Every finding on record at Piedmont Post-Acute

Based on observation, interview, and facility policy review, the facility failed to ensure staff checked temperatures of all foods placed on the steam table for hot holding prior to meal service. Specifically, staff failed to check temperatures of additional batches of food added to the steam table during meal service on 04/03/2026. This had the potential to affect 80 residents who received food from the facility kitchen. Findings included: Review of a facility policy titled, Serving Temperatures for Hot and Cold Foods, effective 2020, revealed, The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. During an observation on 04/03/2026 at 12:36 PM, Dietary Aide (DA)21 placed a new batch of fried chicken on the tray line and plated a plate for a resident and did not take the temperature of the fried chicken. The Assistant Dietary Director (ADD) asked DA21 if she took the temperature of the chicken and DA21 revealed she did not. During a continued observation of the tray line for lunch on 04/03/2026 at 12:55 PM, a new pan of macaroni and cheese was taken out of the oven, placed on the tray line, and plated. DA21 did not take the temperature of the macaroni and cheese, prior to service. During a continued observation of the tray line for lunch on 04/03/2026 at 12:56 PM, a new batch of fried chicken was taken out of the fryer and put on the tray line and plated. DA21 did not take the temperature of the fried chicken. During a concurrent observation and interview on 04/03/2026 at 12:40 PM, DA21 indicated, I do not like serving cold food, I had multiple batches of fried chicken because I like the food to be fresh. During an interview on 04/04/2026 at 12:36 PM, the Administrator revealed the expectation are the dietary department should be meeting all temperature guidelines. The Administrator stated that if additional food was prepared, its temperature must also be taken.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure staff followed infection control practices to help prevent the development and transmission of communicable diseases and infections, which affected 1 of 1 resident, (Resident (R)92), reviewed for tracheostomy care, 1 of 1 resident, (R9), reviewed for pressure ulcers, and 1 of 1 resident, (R87), reviewed for transmission based precautions. The facility also failed to implement a complete water management program for Legionella prevention, which had the potential to affect all the residents in the facility. Findings included: 1. Review of a facility policy titled, Tracheostomy Care, revised 10/2023, revealed, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. The policy revealed, Procedure Guidelines included, 8. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle, and 9. Perform hand hygiene. An admission Record revealed the facility admitted R92 on 03/25/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of acute and chronic respiratory failure with hypoxia and tracheostomy status. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2026, revealed R92 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R92's Care Plan Report included a focus area initiated on 03/28/2026, that indicated the resident had a diagnosis of respiratory failure and indicated that the resident required tracheostomy care and monitoring. Interventions directed staff to manage the resident's artificial airway (initiated 03/28/2026). Review of R92's Order Summary Report, with active orders as of 04/03/2026, revealed an order, dated 03/23/2026, for tracheostomy care every shift. During an observation of R92's tracheostomy care on 04/01/2026 at 9:05 AM, the Respiratory Therapist performed hand hygiene, donned a pair of clean gloves, opened sterile supplies for tracheostomy care, and discarded the gloves. The Respiratory Therapist failed to perform hand hygiene prior to putting on sterile gloves that were within the kit. The Respiratory Therapist then removed the dressing from around the resident's neck and the tracheostomy collar and discarded it. The Respiratory Therapist then, wearing the same gloves, completed cleaning of the tracheostomy area. The Respiratory Therapist did not change gloves and/or perform hand hygiene between removing the dressing and cleaning the area. During an interview on 04/01/2026 at 9:20 AM, the Respiratory Therapist stated that when changing gloves, she was expected to perform hand hygiene between gloves changes. She stated that once she touched the dressing and removed it from around the resident's neck, it was considered dirty, and a new pair of sterile gloves should have been donned. She stated she had been trained and was expected to perform tracheostomy care per the facility's policy and procedures. During an interview on 04/04/2026 at 12:35 PM, the Director of Nursing (DON) stated that staff were required to wash their hands before they donned another pair of clean and/or sterile gloves. She stated that for any process from clean to dirty tasks, the staff were to remove the dirty gloves, perform hand hygiene, and don clean gloves. During an interview on 04/04/2026 at 1:00 PM, the Administrator stated that staff had been trained and were expected to remove gloves, perform hand hygiene, and don clean gloves when completing tracheostomy care. 2. An admission Record revealed the facility admitted R9 on 06/24/2024. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of pressure a Stage IV pressure ulcer of other site. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2026, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had two Stage IV pressure ulcers. Review of R9's Care Plan Report included a focus area initiated 08/05/2024 and revised 11/24/2026, that indicated the resident had pressure ulcers including on their right lateral lower leg. Interventions directed staff to administer treatment as ordered (initiated 08/05/2024). Review of R9's Order Summary Report, with active orders as of 04/03/2026, revealed an order, dated 03/30/2026, for wound care to the right lateral leg. The order specified to cleanse the wound, pat dry, apply a skin barrier, cover the wound with a gauze dressing impregnated with petrolatum followed by calcium alginate, wrap with gauze, cover with a bandage, and apply an elastic tubular support [NAME] for compression. The order indicated that the wound care was to be completed daily and as needed. During and observation of R9's wound care on 04/01/2026 at 9:43 AM, Licensed Practical Nurse (LPN)4 performed hand hygiene, donned a clean pair of gloves, removed a dirty dressing from the resident's right ankle, discarded the dressing, then, wearing the same gloves, cleaned the right ankle wound with wound cleanser. LPN4 discarded one glove during the procedure and donned another clean glove without performing hand hygiene prior to donning a new glove. During an interview on 04/01/2026 at 10:12 AM, LPN 4 stated that she was required to sanitize her hands between glove changes. She stated that prior to going from a dirty procedure to clean procedures, she was to discard her gloves, wash her hands, then put on clean gloves. During an interview on 04/04/2026 at 12:35 PM, the Director of Nursing (DON) stated that staff were required to wash their hands before they donned another pair of clean and/or sterile gloves. She stated that for moving from a clean to dirty task, the staff were to remove their dirty gloves, perform hand hygiene, and don clean gloves. During an interview on 04/04/2026 at 1:00 PM, the Administrator stated that staff had been trained and were expected to remove their gloves, perform hand hygiene, and done clean gloves providing wound care.3. A facility policy titled, Isolation - Categories of Transmission-Based Precautions, revised 09/2022, revealed, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The policy further revealed, Contact Precautions included, 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment; 7. Staff and visitors wear gloves (clean, non-sterile when entering the room; and 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid potentially contaminated surfaces with clothing after gown is removed. An admission Record revealed the facility admitted R87 on 03/23/2026. According to the admission Review, the resident had a medical history that included but was not limited to diagnoses of an infection following a procedure, other surgical site. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/2026, revealed that R87 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated that the resident had a wound infection. Review of R87's Care Plan Report revealed a focus area initiated 04/01/2026, that indicated that resident was on isolation precautions due to MRSA infection. Interventions initiated 04/01/2026 directed staff to follow universal precautions when working with residents in isolation; maintain isolation with contact precautions; perform hand washing after completing care and leaving the room; and use personal protective equipment (PPE) as recommended for the type of infection. Review of R87's hospital Infectious Disease Progress Note, dated 03/16/2026, revealed that the resident developed wound tunneling after surgery on 11/21/2025 with increased drainage from a right lateral knee wound on 01/05/2026. The record revealed that cultures from the wound had Methicillin-resistant Staphylococcus aureus (MRSA; a type of staph infection). The record revealed surgical cultures on 01/09/2026 revealed Bacteroides fragilis (B. fragilis; an anaerobic, Gram-negative bacterium), MRSA, and klebsiella pneumonia (extended spectrum beta lactamase [ESBL] positive, which is a bacteria that makes it resistant to many antibiotics). The record indicated that surgical cultures on the right femur tissue on 02/24/2026 grew MRSA. Review of R87's Order Recap [Recapitulation] Summary contained an order, dated 03/23/2026, for the resident to be on contact precautions related to MRSA. The order also indicated that provision of all care and therapy was to be provided in the resident's room every shift until 04/07/2026. The Order Recap Summary contained an order, dated 03/23/2026, for linezolid (an antibiotic) oral tablet 600 milligrams (mg), one tablet by mouth every 12 hours for MRSA until 04/07/2026. The Order Recap Summary also contained an order, dated 03/23/2026, for vancomycin hydrochloride (HCI) (an antibiotic) oral capsule, 125 mg, one capsule by mouth twice a day for a history of Clostridioides difficile (C-diff; a bacterium causing severe, watery diarrhea, abdominal pain, and colitis often following antibiotic use) until 04/07/2026. Review of R87's Progress Notes included an Admission/re-admission Summary Note, dated 03/23/2026 at 6:14 PM, that revealed that the resident arrived via stretcher after a hospital stay for open reduction internal fixation (ORIF) of the right hip and a wound infection. The note indicated that Resident #87 was on contact precautions for MRSA in the wound until 04/07/2026. During an interview on 03/31/2026 at 2:44 PM, R87 stated they were on isolation for C-diff and MRSA. An observation on 04/01/2026 at 12:28 PM during the noon meal service revealed that R87 had a plastic cart outside their room for PPE. Certified Nurse Assistant (CNA) #19 entered the resident's room to take a meal tray to the resident and did not apply any PPE before entering the room. During an interview on 04/01/2026 at 2:43 PM, CNA19 stated that R87 was on contact precautions. She stated that staff were supposed to use hand sanitizer before entering the room and apply all the PPE before going into the room. She stated that she thought she did put PPE on. CNA19 stated that staff had to set up the resident's tray. She stated that at their last meeting for infection prevention, staff were told to apply gloves and hand sanitizer when going in and coming out, and to remove the PPE when coming out of the room. During an interview on 04/01/2026 at 2:49 PM, CNA17 stated that before going into the room, staff should get all their supplies, apply a gown, gloves, and a mask, then wash their hands or use hand sanitizer. CNA17 stated that when coming out of the room, staff should remove the gown and then wash their hands. CNA17 stated that staff should put a gown on when going in to take a tray into the room but did not think so if they were not touching anything. During an observation on 04/02/2026 at 12:31 PM, CNA7 took R87's meal tray into their room but did not put on any PPE. After setting up the resident's tray on the over-the-bed table, she exited the room without completing hand hygiene. During an interview on 04/02/2026 at 12:39 PM, CNA7 stated for contact precautions, staff should wear a gown, mask, and gloves. She stated that she did not know if she had to wear full PPE when she took the resident's meal tray in. She stated, I just asked because I wasn't sure. and was told no. She stated that she asked another CNA. During an interview on 04/02/2026 at 12:45 PM, Licensed Practical Nurse (LPN)1 stated that staff should wear a gown and gloves whenever entering a resident's room who was on contact precautions. In regard to when staff delivered meal trays, she stated that they should wear a gown and gloves. During an interview on 04/03/2026 at 2:29 PM, the Director of Staff Development (DSD), who was also the Infection Preventionist, stated that staff should be wearing gloves and gowns when passing meal trays. During an interview on 04/04/2026 at 10:48 AM, the Assistant Director of Nursing (ADON) stated that staff should wear a gown and gloves when delivering meal trays to residents on contact precautions. During an interview on 04/04/2026 at 12:05 PM, the Administrator stated he heard about the issue with the contact isolation room. He stated that he expected staff to follow all of contact isolation requirements and to wear the appropriate PPE. 4. A facility policy titled, Legionella Water Management Program, revised 09/2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The Policy Interpretation and Implementation revealed, 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The policy revealed, 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The policy revealed, 5. The water management program includes the following elements, which included, b. A detailed description and diagram of the water system in the facility; c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria; d. The identification of situations that can lead to Legionella growth; e. Specific measures used to control the introduction and/or spread of Legionella; f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. The policy continued, 6. The water management program is reviewed at least once a year. Review of a binder containing an undated Legionella Control Toolkit, developed by the United States Department of Health and Human Services (DHHS), Centers for Disease Control and Prevention (CDC), provided by the facility staff as their water management plan, revealed the first page of the binder was a document that included a building water description that listed out where the water entered the main line of the facility and how that water traveled through the facility; indicated having a back flow device at the road; and that once water entered the building, it supplied the kitchen, laundry, resident rooms, showers, ice machine, beauty shop, housekeeping closets, and nourishment kitchens. The document also indicated that there were seven water heaters in the facility. The document revealed that it did not include any further information about how the facility monitored the water supply, did not specify any specific measures used to control the introduction of situations that could lead to Legionella growth, a diagram of where control measures were applied, a system to monitor control limits and effectiveness of control measures, a plan for when control limits were not met or not effective, or any evidence of when the plan was reviewed. During an interview on 04/03/2026 at 12:59 PM, the Maintenance Director stated he had worked at the facility for about two and a half years. In regard to the water management program, the Maintenance Director stated that he may check ice makers, but the facility's water was from the city, so they did their testing for any water-borne illness. He stated that he did not monitor any of the water in the facility unless something was brought to his attention. Per the Maintenance Director, for things like shower heads, other than cleaning them, they only replaced them if they got nasty but stated that they usually were broken and replaced before they got to that point. The Maintenance Director stated that the diagram in his binder only showed the water going into the water heaters. He stated that they had one eyewash station in the kitchen. He stated that he checked the ice makers randomly to make sure they were clean, but he did not have anything in writing to show where he was monitoring or what points within the facility could be considered a potential risk for development of waterborne illness. He stated that he did have a cleaner that he poured down the drains but understood that there should be more to the water management program. During an interview on 04/03/2026 at 2:29 PM, the Director of Staff Development (DSD), who was also the Infection Preventionist, stated they had not had any residents who had tested positive for Legionnaire's disease. She stated that she was not involved at all with the water management plan. She stated that she helped the Maintenance Director make sure the water was working if needed but nothing else with the water management program. During an interview on 04/04/2026 at 11:34 AM, the Director of Nursing (DON) stated that she expected that the water management program to be monitored by maintenance staff, who should be doing it according to the policy. She stated that the policy should include how they monitored water sources to ensure there was no stagnant water and no risk of waterborne illness. She stated that she was not aware of any outbreaks of waterborne illnesses at the facility. During an interview on 04/04/2026 at 12:05 PM, the Administrator stated that he did not know a lot about the water management plan. He stated that he thought the water should be tested annually, and there should be something in the diagram of what the points of concern were and how those areas were being monitored.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 6 errors out of 44 opportunities, which resulted in a medication error rate of 13.64% for 3 (Residents (R)22, (R)14, and (R)62) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 1. An admission Record indicated the facility admitted R22 on 03/23/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of gastro-esophageal reflux disease without esophagitis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/2026, revealed R22 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R22's Order Summary Report, with active orders as of 04/01/2026, revealed an order dated 03/23/2026, for famotidine oral tablet 20 milligrams (mg), with instructions to give one tablet by mouth one time a day for acid reflux. During an observation of medication administration on 04/01/2026 at 8:07 AM, Licensed Practical Nurse (LPN)2 administered medication to R22, including one famotidine 10 mg tablet. During an interview on 04/01/2026 at 12:38 PM, LPN2 stated that the resident should have had two pills (for a total of famotidine 20 mg) administered based on the physician orders and based on the medication that she had on hand. She stated she had been trained and was expected to follow the physician's orders for medication administration. During an interview on 04/04/2026 at 12:35 PM, the Director of Nursing (DON) stated that the resident should have been given two tablets (for a total of famotidine 20 mg) instead of one tablet (famotidine 10 mg). She stated that staff had been trained and expected to follow physician orders. During an interview on 04/04/20206 at 1:00 PM, the Administrator stated that staff had been trained and expected to follow physician orders regarding medication administration. 2. An admission Record indicated the facility admitted R14 on 03/17/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of muscle weakness and hyperlipidemia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/24/2026, revealed R14 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. Review of R14's Order Summary Report, with active orders as of 04/01/2026, revealed an order dated 03/17/2026 for ferrous sulfate oral tablet delayed release 324 milligrams (mg), with instructions to give one tablet by mouth one time a day every Monday, Wednesday, Friday for anemia. The Order Summary Report revealed an order dated 03/17/2026 for fish oil oral capsule 1200 mg, with instructions to give one capsule by mouth one time a day for heart disease. During an observation of medication administration on 04/01/2026 at 8:20 AM, Licensed Practical Nurse (LPN)1 administered medication to R14, including one ferrous sulfate oral tablet delayed release 325 mg tablet and fish oil oral capsule 500 mg, two capsules by mouth. During an interview on 04/01/2026 at 12:26 PM, LPN1 stated that the ferrous sulfate order for R14 was not what the facility had in stock. She stated the order should have been for ferrous sulfate 325 mg instead, and the dose she administered was 325 mg. LPN1 stated the facility did not carry fish oil 1200 mg and the order was changed after she spoke to the Nurse Practitioner (NP) to fish oil 500 mg two tablets to start on 04/02/2026. She stated that based on the previous orders, she administered the medications incorrectly. She stated she had been trained and was expected to follow the physician's orders for medication administration. During an interview on 04/03/2026 at 10:29 AM, the NP stated that she would have reviewed the resident's medications and signed off on them after staff inputted the information in the system. She stated that the fish oil 1200 mg should have been given and not fish oil 1000 mg that the resident received and was an oversight. She stated the ferrous sulfate dosage could have been an oversight as well because the house stock for the facility was ferrous sulfate 325 mg. 3. An admission Record indicated the facility admitted R62 on 12/24/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of muscle weakness and infection and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026, revealed R62 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R62's Order Summary Report, with active orders as of 04/01/2026, revealed an order dated 03/09/2026 for fluticasone propionate suspension 50 micrograms (mcg), with instructions to give one spray in each nostril every morning and at bedtime for allergic rhinitis. During an observation of medication administration on 04/01/2026 at 8:30 AM, Licensed Practical Nurse (LPN)3 administered medication to R62, including saline nasal spray 0.65%, one spray to each nostril. During an interview on 04/01/2026 at 12:45 PM, LPN3 stated that she spoke with central supply about the saline nasal spray and was told that she should have used fluticasone propionate suspension spray and the two medications were not the same. She stated she had been trained and was expected to follow the physician's orders for medication administration. During an interview on 04/02/2026 at 4:46 PM, the Medical Director stated that the nurse should have checked with the Nurse Practitioner (NP) and the resident before saline nasal spray was administered to see if the resident desired to take it. During an interview on 04/04/2026 at 12:35 PM, the Director of Nursing (DON) stated that the expectation for the nurse would have been to notify the physician that the fluticasone propionate suspension spray was not available and documentation placed in the resident's progress notes.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure sufficient bowel monitoring for 1 (Resident (R)26) of 1 sampled resident reviewed for bowel monitoring. Findings included: A facility policy titled, Bowel Management Protocol, dated 02/15/2015, revealed, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. The policy also indicated, Normal bowel pattern is once every day up to once every three (3) days. Constipation results from factors such as immobility, decreased activity, and as a side effect of numerous medications. The policy also indicated, CNAs [certified nursing assistants] to document each shift the number of bowel movements and size of bowel movements on the resident flow record. The policy also indicated, The Unit Manager will review the resident flow record daily and compose a list of those residents having not had a BM [bowel movement] in three (3) days. The policy also indicated, The nurse will provide medication as ordered by the physician or obtain a physician's order, to residents on the bowel care list. The medication given should be recorded on the MAR [Medication Administration Record]. The policy also indicated, The nurse is to follow up on those residents and document results. The nurse will document results in the chart and on the MAR just as would be done for any PRN [as needed] medication. Documentation should include size and consistency of the bowel movement. (Documentation should match the resident flow record that the CNAs complete). A facility policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, effective 09/2017, revealed in the section Monitoring and Follow-Up that, The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements, and the frequency, severity, and duration of abdominal pain, etc. [et cetera, and other similar things]. A facility policy titled, Change in a Resident's Condition or Status, revised 02/2021, revealed, Our facility promptly notifies the resident his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. [exempli gratia, for example] changes in level of care, billing/payments, resident rights, etc.). An admission Record revealed the facility admitted R26 on 04/25/2019 and readmitted the resident on 06/19/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of constipation, major depressive disorder, and cognitive communication deficit. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2025, revealed R26 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated R26 required substantial to maximum assistance with toileting. The MDS indicated the resident was always incontinent of bowel. A significant change MDS with an ARD date of 01/13/2026, revealed R26 had a BIMS score of 4 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated R26 required substantial to maximum assistance with toileting. The MDS indicated the resident was always incontinent of bowel. The MDS indicated R26 was on hospice services. Review of R26's Care Plan Report included a focus area, initiated on 07/06/2025 and revised on 03/13/2026, that indicated the resident was at risk for gastrointestinal problems related to constipation and gastroesophageal reflux disease (GERD). Interventions directed staff to: Administer medication per the physician's order, monitor the effects, and notify the physician if problems were not relieved; Monitor and document bowel movements every shift; and Monitor for signs and symptoms of gastrointestinal problems and report abnormal findings to the physician. Review of R26's Order Summary Report, with active orders as of 04/01/2026, included: - GlycoLax Powder (Polyethylene Glycol [PEG] 3350, a laxative solution) 17 grams by mouth in the morning for constipation. Hold for loose stool (in Liquid). Mix with 4 - 8 ounces of liquid, started 06/25/2025; - Sennosides Tablet 8.6 milligrams (mg) two tablets by mouth two times a day for constipation, started 06/24/2025; and - Side effects monitoring for Anti-Depressant medication every shift including monitoring for constipation, started 06/19/2025. Review of a facility document titled, [Vendor Name] Standing Orders, dated 07/01/2024, revealed, These orders are standard prn orders designed to streamline care delivery and eliminate lag times in patient care. The document indicated, Constipation: Colace [a stool softener] 100 mg po [by mouth] two times per day prn constipation Or MOM [Milk of Magnesia, a laxative] 30 cc [cubic centimeters] po daily prn constipation. Review of R26's Medication Administration Record (MAR) dated 03/2026, revealed Colace and MOM were not administered. Review of R26's Documentation Survey Report, dated 03/2026, revealed the resident had no bowel movements documented from 03/12/2026 to the day shift of 03/19/2026 and from 03/20/2026 through 03/31/2026. Review of R26's Task: Bowel Continence record dated from 03/04/2026 through 04/04/2026, revealed the resident did not have a bowel movement documented from 03/12/2026 through 03/19/2026 and from 03/21/2026 through 04/01/2026. The Task Bowel Continence record revealed: on 03/20/2026, the bowel movement consistency was Soft; on 04/02/2026 at 3:51 PM, the bowel movement consistency was Constipated/hard; and on 04/02/2026 at 11:27 PM, the bowel movement consistency was Loose/Diarrhea. Review of a facility document titled, Nurse Communication Log, dated 03/14/2026 through 04/02/2026 and located in the Doctor's Book at the nurses' station, revealed R26 was not listed with a concern. Review of a facility document titled, Clinical and Order Alerts Listing Report, dated from 03/12/2026 through 03/19/2026, revealed R26 was not listed on the report. Review of a facility document titled, Clinical and Order Alerts Listing Report, dated from 03/21/2026 through 04/02/2026, revealed R26 was not listed on the report. Review of R26's hospice Visit Note Report, dated 03/30/2026, revealed the resident had a bowel movement on 03/28/2026 and had normal bowel sounds in all four quadrants. Review of R26's hospice Facility Visit Log, dated 04/02/2026 at 10:20 AM, revealed, ? constipation. Added Dulcolax supp [a laxative suppository]. Review of a nurse's Progress Note[s], dated 04/02/2026 at 11:56 AM, revealed, N.O. [new order] to start Dulcolax Rectal Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally one time only for Constipation until 04/02/2026 12:00 AND Insert 1 suppository rectally one time a day for constipation. Review of R26's hospice Facility Visit Log, dated 04/02/2026, revealed, Patient complained of gas pains and was washed up [cleaned]. During a phone interview on 04/01/2026 at 10:52 PM, Licensed Practical Nurse (LPN)9 stated CNAs charted bowel movements, and she did not know if the nurses were supposed to be checking it. LPN9 stated she was sure the bowel movements were checked daily, but she was not sure how that worked. LPN9 stated that by the third day, or probably the second day, if a resident had not had a bowel movement. they should give the resident something. LPN9 stated if a resident went three days without a bowel movement they would give the resident a suppository. LPN9 stated no one had told her a resident had not had a bowel movement. LPN9 stated if a resident did not have a bowel movement for three days, she would notify the provider, there might be a standing order she would follow, and, if not, she would call the provider. LPN9 stated no one told her that R26 had not had a bowel movement. During an interview on 04/02/2026 at 11:11 AM, Hospice Registered Nurse (HRN) stated the hospice visits for R26 were scheduled weekly and as needed. HRN stated a family member called hospice and requested hospice go see R26 and that was why he was at the facility that day. The HRN revealed that R26 might be a little constipated. The HRN stated constipation was part of the pain the resident was having, so they ordered suppositories. During an interview on 04/02/2026 at 3:06 PM, LPN8/Supervisor stated that nurses were to check the electronic medical record system for a resident's bowel schedule. LPN8 stated a resident should have a bowel movement in three days. LPN8 stated she made a list of residents who had not had a bowel movement for a few days and let the nurses know that those residents needed their PRN medications. LPN8 stated the computer system kept the running list, and she printed it off. LPN8 stated she looked at that list daily, but she did not keep copies of the list. LPN8 stated she did not document when she notified a nurse to provide the PRN medications for bowel movements. LPN8 stated that she looked at the list that week and the week prior. LPN8 stated she thought R26 was on the list for last week on Friday (03/27/2026) and also on Monday (03/30/2026). LPN8 stated she asked R26's nurse to give the resident MOM. LPN8 stated the nurses should look at the bowel list, but she thought the nurses relied on her to let them know if a resident had not had a bowel movement in three days. LPN8 stated if a CNA told a nurse that a resident did not have a bowel movement in three days the nurse should follow up, and if a resident did not have an order for MOM they should get one, administer the MOM, and complete a nurse's note. LPN8 stated constipation was an ongoing thing for R26. LPN8 stated R26 would get a little constipated and then have a bowel movement. LPN8 stated that without nurses' notes she could not say if the resident refused the additional treatment for constipation. LPN8 stated, after she reviewed R26's MAR and bowel movement Task Report, that the nurses should have notified her so that R26 could have been put on the bowel movement Alert List. LPN8 stated the hospice aides should report bowel movements to them. LPN8 stated that information should be passed on from shift to shift, and it would be documented in the CNA documentation. During an interview on 04/02/2026 at 3:31 PM, CNA7 stated residents' bowel movements were documented in the electronic medical record. CNA7 stated if the resident had more than one bowel movement on a shift, they would document it each time. CNA7 stated that usually the hospice aide would tell them if a resident had had a bowel movement. CNA7 stated she worked with R26 from 03/20/2026 through 04/01/2026, and R26 did not have a bowel movement during her shifts. CNA7 stated if there was an issue with a resident not having a bowel movement she would report it to the nurse. During a follow-up observation and interview on 04/02/2026 at 3:40 PM, R26 stated they just had a bowel movement after a suppository, the bowel movement was as hard as a rock, and that was why their bottom was hurting. R26 stated it had been two weeks since their last bowel movement, staff had been giving them something for the constipation, but it had not worked, and that was why the bowel movement was as hard as a rock. R26 stated that now they had a bowel movement, they felt better. R26 stated the nurses had kept checking on them, and the resident told the nurses the resident was fine. During a follow-up interview on 04/02/2026 at 3:48 PM, CNA7 confirmed she took care of R26 on her shift on 03/14/2026, 03/15/2026, 03/18/2026, 03/19/2026, 03/22/2026, 03/23/2026, 03/27/2026, 03/28/2026, 03/30/2026, 04/01/2026, and 04/02/2026. CNA 7 revealed R26 did not have a bowel movement during CNA7's shifts from 7:00 AM to 7:00 PM. During an interview on 04/02/2026 at 3:50 PM, LPN2 stated she did not know R26 was having a bowel movement issue until the hospice nurse came and told her that day. LPN2 stated she was PRN and that the CNAs charted bowel movements. LPN2 stated CNAs would usually tell the nurses if a resident had not had a bowel movement in a while. LPN2 stated the CNAs should alert the nurse. LPN2 stated she did not look at the bowel movement Task Report. LPN2 stated she was not sure who monitored the bowel movements. LPN2 stated she was not notified at all about R26 not having a bowel movement until that day. During an interview on 04/02/2026 at 4:16 PM, LPN8 stated there were no nurses' notes related to bowel movements for R26 during the time period of 03/12/2026 through 03/19/2026 and from 03/21/2026 through 04/01/2026. LPN8 stated R26 did not appear on the clinic report, which showed bowel movement alerts, for the time period of 03/12/2026 through 03/19/2026 and from 03/21/2026 through 04/01/2026. LPN8 stated the clinic report was the same report as the Alert Listing. LPN8 stated that R26 did not appear on the Alert Listing. LPN8 stated if a resident did not have a bowel movement in three days the resident should be on the Alert Listing. During a phone interview on 04/02/2026 at 8:55 PM, LPN10 stated she relied on the CNAs to tell her if a resident did not have a bowel movement. She stated if a resident did not have a bowel movement in two to three days the CNA should tell her. LPN10 stated CNAs documented bowel movements in their charting system, and normally if a resident had not had a bowel movement in a while the CNAs usually said something. During an interview on 04/03/2026 at 8:37 AM, the Assistant Director of Nursing (ADON) stated LPN8 generated bowel movement monitoring reports for the whole building, and if a resident did not have a bowel movement for three days it would be flagged in the system on the dashboard. The ADON stated nurses monitored bowel movements shift to shift. The ADON stated CNAs could go into the charting and see the resident's bowel movement history for three shifts prior to their shift, but CNAs were not expected to do that. During an interview on 04/03/2026 9:01 AM, LPN3 stated the CNAs let nurses know when a resident had a bowel movement or if it had been a few days since a resident had a bowel movement. LPN3 stated they could monitor bowel movements on their computer, and they were alerted by the unit manager when a resident had not had a bowel movement in three days. During a phone interview on 04/03/2026 at 10:19 AM, the Nurse Practitioner (NP) stated no one notified her about lack of bowel movements for R26 from 03/12/2026 to 03/19/2026 or from 03/21/2026 to 04/01/2026. The NP stated if a resident had not had a bowel movement within five days the staff should contact her and going beyond five days that would start to be concerning. The NP stated there were standing orders available if a patient had complaints of constipation or hard stool or if CNAs noted the resident did not have a bowel movement in three days and the nurse noticed the resident did not have a bowel movement in three days. During a follow-up phone interview on 04/03/2026 at 10:58 AM, LPN6 stated she was not notified of R26 not having a bowel movement, and the CNAs would notify her or the nurse. LPN6 stated the CNAs monitored the bowel movements. She stated R26 was able to tell the nurse if the resident was in pain or constipated, and the resident had not voiced to her that the resident was constipated. LPN6 stated that for monitoring of bowel movements she would ask CNAs, and most of them communicated very well with the nurses. LPN6 stated she could go into the CNAs' portal to see bowel movements, but it was mostly communicated by the CNAs. During a phone interview on 04/03/2026 at 11:34 AM, LPN11 stated the CNAs monitored the bowel movements, and they let the nurses know if they needed to look or if there was a concern. During an interview on 04/03/2026 at 2:43 PM, CNA17 stated they documented bowel movements on the chart, and she monitored bowel movements by keeping track of whether or not a resident had a bowel movement. CNA17 stated if they did not have the same resident every day they would not know about the resident's bowel movements. CNA17 stated she would probably notify the nurse if a resident did not have a bowel movement in two days. During a follow-up interview on 04/03/2026 at 4:10 PM, the ADON stated she was not made aware of R26 not having a bowel movement for two weeks. During a phone interview on 04/03/2026 at 4:37 PM, the Medical Director stated if a resident did not have a bowel movement from 03/12/2026 to 03/18/2026, that it was a very long time not to have a bowel movement. The Medical Director stated it was hard to believe a resident did not have a bowel movement from 03/21/2026 through 04/01/2026. The Medical Director stated that unfortunately constipation came with the territory with a hospice patient. The Medical Director stated that it sounded like something could have been looked at a little more closely for the lack of bowel movements. The Medical Director stated that it was a clinical issue, was something staff needed to be aware of, and brought to the nurses' and providers' attention. The Medical Director stated that it was disturbing that someone may have gone a two-week period without a bowel movement and no one knew about it. The Medical Director stated that he did not know how that would slip through the cracks, and it should not happen, not being recognized and addressed. During an interview on 04/03/2026 at 4:57 PM, the ADON stated if hospice services had communicated with them that R28 had a bowel movement they would have put it into their system. The ADON stated that from her understanding hospice services did not communicate that R26 had a bowel movement on 03/28/2026. The ADON stated facility staff depended on the Alert Report, and the Director of Staff Development (DSD) monitored CNA documentation. The ADON stated LPN8 monitored the reports, pulled the report daily, and told the nurses if a resident did not have a bowel movement. The ADON stated her expectation was the CNAs were to communicate if they saw a resident was constipated or a resident verbalized they were constipated. The ADON stated that ultimately the nurses were responsible to monitor bowel movements using the dashboard along with their audits. During an interview on 04/04/2026 at 8:38 AM, LPN12 stated she was the weekend supervisor. LPN12 stated for bowel movement monitoring staff knew their residents, and LPN8 ran the bowel movement report during the week, and she (LPN12) ran it on the weekends. LPN12 stated she did not recall R26 being on the bowel movement Alert Listing. LPN12 stated the CNAs were good about telling the nurses about residents' bowel movements. LPN12 stated at the end of the day it was the nurses' responsibility to make sure the residents were having bowel movements. LPN12 stated there were hospice books at the nurses' station, and when hospice came in they would ask hospice what was going on with a resident and the last time the resident had a bowel movement. LPN12 stated if it had been over three days since the resident's last bowel movement and a resident did not have an order or PRN order they had standing orders they could use. LPN12 stated R26 usually had a bowel movement every day to every other day. LPN12 stated she did not know about R26 not having a bowel movement between 03/12/2026 through 03/19/2026 or from 03/21/2026 through 04/01/2026. LPN12 stated she should have been alerted by a CNA, the resident, or the electronic medical record system. LPN12 stated CNAs were the first line, and there was an alert on the computer screen that would show up if a resident did not have a bowel movement in 72 hours. LPN12 stated an alert about R26's bowel movements did not show on the screen that she recalled, and the resident was never on the bowel movement report. LPN12 stated R26's cognition had declined and the resident would report they had not had a bowel movement when they actually had one. During an interview on 04/04/2026 at 12:19 PM, the Director of Nursing (DON) stated her expectation was that the unit manager ran the report from the electronic medical record daily of resident's who had not had a bowel movement, and, if it had been three days they acted on the protocol based on what the doctor prescribed and made sure the resident had a bowel movement and documented it. The DON stated the nurses should always check the CNA documentation to ensure it was completed and to check the bowel movements. The DON stated the CNAs should be documenting in real time, and if it was noticed that it had been two or three days since a resident had a bowel movement to let the nurse know. The DON stated CNAs could look into the charting where bowel movements were documented and should be able to see previous days of charting. The DON stated everything should be documented. During an interview on 04/04/2026 at 12:43 PM, the Administrator stated his expectation was that if a resident did not have a bowel movement in the required timeframe staff was to make sure the resident was taken care of. The Administrator stated they should have a system in place to monitor bowel movements, and when there was an issue it was pushed to the proper people to address it.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's medical record accurately reflected the removal of a lidocaine patch ordered by the physician for 1 (Resident (R)62) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Charting and Documentation, revised 07/2017, revealed, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. An admission Record revealed the facility admitted R62 on 12/24/2025. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026, revealed R62 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated R62 received a scheduled pain medication regimen. Review of R62's Order Summary Report, with active orders as of 04/01/2026, revealed an order dated 01/26/2026, for lidocaine external patch 5%, with instructions to apply to affected area topically one time a day for pain and remove per schedule. Review of R62's Medication Administration Record [MAR] for 03/2026, revealed the transcription of a physician order dated 01/27/2026 to apply a lidocaine external patch 5% to the resident's affected area topically one time a day for pain and remove per schedule with instructions to apply the lidocaine patch at 9:00 AM and remove the lidocaine patch at 8:59 PM. Per the MAR, Licensed Practical Nurse (LPN)5 initialed the resident's MAR to indicate she removed the resident's lidocaine patch on 03/31/2026 at 8:59 PM. During an observation of medication administration on 04/01/2026 at 8:48 AM, LPN3 obtained a lidocaine external patch 5% for administration to R62's sacrum. R62 had a lidocaine patch on their sacrum dated 03/31/2026. LPN3 removed the lidocaine patch dated 03/31/2026 and applied a new lidocaine patch 5% dated 04/01/2026 to the resident's sacrum. During an interview on 04/01/2026 at 3:40 PM, LPN3 stated she removed a lidocaine patch (during medication administration on 04/01/2026 at 8:48 AM) from R62's sacrum prior to applying a new lidocaine patch. LPN3 stated that the lidocaine patch she removed from the resident's sacrum should have been removed during the night shift per the physician's order (on 03/31/2026). During an interview on 04/02/2026 at 5:15 PM, LPN5 stated she could not remember if R62 had a lidocaine patch on or if she had removed the patch. She stated that when she worked, she would remove the patch. LPN5 stated she was expected to remove the lidocaine patch as ordered by the physician. LPN5 stated the lidocaine patch was to be placed on the resident by the day shift staff and removed by the night shift staff.

