evaluation) (and) (treat) (left) fx (fracture) femur displaced..." Nurses Note dated [DATE] at 9:30 p.m. documented, "(Ambulance) at facility transfer (resident) via (by way of) stretcher ..." Nurses Note dated [DATE] at 11:00 p.m. documented, "(Doctor) from (Hospital) ER (emergency room ) reported to this nurse that (resident) expired ..." g. A (Hospital) Emergency Documentation form dated [DATE] documented, "...lt (left) knee red tender ... PRONOUNCEMENT (Wed Sep 12 2012 00:25 (12:25 a.m.)) ... Found unresponsive, Found not breathing, Suspected cause of death is, pulmonary emboli..." h. Staff were interviewed regarding the incident (resident fall from mechanical lift): 1) On [DATE] at 3:10 p.m. the DON stated, "When I looked at the situation of how she was contracted, she was wet and when they positioned her over the pommel cushion in her wheelchair is when she slid out. She was not able to talk, she would moan sometimes. she wasn't moaning that night ([DATE]). I looked at her the next day and she wasn't moaning." 2) On [DATE] at 3:30 p.m., the Licensed Practical Nurse (LPN) #1 who had entered the resident's room immediately after she had fallen was interviewed and she stated, "When I went into the room, I just happened to walk in there. I saw (resident) on the floor and I said what happened. They had given her a shower and the Hoyer was there. The reason I wrote the inservice is when I asked what happened, they said she slipped out of the lift to the right. This is the first time I had dealings with residents slipping out of a sling." 3) On [DATE] at 3:38 p.m., CNA #1, who was present when the resident fell out of the lift sling, was interviewed. She was asked to explain what happened when the resident fell . She stated, "She (resident) was getting a shower that day and after her shower the aide pulled the light in the shower room. I went to see if she needed help and another aide was already in there. I saw the transfer from the shower chair to her wheelchair and it went smooth. She was taken back to her room. I had gone into see if she needed any help. It was (CNA #2) and (CNA #3) and whenever I walked in (CNA #3) was operating the lift. Lifting her (resident) from the wheelchair at the time (CNA #2) was guiding the transfer and (CNA #2) had stepped to side of bed to pull sheets back. When she got the sheets back she (resident) slipped out of the sling. The legs of the lift were open.(CNA #3) was standing in my line of vision." i. On [DATE] at 3:45 p.m., this Surveyor went to the room with CNA #1 to see where the wheelchair and lift were positioned. She showed this Surveyor where the wheelchair was at the foot of the bed facing the entrance door into the room. CNA #1 stated, "She was lifted up and the wheelchair brought back and she slid out toward the foot of the bed." At 3: 51 p.m. CNA #3, another CNA present on [DATE] when the resident fell during a transfer with the lift, stated, (CNA #2) brought her back to her room in the wheelchair after her shower. It was me, (CNA #2) and (CNA #1) . We hooked her (resident) up to the lift. As I was lifting, ((CNA #2) was suppose to hold the sling. She stepped away to pull the sheets back. The sling rolled up the back of her (resident's) legs. She fell out at foot of the bed. When the sling pulled up she fell straight down. When transferring a resident we always have someone guiding them. She wiggles a lot from side to side and trying to grab at the bars. She was doing this that night. No other time that I've assisted with transferring her that there wasn't someone supporting her. We always have someone supporting and guiding her. It was right then, pretty quick when (CNA #2) let go of the sling to pull back the sheets that she fell out. She fell straight down, right in front of the wheelchair. She was raised out of the seat. She was about 3 feet from the floor." At 4:10 p.m., CNA #2, who was also present during the transfer when the resident fell , was asked to explain what had happened on [DATE] when the resident fell from the lift sling. She stated, "We got her (resident) into her room. I made sure it was criss crossed under her legs. She had a blue sling on, which is the shower sling. We were lifting her up and I was holding her and she just went in the floor. I did let go with one hand to pull her sheets back. In that time was when she fell . I didn't have my hand under her. I had a hold with one hand to one of the hooks on the sling. There is always someone supporting and guiding residents who are transferred with the lifts. After I let go to pull the sheet back was when she fell . The sling went up the back and she fell out the front, legs out then butt hit the floor first. It was a mistake. I should have had at least one hand under her bottom. You're suppose to always use 2 hands to guide and support. She was wiggling a little but not much. We checked and changed her and she didn't act like she was in any pain. I probably had not worked with her enough in the past to know how she would act if she was hurting." j. On [DATE] at 7:00 p.m., CNA #3 and CNA #2 