Based on observation, interview, record review, facility policy review, and review of manufacturer guidelines, the facility failed to follow a physician's order to remove a lidocaine patch for 1 (Resident (R)62) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. Review of Manufacturer guidelines titled, Lidoderm, dated 01/2015, revealed, Apply Lidoderm to intact skin to cover the most painful area. Apply the prescribed number of patches (maximum of 3), only once for up to 12 hours within a 24-hour period. Review of R62's admission Record revealed the facility admitted R62 on 12/24/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of infection and inflammatory reaction due to indwelling urethral catheter and muscle weakness. Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/2026, revealed R62 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated R62 received a scheduled pain medication regimen. Review of R62's Order Summary Report, with active orders as of 04/01/2026, revealed an order dated 01/26/2026 for lidocaine external patch 5%, with instructions to apply to affected area topically one time a day for pain and remove per schedule. Review of R62's Medication Administration Record [MAR] for 03/2026, revealed a transcription of a physician order dated 01/27/2026 to apply a lidocaine external patch 5% to the resident's affected area topically one time a day for pain and remove per schedule with instructions to apply the lidocaine patch at 9:00 AM and remove the lidocaine patch at 8:59 PM. Per the MAR, Licensed Practical Nurse (LPN)5 initialed the resident's MAR to indicate she removed the resident's lidocaine patch on 03/31/2026 at 8:59 PM. During an observation of medication administration on 04/01/2026 at 8:48 AM, LPN3 obtained a lidocaine external patch 5% for administration to R62's sacrum. R62 had a lidocaine patch on their sacrum dated 03/31/2026. LPN3 removed the lidocaine patch dated 03/31/2026 and applied a new lidocaine patch 5% dated 04/01/2026 to the resident's sacrum. During an interview on 04/01/2026 at 3:40 PM, LPN3 stated she removed a lidocaine patch from R62's sacrum prior to applying a new lidocaine patch. LPN3 stated that the lidocaine patch she removed from the resident's sacrum should have been removed during the night shift per the physician's order (on 03/31/2026). During an interview on 04/02/2026 at 12:41 PM, LPN5 stated she could not remember if R62 had a lidocaine patch on or if she had removed the patch. She stated that when she worked, she would remove the patch. LPN5 stated that the resident would request that the patch remain on until the next morning. LPN5 stated she was expected to remove the lidocaine patch as ordered by the physician. LPN5 stated the lidocaine patch was to be placed on the resident by the day shift staff and removed by the night shift staff. During an interview on 04/02/2026 at 5:00 PM, the Medical Director stated that he was unaware of any adverse reactions for a lidocaine patch staying on a resident longer than the ordered prescription but would expect staff to follow the physician's order for use. During an interview on 04/03/2026 at 3:24 PM, the Consulting Pharmacist stated that the manufacturer's guidelines stated that lidocaine patches were to be removed from a resident after twelve hours. He stated the manufacturer's guidelines for usage stated for the patch to only be used twelve hours within a 24-hour period. The Consulting Pharmacist stated the expectation was that staff followed the physicians' order for usage. During an interview on 04/04/2026 at 12:35 PM, the Director of Nursing (DON) stated staff were trained and expected to remove patches as ordered by the physician. During an interview on 04/04/2026 at 1:00 PM, the Administrator stated staff were trained and expected to follow physician orders as it related to medication administration.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided catheter care appropriately for 1 (Resident (R)69) of 1 resident reviewed for catheter care.Findings included: Review of a facility policy titled, Catheter Care, Urinary, revised 09/2014 revealed, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy revealed, Steps in the Procedure included, 13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure; 14. Assess the urethral meatus; and 15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. Review of R69's admission Record revealed the facility admitted R69 on 05/11/2017. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of neuromuscular dysfunction of bladder and muscle weakness. Review of R69's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/2026, revealed R69 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an indwelling catheter. Review of R69's Care Plan Report included a focus area initiated on 10/01/2025, that indicated the resident was at risk for complications with their urinary system related to having an indwelling catheter. Interventions directed staff to provide catheter care and empty the catheter every shift and as needed (initiated on 10/01/2025). Review of R69's Order Summary Report, with active orders as of 04/03/2026, revealed an order, dated 07/24/2025, for indwelling urinary catheter care to be provided every shift and as needed. During an observation of R69's catheter care on 04/03/2026 at 11:00 AM, Certified Nursing Assistant (CNA)22 obtained all the supplies for catheter care, performed hand hygiene, and donned personal protective equipment (PPE). CNA22 obtained warm water, liquid soap, and a clean washcloth and exposed the resident for care. During catheter care, CNA22 cleaned the foley catheter from the outside of the labia to the area of the foley catheter attached to the resident's leg. CNA22 failed to separate the labia and cleanse the urethral meatus. During an interview on 04/03/2026 at 11:20 AM, CNA22 stated she thought that she had cleansed the resident's meatus but remembered that she had not. During an interview on 04/04/2026 at 1:00 PM, the Administrator stated that staff were expected to follow the facility's policy and procedures for catheter care.

Based on observation and interview, the facility failed to ensure food was prepared in a sanitary manner, failed to ensure foods were dated and failed to ensure the equipment storage area was maintained in a sanitary condition. This had the potential to affect 81 of 82 residents who consumed food from the kitchen. Findings include: 1.During the initial tour completed on 04/07/25 between 9:20 AM and 9:50 AM with the Dietary Manager (DM) the following observations were noted: Diet Aide (DA) 1, was working in the dish room assisting with washing and stacking dishes. DA1 had a beard and a ponytail, neither were covered with a hair restraint. During an interview on 04/07/25 at 9:25 AM, DA1 confirmed he should be wearing hair restraints. 2.During an observation with the DM on 04/07/25 at 9:30 AM, a box of Mighty Shakes was found on a shelf in the walk-in refrigerator, the box was dated 03/11/25. The DM said the Might Shakes are delivered to the facility frozen, and are thawed in the refrigerator and then had a shelf life of 21 days after removing them from the freezer. When asked what date the supplements were placed in the refrigerator, the DM checked the exterior of the box and was not able to locate any other date. The DM was unable to determine how long the supplements had been in the refrigerator and removed the box, stating they would have to be discarded. Review of the product information for the Might Shakes provided by the DM revealed the manufacturer recommendations were that Might Shakes could be held and served for 14 days after thawing. 3. During an observation with the DM revealed a slicer was observed on a cart in the food preparation area with a cover on it. When asked when it was last used, the DM said about three weeks ago. After removing the cover, food matter had accumulated at the base of the blade guard which appeared to be shreds of meat mixed in with other crumbs. The DM stated the equipment should be cleaned after each use. A can opener, mounted on the countertop in the food preparation area, was observed with food matter adhered to the blade and base. Two plastic bins containing partially used food packages were observed on a cart in the food preparation area, each had a lid that sealed. The lids were soiled with powder-like substance and each of them had visible crumbs and food particulate accumulated inside of both bins. A plastic drawer holder was observed under a food preparation counter. The contents of the drawers were visible, which were utensils. Visible food crumbs and particulate matter were scattered inside the drawers.

Based on observation, interview and record review, the facility failed to ensure: 1.Correct serving sized utensils were used to ensure portion sizes at meals, which had the potential for all residents who received food from the kitchen to have unmet food intakes and potentially to have weight loss. 2. Resident (R)65 received the appropriate texture food (pureed) for dysphagia which had the potential for the resident to choke. Findings include: During an observation on 04/08/25 between 11:50 AM and 12:30 PM, of the meal service, [NAME] (C) 1 was observed plating food to be served to residents. The preplanned menu identified the meal included sliced pork roast, mashed potatoes, and green beans. C1 was observed using the same size scoops for the mashed potatoes, the green beans, and altered textured foods that had been prepared as well. The regular diets were served one slice of pork roast. During an interview on 04/08/25 at 11:55 AM, the Dietary Manager (DM) was asked for the menu spread sheets and or menu extension (a commonly used tool to identify which foods each diet should receive and intended portion serving sizes for the preplanned menu). The DM said to get the information she would have to download 85 pages of information, and said the portion guidelines were on the week at a glance menu. During an interview on 04/08/25, at 12:30 PM, C1 said the regular portions received one slice of meat, and verified all the scoops and ladles used to serve the meal held three ounces of food. When asked about written guidelines for portion serving guidelines were located, she stated she did not know. During an interview on 04/08/25 at 12:45 PM, the DM verified the scoop and ladles used to serve the meal all held a three-ounce portions. However, the portion serving guidelines for the preplanned menu were not available in the kitchen, and were not provided by the DM. During an interview on 04/08/25 at 1:20 PM, the Registered Dietitian (RD) said that standardized menus usually included a four oz portions of potatoes (or starch) and vegetables, and a three or four oz portion of the protein. When asked if she could locate the portion sizes that were intended, including the calorie and nutrient analysis, she stated she would locate it and provide a copy. Review of the nutrient analysis provide by the RD revealed a four oz portion of potatoes and vegetables were planned, however during observation a three oz scoop was used to plate the two items. 2.Review of R65's Admission Record revealed the resident was admitted to the facility on [DATE] witha diagnosis that included dysphagia (a swallowing impairment). Review of R65's Physician Orders included an order for a pureed diet with large portions and thin liquids, and identified a diagnosis of dysphagia. During an observation on 04/08/25 at 12:45 PM, a taste test of the pureed foods revealed the pureed vegetables and meat were a lumpy texture and was not smooth. When placed on a plate the green beans had small bits of the pods and beans were visible. The pureed meat had chunks in the mixture that required chewing. During an interview on 04/08/25 at 1:20 PM, the Registered Dietitian (RD) observed the pureed foods served to residents and she confirmed the food prepared had bits of chopped beans, strings of fiber, and that the meat had bits of meat chunks which were not the right consistency. Review of the facility provided International Dysphagia Diet Standardization Initiative (IDDSI), dated July 2019, revealed the texture should be smooth with no lumps.

Based on review of the facility policy, observations, interviews and record review, the facility failed to ensure oxygen was administered per physician orders for three of three residents reviewed for respiratory care (Resident (R)13, R24 and R76) out of 23 sampled residents. This failure placed the residents at risk for unmet respiratory needs and at risk for respiratory complications. Findings include: Review of the facility's undated policy titled, Oxygen Administration, revealed .Steps in the Procedure .5. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 1.Review of R13's Admission Record revealed R13 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia. Review of R13's Orders revealed O2 [oxygen] @ [at] 2liters via NC [nasal cannula] every shift . dated for 02/07/25. Review of R13's Care Plan revealed a focus initiated on 02/19/25 of End of Life: Resident requires Hospice care and is at risk for rapid decline in .abnormal breathing. The care plan interventions included .Oxygen as ordered . Continued review revealed a focus revised on 02/25/25 of Oxygen: Resident requires the use of oxygen. The resident had a goal initiated on 02/19/25 of Will be maintained at their respiratory baseline with a patent airway and unlabored/respiration. During an observation on 04/07/25 at 2:46 PM, R13 was lying in bed, and oxygen was being administered via nasal cannula at 3.5 liters per minute (lpm). During an observation on 04/08/25 at 12:58 PM, R13 was in the small dining room in a Broda chair being assisted with his lunch meal by staff. R13 was being administered oxygen via nasal cannula at a rate of 3.5 lpm. During an observation and interview on 04/08/25 at 1:00 PM, Licensed Practical Nurse (LPN) 1 observed R13's oxygen concentrator and stated the flow rate was set at 3.5 lpm. When asked what the physician ordered flow rate was, LPN1 reviewed the resident's Electronic Medical Record (EMR) and stated it was ordered at 2 lpm. LPN1 stated the flow rate should be checked by the nurse at least one time per shift. LPN1 also stated she had not checked the flow rate yet. During an interview on 04/09/25 at 2:47 PM, the Director of Nursing (DON) stated it was her expectation R13's oxygen flow rate would have been set per the physician's order to ensure the resident's respiratory concern was appropriately managed. During an interview on 04/09/25 at 2:50 PM, the Administrator stated it was his expectation R13's oxygen would have been administered at the physician ordered flow rate. 2.Review of R76's Admission Record revealed R76 was admitted to the facility on [DATE] with diagnoses that included but are not limited to: of chronic diastolic (congestive) heart failure and pulmonary hypertension. Review of R76's Orders dated 10/16/24 revealed, oxygen at 2 lpm. via nasal cannula to maintain oxygen saturation at or above 90[percent]%. During an observation on 04/07/25 at 11:07 AM, R76's oxygen was set to 3 lpm. During an observation on 04/08/25 at 3:38 PM, R76's oxygen was set to 3 lpm. During observation and interview on 04/08/25 at 4:30 PM, LPN2 confirmed R76's oxygen was set at 3 lpm and said it should be set at 2 lpm. 3.Review of R24's Admission Record revealed R24 was admitted to the facility on [DATE] with diagnoses including, but not limited to; chronic systolic (congestive) heart failure, chronic kidney disease and type 2 diabetes with diabetic polyneuropathy. Review of R24's Orders dated 03/25/25 revealed, oxygen at 2 lpm to maintain oxygen saturation at or above 90%. During observation on 04/07/25 at 10:50 AM, R24's oxygen was set at 1.5 lpm. During observation on 04/08/25 at 3:39 PM, R24's oxygen was set at 1.5 lpm. During observation and interview on 04/08/25 at 4:40 PM, LPN2 confirmed R24's oxygen was set at 1.5 lpm and said it should be set at 2 lpm. 2.Review of R76's Admission Record revealed R76 was admitted to the facility on [DATE] with diagnoses of chronic diastolic (congestive) heart failure, pulmonary hypertension, bipolar disorder. Review of R76's Order Summary revealed an Order dated for 10/16/24 for oxygen at 2 lpm. via nasal cannula to maintain oxygen saturation at or above 90%. During an observation on 04/07/25 at 11:07 AM, R76's oxygen setting was set to 3 lpm. During an observation on 04/08/25 at 3:38 PM, R76's oxygen setting was set to 3 lpm. During an observation on 04/08/25 at 4:30 PM with LPN2 confirmed R76's oxygen was set at 3 lpm and said it should be set at 2 lpm. 3.Review of R24's Admission Record revealed R24 was admitted to the facility on [DATE] with diagnoses of chronic systolic (congestive) heart failure, chronic kidney disease, type 2 diabetes with diabetic polyneuropathy. Review of R24's Orders dated 03/25/25revealed an order for oxygen at 2 lpm to maintain oxygen saturation at or above 90%. During an observation on 04/07/25 at 10:50 AM, R24's oxygen was set at 1.5 lpm. During an observation on 04/08/25 at 3:39 PM, R24's oxygen was set at 1.5 lpm. During an observation on 04/08/25 at 4:40 PM with LPN2 confirmed R24's oxygen was set at 1.5 lpm and said it should be set at 2 lpm. 39857

Based on review of the facility's policy, record review, and interviews, the facility failed to ensure residents with Post Traumatic Stress Disorder (PTSD) received trauma informed care which included identifying triggers of their trauma experiences for one of three sampled residents (Resident (R) 78) reviewed for mood/behavior out of 23 sampled residents. This failure placed the resident at an increased risk of re-traumatization. Findings include: Review of the facility's undated policy titled, Trauma Informed Care and Culturally Competent Care revealed, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of the trauma survivors by minimizing triggers and/or re-traumatization .Definitions .Trigger' is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening .General Guidelines .4. Triggers are highly individualized. Some common triggers may include: .b. exposure to loud noises, or bright/flashing lights; c. certain sights, such as objects; and/or d. sounds, smells, and physical touch .Resident Care Planning. 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident . Review of R78's Admission Record revealed R78 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included PTSD. Review of R78's Medicare Part A 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/31/25 revealed R78 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The MDS revealed PTSD as an active diagnosis. Review of R78's Care Plan revealed .Focus-Mood (Resident Mood Interview): At risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to anxiety, PTSD, depression .Goal. Will minimize the risk for mood and behavioral disturbance . R78's Care Plan did not include any of the resident's PTSD triggers or how to intervene when the resident is triggered. During an interview on 04/07/25 at 3:18 PM, R78 stated he had recently experienced some flash backs and night terrors triggered by his PTSD. The resident stated most recently torrential rain triggered a flashback from the Vietnam war. During an interview on 04/08/25 at 1:15 PM, when asked about R78's diagnosis of PTSD and if the facility had identified his PTSD triggers, the Social Services Director (SSD) stated, the resident told her heavy rains triggered his PTSD. When asked if the resident had a trauma informed care plan incorporated in his comprehensive care plan which identified triggers and interventions, the SSD stated the resident's triggers had not been identified. The SSD stated this was her responsibility and she failed to ensure the care plan included the resident's triggers. During an interview on 04/08/25 at 1:27 PM, the Nurse Practitioner (NP) stated she was a board certified Gerontology NP and her scope of practice included treating psychiatric conditions. The NP stated it was her expectation the facility would have identified R78's PTSD triggers and that the triggers would have been included in his care plan. The NP also stated identifying the resident's PTSD triggers helps the nursing staff to know how to treat and respond to his triggers including nonpharmacological and pharmacological interventions. The NP stated this would help ensure the resident was receiving trauma informed care. During an interview on 04/09/25 at 10:14 AM, R78 stated some of his other PTSD triggers included flashing lights in the sky such as lightening with no sound, loud and undescriptive noises. The resident stated no one from the facility had asked him about his triggers. During an interview on 04/09/25 at 1:59 PM, Certified Nurse Aide (CNA) 2 stated she did not know any of R78's PTSD triggers. During an interview on 04/09/25 at 2:01 PM, when asked what R78's PTSD triggers were, Licensed Practical Nurse (LPN) 1 stated she did not know. The LPN stated if it was not listed on the resident's care plan, then she would not know if he had any triggers. During an interview on 04/09/25 at 2:47 PM, the Director of Nursing (DON) stated it was her expectation that R78's PTSD triggers would have been identified to ensure the facility's staff could assist him better when needed. During an interview on 04/09/25 at 2:50 PM, the Administrator stated it was his expectation any resident with a diagnosis of PTSD would have been asked about their triggers to be able to care for the resident in those times of need.

Based on review of the facility policy, observation, interview and record review, the facility failed to ensure alternatives of similar nutritive values were offered when foods were refused and failed to ensure staff obtained preferences for three (Residents (R) 8, 145and R77) reviewed out of a sample size of 23 residents. This placed these residents at risk for weight loss. Findings include: Review of the facility's undated policy titled, Resident Food Preferences, revealed Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team .1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preference .3. Dietary staff will document the resident's food and eating preferences in the meal ticketing system . 1. Review of R8's Admission Record revealed the resident was admitted to the facility on [DATE]. Review of the R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/25, indicated the resident could feed himself, had lost weight, and was on therapeutic diet. Review of R8's tray card identified R8 was to be served large portions of protein foods. Review of R8's Treatment Administration Record (TAR) revealed R8 was given a supplement one time a day at 10:00 AM in the morning. During the observation of meal service on 04/08/25 (between 11:50 AM and 12:20 PM) R8's plate was prepared and placed on the tray for service. When the plate was prepared a single scoop of each of the foods, pork roast, green beans, and mashed potatoes were placed on the plate. During an observation on 04/08/25 at 12:30 PM, R8 was observed in his room with the tray on the overbed table. The resident did not eat or consume any of the meat that was served. During an interview on 04/08/25 at 1:30 PM, Certified Nursing Assistant (CNA) 5 was interviewed about R8's meal. CNA5 confirmed R8 did not eat any of the pork roast served, and said he received a regular portion of the meat. CNA5 than commented that R8 did not like pork roast or meatballs when served, and really liked chocolate flavored Mighty Shakes, however, R8's tray card did not identify any preferences. 2. During an observation and interview with the Dietary Manager (DM) on 04/08/25 between 11:50 AM and 12:30 PM,Cook (C) 1, was observed plating foods residents. It was noted that Dietary Aide (DA)1 would verbally tell C1, what type of diet was needed for each tray ticket placed on each cart. During the observation it was noted residents who expressed a dislike for green beans were served two scoops of potatoes and no other vegetables. The DM confirmed there was no substitute for the green beans and two scoops of potatoes were given. Review of R145's Admission Record revealed R145 was admitted to the facility on [DATE]. Review of R145's quarterly MDS with an ARD date of 12/18/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. During an interview on 04/08/25 at 12:30 PM, R145 stated he did not like the green beans, and the only food item left on the plate was two scoops of mashed potatoes with gravy on them. Review of the Winter's always offer Menu provided by the facility included a variety of sandwiches, fries, vegetable of the day and three different kinds of soup. Review of the week at a glance menu, included items identified on the preplanned menu (i.e., roast pork, mashed potatoes, green beans, and fruit.) With a notation below the daily menu was a statement alternate menus available on request, but did not include any other information. 3. Review of R77's Admission Record revealed the resident was admitted to the facility on [DATE]. Review of R77's admission MDS with an ARD date of 01/15/25 revealed R77 had a BIMS core of 15 out of 15 which indicated the resident was cognitively intact. Review of R77's Dietary Interview/Pre-Screen V3.0, dated 01/09/25 revealed Section I Interview. A. Spoke with? [selected] 1. Resident. B. Appetite [selected] 1. Good . Section II Beverage Preferences, Section III Snacks [preferences], and Section IV Food Likes/ Dislikes were not completed. During an observation and interview on 04/08/25 at 8:35 AM, R77 was finishing eating her breakfast meal in her room. The resident had scrambled eggs and grits left on her plate. R77 stated she did not like grits nor the facility's liquid eggs. When asked was the facility aware of her food preferences, the resident stated she was asked about her likes and dislikes when she first arrived at the facility, but she still gets the food she does not like. Review of R77's meal ticket, provided by the resident revealed the meal ticket reflected the day of the week of Tuesday, [04/08/25] and noted Apple or Cranberry Juice, Milk, and Coffee. There were no other likes or dislikes identified on the meal ticket. During an observation and interview on 04/08/25 at 1:15 PM, R77's lunch meal included green beans. R77 stated she told the dietary department when she was asked about her likes and dislikes that she did not like green beans. During an interview on 04/08/25 at 2:19 PM, The RD stated the resident's likes and dislikes, including preferences should have been reflected on the resident's meal ticket. During an interview on 04/08/25 at 2:32 PM, the DM tated the facility was having trouble with the Electronic Medical Record (EMR) pulling preferences entered from the Nutritional Management system over, so meal tickets reflect the likes and dislikes on the meal tickets. The DM verified the resident's breakfast tray on 04/08/25 contained eggs, grits, and orange juice. The DM stated she was not aware the resident did not like grits or eggs and these needed to be reflected on the meal ticket. The DM also stated the reason R77 received orange juice was because the facility was out of cranberry and apple juice. The DM further verified the resident's lunch meal would have included green beans as part of her meal. During an interview on 04/09/25 at 2:47 PM, the Director of Nursing (DON) stated it was her expectation that the dietary department would have ensured R77's likes, dislikes, and preferences be reflected on the resident's meal ticket. 36898

Based on interview, record review, and facility document and policy review, the facility failed to ensure two staff members assisted with a mechanical lift transfer for 1 Resident (R)1 of 4 residents reviewed for mechanical lift transfers. The failure resulted in R1 sustaining a laceration to the top right side of their head, which required three staples to repair. Findings included: A facility policy titled, Lifting Machine, Using a Mechanical, revised 07/2017, revealed, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning. 3. Types of lifts that may be available in the facility are: a. Floor based full body sling lifts; b. Overhead full body sling lifts; and c. Sit-to-stand lifts. 4. Lift design and operation vary across manufactures. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. The policy revealed, 18. Once the resident's weight is released, stop the lowering and ensure that the sling bar does not hit the resident. An Admission Record revealed the facility admitted R1 on 04/07/2016. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, anxiety disorder, bipolar disorder, schizophrenia, morbid obesity, muscle weakness, and abnormalities of gait and mobility. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident was dependent on staff for chair-to-bed transfers. R1's care plan included a focus area initiated on 04/07/2016 that indicated the resident required assistance with activities of daily living (ADLs) and mobility. Interventions directed staff to use a mechanical lift with two staff members (revised 12/29/2023). A Five-Day Follow-Up Report, dated 09/12/2024, revealed that, on 09/07/2024 at 7:40 AM, R1 was transferred by staff from bed to a wheelchair via mechanical lift. The report revealed the resident was transferred to the wheelchair without difficulty. Per the report, upon unclipping the sling from the mechanical lift, the metal arm (sling bar) on the lift swung and made contact with the top of the resident's head. The report revealed the resident had a 3 centimeters (cm) long laceration to the top right side of their head. The report revealed the resident was sent to the emergency department for treatment and returned with three staples to repair the laceration. The report revealed R1's representative and physician were notified. R1's Progress Notes, dated 09/07/2024 at 8:40 AM, revealed R1 had an open head injury related to making contact with a mechanical lift. The notes revealed the provider was notified, and orders were received to send the resident to the emergency room . The notes revealed emergency medical services transported the resident to the hospital. R1's ED [Emergency Department] Provider Notes, dated 09/07/2024, revealed that the resident had a 3 cm right-sided scalp laceration. The hospital After Visit Summary, dated 09/07/2024, revealed the resident received staples to close the laceration. During an interview on 12/13/2024 at 4:05 PM, Certified Nursing Assistant (CNA)1 stated that she worked at the facility through a staffing agency. She stated that, on 09/07/2024, she started her rounds at 4:00 AM, and a nurse told her to not get R1 up because they were a fall risk and to get them up last, noting that she was unaware of the nurse's name. She stated that she finished her charting around 7:20 AM. CNA1 stated she was running behind and that her shift was supposed to end at 7:00 AM, but she still had to get R1 up for the day. She stated she went into the resident's room and did not see a sling for the mechanical lift, and the nurse stated that she would get her one. CNA1 stated that she got the resident dressed, and the nurse left a sling outside the door. She stated that the nurse did not come in and ask if she needed help, noting she just left the sling outside the door. She stated that the nurse that left the sling outside the door worked with her on the night shift, and by the time she was ready to transfer the resident, the night shift staff had left for the day. She stated that she grabbed the mechanical lift next to the resident's room. She stated that she, while working alone, transferred the resident to a wheelchair with the mechanical lift. CNA1 stated the resident was seated in the wheelchair when she removed the hooks from the sling, and the arm of the lift (sling bar) swung and hit the resident in the head. She stated the resident was bleeding, and she ran out of the room to get help. She stated there was a CNA that asked if she needed help, but she told that CNA she needed a nurse, noting that she was unaware of the CNA's name. She stated that a nurse came and provided aid to the resident, noting that she was unaware of the nurse's name. CNA1 stated the day shift staff had started their shift and were there before she transferred the resident. She stated she knew she needed two staff members to operate the mechanical lift when transferring a resident, but she did not ask the day shift staff for help. She stated she had not worked at the facility since the incident on 09/07/2024. CNA1 stated that after the incident the staffing agency provided her with training on the proper use of the mechanical lift and having two staff members present when operating the lift for resident transfers. During an interview on 12/13/2024 at 4:54 PM, Licensed Practical Nurse (LPN)2 stated that, On 09/07/2024, he worked the day shift and had just finished receiving report from the night shift nurse when a night shift CNA came and got him, stating that the mechanical lift had hit R1 in the head, and they were bleeding, noting that he was unaware of the night shift CNA's name. He stated that he could not remember all the details of the care that he provided to the resident, but noted he remembered putting something on the resident's head to control the bleeding and then notifying his supervisor. He stated he was unaware that the CNA was in the room with the resident, transferring the resident alone with a mechanical lift. He stated that the CNA never asked for his help with the transfer. LPN2 stated that the night shift nurse did not inform him during report that the CNA was still getting the resident up and that she was still there during the day shift. He stated that two staff members must be present when operating a lift for resident transfers. During an interview on 12/14/2024 at 10:41 AM, CNA3 stated that, on 09/07/2024, she worked the day shift, and at the beginning of her shift she was at the nurses' station when a night shift CNA came out of R1's room, noting that she was unaware of the night shift CNAs name. She stated that she asked the CNA if she needed help, and the CNA told her that she did not need her help but needed a nurse. CNA3 stated that she got the nurse, and they went to the resident's room. She stated that was when she found out that the CNA had transferred the resident alone with the mechanical lift, and the arm of the lift (sling bar) had swung and hit the resident on the head. CNA3 stated that the resident was bleeding and had to be sent to the hospital. She stated that she did not know that the night shift CNA was still working during the day shift and was in the room with the resident, transferring the resident alone. CNA3 stated she never saw the CNA get the mechanical lift and thought the CNA had left for the day. She stated that the CNA never asked for help. She stated two staff members were required to use the mechanical lift to transfer a resident. She stated that she would have helped the CNA if she had asked for help. During an interview on 12/14/2024 at 10:25 AM, the Director of Nursing (DON) stated that after she and the Administrator completed an investigation into the incident that occurred on 09/07/2024 where R1 was transferred with a mechanical lift and was injured, it was determined that CNA1 transferred the resident alone. The DON stated that no other staff members were in the room with CNA1 during the transfer. She stated that when the sling to the mechanical lift was removed from the hook, since no other staff member was holding the arm (sling bar), the arm swung and hit R1 on the head. She stated that the resident had a laceration to the top of their head. She stated two staff members were required to operate the mechanical lift when transferring a resident. The DON stated it was important to have two staff members present when operating the mechanical lift to ensure the resident was safe. She stated that if two staff members had been present during the transfer, one staff member could have held the arm to the lift so that it did not move, and it might not have hit R1 in the head. She stated that she could not say for sure that the arm of the lift would not have hit the resident, but she did not think it would have with two staff members present. The DON stated that the facility was not short-staffed the day of the incident, and the day shift staff were available to assist CNA1 if she had asked for help. She stated that R1 was sent to the hospital and received three staples to repair the laceration to the top of their head. The DON stated she expected two staff members to be present when using the mechanical lift to transfer a resident. During an interview on 12/14/2024 at 11:36 AM, the Administrator stated that after he completed an investigation, he determined that CNA1 transferred R1 with a mechanical lift without another staff member assisting, which was against facility policy. He stated he expected at least two staff members to be present when operating the mechanical lift to transfer a resident.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to document and record pain management on the Medication Administration Record (MAR), for the administration of narcotic medications for 1 Resident (R)5, of 1 resident reviewed for medication administration. Findings include: Review of the facility policy titled, Administering Medication, revised April 2019, revealed Policy Statement, Medications are administered in a safe and timely manner, and as prescribed. The individual administrating the medication initials the resident ' s medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for medication, the individual administering the medication records in the resident ' s medical record: the date and time the medication was administered; the dosage; the route of administration; any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug. Review of R5's Face Sheet indicated R5 was admitted to the facility on [DATE] with diagnoses including but not limited to; Alzheimer's, dementia, anxiety, and psychotic disturbance. Review of R5's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) revealed R5 has a Brief Interview of Mental Status (BIMS) score of 3, indicating she is cognitively impaired. Further review of the MDS indicated R5 was totally dependent on staff for all activities of daily living (ADL)s. Review of R5's Care Plan dated 04/05/22 and revised on 04/26/22 revealed, Resident is at risk for pain related to decreased mobility, incontinence, Alzheimer's, hospice service. R5's goals were: To be kept comfortable through end-of-life care. Interventions included attempting alternative methods for pain relief, Give as needed (PRN) pain medication as ordered for complaints or symptoms of pain, Give routine pain medication per order and monitor for break-through pain, If pain intervention is completed, follow-up with patient in 30min to 1 hour to ensure effectiveness, Notify MD of pain that is not able to be relieved with current interventions, Observe for adverse effects from opioid medication such as nausea, constipation, dizziness, inability to urinate, confusion, slowed breathing, and use 1-10 pain scale or face scale to assess level of pain Review of R5's Physician Orders revealed an order for Tylenol Tablet 325 MG (milligrams) (Acetaminophen), give 2 tablet by mouth every 6 hours as needed for pain and Morphine Sulfate (Concentrate) Solution 20 MG/ML (milliliters), give 0.5 ml sublingually every 1 hours as needed for pain/Shortness of Breath. The order additionally states, Document which nonpharmacologic pain management interventions were tried: A) Adjust Temp, B) Offer Snack, C) Adjust Bed Linen, D)Adjust Lighting, E) Reposition. Review of R5's MAR revealed no documentation of R5's pain medications being administered. Observation on 02/27/24 at 11:57 AM revealed R5 lying im bed alert, but moaning. R5 was heart uttering and moaning, with her face grimacing in pain. An attempt was made to interview R5 with no success. Observation on 02/28/24 at 9:15 AM, revealed R5 moaning with facial grimaces. R5 was uttering the words, hurt and pain. An additional observation on 02/28/24 at 1:22 PM revealed R5 again uttering the words, hurt and pain. During an interview on 02/28/24 at 1:40 PM with Registered Nurse (RN)1 revealed, R5 gets pain medication every hour as needed, per the Physician's order.: She stated, R5 usually cries out for pain medication more in the evenings. When she receives her pain meds, it is documented on the narcotic control medication utilization record. RN1 confirmed staff did not document medication administration on the MAR for R5. During an interview on 02/28/24 at 1:53 PM, the Director of Nursing (DON) stated, All nursing staff were educated and trained to sign off on the MAR when medications were given. She stated, The narcotic control sheet is for counts only. Staff were educated and trained that the narcotic control sheet was not part of the resident's permanent chart/record and should not be used as documentation that a medication was administered. The DON further stated, There is no way for the medication to be monitored for its effectiveness if it was not documented on the MAR.

Based on record review and interviews, the facility failed to ensure that the Ombudsman was notified of a hospitalization for Resident (R)83 in a timely manner for 1 of 5 residents reviewed for hospitalization s. Findings include: The facility admitted R83 with diagnoses including but not limited to, left femur fracture and alzheimer's. Review of Nurses' notes on 02/28/24 revealed documentation that stated, 11/14/2023 at 7:54 AM Residents roommate stated that the resident fell and hit her head trying to get to the bathroom. The roommate yelled out for staff. When this nurse got into the room and observed the resident she was noted to have an open area to her left eyebrow. This nurse applied a pressure dressing to the area and called Third Eye. Spoke with MD, ordered to send resident to the ER for evaluation, RP notified and resident was sent to hospital. There was no evidence in the record that the Ombudsman was notified of the transfer. Further review of the Nurses' notes revealed a note dated, 11/14/23 - resident arrived via stretcher, accompanied by two EMT personnel. She is alert and keeps removing bandaid to laceration. Has two sutures to laceration in left eyebrow. Vitals are stable and within normal limits (WNL). She is in bed resting comfortably, nursing will continue to monitor. During an interview on 02/28/24 at 2:55 PM, the Social Worker (SW) stated that Medical Records handles the bedhold policy and contacting the Ombudsman. During an interview on 02/28/24 at 2:56 PM, Medical Records stated I guess I don't have one for her after not being able to locate the documentation for the bedhold in the binder and in the medical record. She reported that the Assistant Director of Nursing (ADON) notifies the Ombudsman. During an interview on 02/28/24 at 3:00 PM, the ADON and DON both reported that Medical Records was to notify the Ombudsman. During an interview on 02/28/24 at 3:30 PM, the DON brought the bed hold policy for R83 to the surveyor. The DON stated, Medical Records is fairly new to her role and was not told she needed to notify the Ombudsman when she transferred into her current position. Medical Records was working on notifying the Ombudsman for all Bed Holds from January 2023 - January 2024. The February list will be sent on Friday, March 1. During an interview on 02/28/24 at 3:47 PM, the DON reported that there is no documentation that the Ombudsman was notified, but will start tracking when notification is sent to family representatives and to the Ombudsman.