demonstrated for the surveyors how the lift was used the day of the incident with Resident #2. They positioned a shower sling in a chair. A surveyor sat in the chair on the sling. The sling was attached to the lift hooks. CNA #2 grasped the loops on either side of the sling. The loops were at the hip/upper buttocks area. After the surveyor was raised from the chair CNA #2 let go of the loop on the left side as if reaching for the sheet on the bed. Surveyor did not move or tilt. Surveyor had the CNAs to place the front of the sling (longest end) into the lift hooks. After raising the surveyor and repeating the above there was no movement of the sling or the surveyor. k. On [DATE] at 6:40 p.m., LPN #2 stated, "I do the orientation with all the CNAs when they start. The packet I have does not have return demonstration for the CNAs when they are hired. When a CNA initials the orientation that means they have done a return demonstration with a CNA on the floor. I don't do any return demonstration with CNAs prior to them going to the floor. This incudes anything." 1) On [DATE] at 5:35 p.m., CNA #2 (this CNA had been employed at this facility since [DATE]) stated, "I received a copy of how to use the Vanderbilt in my orientation packet. I have not been asked to do a return demonstration until after the incident with (Resident #2)." On [DATE] at 7:48 p.m., LPN #2 stated, "I am the one that gave this form to (CNA #2) to sign but she did not do a return demonstration as she signed before and I just verified it with her." On [DATE] at 6:47 p.m., the DON stated, "I know they are doing return demonstration prior to going to the floor because they signed off on the check off sheet. (CNA #2) should have done return demonstration prior to using a lift. The CNA's on the hall are responsible for checking them. They are shown how to use the lift and receive lift information and watch video. They do not do return demonstration prior to going to the floor. They have been shown how to use the lift so when they go to the floor they use it with someone else." 2) On [DATE] at 5:30 p.m., CNA #3 stated, "I have been checked off on the use of a Vanderlilt by return demonstration and again just the other day after the incident with (Resident #2)." 3) A form signed and dated [DATE] by CNA #8 documented, "I (CNA #8) , have received a copy of and read the operation instructions for the Vanderbilt and the Sit to Stand currently in use at (Facility). My signature below indicates that I am aware of the correct use and operation of each lift. I have performed a return demonstration of the use of the Vanderbilt and Sit to Stand." On [DATE] at 7:45 p.m., CNA #8 stated, (Van Driver #1) showed us the use of the lifts/pads on [DATE]. I did not do a return demonstration as I signed above until yesterday ([DATE])." 4) On [DATE] at 5:40 p.m. CNA #8 stated, "I started 4 days ago. I received instructions how to use the Vanderbilt during orientation. I was observed yesterday using the Vanderbilt. I've used the Vanderbilt prior to yesterday." l. The facility removed the Immediate Jeopardy and reduced the scope/severity to "G" prior to survey entrance date when the following corrective actions were taken: 1) An Inservice Education Report dated [DATE] documented, "Please position (resident) correctly in sling-always check bottom part of sling for correct positioning before lifting (resident) with Hoyer-be sure (resident) is not leaning in sling..." There were 22 Certified Nurses Assistants' signatures, including the 3 who were present during the fall. 2) On [DATE] at 4:30 p.m., the DON stated, "Inservices were initiated on [DATE]. The CNAs are being trained to support the resident's lower body during transfers now." 3) On [DATE] at 6:00 p.m., the DON stated, "Prior to the incident with (Resident #2) we randomly checked the CNAs return demonstration with the use of the lift. We now check 3 CNAs a week, different shifts for return demonstration." On [DATE] at 6:15 p.m. the facility's check list for return demonstration was reviewed prior to the incident. This list was initially dated [DATE]-[DATE]. The new check list started on [DATE]. On [DATE] at 7:22 p.m., the DON stated, "Return demonstration was started on [DATE]. One CNA was done on this date. During the time from [DATE]-[DATE] the CNAs were allowed to continue to use the lifts prior to the completion of the return demonstrations." B. Based on observation, record review and interview, the facility failed to ensure interventions to reduce the risk of burns from hot liquids were developed and communicated to staff, consistently implemented and reevaluated for effectiveness for 2 (Residents #1 and #6) of 3 (Resident's #1, #4 and #6) case mix residents who were assessed to be at risk for use of hot liquids. These failed practices had the potential to affect 50 residents at risk for injury from use of hot liquids per a list provided by the DON on [DATE] at 11:00 a.m. a.m. The findings are: 1. Resident #6 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of [DATE] documented the resident scored 7 (,[DATE] indicates