Based on review of the facility policy titled, Accommodation of Needs, and Activities of Daily Living (ADLs), Supporting, observations, record reviews and interviews, the facility failed to implement the comprehensive plan of care for Resident (R)24, related to activities of daily living. Specifically, R24 was observed with heavy beard growth on his face and to the base of his neck for 1 of 3 residents reviewed for Activities of Daily Living, related to grooming. Findings include: Review of the facility policy titled, Accommodation of Needs, revised March 2021, states in the policy statement,Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well being. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining, independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, states under the policy statement, Resident's who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility admitted R24 with diagnoses including, but not limited to, hemiplegia and hemiparesis, tissue damage to left heel and pressure ulcer of right heel and is receiving hospice care and services. During an observation on 02/27/2024 at 11:45 AM, R24 was noted lying in bed, and feet against the foot board of the bed. He was observed with a heavy growth of a beard to his face and down his neck to his collar area. During an interview on 02/27/2024 at 11:46 AM with R24, this surveyor asked if he was comfortable with the beard growing down his neck, and he replied, no, that he would like to be shaven. R24 then stated that the staff do not even ask him if he would like to be shaven. During an observation on 02/28/2024 at 09:26 AM, R24 still had the heavy growth of facial hair down to the base of his neck. An observation on 02/29/2024 at 10:15 AM of R24, revealed, he still had not been shaven. Review on 02/29/2024 at 11:32 AM of the comprehensive plan of care revealed as a focus area: Resident has an Activities of Daily Living (ADLs) self care performance deficit related to pneumonia. The interventions include: Bathing/ showering, assistance of 1. Dressing, assistance of 1. Personal hygiene, assistance of 1. Review on 02/29/2024 at 12:28 PM of the facility documentation on bathing R24, it is documented that he had a bed bath daily, no showers. There is no documentation to ensure he had been shaven during the bathing process. During an interview on 02/20/2024 at 12:35 PM with the Director of Nursing, she stated that R24 would be shaven after lunch. The DON did not offer any comment as to why R24 had not been shaven.

Based on review of the facility policy titled, Accommodation of Needs, and Activities of Daily Living (ADLs), Supporting, observations, record reviews and interviews, the facility failed to ensure R24 received the care and services during ADL care related to shaving. Specifically, R24 was observed with heavy beard growth on his face and to the base of his neck for 1 of 3 residents reviewed for Activities of Daily Living related to grooming. Findings include: Review of the facility policy titled, Accommodation of Needs, revised March 2021, states in the policy statement,Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well being. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining, independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, states under the policy statement, Resident's who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility admitted R24 with diagnoses including, but not limited to, hemiplegia and hemiparesis, tissue damage to left heel and pressure ulcer of right heel and is receiving hospice care and services. During an observation on 02/27/2024 at 11:45 AM, R24 was noted lying in bed, and feet against the foot board of the bed, he was observed with a heavy growth of a beard to his face and down his neck to his collar area. During an interview on 02/27/2024 at 11:46 AM with R24, this surveyor asked if he was comfortable with the beard growing down his neck, and he replied, no, that he would like to be shaven. R24 then stated that the staff do not even ask him if he would like to be shaven. During an observation on 02/28/2024 at 09:26 AM R24 still had the heavy growth of facial hair down to the base of his neck. An observation on 02/29/2024 at 10:15 AM of R24, revealed, he still had not been shaven. Review on 02/29/2024 at 12:28 PM of the facility documentation on bathing R24, it is documented that he had a bed bath daily, no showers. There is no documentation to ensure he had been shaven during the bathing process. During an interview on 02/20/2024 at 12:35 PM with the Director of Nursing, she stated that R24 would be shaven after lunch. The DON did not offer any comment as to why R24 had not been shaven.

Based on review of facility policy, record review, observation, and interview, the facility failed to provide 1 of 1 resident,(R)68, resident centered activities based on resident's preferences, interests, and choice. Findings include: Review of the facility policy titled, Activity Programs, with revised date of August 2006, states 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 7. Individualized and group activities are provided that: Reflect the schedules, choices, and rights of the residents; are offered at hours convenient to the residents, including evenings, holidays and weekends; reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents. Review of R68's face sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to dementia without behavioral disturbances, mood and anxiety disorder, and dysphasia following cerebral infarction. Review of R68 Activity Assessment effective date 07/14/23 revealed, preferences on admission included, but are not limited to: Somewhat important to have books, newspapers, and magazines to read, somewhat important to listen to music you like, somewhat important to keep up with the news, somewhat important to do things with groups of people, somewhat important do your favorite activities, somewhat important to go outside to get fresh air when the weather is good. The primary respondent noted was R68. Other interests listed on activity assessment: cards, games, basketball on television, music, reading, outdoors, watching television/movies and keeping up with the news. Location of activity preferences: Activity room, infacility anywhere, and/or outdoors at facility. Review of R68's care plan 07/14/23 revealed, has a need for activities that are consistent with abilities and interest. Enjoyable, meaningful activities to the resident include, but are not limited to sports on tv, music, reading, social conversations. Resident diagnosis include dementia, anxiety disorder, mood affective disorder, and severe protein calorie malnutrition. The goal for this Care Plan indicated, Will participate in activities of choice throughout the week. Interventions/tasks encourage family to visit, encourage socialization, encourage to attend activities of interest, and included but not limited to providing resident's areas of interest; cards/games, basketball on television, music, reading, outdoors, television/movies, social conversations, and keeping up with the news. Review of R68's Activity Log for December 2023 Activity Log reveals that R68 did not participate in group activities. R68 did participate in seven one-to-one visits for the month of December. Review of the January 2024 Activity Log indicates that R68 did not participate in group activities, but did participate in five, one-to-one visits. Review of the February 24 Activity Log revealed that R68, participated in two group activities of hydration and 1 one-to-one visit for the month of February. Review of R68's Activity Log revealed a legend for coding which stated, Activity log legend reveals 99 - as resident not available, 98 - resident refused, and 97 - not applicable. The Activity Log revealed the following codes: February 2024 was coded 99 for 17 days for group activities. January 24 was coded 99 for 21 days for group activities and for December 23 was coded 99 for 16 days for group activities. Review of R68's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 revealed a Brief Interview of Mental Status (BIMS) score of 8 out of 15, indicating mild cognitive impairment. Additional review of the MDS revealed no issues documented with behavior or rejection of care. During an observation on 02/27/24 at 11:34 AM, R68 was lying in bed, the television and radio were off. R68 was laying on his side staring at the curtain. During an interview on 02/27/24 at 11:34 AM, R68 stated he did not know what the paper on the wall meant. R68 stated he watches tv occasionally and he is not asked about attending activities and he wants to attend activities today. R68 reports that he is not offered activities. During an observation and interview on 02/28/24 at 12:58 PM, R68 was in bed lying on left side. R68 stated, No one from the facility has asked him if he wanted to participate in any activity today. During an observation on 02/29/24 at 1:10 PM, R68 was lying in bed without any activities. During an interview on 02/29/24 at 8:49 AM, the Activity Assistant (AA) revealed that activity walks around a couple of times every day and specifically designates three days a week to speak with R68. R68 likes to talk about history, cars and sometimes watch the news. She stated that activity visits R68 three times a week after lunch and stay in the room for 30 - 45mins. The activity is written on a census sheet then transcribed to the activity documentation on the computer. We just noticed yesterday that if we input a comment in the system, it is putting a code 97 or 99 in with the activity code. The AA states, the Activity Director and the AA are responsible for inputting the group and one-to-one activity. The AA reports that she is aware of R68's care plan and activity preferences and acknowledges that R68 at times feel ill and reports that she makes it a point to see the resident. During an interview on 02/29/24 at 10:48 AM, the Administrator stated they run three group activities every day and as needed to adjust to the personal needs of residents. Activity is provided for residents daily and activity staff is to visit to the patient's room daily. They are to ask if they want to attend group or a one-to-one, we provide alternatives. The Administrator states that he is aware of R68 preferences and states that his expectation is that activity staff is offering R68 options daily to attend group activity or a one-to-one activity. The Administrator reports having two and a half activity staff for this facility. He reports having one Activity Director, one Activity Assistant, and the old Activity Director that has stepped down but assisting with activity. The Administrator admits to being told of an issue with documentation of activity codes and reports that he has been following up concerns with coding since 02/28/24.

Based on facility policy review, record review and observations, the facility failed to administer oxygen therapy within professional standards related to the storage of respiratory equipment when not in use for 2 (Resident (R)15 and R39) of 3 residents reviewed for respiratory care. Findings include: Review of the facility policy titled, Oxygen Administration, revised October 2010, revealed Purpose Statement: The purpose of this procedure is to provide guidelines for safe oxygen administration. Check the tubing connected to the oxygen cylinder to assure it is free of kinks. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. Discard used supplies into designated containers. Review of R15's Face Sheet indicated the facility admitted the resident on 08/13/2023, with diagnoses including, but not limited to; chronic combined systolic (congestive) heart failure chronic obstructive pulmonary disease, major depressive disorder, post-traumatic stress disorder, chronic, and cognitive communication deficit. Review of R15's Annual Minimum Data Set (MDS) dated [DATE] revealed, R15 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident was moderately impaired. R15 is coded for oxygen therapy. Review of R15's care plan revealed, resident is at risk for respiratory complications related to Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), acute respiratory failure. Date Initiated: 01/25/2023 Revision on: 09/02/2023. R15's goal was to not have any acute exacerbation of respiratory disease through next review Date Initiated: 01/25/2023 Revision on: 02/06/2024 Target Date: 02/13/2024. Interventions included Elevating head of bed to tolerance to decrease difficulty breathing Date Initiated: 01/25/2023. Encourage deep breathing and other breathing exercises as indicated Date Initiated: 01/25/2023 Incentive spirometer as indicated Date Initiated: 11/14/2023 Labs and chest x-rays per order. Date Initiated: 01/25/2023 Lung sounds and vital signs as indicated Date Initiated: 01/25/2023 Medications per order Date Initiated: 01/25/2023. Monitor/document/report to Medical Doctor (MD) as needed (PRN) any signs and symptoms (s/sx) of respiratory infection: Fever, Chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing. Date Initiated: 01/25/2023 Observe/ Document/Report symptoms of respiratory distress such as tachypnea, abnormal lung sounds, anxiety, difficulty breathing. Date Initiated: 01/25/2023 oxygen as ordered Date Initiated: 08/13/2023 Takes rest periods as needed to decrease shortness of air with activity. Date Initiated: 01/25/2023. Review of R15's Physician's Orders revealed, O2- 2 liters nasal canula at bedtime. On 02/29/2024 at 11:50 AM, R15 observed in bed alert with the bed in the lowest position. R15's oxygen cannula was observed wrapped around the bed rails and lying on the floor, oxygen concentrator was not in use. On 02/29/2024 at 1:27 PM, observation revealed R15's nasal cannula was wrapped around the oxygen concentrator, concentrator not in use. On 02/29/2024 at 1:30 PM, during an interview, Licensed Practical Nurse (LPN)1 stated, Nasal cannula tubing is replaced on second shift, every Sunday. R15 has orders for oxygen therapy at night and if their O2 saturation drops below 90 % or resident feels as if they needed it. Staff usually does not store R15's oxygen cannula in a bag or out of resident's reach because the resident wanted it close by. R15 would get anxious if cannula was not in reach often winding it around the bed rail. On 02/29/2024 at 3:20 PM, the Director of Nursing (DON) stated, Nasal cannulas are replaced every Sunday evening. During the week, tubing should be stored in a Ziploc bag for reuse by the resident. On 02/29/2024 at 4:23 PM, the Director of Nursing (DON) stated the facility is a smoke free facility and the residents do not have flammable items/belongings in their rooms, therefore staff was not required to place oxygen in use signs on the doors of residents on oxygen therapy or while oxygen was in use. 49801 Findings include: Review of the facility's policy titled, Continuous Positive Airway Pressure (CPAP)/Bilevel positive airway pressure (BiPAP) Support dated 03/15 revealed, Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. General Guidelines: 4. CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. Equipment and Supplies: 1. NO SMOKING sign for the resident's room. General Guidelines for Cleaning: 4. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 6. Filter cleaning; a. Rinse washable filter under running water once a week to remove dust and debris. Relace this filter at least once a year. b. Replace disposable filters monthly 7. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Documentation Document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure. 5. How the resident tolerated the procedure; and 6. Oxygen saturation during therapy. Review of the facility's policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer dated 10/10 revealed, Purpose-The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Equipment and Supplies: 4. Nebulizer kit, including nebulizer, medication cup, T-piece, mouthpiece (or facemask), and tubing; and 5. Pressurized gas source (e.g., compressor). Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds. 18. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. 24. When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup. 26. Obtain post-treatment pulse, respiratory rate and lung sounds. 27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for Five minutes; d. Rinse all pieces with sterile water (NOT tap, bottled, or distilled); and e. Allow to air dry on a paper towel. 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. change equipment and tubing every seven days, or according to facility protocol. 31. Disinfect outside of the compressor between residents, according to manufacturer's instructions. Documentation The following information should be recorded in the resident's medical record. 2. The date, time and length of treatment (treatment administration record). 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment. 8. the resident's tolerance of the treatment. Review of R39's Face Sheet revealed R39 was admitted to the facility on [DATE] with diagnoses including but not limited to; asthma, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of R39's Quarterly MDS with an Assessment Reference Date (ARD) date of 12/26/2023 revealed a BIMS score of 15 out of 15, indicating R39 has was cognitively intact. Review of R39's Care Plan with a start date of 06/21/23 documented, Problem-Respiratory/Oxygen Use, Resident is at risk for respiratory complications related to asthma, COPD, sleep apnea Date Initiated: 06/27/2023. Goal- Resident will be compliant with respiratory treatment through next review. Further review of the Care Plan revealed the following Interventions- CPAP as ordered, Encourage deep breathing and other breathing exercises as indicated, Labs and chest x-rays per order, Lung sounds and vital signs as indicated, Medications per order, Monitor/document/report to MD PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing and Observe/ Document/Report symptoms of respiratory distress such as tachypnea, abnormal lung sounds, anxiety, difficulty breathing. Review of R39's Physician Order with a start date of 10/31/23 documented, Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 applicator inhale orally via nebulizer every 4 hours as needed for Wheezing/SOB . C-PAP settings Pressure: 8-10 cmH2O EPR: 2 Starting Ramp pressure: cm H20 Ramp time: min off at bedtime for C-PAP settings Per ST. [NAME] sleep study. During an observation of R39's room on 02/27/24 at 12:02 PM, the nebulizer device was observed on the bedside table with the mouthpiece dated as 02/26/24. The mouthpiece was observed in the top drawer, uncovered. The CPAP device was observed on the bedside table with the mask, undated and uncovered, hanging from the side rail. Observation revealed there was not a No Smoking sign for the resident's room at or near the doorway. During an observation of R39's room on 02/28/24 at 8:53 AM, the nebulizer mouthpiece was observed in the top drawer of the bedside stand, uncovered. The CPAP device was observed on the bedside table with mask undated and uncovered, hanging from the side rail. There was not a No Smoking sign for the resident's room at or near the doorway. During an observation of R39's room on 02/29/24 at 11:45 AM, the nebulizer mouthpiece was observed in the top drawer of the bedside stand in a plastic bag. The CPAP device was observed on the bedside table with mask undated and uncovered hanging from the side rail. There was not a No Smoking sign for the resident's room at or near the doorway. During an interview on 02/29/24 at 3:11 PM, Registered Nurse (RN)2 stated that nebulizer masks should be stored on top of the machine or in the top drawer.She stated that she did not think there was a special bag to store it in between use. RN2 reported that the tubing and masks for nebulizer devices are changed on nightshift on either Saturday or Sunday. Surveyor requested that RN2 locate R39's orders to check and when checked by RN2, it was reported that she could not find an order for changing the nebulizer tubing and mask weekly. She also did not see an order for care and storage of the CPAP mask after each use or for care and storage of the nebulizer mouthpiece. During an interview on 02/29/24 at 3:34 PM, the DON reported that her expectation for the use of nebulizers to administer medication includes cleaning and storing equipment after use in a Ziploc bag. When reviewing the Medication Administration Record (MAR) for weekly nebulizer mask changes, it revealed no order for nurses to document the task. When reviewing the MAR for cleaning/storing the CPAP mask, it revealed no order. The DON confirmed that the expectation was for the nurses to be signing off on the MAR/TAR for these tasks.

Based on the facility policy titled, Adverse Consequences and Medication Errors, and Insulin Pen Administration Steps, observations and interviews, the facility failed to ensure a medication administration error rate less than 5 percent. Specifically, the medication Questran for Resident (R)1 was ordered to be mixed in 8 ounces of liquid and it was mixed in 4 ounces of liquid and administered. The medication, Potassium Extended Release for R6, was crushed and administered with other crushed medications for R6. The Insulin, Novolog, Flex Pen for R1 was not primed correctly, nor was it administered correctly for R1. The medication error rate was 12 percent for 3 out of 25 opportunities for error. Findings include: Review of the facility policy titled, Adverse Consequences and Medication Errors, states under,Medication Errors, 1. A medication error, is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Review of the, Insulin Pen Administration Steps, Competency Evaluation Worksheet, revealed: 5. Pull the pen cap straight off. Do not remove the pen label. Wipe the rubber seal with an alcohol swab. 7. Select a new needle. Pull off the paper tab from the outer needle shield. Push the capped needle straight onto the pen and twist the needle on until tight. 8. Priming your pen. Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection your may get too much or too little insulin. 9. To prime the pen, turn the dose knob to select 2 units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. 10. Continue holding the pen with the needle pointing up. Push the dose knob until it stops, and 0 is seen in the dose window. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps, no more than 4 times. If you still do not see insulin, change the needle and repeat priming steps. 11. Turn the dose knob to select the number of units you need to inject. The dose indicator should line up with your dose. 12. Choose your injection site. Rotate sites. 13. Insert the needle into skin. Push the dose knob all the way in. Continue to hold the dose knob in and count to 10 before removing the needle. During medication administration on 02/28/2024 at 08:55 AM for R1 went as follows: Registered Nurse (RN)3 mixed Questran 1 package into 4 ounces of cranberry juice and administered the medication. Review of the physician's order stated to administer Questran in 8 ounces of liquid. During an interview on 02/28/2024 at 09:00 AM, RN3 confirmed that she had only mixed the medication in 4 ounces instead of the ordered 8 ounces of liquid. During medication administration on 02/28/2024 at 09:27 AM for R6 went as follows: RN1 crushed the medication, Potassium Extended Release 10 milli-equivelants and placed it with other crushed medications and administered it in applesauce. During an interview on 02/28/2024 at 09:30 AM, RN1 confirmed that she had crushed the extended release medication. During medication administration on 02/29/2024 at 12:10 PM for R1 went as follows: RN3 administered Novolog 6 units via a flex pen for a blood sugar of 275. RN3 did not apply the needle to the pen and dialed up 2 units and pushed the dose knob holding the pen horizontal. RN3 then applied the needle and went into R1's room and wiped the skin and then placed the needle onto the resident's skin and push the dose knob and immediately removed the needle. RN3 confirmed the insulin administration as noted above.

Based on record reviews and interviews, it was determined the facility failed to provide supervision to prevent falls, failed to investigate the root cause of fall, and failed to review care plan interventions and develop new care plan interventions for falls for one (Resident #11) of three sampled residents reviewed for falls. This resulted in Resident #11 sustaining a [MEDICAL CONDITION] that required surgical intervention. The findings included: Resident #11 had [DIAGNOSES REDACTED]. The resident #11 care plan documented on 01/31/2019 that a bed alarm was placed and on 03/13/2019 the resident was to have visual checks every 30-minute for two weeks. There was no further clinical documentation that the 30-minute checks were to be continued after the initial two week period. The facility's fall risk evaluation dated 03/14/2019, documented a fall risk score of 14. The evaluation form stated any score above a 10 represented a high fall risk. The fall evaluation documented the required interventions to include: alternate bed placement, assist with transfers/mobility as needed, encourage alternate periods of activity with periods of rest, observe for fatigue, encourage to participate in activities of Resident's choice, place call light within reach, encourage Resident to ask for assistance with transfers, provide Resident with an assistive device for ambulation and transfers as appropriate, and provide Resident with a clutter free environment with unobstructed pathways. An incident report dated, 05/22/2019 at 5:59 AM, documented the resident was found sitting on the floor with her/his back against the wheelchair (wc). No injuries were noted and as a result of the fall, the intervention put in place was to have Physical Therapy check the wheelchair seat. There was no documentation the facility had investigated the fall to determine the root cause of the fall. No additional care plan interventions to prevent future falls were initiated. An incident report, dated 06/26/2019 at 7:25 AM, documented the resident was found on the floor, on her/his left side in front of the wc. The resident exhibited pain when her/his left hip was palpated. X-rays were ordered. No results of the X-rays were available for review during the survey. S/he did not require a transfer to the hospital. The resident's care plan documented the wc cushion was replaced. There was no documentation the facility had investigated the fall to determine the root cause of the fall. No additional care plan interventions to prevent future falls were initiated. An incident report, dated 07/11/2019 at 6:30 AM, documented the resident was observed on the floor on her/his right side. No injuries were noted. The incident report also documented the resident consistently slumped and slid down the wc seat. There was no documentation the fall was investigated to determine the root cause of the fall. There was no documentation of new care plan interventions to prevent future falls having been initiated. The resident's annual Minimum Data Set (MDS) assessment, dated 09/06/2019, documented the resident was moderately impaired in cognition. S/he required extensive assistance for activities of daily living (ADLs). An incident report dated 09/06/2019 at 5:45 AM, documented the resident was found on the floor in the dayroom in front of her/his wc. S/he was on her/his right side. S/he was assisted back to the wc and was observed to have an abrasion and discoloration to the back of her head. The report documented no additional injuries were noted. A nurse's note dated 09/06/2019 at 9:18 AM, documented the restorative aide was assisting the resident to the main dining room when s/he noticed the resident's right foot was rotated inward and the resident was unable to lift her/his leg. S/he was assisted to bed and evaluated for pain. A clinical record documented on 09/06/19, the physician was notified and x-rays were ordered. The results were positive for right intertrochanteric fracture ([MEDICAL CONDITION]). The resident was transferred to a local hospital for higher care. S/he had surgery and returned to the facility. The resident's care plan documented a new intervention was put in place after the resident's fall, on 09/06/2019. The new intervention was to offer the Resident the option to sleep in instead of an early wake up. On 03/25/2020 at 4:00 PM, Certified Nurse Aide (CNA) #1 was asked what time s/he had got Resident #11 out of bed the morning of 09/06/2019. S/he stated s/he always got the resident up at 5:00 AM. S/he was asked if the resident wished to get up that early. The CNA stated s/he had been told the family wanted the resident to get up early. S/he was asked if the resident would fall asleep in her/his wc. The CNA responded All the time. S/he then added she had told the nurses that the resident was getting up too early, but they told her/him the family had requested the early wake up. The CNA stated the resident was always falling asleep and sliding out of the wc. The CNA was asked if the resident was on frequent visualization checks. S/he stated s/he was never told to do that. On 03/26/2020 at 10:00 AM, Licensed Practical Nurse (LPN) #1 was interviewed. S/he stated the resident fell out of the chair often. S/he stated they frequently had to pull her/his up and prevent falling out of the wc. S/he stated the pommel cushion didn't help and thought it made sliding out of the chair worse. S/he was asked if the resident was on frequent visual checks. S/he stated s/he didn't think so and that the resident wandered around the facility in her wc. The LPN was asked if the resident had any other interventions in place to prevent falls from the wc. S/he stated s/he didn't think so. On 03/25/2020 at 2:00 PM, the Corporate Vice President of Clinical Services was interviewed. S/he was asked for documentation proving the falls had been investigated to determine the root cause of the falls. S/he stated there was no documentation. S/he was asked if the resident was on a get up list from the night shift. S/he stated s/he didn't know. S/he was asked if additional interventions had been initiated. S/he stated there was no documentation of any. S/he added that no one who was directly involved with the fall remained employed at the facility. S/he stated s/he assumed Resident #11 was on the night shift get up list.

Based on review of facility files and interview, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical status. Resident #14 was noted to have swelling and increased pain in his/her right arm. Review of facility files revealed the resident's physician was not notified timely related to the resident's change in condition. Resident #201 was noted to have respiratory difficulty on [DATE] with no documented intervention till [DATE]. Resident #138 was noted to have a decline in condition on [DATE]. The resident's physician was not notified of the resident's change in condition. Three of four residents reviewed for notification. The findings included: The facility reported an injury of unknown origin to the State Agency for Resident #14 on [DATE]. The resident was noted to have an x-ray that revealed a [MEDICAL CONDITION] humerus. Review of the facility's Five-Day Follow-Up Report dated [DATE] revealed the resident complained of pain and swelling was noted to the right arm. An x-ray was ordered which revealed a [MEDICAL CONDITION] proximal humerus. Review of the Nurses' Notes dated [DATE] by the ADON (Assistant Director of Nursing) indicated Resident #14 had increased pain in his/her right arm and yelled out in pain during movement. The resident's arm seemed swollen. The resident's responsible party and physician were notified. Review of the Nurses' Notes dated [DATE] indicated the physician was called and ordered a doppler for Resident #14's right arm. Review of the Nurses' Notes dated [DATE] indicated a new order for an x-ray in the AM of the right shoulder and right arm. Resident noted with right shoulder pain and [MEDICAL CONDITION]. Further review of the Nurses' Notes dated [DATE] revealed Resident #14 had a humerus fracture. Nurses' Notes were reviewed from [DATE]-[DATE] with no documentation related to reports the resident had increased pain or swelling to the right arm. There was no documentation that the nurse practitioner or physician saw the resident. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated after investigation Resident #14's fracture likely occurred due to [MEDICAL CONDITION]. The resident's care plan was reviewed and revised to reflect the new diagnosis. Review of Resident #14's Weekly Body Audit forms revealed only two body audits were completed for the months of October and November, on [DATE] and [DATE]. CNA #3's facility-obtained statement dated [DATE] indicated that around [DATE]th s/he reported to the nurse that Resident #14 had increased pain and swelling in his/her arm. CNA #3 asked therapy to take a look at the resident's arm. In an interview with the surveyor on [DATE] at approximately 11:50 AM, CNA #3 stated s/he is usually assigned to the resident. CNA #3 remembers the resident's arm being swollen and s/he told the nurse and also asked therapy to look at the resident's arm. CNA #3 stated therapy can tell if a resident's arm is dislocated. Therapy looked at the resident's arm and talked with the nurse about it, they didn't say anything to CNA #3 about the assessment. CNA #4's facility-obtained statement dated [DATE] indicated that about 2 weeks before s/he asked Resident #14 what happened to his/her arm. Resident #14 had a skin tear and said that black and white girl hurt my arm. It was painful to the touch. CNA #4 left a note in the ADON's box the same day. CNA #5's facility-obtained statement dated [DATE] indicated s/he saw Resident #14 on [DATE] for range of motion exercises and the resident had no swelling or complaints of pain. CNA #5 was noted to be a restorative aide. When CNA #5 saw the resident on ,[DATE] and ,[DATE] the resident complained of increased pain. No swelling was noted on those days. On [DATE] the resident had very increased pain and noticeable swelling. CNA #5 reported to the nurse and unit manager. On [DATE] the resident still had increased pain and swelling. S/he observed on [DATE] that the swelling had gotten worse and reported it to the nurse. The ADON's facility-obtained statement dated [DATE] indicated a note from CNA #4 on [DATE] indicated the resident had a skin tear to his/her right arm. The ADON went to investigate and noted the resident's right arm and hand to be swollen. The ADON asked the resident's caregivers if they had noted changes. The resident's CNA stated Resident #14 would yell in pain when they moved his/her right arm. The ADON asked the nurse practitioner if they could do an x-ray. The nurse practitioner stated s/he looked at that arm the week before and s/he didn't want to do anything with it right now. On [DATE] they received results of a Doppler that were negative and the nurse practitioner ordered an x-ray to the right shoulder and arm. On [DATE] the x-ray was positive for a [MEDICAL CONDITION] right humerus. In an interview with the surveyor on [DATE] at approximately 11:40 AM, the ADON stated when s/he saw Resident #14's arm on [DATE] that was the first time s/he had looked at it. The ADON stated s/he was not sure how long the resident's arm had been swollen. review of the resident's medical record revealed [REDACTED]. of pain and swelling or the ADON talking with the nurse practitioner on [DATE]. There was no documentation in Resident #14's medical record that the nurse practitioner saw the resident in the two weeks prior to the identification of the fracture. In an interview with the surveyor on [DATE] at approximately 1:33 PM, the Director of Nursing (DON) stated the only body audits found for the months of October and [DATE] were the ones dated [DATE] and [DATE]. The DON stated that Nurses' Notes should address any concerns noted and include the assessment and what was done. The DON confirmed there was no documentation that the nurse practitioner looked at the resident's arm. The DON confirmed there should have been documentation in the Nurses' Notes if there was something there for the nurse practitioner to look at. The facility reported an allegation of neglect to the State Agency related to Resident #138 on [DATE]. Resident #138 was noted unresponsive at the bedside and CPR was not initiated. Resident was later noted to be a full code. Resident #138 expired at the facility on [DATE] Review of the resident's Social Services Admission note revealed the resident wanted to be a full code. Review of the resident's Consent for Cardiopulmonary Resuscitation revealed the resident signed the form on [DATE] for CPR to be done. Review of the medical record revealed a Physician's Telephone Order dated [DATE] for the resident to be a full code. Review of the resident's care plan revealed full code status was identified as a problem area. Interventions and approaches to this problem were documented on the care plan and included to honor full code status and place a green sheet in front of the chart that designates full code. Review of the Resident #138's Nurses' Notes dated ,[DATE]-[DATE] revealed the resident's O2 sats were usually between ,[DATE]%. Further review of the Nurses' Notes revealed there were no entries on [DATE]. There was only one entry on [DATE] at 12:30 PM that indicated the resident was without blood pressure, respirations, temperature or O2 sats. The resident's family and physician were notified. Review of the resident's Medication Administration Record [REDACTED]. The order was discharged on [DATE] related to non-use. The resident did not receive the medication in June or [DATE]. Review of the facility's Change in Condition policy revealed that in order to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner. Further review of the policy revealed guidelines that included when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed . Information included vital signs, current level of pain and any recent changes in pain level, onset, duration, and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect information to report to the physician. The nursing staff will contact the physician about significant change in condition. CNA #2's facility-obtained statement dated [DATE] indicated s/he clocked in at 7:00 AM. S/he checked on Resident #138's vital signs around 7:20 AM. His/her O2 sats were ,[DATE]%. CNA #2 went to inform the resident's nurse of his/her O2 sats, and the nurse acknowledged with okay. Around 9:00 AM, Resident #138 put on his/her light and stated s/he felt like s/he couldn't breath. CNA #2 told the nurse and the nurse stated s/he would give the resident a breathing treatment. Around 10:30 AM Resident #138 placed his/her light on and stated his/her heart hurt. CNA #2 told the nurse and the nurse just said (s/he's) going to have to and seemed agitated. Around 11:15 AM CNA #2 checked on the resident and s/he was asleep. Around 12:,[DATE]:20 PM, another CNA took Resident #138 his/her meal tray and told CNA #2 to go look how they left the resident. CNA #2 walked in the room and observed the resident's brief and sheets on the bed. CNA #2 began to look around and found Resident #138 on the floor. S/he told the other CNA, who checked for a respiration which wasn't visible. The CNA yelled code down the hall to the nurse. LPN #2 came and advised them to get the resident up. They got the resident up to bed. In an interview with the surveyor on [DATE] at approximately 2:00 PM, CNA #2 stated s/he usually worked with Resident #138 on the ,[DATE] shift. Resident #138 was pleasant, alert and oriented. LPN #2 was usually assigned to the resident also. The O2 sat of 82--83% was low for the resident. CNA #2 told the nurse so s/he could get oxygen if needed. CNA #2 stated the nurse did not go check on the resident. Resident #138 put on the call light and said it felt like s/he couldn't breathe. CNA #2 said s/he would let the nurse know and s/he went and told LPN #2. When the resident complained his/her heart hurt, CNA #2 told LPN #2. The nurse said (s/he's) just going to have to and didn't complete the statement. LPN #2 seemed agitated. That was the LPN's usual demeanor. There was a brief on the bed that was open when CNA #2 entered the room. The sheet was moved like the resident had just gotten out of bed and the brief was on the sheet where the resident would have been. CNA #2 found the resident on the floor on the other side of the bed near the window. Resident #138 was on his/her face. He had on his gown. Another CNA in the room noticed the resident wasn't breathing. LPN #3 told the CNAs to get the resident out of the floor because s/he was a DNR. In an interview with the surveyor on [DATE] at approximately 4:45 PM, the DON (Director of Nursing) stated the incident happened on a weekend. The DON stated that the documentation on Resident #138 that day was poor. There was no documentation between ,[DATE]-,[DATE]. The DON stated that from some of the CNA statements the nurses notes did not reflect that anything went on that morning with the resident's status. LPN #2 told the DON s/he gave the resident something for pain. The DON stated that for O2 sats less than 90% you usually should call the physician and let know and see what the physician wants started. The DON stated s/he would have expected LPN #2 to call the physician that morning when the resident had low O2 sats. Resident #201 was admitted to the facility [DATE] and noted with chronic [MEDICAL CONDITION] on oxygen on the admission History and Physical. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #201 as having a Brief Interview for Mental Status score of 15. Review of the resident's care plan revealed at risk for impaired breathing pattern related to [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide with oxygen as ordered, notify physician as needed, and O2 sats as indicated. Review of the hospital Discharge Summary for Resident #201's hospitalization ,[DATE]-[DATE] revealed the resident had acute interstitial pneumonia, acute [MEDICAL CONDITION], bacterial pneumonia, acute [MEDICAL CONDITION] and acute diverticulitis. Resident #201 was also noted to have a history of pneumonia in [DATE]. Review of the physician progress notes [REDACTED]. Review of the resident's admission orders [REDACTED]. Another order indicated [MEDICATION NAME][MEDICATION NAME] 40 mg every day x 3 days with a stop date of [DATE]. Review of the Occupational Therapy Daily Treatment Note dated [DATE] revealed Resident #201 requested an x-ray due to concerns of pneumonia, with nursing staff notified of resident concerns/request. Resident O2 sats fluctuated from 79% after completing shower to 90% at rest. Review of the Physical Therapy Daily Treatment Note dated [DATE] revealed Resident #201 complained of feeling short of breath today with O2 readings in ,[DATE] with breathing treatment, notifying nursing. Review of Resident #201's Nurses' Notes revealed only one entry on [DATE] at 2:59 AM. There were no Nurses' Notes on [DATE] related to the resident's change in condition. Review of the SBAR Communication Form dated [DATE] revealed the resident was noted with SOB, wheezing and loss of appetite that started on [DATE]. Review of the Physician's Telephone Orders dated [DATE] revealed an order for [REDACTED].#201's chest x-ray was positive with left lower lobe atelectasis or focal infiltrates. In an interview with the surveyor on [DATE] at approximately 4:10 PM, the DON (Director of Nursing) stated Resident #201 was sent out to the hospital. The DON stated s/he was not sure why the resident went out, and could not tell based on looking at the SBAR and Nurses Notes. The DON stated the physician should have been notified sooner. The DON stated s/he would expect nursing to document that they were notified of the resident's change in condition by the therapy staff. When asked about the SBAR stating that the resident's change in condition started on [DATE] and the only documentation was that the physician was notified on [DATE], the DON confirmed that there should have been documentation that the physician was notified on [DATE]. On [DATE] at approximately 3:15 PM the facility Administrator and Nurse Consultant were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. Immediate Jeopardy and Substandard Quality of Care existed in the facility as of [DATE], when staff were made aware of a [MEDICAL CONDITION] of Resident #14. The licensed staff had been made aware of Resident #14's complaints of pain and swelling for several days but did not assess the resident or notify the physician timely. The facility responded to the incident by having licensed staff and certified nursing assistants complete skin assessments on all residents, document their findings and determine if there was any change in condition. This was started on [DATE] and was completed on [DATE]. The Interact Stop-n-Watch program, a communication tool, was utilized to identify and report changes in condition to the licensed nurse. All nursing staff received reeducation by the Director of Nursing on [DATE] related to reporting injuries of unknown origin immediately. Nursing Administration reviewed all 24 hour review reports for 4 weeks to ensure changes in condition continued to be identified and followup was done in the monthly QA meetings. The next incident involving Immediate Jeopardy and Substandard Quality of Care involved Resident #201 and existed in the facility as of [DATE] when the resident had respiratory difficulty and expressed this concern to the staff on [DATE]. The staff did not respond until [DATE] and the resident was sent out to the hospital for evaluation and was found to have pneumonia. At that time Nursing Administration completed an audit of 24 hour reports to assess for any change in condition of other residents. Licensed Nurses were re-educated by the Staff Development Coordinator related to identifying resident change in condition and documentation. Nursing Administration completed 24 hour report audits weekly for four weeks and monthly for 2 months. On [DATE] Resident #138 had complained of respiratory difficulty and chest pain. Later the resident was found unresponsive and was not provided CPR even though he was a full code. Documentation related to this incident was very poor. At this time the facility addressed these issues with a detailed plan of action that included: Reporting the incident as neglect to the State survey agency. Termination of the staff involved and reporting the licensed staff to the State Board of Nursing. All residents were reviewed to insure advance directive documents were in order and filed, assessments and documentation were completed and any change in condition was noted, addressed and the physician was notified. Staff received education on advance directives, assessments, documentation and reporting. The Stop and Watch Interact communication tool was also part of the education. This was mandatory for staff to work. Nursing Administration then conducted audits on nurses notes, 24 hour reports and advance directives weekly for 4 weeks. Nursing Administration also completed a questionnaire with 2 Licensed Nurses per shift weekly for 4 weeks related to assessing residents and those residents found without vital signs. The Immediate Jeopardy and Substandard Quality of Care was cited at a scope and severity of J at F157, F224, F281, F309, F323 and F514. On [DATE] the facility had removed the immediacy through review of all resident clinical records, assessment of residents as indicated and education of all staff. The deficiencies remained and were lowered in scope and severity to an E. During the survey of [DATE], based on interview of staff, record review and observation, the Jeopardy tags of F157, F224, F281, F309, F323 and F514 were corrected as of [DATE]. Audits completed were reviewed, education content and sign in sheets were reviewed and interviews with the Director of Nursing and both licensed and certified staff revealed knowledge of reporting, use of the Stop and Watch tool and assessment of residents.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit neglect of residents. Resident #25 sustained a fracture when CNA #1 transferred the resident with the wrong lift and without the assistance of a second staff member and Resident #9 sustained a laceration when a CNA transferred the resident with the wrong sling lift and without the assistance of a second staff member. Resident #14 complained of pain and discomfort noted by staff for several days prior to medical intervention. Resident #138 complained of chest pain and respiratory difficulty without intervention, was found unresponsive and LPN #2 did not administer cardiopulmonary resuscitation per the resident's advance directive. Three of five residents reviewed for accidents and one of two residents reviewed for death. The findings included: The facility admitted resident #9 with [DIAGNOSES REDACTED]. Observation of the resident on [DATE] at 10:49:01 AM revealed the resident was lying in bed on left side, head of bed elevated. No verbal response. Awake, will make eye contact when called by name but immediately looks away. On air mattress with wings, no side rails. O-2 at 2L a min via nasal cannula. Fall mats at bedside. High back wheelchair in room with pressure relieving cushion. Further review of the medical record revealed the resident was care planned on [DATE] for Fall Risk r/t (related to) dementia, weakness, hx (history of) falls, decreased mobility, medications and incontinence. Approaches included but were not limited to: winged air mattress. Provide safe clutter free environment. [DATE]- winged air mattress to bed, Mat at bedside while in bed. [DATE]- staff education r/t lift usage and using 2 assist. Review of the Nurse Aides's Information Sheet (not dated) revealed the resident was checked for highback wheelchair, assist transfers, lift to chair, sling lift with 2 assistance. Review of the Nurses Notes revealed on [DATE], Pt (patient) sent to ER (emergency room ) for [MEDICAL CONDITION]. Pt returned with 8 staples to left side of head 10:00 PM- Res (resident) returned at 5:30 p via stretcher. Head is wrapped in gauze and no blood seeping thru. [DATE] 9AM Pt's fall on [DATE] discussed by IDT (Interdisciplinary Department Team). Pt was being transferred to bed using a sling lift when the sling pad slipped from the lift, causing the pt to fall to the ground. Laceration sustained to head. Pt was transferred to ER and staples were placed. CT (scan) of head and spine are negative. Pt transferred back to facility following staples. Following staff interviews, it was discovered that the incorrect sling pad for the lift was used and that only one staff member was present for the transfer. Education provided for staff regarding proper lift usage. CP (care plan) in place. Review of the facility Policy and Procedure entitled, Safe Lifting and Movement of Residents:, stated The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. The facility reported an injury of unknown origin for Resident #25 to the State Agency on [DATE]. Resident #25 was noted to have a [MEDICAL CONDITION] tibia of the right leg. Review of the care plan revealed require staff assistance for ADLs and mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included sling lift for transfers. The problem onset date was noted as [DATE]. Review of Resident #25's Nurses' Notes dated [DATE] at 9:30 PM indicated resident noted to have swollen right leg with purple and blue discoloration. Resident expresses verbal complaints of pain when right leg and foot area touched or moved. This was noticed when a CNA went to to put the resident to bed. The physician was notified and ordered a stat x-ray. Review of the Radiology Report dated [DATE] revealed Resident #25 had an acute proximal tibial fracture. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated after completion of investigation believe the fracture occurred during a transfer. CNA #1's facility-obtained statement dated [DATE] indicated s/he got Resident #25 up from bed using a stand lift. An addendum indicated that during a second phone conversation with CNA #1 s/he stated s/he did not have anyone assist with the stand lift during transfer on [DATE]. CNA #1 was asked about assistance with other lift transfers, s/he said s/he did not get assistance to do transfers. The DON informed the resident that Resident #25 used a sling lift and required 2 assist. In an interview with the surveyor on [DATE] at approximately 1:20 PM, the DON (Director of Nursing) stated 2 CNAs were putting Resident #25 to bed on 2nd shift. As they were moving the resident, s/he yelled in pain. The CNAs got the nurse and the nurse noted discoloration on assessment. During the investigation, CNA #1 was found to have used improper transfer technique. CNA #1 transferred Resident #25 with a stand lift by herself. Resident #25 required a sling lift with 2 person assist for transfers. The DON stated Resident #25 was inconsistent with being able to hold on to a stand lift which is why s/he required a sling lift. The DON stated all mechanical lifts require 2 people. The DON stated she does not recall the resident having any falls around the time frame the fracture was found. The DON stated transfer status is on the care card inside the resident's closet door. The DON stated s/he checked after the incident and noted Resident #25's care card was in place. Review of the facility's Safe Lifting and Movement of Residents policy revealed guidelines that included The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. The policy had a revision date of [DATE]. The facility reported an allegation of neglect to the State Agency related to Resident #138 on [DATE]. Resident #138 was noted unresponsive at the bedside and CPR was not initiated. Resident was later noted to be a full code. Resident #138 expired at the facility on [DATE] Review of the resident's Social Services Admission note revealed the resident wanted to be a full code. Review of the resident's Consent for Cardiopulmonary Resuscitation revealed the resident signed the form on [DATE] for CPR to be done. Review of the medical record revealed a Physician's Telephone Order dated [DATE] for the resident to be a full code. Review of the resident's care plan revealed full code status was identified as a problem area. Interventions and approaches to this problem were documented on the care plan and included to honor full code status and place a green sheet in front of the chart that designates full code. Review of the Resident #138's Nurses' Notes dated ,[DATE]-[DATE] revealed the resident's O2 sats were usually between ,[DATE]%. Further review of the Nurses' Notes revealed there were no entries on [DATE]. There was only one entry on [DATE] at 12:30 PM that indicated the resident was without blood pressure, respirations, temperature or O2 sats. The resident's family and physician were notified. Review of the facility's Change in Condition policy revealed that in order to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner. Further review of the policy revealed guidelines that included when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed . Information included vital signs, current level of pain and any recent changes in pain level, onset, duration, and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect information to report to the physician. The nursing staff will contact the physician about significant change in condition. CNA #2's facility-obtained statement dated [DATE] indicated s/he clocked in at 7:00 AM. S/he checked on Resident #138's vital signs around 7:20 AM. His/her O2 sats were ,[DATE]%. CNA #2 went to inform the resident's nurse of his/her O2 sats, and the nurse acknowledged with okay. Around 9:00 AM, Resident #138 put on his/her light and stated s/he felt like s/he couldn't breath. CNA #2 told the nurse and the nurse stated s/he would give the resident a breathing treatment. Around 10:30 AM Resident #138 placed his/her light on and stated his/her heart hurt. CNA #2 told the nurse and the nurse just said (s/he's) going to have to and seemed agitated. Around 11:15 AM CNA #2 checked on the resident and s/he was asleep. Around 12:,[DATE]:20 PM, another CNA took Resident #138 his/her meal tray and told CNA #2 to go look how they left the resident. CNA #2 walked in the room and observed the resident's brief and sheets on the bed. CNA #2 began to look around and found Resident #138 on the floor. S/he told the other CNA, who checked for a respiration which wasn't visible. The CNA yelled code down the hall to the nurse. LPN #2 came and advised them to get the resident up. They got the resident up to bed. In an interview with the surveyor on [DATE] at approximately 2:00 PM, CNA #2 stated s/he usually worked with Resident #138 on the ,[DATE] shift. Resident #138 was pleasant, alert and oriented. LPN #2 was usually assigned to the resident also. The O2 sat of 82--83% was low for the resident. CNA #2 told the nurse so s/he could get oxygen if needed. CNA #2 stated the nurse did not go check on the resident. Resident #138 put on the call light and said it felt like s/he couldn't breathe. CNA #2 said s/he would let the nurse know and s/he went and told LPN #2. When the resident complained his/her heart hurt, CNA #2 told LPN #2. The nurse said (s/he's) just going to have to and didn't complete the statement. LPN #2 seemed agitated. That was the LPN's usual demeanor. There was a brief on the bed that was open when CNA #2 entered the room. The sheet was moved like the resident had just gotten out of bed and the brief was on the sheet where the resident would have been. CNA #2 found the resident on the floor on the other side of the bed near the window. Resident #138 was on his/her face. He had on his gown. Another CNA in the room noticed the resident wasn't breathing. LPN #3 told the CNAs to get the resident out of the floor because s/he was a DNR. RN (Registered Nurse) #2' facility-obtained statement dated [DATE] indicated s/he was asked to go to Resident #138's room on [DATE]. Resident #138 did not have a pulse or respirations. LPN #2 stated (s/he) is a DNR. RN #2 returned to his/her assigned hall. LPN #1's facility-obtained statement dated [DATE] indicated s/he was asked to assist LPN #2. Upon arriving to the room s/he observed 3 CNAs getting Resident #138 up off the floor with a sheet. Resident #138 did not have a pulse nor respirations. When LPN #2 was asked about whether the resident was a full code or a DNR, LPN #2 stated that the resident was a DNR. In an interview with the surveyor on [DATE] at approximately 2:40 PM, LPN #1 stated s/he was working on the Wren Unit(100). S/he was sitting at the desk and the weekend supervisor asked them to come help with a code. When s/he got there the CNAs were getting the resident up with a sheet. S/he and another nurse checked the resident for pulse or respirations. They asked the resident's nurse what his/her code status was and LPN #2 said DNR. LPN #2 was standing back and had already checked for respirations and pulse. Resident #138 was warm to the touch and pale. LPN #1 stated you know a resident's code status by looking at the chart, on the front of the chart there is a red sheet or a green sheet. Red is a DNR and green indicates a full code. LPN #1 did not look at the front of the resident's chart to check his/her code status. LPN #1 stated the yellow MD card tells who the doctor is, the yellow card is behind the code status form in the resident's chart. The yellow form has only the doctor's name and phone number. LPN #1 was not sure why LPN #2 would have seen the yellow MD card and thought the resident was a DNR. CNA #6's facility-obtained statement indicated around 1:00 PM, Resident #138's family asked LPN #2 if s/he could please come here. LPN #2 asked the CNA if s/he could go in with him/her. The resident's daughter asked if LPN #2 knew what happened. LPN #2 stated s/he believed the resident aspirated. The other daughter stated the hospital told them that was possible. LPN #2 went on to tell the daughter that their was nothing that could have been done that the resident was a DNR. LPN #2's facility-obtained statement indicated between ,[DATE] AM s/he was informed Resident #138 was having chest pains and wanting a breathing treatment. At 9:30 AM s/he quickly moved the medication cart to the resident's room to address the issues s/he was currently having. LPN #2 checked the residents Medication Administration Record [REDACTED]. Upon entering the resident's room, the resident was lying with HOB flat peacefully. LPN #2 told the resident s/he had put his/her scheduled pain pill in the medications and that should help with his/her pain. LPN #2 waited for the resident to swallow his/her medications. The resident stated it hurts to swallow. LPN #2 had no further issues with Resident #138 between ,[DATE] AM. LPN #2 took lunch and returned to the unit at 12:05 PM. Between 12:,[DATE]:15 PM the CNA yelled for him/her to come check on Resident #138. The CNA stated (s/he) coded I think. At that point LPN #2 told the CNA to get a stethoscope and grabbed the oxiometer. LPN #2 quickly glanced at Resident #138's chart and saw only the yellow MD card and at that point s/he determined the resident was a DNR status. LPN #2 went in and assessed the resident; s/he found the resident unresponsive and with no vitals. LPN #2 went to get RN assistance. In the process of going to get an RN s/he called the DON and informed him/her of the situation. After the RN assessed the resident with no vitals, s/he instructed him to call the POA to inform them of the change in status. At 1:00 PM, LPN #2 talked with the resident's family member. At 5:00 PM, the physician called LPN #2 and asked if this was his patient. LPN #2 proceeded to check the chart and told the doctor it was his patient. LPN #2 flipped open the chart to find some of the resident's paperwork, that is when s/he came upon the resident's advance directives that his/her code status was full code. LPN #2 then called the DON to inform him/her of the findings. LPN #2's facility-obtained statement dated [DATE] indicated s/he came back from his/her lunch break around 12:00 PM. A CNA yelled for him/her to come down to check on Resident #138. LPN #2 quickly glanced to check the chart, in that few moments s/he checked s/he only saw the yellow card with the physician's information on it. LPN #2 thought at the moment of the incident the resident was a DNR. LPN #2 ran to the room to check the resident's vital signs. LPN #2 found the resident unresponsive beside the bed. LPN #2 manually checked for a pulse. Figuring the resident was a DNR s/he followed the DNR protocol. LPN #2 called the DON and told him/her on the phone that Resident #138 was a DNR. LPN #2 went to another unit to get assistance from one of the RNs. S/he proceeded to come over to assist him/her with the resident. In an interview with the surveyor on [DATE] at approximately 4:45 PM, the DON (Director of Nursing) stated the incident happened on a weekend. LPN #2 called and notified him/her that Resident #138 had passed. The DON asked LPN #2 if the resident was a full code. The DON stated s/he remembered asking the LPN twice about the resident's code status. LPN #2 stated Resident #138 was a DNR (do not resuscitate). LPN #2 called the resident's physician to notify him/her about the resident passing. The physician questioned who the resident was and didn't think it was his/her patient. The physician asked LPN #2 to go back through the chart. At 5:11 PM, LPN #2 called the DON back and told him/her the physician had requested paperwork be faxed to him/her. When LPN #2 went through Resident #138's medical record to get the information s/he realized the resident was a full code. The DON stated they have a red/green system in place for code status. The DON asked LPN #2 and s/he said when s/he opened the chart s/he didn't see a red or green form. LPN #2 saw the yellow form physician information form. The yellow form was loose in front of the code status sheet. The code sheet was a green full code sheet in a plastic sheet protector. The DON stated s/he came to the facility to look at the resident's medical record. The green full code sheet was in the sheet protector and you could see the green border behind the yellow physician information sheet. When the 2nd nurse came to the room to assess Resident #138, LPN #2 told him/her the resident was a DNR. The DON stated that the documentation on Resident #138 that day was poor. There was no documentation between ,[DATE]-,[DATE]. The DON stated that from some of the CNA statements the nurses notes did not reflect that anything went on that morning with the resident's status. LPN #2 told the DON s/he gave the resident something for pain. The DON stated that for O2 sats less than 90% you usually should call the physician and let know and see what the physician wants started. The DON stated s/he would have expected LPN #2 to call the physician that morning when the resident had low O2 sats. The facility reported an injury of unknown origin to the State Agency for Resident #14 on [DATE]. The resident was noted to have an x-ray that revealed a [MEDICAL CONDITION] humerus. Review of the facility's Five-Day Follow-Up Report dated [DATE] revealed the resident complained of pain and swelling was noted to the right arm. An x-ray was ordered which revealed a [MEDICAL CONDITION] proximal humerus. Review of the Nurses' Notes dated [DATE] by the ADON (Assistant Director of Nursing) indicated Resident #14 had increased pain in his/her right arm and yelled out in pain during movement. The resident's arm seemed swollen. The resident's responsible party and physician were notified. Review of the Nurses' Notes dated [DATE] indicated the physician was called and ordered a doppler for Resident #14's right arm. Review of the Nurses' Notes dated [DATE] indicated a new order for an x-ray in the AM of the right shoulder and right arm. Resident noted with right shoulder pain and [MEDICAL CONDITION]. Further review of the Nurses' Notes dated [DATE] revealed Resident #14 had a humerus fracture. Nurses' Notes were reviewed from [DATE]-[DATE] with no documentation related to reports the resident had increased pain or swelling to the right arm. There was no documentation that the nurse practitioner or physician saw the resident. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated after investigation Resident #14's fracture likely occurred due to [MEDICAL CONDITION]. The resident's care plan was reviewed and revised to reflect the new diagnosis. Review of Resident #14's Weekly Body Audit forms revealed only two body audits were completed for the months of October and November, on [DATE] and [DATE]. CNA #3's facility-obtained statement dated [DATE] indicated that around [DATE]th s/he reported to the nurse that Resident #14 had increased pain and swelling in his/her arm. CNA #3 asked therapy to take a look at the resident's arm. In an interview with the surveyor on [DATE] at approximately 11:50 AM, CNA #3 stated s/he is usually assigned to the resident. CNA #3 remembers the resident's arm being swollen and s/he told the nurse and also asked therapy to look at the resident's arm. CNA #3 stated therapy can tell if a resident's arm is dislocated. Therapy looked at the resident's arm and talked with the nurse about it, they didn't say anything to CNA #3 about the assessment. CNA #4's facility-obtained statement dated [DATE] indicated that about 2 weeks before s/he asked Resident #14 what happened to his/her arm. Resident #14 had a skin tear and said that black and white girl hurt my arm. It was painful to the touch. CNA #4 left a note in the ADON's box the same day. CNA #5's facility-obtained statement dated [DATE] indicated s/he saw Resident #14 on [DATE] for range of motion exercises and the resident had no swelling or complaints of pain. CNA #5 was noted to be a restorative aide. When CNA #5 saw the resident on ,[DATE] and ,[DATE] the resident complained of increased pain. No swelling was noted on those days. On [DATE] the resident had very increased pain and noticeable swelling. CNA #5 reported to the nurse and unit manager. On [DATE] the resident still had increased pain and swelling. S/he observed on [DATE] that the swelling had gotten worse and reported it to the nurse. The ADON's facility-obtained statement dated [DATE] indicated a note from CNA #4 on [DATE] indicated the resident had a skin tear to his/her right arm. The ADON went to investigate and noted the resident's right arm and hand to be swollen. The ADON asked the resident's caregivers if they had noted changes. The resident's CNA stated Resident #14 would yell in pain when they moved his/her right arm. The ADON asked the nurse practitioner if they could do an x-ray. The nurse practitioner stated s/he looked at that arm the week before and s/he didn't want to do anything with it right now. On [DATE] they received results of a Doppler that were negative and the nurse practitioner ordered an x-ray to the right shoulder and arm. On [DATE] the x-ray was positive for a [MEDICAL CONDITION] right humerus. In an interview with the surveyor on [DATE] at approximately 11:40 AM, the ADON stated when s/he saw Resident #14's arm on [DATE] that was the first time s/he had looked at it. The ADON stated s/he was not sure how long the resident's arm had been swollen. review of the resident's medical record revealed [REDACTED]. of pain and swelling or the ADON talking with the nurse practitioner on [DATE]. There was no documentation in Resident #14's medical record that the nurse practitioner saw the resident in the two weeks prior to the identification of the fracture. In an interview with the surveyor on [DATE] at approximately 1:33 PM, the Director of Nursing (DON) stated the only body audits found for the months of October and [DATE] were the ones dated [DATE] and [DATE]. The DON stated that Nurses' Notes should address any concerns noted and include the assessment and what was done. The DON confirmed there was no documentation that the nurse practitioner looked at the resident's arm. The DON confirmed there should have been documentation in the Nurses' Notes if there was something there for the nurse practitioner to look at. On [DATE] at approximately 3:15 PM the facility Administrator and Nurse Consultant were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. Immediate Jeopardy and Substandard Quality of Care existed in the facility as of [DATE], when staff were made aware of a [MEDICAL CONDITION] of Resident #14. The licensed staff had been made aware of Resident #14's complaints of pain and swelling for several days but did not assess the resident or notify the physician timely. The facility responded to the incident by having licensed staff and certified nursing assistants complete skin assessments on all residents, document their findings and determine if there was any change in condition. This was started on [DATE] and was completed on [DATE]. The Interact Stop-n-Watch program, a communication tool, was utilized to identify and report changes in condition to the licensed nurse. All nursing staff received reeducation by the Director of Nursing on [DATE] related to reporting injuries of unknown origin immediately. Nursing Administration reviewed all 24 hour review reports for 4 weeks to ensure changes in condition continued to be identified and followup was done in the monthly QA meetings. On [DATE], Resident #25 was transferred incorrectly with the assistance of only one staff member and after complaints of pain was found to have a tibial fracture. On [DATE] Resident #138 had complained of respiratory difficulty and chest pain. Later the resident was found unresponsive and was not provided CPR even though he was a full code. Documentation related to this incident was very poor. On [DATE], Resident #9 was transferred inappropriately by a staff member using the wrong sling on a lift which resulted in a laceration requiring emergency treatment. At this time the facility addressed these issues with a detailed plan of action that included: Reporting the incident as neglect to the State survey agency. Termination of the staff involved and reporting the licensed staff to the State Board of Nursing. All residents were reviewed to insure advance directive documents were in order and filed, assessments and documentation were completed and any change in condition was noted, addressed and the physician was notified. Staff received education on advance directives, assessments, documentation and reporting. The Stop and Watch Interact communication tool was also part of the education. This was mandatory for staff to work. Nursing Administration then conducted audits on nurses notes, 24 hour reports and advance directives weekly for 4 weeks. Nursing Administration also completed a questionnaire with 2 Licensed Nurses per shift weekly for 4 weeks related to assessing residents and those residents found without vital signs. The Immediate Jeopardy and Substandard Quality of Care was cited at a scope and severity of J at F157, F224, F281, F309, F323 and F514. On [DATE] the facility had removed the immediacy through review of all resident clinical records, assessment of residents as indicated, 100% audit of all residents transferred via lift, and education of all staff. The deficiencies remained and were lowered in scope and severity to an E. During the survey, based on interview of staff, record review and observation, the Jeopardy tags were corrected as of [DATE]. Audits completed were reviewed, education content and sign in sheets were reviewed and interviews with staff revealed knowledge of reporting, use of the Stop and Watch tool, appropriate transfer of residents and assessment of residents. Documentation was found in the clinical records and the incidents involving Residents #9 and #25 were addressed and reported timely and plans of correction were put in place to address the incorrect transfers.