severely impaired) on the Brief Interview For Mental Status (BIMS), required limited assistance of 1 person for eating, and limited range of motion of one upper extremity. a. The Resident Assessment, Hot Liquids Safety assessment dated [DATE] documented: "... Two or more (checks) indicate the resident is at risk for injury from spills of hot liquids. ... BIMS score equal to or less than 7 ... Weakness/paresis in upper extremities ... Loss of mobility/reduced movement in upper extremities ... Total Score 3 ... Resident to drink hot liquids while sitting at table only. (This was discontinued on [DATE].) [DATE], Resident to wear clothing protector/lap protector. Resident to use cup with lid..." The Hot Liquids Assessment with the last assessment dated [DATE] documented, "... [DATE], Other: (Resident) to wear Smoking apron if consuming hot liquids in bed..." b. As of [DATE], the Care Plan last reviewed on [DATE] did not document any problems or interventions for precautions when drinking hot liquids. c. The Unusual Occurrence Report dated [DATE] at 2:20 p.m. documented, "... (Resident #6) ... Thermal Burn ... Notified by CNA (Certified Nurse Assistant) that resident stated he spilled coffee on himself. Resident noted to sitting up in bed; gown wet to left side of body. (Left) side of abdomen red. Lid to coffee mug was on (and) in place... Unusual Occurrence Investigation Report ... 7. Summarize factors that contributed to this unusual occurrence: a. Based on the gathered facts what may have caused the event to occur? ... Resident lost grip on mug... c. Who was involved in the event? Resident... 8. What immediate interventions have you initiated to prevent this event from occurring again. 1. Tx (Treatment) order - Zinc Oxide ointment BID (twice a day). 2. Monitor affected area for blistering or (increase) in symptoms X (times) 72 hours. 3. Must wear clothing protector/Apron when drinking coffee in bed... DON/Designee to complete investigation of event within 5 days. New tx orders, (Resident) to wear smoking/thermal apron when consuming hot liquids in bed. Date Plan of Care Amended: [DATE]... Date CNA Plan/Info Sheet Amended, [DATE]..." This entry was signed by the DON and the Assistant Administrator. d. An Inservice Education Report dated [DATE] documented, (Room # of the Resident and which bed) Must have Apron on when drinking coffee in bed." The inservice was signed by 10 CNAs. e. On [DATE] at 9:45 a.m., the resident was in the bed with the head of the bed up. There was a cup of coffee at the bedside in reach of the resident. The resident had a hospital gown on and no clothing protector/thermal apron. There was no lid on the resident's coffee cup. The resident remembered the surveyor from the day before. Resident #6 was asked if he had ever been burnt from hot coffee. The resident stated, "Yes" and showed the surveyor a healed area on the left upper thigh which surveyor later discovered was not the burn. The resident was asked if the facility staff put lids on his coffee. The resident stated, "Yes, but I can take it off." The Skin Condition Record dated [DATE] documented, "Date First Observed: [DATE], (Diagram indicated left abdomen and noted 'open blister'), Site/location: ... 4.0 X 3.0 open area from blister (surface burn)... [DATE]: Healed..." f. On [DATE] at 12:35 p.m., the DON was asked if the resident ever had any other burns from hot liquids other than on [DATE]. The DON stated, "Not that I am aware of." The DON was asked if she was aware of the resident refusing to wear the apron. The DON stated, "I think he does at times." On [DATE] at 12:40 p.m., the Assistant Director of Nursing (ADON) stated that she did not know if the resident refused the apron in the bed, but knew he took it off in the dining room. g. On [DATE] at 2:25 p.m., CNAs #4 and #5 were asked what was supposed to be done when they gave Resident #6 hot liquids. Both CNAs stated, "to put smoking apron on" and both stated that he would refuse at times. CNA #4 stated, "If he refuses, we try to coax him into wearing it, put lots of ice in the coffee, or try to get him up to go to the dining room." CNA #4 was asked if they had closet care plans. She took a folded sheet of paper from her pocket and showed me the Care Plan. She looked for Resident #6's Care Plan and said that the apron was on the care plan, but it was not on the one for today. The CNA stated that they got new care plans each day. On [DATE] at 2:46 p.m., CNA #6 was asked if she was the one that brought Resident #6's breakfast. She stated, "Yes." The CNA was asked if she brought him the coffee. She stated, "I don't remember if he had coffee or not." The surveyor told the CNA that the resident did have coffee when the surveyor entered his room. The CNA stated, "I guess he did then." The surveyor asked if she knew what she was supposed to do when the resident was given hot liquids. The CNA stated, "I don't guess I do." I asked her if she had her care plan with her and she got it from her pocket, looked at it and stated, "You're supposed to put a lid on it." h. A copy of the Pocket Care Plan/Resident Information Sheet was received from CNA #7 on [DATE] at 2:49 p.m. The Care Plan documented, "...