Based on record review, review of facility reported incidents and staff interviews, the facilty failed to provide services that met professional standards of quality. Residents #9 and #25 were injured during an incorrect transfer by Certified Nursing Assistants, (2 of 5 residents reviewed for injury) and Residents #14, #138 and #201 had a change in condition requiring medical intervention that was not addressed timely resulting in harm. The findings included: The facility admitted resident #9 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was care planned on [DATE] for Fall Risk r/t (related to) dementia, weakness, hx (history of) falls, decreased mobility, medications and incontinence. Approaches included but were not limited to: winged air mattress. Provide safe clutter free environment. [DATE]- winged air mattress to bed, Mat at bedside while in bed. [DATE]- staff education r/t lift usage and using 2 assist. Review of the Nurse Aides's Information Sheet (not dated) revealed the resident was checked for highback wheelchair, assist transfers, lift to chair, sling lift with 2 assistance. Review of the Nurses Notes revealed on [DATE], Pt (patient) sent to ER (emergency room ) for [MEDICAL CONDITION]. Pt returned with 8 staples to left side of head 10:00 PM- Res (resident) returned at 5:30 p via stretcher. Head is wrapped in gauze and no blood seeping thru. [DATE] 9AM Pt's fall on [DATE] discussed by IDT (Interdisciplinary Department Team). Pt was being transferred to bed using a sling lift when the sling pad slipped from the lift, causing the pt to fall to the ground. Laceration sustained to head. Pt was transferred to ER and staples were placed. CT (scan) of head and spine are negative. Pt transferred back to facility following staples. Following staff interviews, it was discovered that the incorrect sling pad for the lift was used and that only one staff member was present for the transfer. Education provided for staff regarding proper lift usage. CP (care plan) in place. Review of the facility Policy and Procedure entitled, Safe Lifting and Movement of Residents:, stated The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. The facility reported an injury of unknown origin for Resident #25 to the State Agency on [DATE]. Resident #25 was noted to have a [MEDICAL CONDITION] tibia of the right leg. Review of the care plan revealed require staff assistance for ADLs and mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included sling lift for transfers. The problem onset date was noted as [DATE]. Review of Resident #25's Nurses' Notes dated [DATE] at 9:30 PM indicated resident noted to have swollen right leg with purple and blue discoloration. Resident expresses verbal complaints of pain when right leg and foot area touched or moved. This was noticed when a CNA went to to put the resident to bed. The physician was notified and ordered a stat x-ray. Review of the Radiology Report dated [DATE] revealed Resident #25 had an acute proximal tibial fracture. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated after completion of investigation believe the fracture occurred during a transfer. CNA #1's facility-obtained statement dated [DATE] indicated s/he got Resident #25 up from bed using a stand lift. An addendum indicated that during a second phone conversation with CNA #1 s/he stated s/he did not have anyone assist with the stand lift during transfer on [DATE]. CNA #1 was asked about assistance with other lift transfers, s/he said s/he did not get assistance to do transfers. The DON informed the resident that Resident #25 used a sling lift and required 2 assist. Review of the facility's Safe Lifting and Movement of Residents policy revealed guidelines that included The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. The policy had a revision date of [DATE]. The facility reported an allegation of neglect to the State Agency related to Resident #138 on [DATE]. Resident #138 was noted unresponsive at the bedside and CPR was not initiated. Resident was later noted to be a full code. Resident #138 expired at the facility on [DATE] Review of the resident's Social Services Admission note revealed the resident wanted to be a full code. Review of the resident's Consent for Cardiopulmonary Resuscitation revealed the resident signed the form on [DATE] for CPR to be done. Review of the medical record revealed a Physician's Telephone Order dated [DATE] for the resident to be a full code. Review of the resident's care plan revealed full code status was identified as a problem area. Interventions and approaches to this problem were documented on the care plan and included to honor full code status and place a green sheet in front of the chart that designates full code. Review of the Resident #138's Nurses' Notes dated ,[DATE]-[DATE] revealed the resident's O2 sats were usually between ,[DATE]%. Further review of the Nurses' Notes revealed there were no entries on [DATE]. There was only one entry on [DATE] at 12:30 PM that indicated the resident was without blood pressure, respirations, temperature or O2 sats. The resident's family and physician were notified. Review of the facility's Change in Condition policy revealed that in order to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner. Further review of the policy revealed guidelines that included when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed . Information included vital signs, current level of pain and any recent changes in pain level, onset, duration, and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect information to report to the physician. The nursing staff will contact the physician about significant change in condition. CNA #2's facility-obtained statement dated [DATE] indicated s/he clocked in at 7:00 AM. S/he checked on Resident #138's vital signs around 7:20 AM. His/her O2 sats were ,[DATE]%. CNA #2 went to inform the resident's nurse of his/her O2 sats, and the nurse acknowledged with okay. Around 9:00 AM, Resident #138 put on his/her light and stated s/he felt like s/he couldn't breath. CNA #2 told the nurse and the nurse stated s/he would give the resident a breathing treatment. Around 10:30 AM Resident #138 placed his/her light on and stated his/her heart hurt. CNA #2 told the nurse and the nurse just said (s/he's) going to have to and seemed agitated. Around 11:15 AM CNA #2 checked on the resident and s/he was asleep. Around 12:,[DATE]:20 PM, another CNA took Resident #138 his/her meal tray and told CNA #2 to go look how they left the resident. CNA #2 walked in the room and observed the resident's brief and sheets on the bed. CNA #2 began to look around and found Resident #138 on the floor. S/he told the other CNA, who checked for a respiration which wasn't visible. The CNA yelled code down the hall to the nurse. LPN #2 came and advised them to get the resident up. They got the resident up to bed. In an interview with the surveyor on [DATE] at approximately 2:00 PM, CNA #2 stated s/he usually worked with Resident #138 on the ,[DATE] shift. Resident #138 was pleasant, alert and oriented. LPN #2 was usually assigned to the resident also. The O2 sat of 82--83% was low for the resident. CNA #2 told the nurse so s/he could get oxygen if needed. CNA #2 stated the nurse did not go check on the resident. Resident #138 put on the call light and said it felt like s/he couldn't breathe. CNA #2 said s/he would let the nurse know and s/he went and told LPN #2. When the resident complained his/her heart hurt, CNA #2 told LPN #2. The nurse said (s/he's) just going to have to and didn't complete the statement. LPN #2 seemed agitated. That was the LPN's usual demeanor. There was a brief on the bed that was open when CNA #2 entered the room. The sheet was moved like the resident had just gotten out of bed and the brief was on the sheet where the resident would have been. CNA #2 found the resident on the floor on the other side of the bed near the window. Resident #138 was on his/her face. He had on his gown. Another CNA in the room noticed the resident wasn't breathing. LPN #3 told the CNAs to get the resident out of the floor because s/he was a DNR. The facility reported an injury of unknown origin to the State Agency for Resident #14 on [DATE]. The resident was noted to have an x-ray that revealed a [MEDICAL CONDITION] humerus. Review of the facility's Five-Day Follow-Up Report dated [DATE] revealed the resident complained of pain and swelling was noted to the right arm. An x-ray was ordered which revealed a [MEDICAL CONDITION] proximal humerus. Review of the Nurses' Notes dated [DATE] by the ADON (Assistant Director of Nursing) indicated Resident #14 had increased pain in his/her right arm and yelled out in pain during movement. The resident's arm seemed swollen. The resident's responsible party and physician were notified. Review of the Nurses' Notes dated [DATE] indicated the physician was called and ordered a doppler for Resident #14's right arm. Review of the Nurses' Notes dated [DATE] indicated a new order for an x-ray in the AM of the right shoulder and right arm. Resident noted with right shoulder pain and [MEDICAL CONDITION]. Further review of the Nurses' Notes dated [DATE] revealed Resident #14 had a humerus fracture. Nurses' Notes were reviewed from [DATE]-[DATE] with no documentation related to reports the resident had increased pain or swelling to the right arm. There was no documentation that the nurse practitioner or physician saw the resident. Review of Resident #14's Weekly Body Audit forms revealed only two body audits were completed for the months of October and November, on [DATE] and [DATE]. CNA #3's facility-obtained statement dated [DATE] indicated that around [DATE]th s/he reported to the nurse that Resident #14 had increased pain and swelling in his/her arm. CNA #3 asked therapy to take a look at the resident's arm. In an interview with the surveyor on [DATE] at approximately 11:50 AM, CNA #3 stated s/he is usually assigned to the resident. CNA #3 remembers the resident's arm being swollen and s/he told the nurse and also asked therapy to look at the resident's arm. CNA #3 stated therapy can tell if a resident's arm is dislocated. Therapy looked at the resident's arm and talked with the nurse about it, they didn't say anything to CNA #3 about the assessment. CNA #4's facility-obtained statement dated [DATE] indicated that about 2 weeks before s/he asked Resident #14 what happened to his/her arm. Resident #14 had a skin tear and said that black and white girl hurt my arm. It was painful to the touch. CNA #4 left a note in the ADON's box the same day. CNA #5's facility-obtained statement dated [DATE] indicated s/he saw Resident #14 on [DATE] for range of motion exercises and the resident had no swelling or complaints of pain. CNA #5 was noted to be a restorative aide. When CNA #5 saw the resident on ,[DATE] and ,[DATE] the resident complained of increased pain. No swelling was noted on those days. On [DATE] the resident had very increased pain and noticeable swelling. CNA #5 reported to the nurse and unit manager. On [DATE] the resident still had increased pain and swelling. S/he observed on [DATE] that the swelling had gotten worse and reported it to the nurse. The ADON's facility-obtained statement dated [DATE] indicated a note from CNA #4 on [DATE] indicated the resident had a skin tear to his/her right arm. The ADON went to investigate and noted the resident's right arm and hand to be swollen. The ADON asked the resident's caregivers if they had noted changes. The resident's CNA stated Resident #14 would yell in pain when they moved his/her right arm. The ADON asked the nurse practitioner if they could do an x-ray. The nurse practitioner stated s/he looked at that arm the week before and s/he didn't want to do anything with it right now. On [DATE] they received results of a Doppler that were negative and the nurse practitioner ordered an x-ray to the right shoulder and arm. On [DATE] the x-ray was positive for a [MEDICAL CONDITION] right humerus. In an interview with the surveyor on [DATE] at approximately 11:40 AM, the ADON stated when s/he saw Resident #14's arm on [DATE] that was the first time s/he had looked at it. The ADON stated s/he was not sure how long the resident's arm had been swollen. review of the resident's medical record revealed [REDACTED]. of pain and swelling or the ADON talking with the nurse practitioner on [DATE]. There was no documentation in Resident #14's medical record that the nurse practitioner saw the resident in the two weeks prior to the identification of the fracture. In an interview with the surveyor on [DATE] at approximately 1:33 PM, the Director of Nursing (DON) stated the only body audits found for the months of October and [DATE] were the ones dated [DATE] and [DATE]. The DON stated that Nurses' Notes should address any concerns noted and include the assessment and what was done. The DON confirmed there was no documentation that the nurse practitioner looked at the resident's arm. The DON confirmed there should have been documentation in the Nurses' Notes if there was something there for the nurse practitioner to look at. Resident #201 was admitted to the facility [DATE] and noted with chronic [MEDICAL CONDITION] on oxygen on the admission History and Physical. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #201 as having a Brief Interview for Mental Status score of 15. Review of the resident's care plan revealed at risk for impaired breathing pattern related to [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide with oxygen as ordered, notify physician as needed, and O2 sats as indicated. Review of the hospital Discharge Summary for Resident #201's hospitalization ,[DATE]-[DATE] revealed the resident had acute interstitial pneumonia, acute [MEDICAL CONDITION], bacterial pneumonia, acute [MEDICAL CONDITION] and acute diverticulitis. Resident #201 was also noted to have a history of pneumonia in [DATE]. Review of the Occupational Therapy Daily Treatment Note dated [DATE] revealed Resident #201 requested an x-ray due to concerns of pneumonia, with nursing staff notified of resident concerns/request. Resident O2 sats fluctuated from 79% after completing shower to 90% at rest. Review of the Physical Therapy Daily Treatment Note dated [DATE] revealed Resident #201 complained of feeling short of breath today with O2 readings in ,[DATE] with breathing treatment, notifying nursing. Review of Resident #201's Nurses' Notes revealed only one entry on [DATE] at 2:59 AM. There were no Nurses' Notes on [DATE] related to the resident's change in condition. Review of the SBAR Communication Form dated [DATE] revealed the resident was noted with SOB, wheezing and loss of appetite that started on [DATE]. Review of the Physician's Telephone Orders dated [DATE] revealed an order for [REDACTED].#201's chest x-ray was positive with left lower lobe atelectasis or focal infiltrates. In an interview with the surveyor on [DATE] at approximately 4:10 PM, the DON (Director of Nursing) stated Resident #201 was sent out to the hospital. The DON stated s/he was not sure why the resident went out, and could not tell based on looking at the SBAR and Nurses Notes. The DON stated the physician should have been notified sooner. The DON stated s/he would expect nursing to document that they were notified of the resident's change in condition by the therapy staff. When asked about the SBAR stating that the resident's change in condition started on [DATE] and the only documentation was that the physician was notified on [DATE], the DON confirmed that there should have been documentation that the physician was notified on [DATE]. On [DATE] at approximately 3:15 PM the facility Administrator and Nurse Consultant were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. Immediate Jeopardy and Substandard Quality of Care existed in the facility as of [DATE], when staff were made aware of a [MEDICAL CONDITION] of Resident #14. The licensed staff had been made aware of Resident #14's complaints of pain and swelling for several days but did not assess the resident or notify the physician timely. The facility responded to the incident by having licensed staff and certified nursing assistants complete skin assessments on all residents, document their findings and determine if there was any change in condition. This was started on [DATE] and was completed on [DATE]. The Interact Stop-n-Watch program, a communication tool, was utilized to identify and report changes in condition to the licensed nurse. All nursing staff received reeducation by the Director of Nursing on [DATE] related to reporting injuries of unknown origin immediately. Nursing Administration reviewed all 24 hour review reports for 4 weeks to ensure changes in condition continued to be identified and followup was done in the monthly QA meetings. The next incident involving Immediate Jeopardy and Substandard Quality of Care involved Resident #201 and existed in the facility as of [DATE] when the resident had respiratory difficulty and expressed this concern to the staff on [DATE]. The staff did not respond until [DATE] and the resident was sent out to the hospital for evaluation and was found to have pneumonia. At that time Nursing Administration completed an audit of 24 hour reports to assess for any change in condition of other residents. Licensed Nurses were re-educated by the Staff Development Coordinator related to identifying resident change in condition and documentation. Nursing Administration completed 24 hour report audits weekly for four weeks and monthly for 2 months. On [DATE], Resident #25 was transferred incorrectly with the assistance of only one staff member and after complaints of pain was found to have a tibial fracture. On [DATE] Resident #138 had complained of respiratory difficulty and chest pain. Later the resident was found unresponsive and was not provided CPR even though he was a full code. Documentation related to this incident was very poor. On [DATE], Resident #9 was transferred inappropriately by a staff member using the wrong sling on a lift which resulted in a laceration requiring emergency treatment. At this time the facility addressed these issues with a detailed plan of action that included: Reporting the incident as neglect to the State survey agency. Termination of the staff involved and reporting the licensed staff to the State Board of Nursing. All residents were reviewed to insure advance directive documents were in order and filed, assessments and documentation were completed and any change in condition was noted, addressed and the physician was notified. Staff received education on advance directives, assessments, documentation and reporting. The Stop and Watch Interact communication tool was also part of the education. This was mandatory for staff to work. Nursing Administration then conducted audits on nurses notes, 24 hour reports and advance directives weekly for 4 weeks. Nursing Administration also completed a questionnaire with 2 Licensed Nurses per shift weekly for 4 weeks related to assessing residents and those residents found without vital signs. The Immediate Jeopardy and Substandard Quality of Care was cited at a scope and severity of J at F157, F224, F281, F309, F323 and F514. On [DATE] the facility had removed the immediacy through review of all resident clinical records, assessment of residents as indicated, 100% audit of all residents transferred via lift, and education of all staff. The deficiencies remained and were lowered in scope and severity to an E. During the survey, based on interview of staff, record review and observation, the Jeopardy tags were corrected as of [DATE]. Audits completed were reviewed, education content and sign in sheets were reviewed and interviews with staff revealed knowledge of reporting, use of the Stop and Watch tool, appropriate transfer of residents and assessment of residents. Documentation was found in the clinical records and the incidents involving Residents #9 and #25 were addressed and reported timely and plans of correction were put in place to address the incorrect transfers.

Based on review of facility files and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Resident #14 was noted to have swelling and increased pain in his/her right arm. Review of facility files revealed the resident's physician was not notified timely related to the resident's change in condition and staff did not respond timely to intervene when notified. Resident #138 was noted to have a decline in condition on [DATE]. There was no evidence the resident's decline was assessed, the resident's physician was not notified of the resident's change in condition to allow for a change in treatment and CPR was not initiated upon discovering the resident was unresponsive. Resident #201 complained of respiratory difficulty which was not addressed immediately but the next day when he was sent out with pneumonia. Two of two residents reviewed for hospitalization and one of two residents reviewed for death. The findings included: The facility reported an injury of unknown origin to the State Agency for Resident #14 on [DATE]. The resident was noted to have an x-ray that revealed a [MEDICAL CONDITION] humerus. Review of the facility's Five-Day Follow-Up Report dated [DATE] revealed the resident complained of pain and swelling was noted to the right arm. An x-ray was ordered which revealed a [MEDICAL CONDITION] proximal humerus. Review of the Nurses' Notes dated [DATE] by the ADON (Assistant Director of Nursing) indicated Resident #14 had increased in pain in his/her right arm and yelled out in pain during movement. The resident's arm seemed swollen. The resident's responsible party and physician were notified. Review of the Nurses' Notes dated [DATE] indicated the physician was called and ordered a doppler for Resident #14's right arm. Review of the Nurses' Notes dated [DATE] indicated a new order for an x-ray in the AM of the right shoulder and right arm. Resident noted with right shoulder pain and [MEDICAL CONDITION]. Further review of the Nurses' Notes dated [DATE] revealed Resident #14 had a humerus fracture. Nurses' Notes were reviewed from [DATE]-[DATE] with no documentation related to reports the resident had increased pain or swelling to the right arm. There was no documentation that the nurse practitioner or physician saw the resident. Review of the facility's Five-Day Follow-Up Report dated [DATE] indicated after investigation Resident #14's fracture likely occurred due to [MEDICAL CONDITION]. The resident's care plan was reviewed and revised to reflect the new diagnosis. Review of Resident #14's Weekly Body Audit forms revealed only two body audits were completed for the months of October and November, on [DATE] and [DATE]. CNA #3's facility-obtained statement dated [DATE] indicated that around [DATE]th s/he reported to the nurse that Resident #14 had increased pain and swelling in his/her arm. CNA #3 asked therapy to take a look at the resident's arm. In an interview with the surveyor on [DATE] at approximately 11:50 AM, CNA #3 stated s/he is usually assigned to the resident. CNA #3 remembers the resident's arm being swollen and s/he told the nurse and also asked therapy to look at the resident's arm. CNA #3 stated therapy can tell if a resident's arm is dislocated. Therapy looked at the resident's arm and talked with the nurse about it, they didn't say anything to CNA #3 about the assessment. CNA #4's facility-obtained statement dated [DATE] indicated that about 2 weeks before s/he asked Resident #14 what happened to his/her arm. Resident #14 had a skin tear and said that black and white girl hurt my arm. It was painful to the touch. CNA #4 left a note in the ADON's box the same day. CNA #5's facility-obtained statement dated [DATE] indicated s/he saw Resident #14 on [DATE] for range of motion exercises and the resident had no swelling or complaints of pain. CNA #5 was noted to be a restorative aide. When CNA #5 saw the resident on ,[DATE] and ,[DATE] the resident complained of increased pain. No swelling was noted on those days. On [DATE] the resident had very increased pain and noticeable swelling. CNA #5 reported to the nurse and unit manager. On [DATE] the resident still had increased pain and swelling. S/he observed on [DATE] that the swelling had gotten worse and reported it to the nurse. The ADON's facility-obtained statement dated [DATE] indicated a note from CNA #4 on [DATE] indicated the resident had a skin tear to his/her right arm. The ADON went to investigate and noted the resident's right arm and hand to be swollen. The ADON asked the resident's caregivers if they had noted changes. The resident's CNA stated Resident #14 would yell in pain when they moved his/her right arm. The ADON asked the nurse practitioner if they could do an x-ray. The nurse practitioner stated s/he looked at that arm the week before and s/he didn't want to do anything with it right now. On [DATE] they received results of a Doppler that were negative and the nurse practitioner ordered an x-ray to the right shoulder and arm. On [DATE] the x-ray was positive for a [MEDICAL CONDITION] right humerus. In an interview with the surveyor on [DATE] at approximately 11:40 AM, the ADON stated when s/he saw Resident #14's arm that was the first time s/he had looked at it. The ADON stated s/he was not sure how long the resident's arm had been swollen. review of the resident's medical record revealed [REDACTED]. of pain and swelling or the ADON talking with the nurse practitioner on [DATE]. There was no documentation in Resident #14's medical record that the nurse practitioner saw the resident in the two weeks prior to the identification of the fracture. In an interview with the surveyor on [DATE] at approximately 1:33 PM, the Director of Nursing (DON) stated the only body audits found for the months of October and [DATE] were the ones dated [DATE] and [DATE]. The DON stated that Nurses' Notes should address any concerns noted and include the assessment and what was done. The DON confirmed there was no documentation that the nurse practitioner looked at the resident's arm. The DON confirmed there should have been documentation in the Nurses' Notes if there was something there for the nurse practitioner to look at. The facility reported an allegation of neglect to the State Agency related to Resident #138 on [DATE]. Resident #138 was noted unresponsive at the bedside and CPR was not initiated. Resident was later noted to be a full code. Resident #138 expired at the facility on [DATE] Review of the resident's Social Services Admission note revealed the resident wanted to be a full code. Review of the resident's Consent for Cardiopulmonary Resuscitation revealed the resident signed the form on [DATE] for CPR to be done. Review of the medical record revealed a Physician's Telephone Order dated [DATE] for the resident to be a full code. Review of the resident's care plan revealed full code status was identified as a problem area. Interventions and approaches to this problem were documented on the care plan and included to honor full code status and place a green sheet in front of the chart that designates full code. Review of the Resident #138's Nurses' Notes dated ,[DATE]-[DATE] revealed the resident's O2 sats were usually between ,[DATE]%. Further review of the Nurses' Notes revealed there were no entries on [DATE]. There was only one entry on [DATE] at 12:30 PM that indicated the resident was without blood pressure, respirations, temperature or O2 sats. The resident's family and physician were notified. Review of the resident's Medication Administration Record [REDACTED]. The order was discharged on [DATE] related to non-use. The resident did not receive the medication in June or [DATE]. Review of the facility's Change in Condition policy revealed that in order to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner. Further review of the policy revealed guidelines that included when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed . Information included vital signs, current level of pain and any recent changes in pain level, onset, duration, and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect information to report to the physician. The nursing staff will contact the physician about significant change in condition. CNA #2's facility-obtained statement dated [DATE] indicated s/he clocked in at 7:00 AM. S/he checked on Resident #138's vital signs around 7:20 AM. His/her O2 sats were ,[DATE]%. CNA #2 went to inform the resident's nurse of his/her O2 sats, and the nurse acknowledged with okay. Around 9:00 AM, Resident #138 put on his/her light and stated s/he felt like s/he couldn't breath. CNA #2 told the nurse and the nurse stated s/he would give the resident a breathing treatment. Around 10:30 AM Resident #138 placed his/her light on and stated his/her heart hurt. CNA #2 told the nurse and the nurse just said (s/he's) going to have to and seemed agitated. Around 11:15 AM CNA #2 checked on the resident and s/he was asleep. Around 12:,[DATE]:20 PM, another CNA took Resident #138 his/her meal tray and told CNA #2 to go look how they left the resident. CNA #2 walked in the room and observed the resident's brief and sheets on the bed. CNA #2 began to look around and found Resident #138 on the floor. S/he told the other CNA, who checked for a respiration which wasn't visible. The CNA yelled code down the hall to the nurse. LPN #2 came and advised them to get the resident up. They got the resident up to bed. In an interview with the surveyor on [DATE] at approximately 2:00 PM, CNA #2 stated s/he usually worked with Resident #138 on the ,[DATE] shift. Resident #138 was pleasant, alert and oriented. LPN #2 was usually assigned to the resident also. The O2 sat of 82--83% was low for the resident. CNA #2 told the nurse so s/he could get oxygen if needed. CNA #2 stated the nurse did not go check on the resident. Resident #138 put on the call light and said it felt like s/he couldn't breathe. CNA #2 said s/he would let the nurse know and s/he went and told LPN #2. When the resident complained his/her heart hurt, CNA #2 told LPN #2. The nurse said (s/he's) just going to have to and didn't complete the statement. LPN #2 seemed agitated. That was the LPN's usual demeanor. There was a brief on the bed that was open when CNA #2 entered the room. The sheet was moved like the resident had just gotten out of bed and the brief was on the sheet where the resident would have been. CNA #2 found the resident on the floor on the other side of the bed near the window. Resident #138 was on his/her face. He had on his gown. Another CNA in the room noticed the resident wasn't breathing. LPN #3 told the CNAs to get the resident out of the floor because s/he was a DNR. RN (Registered Nurse) #2' facility-obtained statement dated [DATE] indicated s/he was asked to go to Resident #138's room on [DATE]. Resident #138 did not have a pulse or respirations. LPN #2 stated (s/he) is a DNR. RN #2 returned to his/her assigned hall. LPN #1's facility-obtained statement dated [DATE] indicated s/he was asked to assist LPN #2. Upon arriving to the room s/he observed 3 CNAs getting Resident #138 up off the floor with a sheet. Resident #138 did not have a pulse nor respirations. When LPN #2 was asked about whether the resident was a full code or a DNR, LPN #2 stated that the resident was a DNR. In an interview with the surveyor on [DATE] at approximately 2:40 PM, LPN #1 stated s/he was working on the Wren Unit(100). S/he was sitting at the desk and the weekend supervisor asked them to come help with a code. When s/he got there the CNAs were getting the resident up with a sheet. S/he and another nurse checked the resident for pulse or respirations. They asked the resident's nurse what his/her code status was and LPN #2 said DNR. LPN #2 was standing back and had already checked for respirations and pulse. Resident #138 was warm to the touch and pale. LPN #1 stated you know a resident's code status by looking at the chart, on the front of the chart there is a red sheet or a green sheet. Red is a DNR and green indicates a full code. LPN #1 did not look at the front of the resident's chart to check his/her code status. LPN #1 stated the yellow MD card tells who the doctor is, the yellow card is behind the code status form in the resident's chart. The yellow form has only the doctor's name and phone number. LPN #1 was not sure why LPN #2 would have seen the yellow MD card and thought the resident was a DNR. CNA #6's facility-obtained statement indicated around 1:00 PM, Resident #138's family asked LPN #2 if s/he could please come here. LPN #2 asked the CNA if s/he could go in with him/her. The resident's daughter asked if LPN #2 knew what happened. LPN #2 stated s/he believed the resident aspirated. The other daughter stated the hospital told them that was possible. LPN #2 went on to tell the daughter that their was nothing that could have been done that the resident was a DNR. LPN #2's facility-obtained statement indicated between ,[DATE] AM s/he was informed Resident #138 was having chest pains and wanting a breathing treatment. At 9:30 AM s/he quickly moved the medication cart to the resident's room to address the issues s/he was currently having. LPN #2 checked the residents Medication Administration Record [REDACTED]. Upon entering the resident's room, the resident was lying with HOB flat peacefully. LPN #2 told the resident s/he had put his/her scheduled pain pill in the medications and that should help with his/her pain. LPN #2 waited for the resident to swallow his/her medications. The resident stated it hurts to swallow. LPN #2 had no further issues with Resident #138 between ,[DATE] AM. LPN #2 took lunch and returned to the unit at 12:05 PM. Between 12:,[DATE]:15 PM the CNA yelled for him/her to come check on Resident #138. The CNA stated (s/he) coded I think. At that point LPN #2 told the CNA to get a stethoscope and grabbed the oxiometer. LPN #2 quickly glanced at Resident #138's chart and saw only the yellow MD card and at that point s/he determined the resident was a DNR status. LPN #2 went in and assessed the resident; s/he found the resident unresponsive and with no vitals. LPN #2 went to get RN assistance. In the process of going to get an RN s/he called the DON and informed him/her of the situation. After the RN assessed the resident with no vitals, s/he instructed him to call the POA to inform them of the change in status. At 1:00 PM, LPN #2 talked with the resident's family member. At 5:00 PM, the physician called LPN #2 and asked if this was his patient. LPN #2 proceeded to check the chart and told the doctor it was his patient. LPN #2 flipped open the chart to find some of the resident's paperwork, that is when s/he came upon the resident's advance directives that his/her code status was full code. LPN #2 then called the DON to inform him/her of the findings. LPN #2's facility-obtained statement dated [DATE] indicated s/he came back from his/her lunch break around 12:00 PM. A CNA yelled for him/her to come down to check on Resident #138. LPN #2 quickly glanced to check the chart, in that few moments s/he checked s/he only saw the yellow card with the physician's information on it. LPN #2 thought at the moment of the incident the resident was a DNR. LPN #2 ran to the room to check the resident's vital signs. LPN #2 found the resident unresponsive beside the bed. LPN #2 manually checked for a pulse. Figuring the resident was a DNR s/he followed the DNR protocol. LPN #2 called the DON and told him/her on the phone that Resident #138 was a DNR. LPN #2 went to another unit to get assistance from one of the RNs. S/he proceeded to come over to assist him/her with the resident. In an interview with the surveyor on [DATE] at approximately 4:45 PM, the DON (Director of Nursing) stated the incident happened on a weekend. LPN #2 called and notified him/her that Resident #138 had passed. The DON asked LPN #2 if the resident was a full code. The DON stated s/he remembered asking the LPN twice about the resident's code status. LPN #2 stated Resident #138 was a DNR (do not resuscitate). LPN #2 called the resident's physician to notify him/her about the resident passing. The physician questioned who the resident was and didn't think it was his/her patient. The physician asked LPN #2 to go back through the chart. At 5:11 PM, LPN #2 called the DON back and told him/her the physician had requested paperwork be faxed to him/her. When LPN #2 went through Resident #138's medical record to get the information s/he realized the resident was a full code. The DON stated they have a red/green system in place for code status. The DON asked LPN #2 and s/he said when s/he opened the chart s/he didn't see a red or green form. LPN #2 saw the yellow form physician information form. The yellow form was loose in front of the code status sheet. The code sheet was a green full code sheet in a plastic sheet protector. The DON stated s/he came to the facility to look at the resident's medical record. The green full code sheet was in the sheet protector and you could see the green border behind the yellow physician information sheet. When the 2nd nurse came to the room to assess Resident #138, LPN #2 told him/her the resident was a DNR. The DON stated that the documentation on Resident #138 that day was poor. There was no documentation between ,[DATE]-,[DATE]. The DON stated that from some of the CNA statements the nurses notes did not reflect that anything went on that morning with the resident's status. LPN #2 told the DON s/he gave the resident something for pain. The DON stated that for O2 sats less than 90% you usually should call the physician and let know and see what the physician wants started. The DON stated s/he would have expected LPN #2 to call the physician that morning when the resident had low O2 sats. Resident #201 was admitted to the facility [DATE] and noted with chronic [MEDICAL CONDITION] on oxygen on the admission History and Physical. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #201 as having a Brief Interview for Mental Status score of 15. Review of the resident's care plan revealed at risk for impaired breathing pattern related to [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide with oxygen as ordered, notify physician as needed, and O2 sats as indicated. Review of the hospital Discharge Summary for Resident #201's hospitalization ,[DATE]-[DATE] revealed the resident had acute interstitial pneumonia, acute [MEDICAL CONDITION], bacterial pneumonia, acute [MEDICAL CONDITION] and acute diverticulitis. Resident #201 was also noted to have a history of pneumonia in [DATE]. Review of the physician progress notes [REDACTED]. Review of the resident's admission orders [REDACTED]. Another order indicated [MEDICATION NAME][MEDICATION NAME] 40 mg every day x 3 days with a stop date of [DATE]. Review of the Occupational Therapy Daily Treatment Note dated [DATE] revealed Resident #201 requested an x-ray due to concerns of pneumonia, with nursing staff notified of resident concerns/request. Resident O2 sats fluctuated from 79% after completing shower to 90% at rest. Review of the Physical Therapy Daily Treatment Note dated [DATE] revealed Resident #201, complained of feeling short of breath today with O2 readings in ,[DATE] with breathing treatment, notifying nursing. Review of Resident #201's Nurses' Notes revealed only one entry on [DATE] at 2:59 AM. There were no Nurses' Notes on [DATE] related to the resident's change in condition. Review of the SBAR Communication Form dated [DATE] revealed the resident was noted with SOB, wheezing and loss of appetite that started on [DATE]. Review of the Physician's Telephone Orders dated [DATE] revealed an order for [REDACTED].#201's chest x-ray was positive with left lower lobe atelectasis or focal infiltrates. In an interview with the surveyor on [DATE] at approximately 4:10 PM, the DON (Director of Nursing) stated Resident #201 was sent out to the hospital. The DON stated s/he was not sure why the resident went out, and could not tell based on looking at the SBAR and Nurses Notes. The DON stated the physician should have been notified sooner. The DON stated s/he would expect nursing to document that they were notified of the resident's change in condition by the therapy staff. When asked about the SBAR stating that the resident's change in condition started on [DATE] and the only documentation was that the physician was notified on [DATE], the DON confirmed that there should have been documentation that the physician was notified on [DATE]. Review of the Physician's Telephone Orders for Resident #201 revealed an order dated [DATE] to discontinue the resident's PICC line. Review of Resident #201's Nurses' Notes revealed an entry on [DATE] that indicated RN (Registered Nurse) discontinued the PICC line, resident tolerated procedure well with no complaints or concerns noted. PICC line 35 cm with tip intact. In an interview with the surveyor on [DATE] at approximately 3:45 PM, the DON (Director of Nursing) stated s/he knew the nurses had specific training related to PICCs by Omnicare, their pharmacy. The DON was asked if nurses are allowed to remove PICC lines at the facility, and s/he stated that they are. In an interview with the surveyor on [DATE] at approximately 4:30 PM, the facility Administrator stated they don't have a competency on PICC line removal for the nurses. The RN who removed Resident #201's PICC was educated in June by pharmacy. There is a competency list of what the nurse was checked off on. The Administrator provided the competency information, Review of the Medication Pass Worksheet. The Review of the Medication Worksheet for RN # was reviewed and revealed there was no indication the nurse was educated on PICC lines or PICC line removal. The facility was asked to provide a copy of their policy related to PICC line removal. The facility Administrator stated they did not have a policy but used the pharmacy policy. Review of the Omnicare pharmacy policy titled Midline Catheter Removal revealed to be performed by Licensed nurses according to state law and facility policy. The nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice. The nurse shall be accountable for attaining and maintaining competence with infusion therapy within her or his scope of practice. On [DATE] at approximately 3:15 PM the facility Administrator and Nurse Consultant were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. Immediate Jeopardy and Substandard Quality of Care existed in the facility as of [DATE], when staff were made aware of a [MEDICAL CONDITION] of Resident #14. The licensed staff had been made aware of Resident #14's complaints of pain and swelling for several days but did not assess the resident or notify the physician timely. The facility responded to the incident by having licensed staff and certified nursing assistants complete skin assessments on all residents, document their findings and determine if there was any change in condition. This was started on [DATE] and was completed on [DATE]. The Interact Stop-n-Watch program, a communication tool, was utilized to identify and report changes in condition to the licensed nurse. All nursing staff received reeducation by the Director of Nursing on [DATE] related to reporting injuries of unknown origin immediately. Nursing Administration reviewed all 24 hour review reports for 4 weeks to ensure changes in condition continued to be identified and followup was done in the monthly QA meetings. The next incident involving Immediate Jeopardy and Substandard Quality of Care involved Resident #201 and existed in the facility as of [DATE] when the resident had respiratory difficulty and expressed this concern to the staff on [DATE]. The staff did not respond until [DATE] and the resident was sent out to the hospital for evaluation and was found to have pneumonia. At that time Nursing Administration completed an audit of 24 hour reports to assess for any change in condition of other residents. Licensed Nurses were re-educated by the Staff Development Coordinator related to identifying resident change in condition and documentation. Nursing Administration completed 24 hour report audits weekly for four weeks and monthly for 2 months. On [DATE] Resident #138 had complained of respiratory difficulty and chest pain. Later the resident was found unresponsive and was not provided CPR even though he was a full code. Documentation related to this incident was very poor. At this time the facility addressed these issues with a detailed plan of action that included: Reporting the incident as neglect to the State survey agency. Termination of the staff involved and reporting the licensed staff to the State Board of Nursing. All residents were reviewed to insure advance directive documents were in order and filed, assessments and documentation were completed and any change in condition was noted, addressed and the physician was notified. Staff received education on advance directives, assessments, documentation and reporting. The Stop and Watch Interact communication tool was also part of the education. This was mandatory for staff to work. Nursing Administration then conducted audits on nurses notes, 24 hour reports and advance directives weekly for 4 weeks. Nursing Administration also completed a questionnaire with 2 Licensed Nurses per shift weekly for 4 weeks related to assessing residents and those residents found without vital signs. The Immediate Jeopardy and Substandard Quality of Care was cited at a scope and severity of J at F157, F224, F281, F309, F323 and F514. On [DATE] the facility had removed the immediacy through review of all resident clinical records, assessment of residents as indicated and education of all staff. The deficiencies remained and were lowered in scope and severity to an E. During the survey of [DATE], based on interview of staff, record review and observation, the Jeopardy tags of F157, F224, F281, F309, F323 and F514 were corrected as of [DATE]. Audits completed were reviewed, education content and sign in sheets were reviewed and interviews with the Director of Nursing and both licensed and certified staff revealed knowledge of reporting, use of the Stop and Watch tool and assessment of residents.