(Resident #6) ... Lid on Hot Liquids - Res (resident) often refuses..." There was no documentation of use of the apron. i. A copy of the breakfast, lunch, and supper tray cards were received from the DON on [DATE] at 4:03 p.m. The tray cards documented, "(Resident #6) ... Oct (October) 3, 2012 ... Eating Devices: Lid on Hot Liquids..." There was no documentation of the use of the apron. j. On [DATE] at 2:55 p.m., the Surveyor informed the DON that CNA #6 did not know to put the smoking apron on the resident and that the resident had coffee at the bedside this a.m. with no apron on. The DON stated, "She is new." The DON was asked how a CNA who had not taken care of the resident before would know to use the apron. The DON stated, "It is supposed to be on the CNA Resident info sheet. I don't know how it got off of there. The surveyor asked who was responsible for making this out each day. The DON stated, "I am. I go in and update, such as if an intervention is updated. It was there, I don't know how it got deleted." The DON stated that "other staff that have access to this were the ADON (Assistant Director of Nursing), the Medicare Manager, the MDS Coordinator, Medical Records, the Administrator, and that 2 Restorative Nursing Aides (RNAs) print them out each day." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment ARD of [DATE] documented the resident scored 7 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required supervision with set up help only with eating, and had no functional limitation in range of motion in upper extremities. a. The Hot Liquids Safety assessment dated [DATE], [DATE] and [DATE] documented two or more (checks) indicating the resident was at risk for injury from spills of hot liquids without any documented interventions put in place to prevent injury from hot liquids. b. As of [DATE] at 4:30 p.m., the Nutrition Assessments from [DATE] through [DATE] did not address the resident was at risk for hot liquids; however, it did document the resident liked hot chocolate and coffee. c. The Resident's Certified Nurses Assistant (CNA) Information (Info.) Sheet dated [DATE] provided by the Administrator In Training on [DATE] at 4:30 p.m. did not document the resident was at risk for hot liquids nor were there any interventions to prevent burns from hot liquids. d. On [DATE] at 2:30 p.m., the DON was asked to look at the last 3 Hot Liquid Risk Assessments for this resident and tell the Surveyor what they indicated to her. She stated, "That she is at risk for hot liquids." When she was asked if that was what was documented she stated, "No, but it should be. After they are assessed at risk for hot liquids it should be care planned, dietary gets notification and the CNA Info Sheet for that resident will also document that they are at risk and what interventions should be implemented." The DON was asked if there was a Policy and Procedure for Resident's at Risk for Hot Liquids and she said no. e. On [DATE] at 4:15 p.m., LPN #2 was shown the Hot Liquid Risk Assessment for this resident and was asked if she had completed the last 3 assessments. She stated, "Yes, but they were not done correctly. She should be at risk for hot liquids and have interventions to prevent injury from hot liquids. When asked if she was trained on how to complete this accurately. She stated, "Yes, by the previous MDS Coordinator who did these. If I had done these correctly, I should have implemented an intervention, updated her care plan and CNA Info Sheet and alerted Dietary that she was at risk for hot liquids." C. Based on record review and interview, the facility failed to ensure all staff were trained and routinely retrained in the proper/safe use of the manual van lift to prevent the potential for injury for 1 (Resident #4) of 5 (Resident #1, 3 - 6) case mix residents who used the van lift to be placed in the van for transportation. These failed practices had the potential to affect 79 residents who used the van lift per a list provided by the DON on [DATE] at 11:00 a.m. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of [DATE] documented the resident scored 15 (13 - 15 indicates cognitively intact) on the BIMS, was totally dependent on 1 staff member for locomotion on and off unit, had functional limitations in range of motion in both lower extremities, and used a wheelchair as a mobility device. a. The Unusual Occurrence Report dated [DATE] at 7:20 p.m. documented, "...Resident was hanging half way off van lift manually lifted her off the van lift; resident stated, 'didn't get hurt' assessment proves no visible signs of injury' ... 5. Contributing Factors: (checked) Equipment related... 6. Environmental Contributing Factors: (checked) Equipment failure... 7. Summarize factors that contributed to this unusual occurrence: a. Based on the gathered facts, what may have caused the event to occur: faulty van lift (hand written in) c. Who was involved in the event? (Resident) and Activities Director... 