Based on record review, observation, and interviews the facility failed to provide supervision of staff to prevent inappropriate transfers which resulted in major injury for 2 of 3 residents reviewed for accidents with injury. Resident # 9 and #25 were transferred with wrong sling and/or only one assist which resulted in major injury, The findings included: The facility admitted resident #9 with [DIAGNOSES REDACTED]. Observation of the resident on 10/24/2016 at 10:49:01 AM revealed the resident was lying in bed on left side, head of bed elevated. No verbal response. Awake, will make eye contact when called by name but immediately looks away. On air mattress with wings, no side rails. O-2 at 2L a min via nasal cannula. Fall mats at bedside. High back wheelchair in room with pressure relieving cushion. Further review of the medical record revealed the resident was care planned on 7/28/16 for Fall Risk r/t (related to) dementia, weakness, hx (history of) falls, decreased mobility, medications and incontinence. Approaches included but were not limited to: winged air mattress. Provide safe clutter free environment. 7/16/16- winged air mattress to bed, Mat at bedside while in bed. 8/4/16- staff education r/t lift usage and using 2 assist. Review of the Nurse Aides's Information Sheet (not dated) revealed the resident was checked for highback wheelchair, assist transfers, lift to chair, sling lift with 2 assistance. Review of the Nurses Notes revealed on 8/4/16, Pt (patient) sent to ER (emergency room ) for head laceration. Pt returned with 8 staples to left side of head 10:00 PM- Res (resident) returned at 5:30 p via stretcher. Head is wrapped in gauze and no blood seeping thru. 8/5/16 9AM Pt's fall on 8/4/16 discussed by IDT (Interdisciplinary Department Team). Pt was being transferred to bed using a sling lift when the sling pad slipped from the lift, causing the pt to fall to the ground. Laceration sustained to head. Pt was transferred to ER and staples were placed. CT (scan) of head and spine are negative. Pt transferred back to facility following staples. Following staff interviews, it was discovered that the incorrect sling pad for the lift was used and that only one staff member was present for the transfer. Education provided for staff regarding proper lift usage. CP (care plan) in place. Review of the facility Policy and Procedure entitled, Safe Lifting and Movement of Residents:, stated The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. An inservice was held on 5/25/16 regarding use of lifts. Lifts are to be operated with TWO staff members present at all times during transfers. Transfer status sheets are on the inside of every patient's closet door and in the ADL (Activities of Daily Living) books. Check BEFORE you transfer someone. The CNA who transferred the resident on 8/4/16 was signed in as attended the inservice. On 10/26/16 the Director of Nursing (DON) was interviewed by the surveyor. The DON stated, I was called to her room. I entered the only persons in the room was the roommate and the CNA. Resident #9 was on the floor, blood on floor. CNA (Certified Nursing Assistant) said the resident had fell from the lift. She said the sling loops didn't hook. Ice applied to the resident's head. I stayed with the resident until the ambulance came. I didn't move her. They stapled her head and sent her back. I went and checked the lift pad, no tears. The lift training person checked the sling. S/he stated the pad (sling) should not have been used with that lift. The lift was a sling lift but the pad was not for the lift used. The lifts have different manufacturers. A couple of days later s/he (Resident #9) started having shortness of breath. We sent her/him back to the hospital and s/he was found to have a fractured clavicle, fractured ribs and a punctured lung. They should have found that when s/he went after the fall. The facility reported an injury of unknown origin for Resident #25 to the State Agency on 5/21/16. Resident #25 was noted to have a fracture of the proximal tibia of the right leg. Review of the care plan revealed require staff assistance for ADLs and mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included sling lift for transfers. The problem onset date was noted as 7/5/13. Review of Resident #25's Nurses' Notes dated 5/20/16 at 9:30 PM indicated resident noted to have swollen right leg with purple and blue discoloration. Resident expresses verbal complaints of pain when right leg and foot area touched or moved. This was noticed when a CNA went to to put the resident to bed. The physician was notified and ordered a stat x-ray. Review of the Radiology Report dated 5/20/16 revealed Resident #25 had a acute proximal tibial fracture. Review of the facility's Five-Day Follow-Up Report dated 5/24/16 indicated after completion of investigation believe the fracture occurred during a transfer. CNA #1's facility-obtained statement dated 5/23/16 indicated s/he got Resident #25 up from bed using a stand lift. An addendum indicated that during a second phone conversation with CNA #1 s/he stated s/he did not have anyone assist with the stand lift during transfer on 5/20/16. CNA #1 was asked about assistance with other lift transfers, s/he said s/he did not get assistance to do transfers. The DON informed the resident that Resident #25 used a sling lift and required 2 assist. In an interview with the surveyor on 10/26/16 at approximately 1:20 PM, the DON (Director of Nursing) stated 2 CNAs were putting Resident #25 to bed on 2nd shift. As they were moving the resident, s/he yelled in pain. The CNAs got the nurse and the nurse noted discoloration on assessment. During the investigation, CNA #1 was found to have used improper transfer technique. CNA #1 transferred Resident #25 with a stand lift by herself. Resident #25 required a sling lift with 2 person assist for transfers. The DON stated Resident #25 was inconsistent with being able to hold on to a stand lift which is why s/he required a sling lift. The DON stated all mechanical lifts require 2 people. The DON stated she does not recall the resident having any falls around the time frame the fracture was found. The DON stated transfer status is on the care card inside the resident's closet door. The DON stated s/he checked after the incident and noted Resident #25's care card was in place. Review of the facility's Safe Lifting and Movement of Residents policy revealed guidelines that included The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. The policy had a revision date of 10/3/13. On 10/25/16 at approximately 3:15 PM the facility Administrator and Nurse Consultant were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. Immediate Jeopardy and Substandard Quality of Care existed in the facility. The Immediate Jeopardy and Substandard Quality of Care was cited at a scope and severity of J at F157, F224, F281, F309, F323 and F514. On 8/5/2016 the facility had removed the immediacy through review of all resident clinical records, assessment of residents as indicated, 100% audit of all residents transferred via lift, and education of all staff. The deficiencies remained and were lowered in scope and severity to an E. During the survey, based on interview of staff, record review and observation, the Jeopardy tags were corrected as of 8/28/16. Audits completed were reviewed, education content and sign in sheets were reviewed and interviews with staff revealed knowledge of reporting, use of the Stop and Watch tool, appropriate transfer of residents and assessment of residents. Documentation was found in the clinical records and the incidents involving Residents #9 and #25 were addressed and reported timely and plans of correction were put in place to address the incorrect transfers.

Based on clinical record review the facility failed to maintain records that were complete and accurately documented. Two of two records reviewed for incidents requiring hospital evaluation and one of one record of a resident that expired in the facility. Resident #14 found to have a [MEDICAL CONDITION], Resident #201 with complaints of respiratory difficulty and Resident #138 with complaints of respiratory difficulty and chest pain found unresponsive and was not given CPR per the advance directive. The findings included: The facility reported an injury of unknown origin to the State Agency for Resident #14 on [DATE]. The resident was noted to have an x-ray that revealed a [MEDICAL CONDITION] humerus. Review of the facility's Five-Day Follow-Up Report dated [DATE] revealed the resident complained of pain and swelling was noted to the right arm. An x-ray was ordered which revealed a [MEDICAL CONDITION] proximal humerus. Review of the Nurses' Notes dated [DATE] by the ADON (Assistant Director of Nursing) indicated Resident #14 had increased in pain in his/her right arm and yelled out in pain during movement. The resident's arm seemed swollen. The resident's responsible party and physician were notified. Review of the Nurses' Notes dated [DATE] indicated the physician was called and ordered a doppler for Resident #14's right arm. Review of the Nurses' Notes dated [DATE] indicated a new order for an x-ray in the AM of the right shoulder and right arm. Resident noted with right shoulder pain and [MEDICAL CONDITION]. Further review of the Nurses' Notes dated [DATE] revealed Resident #14 had a humerus fracture. Nurses' Notes were reviewed from [DATE]-[DATE] with no documentation related to reports the resident had increased pain or swelling to the right arm. There was no documentation that the nurse practitioner or physician saw the resident. Review of Resident #14's Weekly Body Audit forms revealed only two body audits were completed for the months of October and November, on [DATE] and [DATE]. CNA #3's facility-obtained statement dated [DATE] indicated that around [DATE]th s/he reported to the nurse that Resident #14 had increased pain and swelling in his/her arm. CNA #3 asked therapy to take a look at the resident's arm. In an interview with the surveyor on [DATE] at approximately 11:50 AM, CNA #3 stated s/he is usually assigned to the resident. CNA #3 remembers the resident's arm being swollen and s/he told the nurse and also asked therapy to look at the resident's arm. CNA #3 stated therapy can tell if a resident's arm is dislocated. Therapy looked at the resident's arm and talked with the nurse about it, they didn't say anything to CNA #3 about the assessment. CNA #4's facility-obtained statement dated [DATE] indicated that about 2 weeks before s/he asked Resident #14 what happened to his/her arm. Resident #14 had a skin tear and said that black and white girl hurt my arm. It was painful to the touch. CNA #4 left a note in the ADON's box the same day. CNA #5's facility-obtained statement dated [DATE] indicated s/he saw Resident #14 on [DATE] for range of motion exercises and the resident had no swelling or complaints of pain. CNA #5 was noted to be a restorative aide. When CNA #5 saw the resident on ,[DATE] and ,[DATE] the resident complained of increased pain. No swelling was noted on those days. On [DATE] the resident had very increased pain and noticeable swelling. CNA #5 reported to the nurse and unit manager. On [DATE] the resident still had increased pain and swelling. S/he observed on [DATE] that the swelling had gotten worse and reported it to the nurse. The ADON's facility-obtained statement dated [DATE] indicated a note from CNA #4 on [DATE] indicated the resident had a skin tear to his/her right arm. The ADON went to investigate and noted the resident's right arm and hand to be swollen. The ADON asked the resident's caregivers if they had noted changes. The resident's CNA stated Resident #14 would yell in pain when they moved his/her right arm. The ADON asked the nurse practitioner if they could do an x-ray. The nurse practitioner stated s/he looked at that arm the week before and s/he didn't want to do anything with it right now. On [DATE] they received results of a Doppler that were negative and the nurse practitioner ordered an x-ray to the right shoulder and arm. On [DATE] the x-ray was positive for a [MEDICAL CONDITION] right humerus. review of the resident's medical record revealed [REDACTED]. of pain and swelling or the ADON talking with the nurse practitioner on [DATE]. There was no documentation in Resident #14's medical record that the nurse practitioner saw the resident in the two weeks prior to the identification of the fracture. In an interview with the surveyor on [DATE] at approximately 1:33 PM, the Director of Nursing (DON) stated the only body audits found for the months of October and [DATE] were the ones dated [DATE] and [DATE]. The DON stated that Nurses' Notes should address any concerns noted and include the assessment and what was done. The DON confirmed there was no documentation that the nurse practitioner looked at the resident's arm. The DON confirmed there should have been documentation in the Nurses' Notes if there was something there for the nurse practitioner to look at. The facility reported an allegation of neglect to the State Agency related to Resident #138 on [DATE]. Resident #138 was noted unresponsive at the bedside and CPR was not initiated. Resident was later noted to be a full code. Resident #138 expired at the facility on [DATE] Review of the resident's Social Services Admission note revealed the resident wanted to be a full code. Review of the resident's Consent for Cardiopulmonary Resuscitation revealed the resident signed the form on [DATE] for CPR to be done. Review of the medical record revealed a Physician's Telephone Order dated [DATE] for the resident to be a full code. Review of the resident's care plan revealed full code status was identified as a problem area. Interventions and approaches to this problem were documented on the care plan and included to honor full code status and place a green sheet in front of the chart that designates full code. Review of the Resident #138's Nurses' Notes dated ,[DATE]-[DATE] revealed the resident's O2 sats were usually between ,[DATE]%. Further review of the Nurses' Notes revealed there were no entries on [DATE]. There was only one entry on [DATE] at 12:30 PM that indicated the resident was without blood pressure, respirations, temperature or O2 sats. The resident's family and physician were notified. Review of the facility's Change in Condition policy revealed that in order to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner. Further review of the policy revealed guidelines that included when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed . Information included vital signs, current level of pain and any recent changes in pain level, onset, duration, and severity. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect information to report to the physician. The nursing staff will contact the physician about significant change in condition. CNA #2's facility-obtained statement dated [DATE] indicated s/he clocked in at 7:00 AM. S/he checked on Resident #138's vital signs around 7:20 AM. His/her O2 sats were ,[DATE]%. CNA #2 went to inform the resident's nurse of his/her O2 sats, and the nurse acknowledged with okay. Around 9:00 AM, Resident #138 put on his/her light and stated s/he felt like s/he couldn't breath. CNA #2 told the nurse and the nurse stated s/he would give the resident a breathing treatment. Around 10:30 AM Resident #138 placed his/her light on and stated his/her heart hurt. CNA #2 told the nurse and the nurse just said (s/he's) going to have to and seemed agitated. Around 11:15 AM CNA #2 checked on the resident and s/he was asleep. Around 12:,[DATE]:20 PM, another CNA took Resident #138 his/her meal tray and told CNA #2 to go look how they left the resident. CNA #2 walked in the room and observed the resident's brief and sheets on the bed. CNA #2 began to look around and found Resident #138 on the floor. S/he told the other CNA, who checked for a respiration which wasn't visible. The CNA yelled code down the hall to the nurse. LPN #2 came and advised them to get the resident up. They got the resident up to bed. In an interview with the surveyor on [DATE] at approximately 2:00 PM, CNA #2 stated s/he usually worked with Resident #138 on the ,[DATE] shift. Resident #138 was pleasant, alert and oriented. LPN #2 was usually assigned to the resident also. The O2 sat of 82--83% was low for the resident. CNA #2 told the nurse so s/he could get oxygen if needed. CNA #2 stated the nurse did not go check on the resident. Resident #138 put on the call light and said it felt like s/he couldn't breathe. CNA #2 said s/he would let the nurse know and s/he went and told LPN #2. When the resident complained his/her heart hurt, CNA #2 told LPN #2. The nurse said (s/he's) just going to have to and didn't complete the statement. LPN #2 seemed agitated. That was the LPN's usual demeanor. There was a brief on the bed that was open when CNA #2 entered the room. The sheet was moved like the resident had just gotten out of bed and the brief was on the sheet where the resident would have been. CNA #2 found the resident on the floor on the other side of the bed near the window. Resident #138 was on his/her face. He had on his gown. Another CNA in the room noticed the resident wasn't breathing. LPN #3 told the CNAs to get the resident out of the floor because s/he was a DNR. In an interview with the surveyor on [DATE] at approximately 4:45 PM, the DON (Director of Nursing) stated the incident happened on a weekend. The DON stated that the documentation on Resident #138 that day was poor. There was no documentation between ,[DATE]-,[DATE]. The DON stated that from some of the CNA statements the nurses notes did not reflect that anything went on that morning with the resident's status. LPN #2 told the DON s/he gave the resident something for pain. The DON stated that for O2 sats less than 90% you usually should call the physician and let know and see what the physician wants started. The DON stated s/he would have expected LPN #2 to call the physician that morning when the resident had low O2 sats. Resident #201 was admitted to the facility [DATE] and noted with chronic [MEDICAL CONDITION] on oxygen on the admission History and Physical. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #201 as having a Brief Interview for Mental Status score of 15. Review of the resident's care plan revealed at risk for impaired breathing pattern related to [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide with oxygen as ordered, notify physician as needed, and O2 sats as indicated. Review of the hospital Discharge Summary for Resident #201's hospitalization ,[DATE]-[DATE] revealed the resident had acute interstitial pneumonia, acute [MEDICAL CONDITION], bacterial pneumonia, acute [MEDICAL CONDITION] and acute diverticulitis. Resident #201 was also noted to have a history of pneumonia in [DATE]. Review of the physician progress notes [REDACTED]. Review of the resident's admission orders [REDACTED]. Another order indicated [MEDICATION NAME][MEDICATION NAME] 40 mg every day x 3 days with a stop date of [DATE]. Review of the Occupational Therapy Daily Treatment Note dated [DATE] revealed Resident #201 requested an x-ray due to concerns of pneumonia, with nursing staff notified of resident concerns/request. Resident O2 sats fluctuated from 79% after completing shower to 90% at rest. Review of the Physical Therapy Daily Treatment Note dated [DATE] revealed Resident #201, complained of feeling short of breath today with O2 readings in ,[DATE] with breathing treatment, notifying nursing. Review of Resident #201's Nurses' Notes revealed only one entry on [DATE] at 2:59 AM. There were no Nurses' Notes on [DATE] related to the resident's change in condition. Review of the SBAR Communication Form dated [DATE] revealed the resident was noted with SOB, wheezing and loss of appetite that started on [DATE]. Review of the Physician's Telephone Orders dated [DATE] revealed an order for [REDACTED].#201's chest x-ray was positive with left lower lobe atelectasis or focal infiltrates. In an interview with the surveyor on [DATE] at approximately 4:10 PM, the DON (Director of Nursing) stated Resident #201 was sent out to the hospital. The DON stated s/he was not sure why the resident went out, and could not tell based on looking at the SBAR and Nurses Notes. The DON stated the physician should have been notified sooner. The DON stated s/he would expect nursing to document that they were notified of the resident's change in condition by the therapy staff. When asked about the SBAR stating that the resident's change in condition started on [DATE] and the only documentation was that the physician was notified on [DATE], the DON confirmed that there should have been documentation that the physician was notified on [DATE]. On [DATE] at approximately 3:15 PM the facility Administrator and Nurse Consultant were notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. Immediate Jeopardy and Substandard Quality of Care existed in the facility as of [DATE], when staff were made aware of a [MEDICAL CONDITION] of Resident #14. The licensed staff had been made aware of Resident #14's complaints of pain and swelling for several days but did not assess the resident or notify the physician timely. The facility responded to the incident by having licensed staff and certified nursing assistants complete skin assessments on all residents, document their findings and determine if there was any change in condition. This was started on [DATE] and was completed on [DATE]. The Interact Stop-n-Watch program, a communication tool, was utilized to identify and report changes in condition to the licensed nurse. All nursing staff received reeducation by the Director of Nursing on [DATE] related to reporting injuries of unknown origin immediately. Nursing Administration reviewed all 24 hour review reports for 4 weeks to ensure changes in condition continued to be identified and followup was done in the monthly QA meetings. The next incident involving Immediate Jeopardy and Substandard Quality of Care involved Resident #201 and existed in the facility as of [DATE] when the resident had respiratory difficulty and expressed this concern to the staff on [DATE]. The staff did not respond until [DATE] and the resident was sent out to the hospital for evaluation and was found to have pneumonia. At that time Nursing Administration completed an audit of 24 hour reports to assess for any change in condition of other residents. Licensed Nurses were re-educated by the Staff Development Coordinator related to identifying resident change in condition and documentation. Nursing Administration completed 24 hour report audits weekly for four weeks and monthly for 2 months. On [DATE] Resident #138 had complained of respiratory difficulty and chest pain. Later the resident was found unresponsive and was not provided CPR even though he was a full code. Documentation related to this incident was very poor. At this time the facility addressed these issues with a detailed plan of action that included: Reporting the incident as neglect to the State survey agency. Termination of the staff involved and reporting the licensed staff to the State Board of Nursing. All residents were reviewed to insure advance directive documents were in order and filed, assessments and documentation were completed and any change in condition was noted, addressed and the physician was notified. Staff received education on advance directives, assessments, documentation and reporting. The Stop and Watch Interact communication tool was also part of the education. This was mandatory for staff to work. A new Administrator started on [DATE]. Nursing Administration then conducted audits on nurses notes, 24 hour reports and advance directives weekly for 4 weeks. Nursing Administration also completed a questionnaire with 2 Licensed Nurses per shift weekly for 4 weeks related to assessing residents and those residents found without vital signs. The Immediate Jeopardy and Substandard Quality of Care was cited at a scope and severity of J at F157, F224, F281, F309, F323 and F514. On [DATE] the facility had removed the immediacy through review of all resident clinical records, assessment of residents as indicated and education of all staff. The deficiencies remained and were lowered in scope and severity to an E. During the survey of [DATE], based on interview of staff, record review and observation, the Jeopardy tags of F157, F224, F281, F309, F323 and F514 were corrected as of [DATE]. Audits completed were reviewed, education content and sign in sheets were reviewed and interviews with the Director of Nursing and both licensed and certified staff revealed knowledge of reporting, use of the Stop and Watch tool and assessment of residents.

Based on record review, observation, and interviews the facility failed to follow the care plan that resulted in injury for 2 of 3 residents reviewed for accidents with injury. Resident # 9 was transferred with wrong sling and only one assist which resulted in major injury and Resident #25 was transferred with only one assist which resulted in a fracture. The findings included: The facility admitted resident #9 with [DIAGNOSES REDACTED]. Observation of the resident on 10/24/2016 at 10:49 AM revealed the resident was lying in bed on left side, Head of bed elevated. No verbal response. Awake, will make eye contact when called by name but immediately looks away. On air mattress with wings, no side rails. O-2 at 2L a min via nasal cannula. Fall mats at bedside. Suction machine in room, clean High back wheelchair in room with pressure relieving cushion. Further review of the medical record revealed the resident was care planned on 7/28/16 for Fall Risk r/t (related to) dementia, weakness, hx (history of) falls, decreased mobility, medications and incontinence. Approaches included but were not limited to: winged air mattress. Provide safe clutter free environment. 7/16/16- winged air mattress to bed, Mat at bedside while in bed. 8/4/16- staff education r/t lift usage and using 2 assist. Review of the Nurse Aides's Information Sheet (not dated) revealed the resident was checked for highback wheelchair, assist transfers, lift to chair, sling lift with 2 assistance. Review of the Nurses Notes revealed on 8/4/16, Pt (patient) sent to ER (emergency room ) for [MEDICAL CONDITION]. Pt returned with 8 staples to left side of head 10:00 PM- Res (resident) returned at 5:30pm via stretcher. Head is wrapped in gauze and no blood seeping thru. 8/5/16 9AM Pt's fall on 8/4/16 discussed by IDT (Interdisciplinary Department Team). Pt was being transferred to bed using a sling lift when the sling pad slipped from the lift, causing the pt to fall to the ground. Laceration sustained to head. Pt was transferred to ER and staples were placed. CT (scan) of head and spine are negative. Pt transferred back to facility following staples. Following staff interviews, it was discovered that the incorrect sling pad for the lift was used and that only one staff member was present for the transfer. Education provided for staff regarding proper lift usage. CP (care plan) in place. On 10/26/16 the Director of Nursing (DON) was interviewed by the surveyor. The DON stated, I was called to her room. I entered, the only persons in the room was the roommate and the CNA. Resident #9 was on the floor, blood on floor. CNA (Certified Nursing Assistant) said the resident had fell from the lift. She said the sling loops didn't hook. Ice applied to the resident's head. I stayed with the resident until the ambulance came. I didn't move her. They stapled her head and sent her back. I went and checked the lift pad, no tears. The lift training person checked the sling. S/he stated the pad (sling) should not have been used with that lift. The lift was a sling lift but the pad was not for the lift used. The lifts have different manufacturers. A couple of days later s/he (Resident #9) started having shortness of breath. We sent her/him back to the hospital and s/he was found to have a fractured clavicle, fractured ribs and a punctured lung. They should have found that when s/he went after the fall. The facility reported an injury of unknown origin for Resident #25 to the State Agency on 5/21/16. Resident #25 was noted to have a [MEDICAL CONDITION] tibia of the right leg. Review of the care plan revealed require staff assistance for ADLs and mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included sling lift for transfers. The problem onset date was noted as 7/5/13. Review of Resident #25's Nurses' Notes dated 5/20/16 at 9:30 PM indicated resident noted to have swollen right leg with purple and blue discoloration. Resident expresses verbal complaints of pain when right leg and foot area touched or moved. This was noticed when a CNA went to to put the resident to bed. The physician was notified and ordered a stat x-ray. Review of the Radiology Report dated 5/20/16 revealed Resident #25 had a acute proximal tibial fracture. Review of the facility's Five-Day Follow-Up Report dated 5/24/16 indicated after completion of investigation believe the fracture occurred during a transfer. CNA #1's facility-obtained statement dated 5/23/16 indicated s/he got Resident #25 up from bed using a stand lift. An addendum indicated that during a second phone conversation with CNA #1 s/he stated s/he did not have anyone assist with the stand lift during transfer on 5/20/16. CNA #1 was asked about assistance with other lift transfers, s/he said s/he did not get assistance to do transfers. The DON informed the resident that Resident #25 used a sling lift and required 2 assist. In an interview with the surveyor on 10/26/16 at approximately 1:20 PM, the DON (Director of Nursing) stated 2 CNAs were putting Resident #25 to bed on 2nd shift. As they were moving the resident, s/he yelled in pain. The CNAs got the nurse and the nurse noted discoloration on assessment. During the investigation, CNA #1 was found to have used improper transfer technique. CNA #1 transferred Resident #25 with a stand lift by herself. Resident #25 required a sling lift with 2 person assist for transfers. The DON stated Resident #25 was inconsistent with being able to hold on to a stand lift which is why s/he required a sling lift. The DON stated all mechanical lifts require 2 people. The DON stated she does not recall the resident having any falls around the time frame the fracture was found. The DON stated transfer status is on the care card inside the resident's closet door. The DON stated s/he checked after the incident and noted Resident #25's care card was in place. Review of the facility's Safe Lifting and Movement of Residents policy revealed guidelines that included The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. The policy had a revision date of 10/3/13.