8. What immediate intervention have you initiated to prevent this event from occurring again... staff assisted, van to be repaired (handwritten in)..." The Investigation of Event within 5 days after incident dated [DATE] documented, "... (checked) Repair/replace defective equipment... Describe those items checked: Van lift assessed to make sure it was properly working. Date Plan of Care Amended: [DATE]... Investigation Completed by: (Administrator in Training) [DATE]... Results of (follow up): van lift working properly..." 1) The OLTC (Office of Long Term Care) Witness Statement Form dated [DATE] at 7:20 p.m. documented, "...(Activities Director)... I had taken (Resident) to a MS picnic (support group) and when I brought her back and was situating her in the van lift. (She is large lady so you have to be careful in situating her). The air from the manual lift started seeping out, causing it to slowly go down. (Resident) was not hurt due to the back belt in place..." 2) On [DATE] at 12:30 p.m. the Activities Director was asked to explain what had happened with this resident and the van lift. She stated, "Our electrical remote to the lift was broken. We did not have another van to use because CNA #5 had told me that it had broken on her that week and was unable to get the van at (Sister Facility) because the one they had to lend was broken too. I couldn't remember how to use it manually so I had CNA #5 tell me, we were at a ball game at the same time, before I used it that day (Saturday). (Resident) had been planning to go to this picnic for approximately 1 month. Prior to us going, I went to her room and told her the electric lift was broken and I would have to use the manual one. She still wanted to go. I didn't have any trouble getting her in the van to take her to the the picnic nor out of it at the picnic or again leaving the picnic. It was when I got her back to the facility when I had the trouble. I let the lift down level to the van floor. I was getting her situated onto the lift, she is a heavy lady and there is not much room on either side. The air started seeping out and she started slowly going down to ground on the lift. The belt was attached tightly behind the wheelchair. As the lift was slowly going down it caused the lip of the lift to rise causing the feet of her wheelchair to tip her backward. I am standing on the floor of the van holding her foot pedals to keep her from being scraped on back of legs and falling off of the lift. My cell phone was up at the front of the van so I started screaming for help. It was probably just a couple of minutes before the Maintenance Man's wife here visiting him came out and I sent her back in for lots of help. Six or seven people came within a couple of minutes to assist. We all lifted her in her wheelchair up and off of the lift. The belt is what kept her from coming out the back onto the ground. I use the van once or twice a month to transport resident's. This was the first time I had to use the van lift manually. It was about a year ago when I received training on how to use the van lift manually. I have not received any training/re-training since then." b. On [DATE] at 1:00 p.m., CNA #5 was asked when the electrical (remote) broke on the van lift and who if anyone she reported it to. She stated, "The electrical box on the lift that controls the lift up and down broke on Thursday ([DATE]) around 2:00 p.m. when I was going to transport another resident to his mother's funeral. We were loading him onto the lift that was lying on the ground when I reached for the remote box and all of the wires came out. I called the Maintenance Man and he looked at it and concluded that it was not fixable and would have to order a part to repair it. I think it came in last Monday ([DATE]). The Assistant Director of Nursing and another staff member took me over to (Sister Facility) to get one of their vans since ours was broke but the same thing was broken on that one too. I went ahead and brought that one back and used the manual lift (instructed how by the previous van driver #1) to lift him up into the van. I did not have any problems. I verbally told (Activities Director) it was broke and how to manually use the van lift. The Maintenance Man, AIT (Administrator in Training), DON and ADON knew that it was broken on our van. I do not know if they knew the same thing was broken on (Sister Facility) van." c. The Activities Director Van Driver Orientation Check List dated [DATE] provided by the AIT on [DATE] at 1:19 p.m. documented, "...(Activity Director's initials) shows knowledge of general van operation, operation of installed equipment... (Activity Director's initials) know location of instructions for installed equipment (lift, safety harnesses, wheelchair locks, etc)..." d. On [DATE] at 1:30 p.m. the AIT stated, "I was not aware that the lift on our van was broken prior to this incident. If something is wrong with our van (we only have the one) we use the (Sister Facility)'s van. Van Driver #2 is responsible for letting me know if something is wrong with the vans but she was on vacation. I