Every finding on record at Pine Crest Guest Home Inc

Based on observation, interview, and record review, the facility failed to protect a resident from accidents hazards when the facility failed to obtain immediate medical assistance when a resident sustained a fall from a wheelchair in the facility van and was not assessed by licensed personnel for approximately 42 miles while being transported back to the facility while lying on the floor for one (1) of four (4) sampled residents. (Resident #1). The facility's failure to ensure Resident #1 was properly secured and transported safely, under trained supervision, resulted in her fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately 42 miles and arrived back at the facility at 2:40 PM. This failure and a lack of immediate assessment by licensed personnel placed the resident in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when Resident #1 sustained a fall from a wheelchair in the facility van and was not assessed by licensed staff for approximately thirty (30) minutes during transport. The State Agency (SA) notified the Administrator of the IJ on [DATE] at 04:20 PM and provided an IJ Template. The SA validated the Removal Plan on [DATE], and determined that the IJ was removed on [DATE], prior to SA exit. Therefore, the scope and severity for CFR 483.25(d)(1)(2) Accidents/Hazards - F689 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Transportation Assistant Document, dated Copyright 2024, revealed, Position Purpose; Provides transport assistive services to assigned residents in accordance with care plans, facility policies and procedures and at the direction of supervisor(s); Required Qualifications . Certified Nursing Assistant in good standing with the state . Current CPR/BLS (Cardiopulmonary Resuscitation/Basic Life Support) certifications. A review of the facility's policy, Transporting a Resident (Facility Van), dated Copyright 2025, revealed, .It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments . 3.Facility will ensure that residents who require an escort to appointments due to cognitive or physical limitations have arrangements made ahead of time .6. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie downs . Record review of the incident report dated [DATE] revealed Resident arrived at facility in facility van accompanied by facility employee. Resident positioned on buttocks, resting on bilateral footrests. Resident WC (wheelchair) foot pedals resting on van floor. WC secured with four floor harnesses. Tilted forward slightly. Lap seat belt buckled but not tightened across resident abdominal area. Pressure cushion tilted forward slightly and down towards floors at front edge of WC seat, resting against mid-thoracic region of back. Resident's left foot extended straight beneath back bench seat, sock intact. Right lower extremity extended forward slightly with knee flexed and right foot resting in front of pelvic region. Sock is intact to right foot. Does not recall how she came to be seated on bilateral WC footrests on van floor. During an interview on [DATE] at 3:49 PM, the Resident Representative (RR) for Resident #1, she explained that the Director of Nursing Services (DNS) informed them that Resident #1 had fallen out of her wheelchair in the van during transport and was returned to the facility unsecured on the floor. They stated that the Administrator should have contacted emergency services and not transported the resident alone. They confirmed Resident #1 was admitted to a medical center on [DATE] due to Congestive Heart Failure, Urinary Tract Infection, and Septicemia. During an interview on [DATE] at 4:15 PM, with the Administrator, he explained he transported Resident #1 alone to an appointment approximately thirty-five (35) miles away. He stated the resident began scooting forward, fell to the floor of the van, and did not verbally respond after the fall. He confirmed he did not seek emergency assistance and drove back to the facility with the resident lying on the floor between the back of a van seat and the wheelchair. During an interview on [DATE] at 11:15 AM, with the DNS, she explained she was unaware that the Administrator transported Resident #1 alone and did not call emergency services after the fall. They described the resident's position as lodged between the wheelchair and van seat, with her legs extended and the seatbelt loose. Emergency services were contacted at 2:43 PM and arrived at 2:50 PM. The DNS confirmed the Administrator had not contacted them during the return transport. During an observation on [DATE] at 3:00 PM, the Administrator demonstrated the resident's position on the van floor, confirming the resident was lodged between the wheelchair and a van seat with her legs extended and unrestrained. A record review of Resident #1's admission Record revealed an admission date of [DATE] with diagnoses including Major Depressive Disorder, Dementia, Lung Cancer, Panic Disorder, and Difficulty Walking. A record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition. The MDS identified Resident #1 as non-ambulatory and dependent on a wheelchair for mobility. The facility implemented the following plan to remove the Immediate Jeopardy: Incident on [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06pm with no assistance from nurse or certified nursing assistant(CNA). At 1:49pm on [DATE] the Administrator called LPN#1 to inform her that Resident#1 had slipped from wheelchair, but he stated she was not injured and was on the way back to the facility with the resident. Director of Nursing(DON) was notified by LPN#1 that the Administrator was on the way back to the facility with the resident in the transportation van. At 2:40pm on [DATE], the Administrator arrived and DON, Assistant Director of Nursing(ADON), Quality Assurance(Q/A) nurse and LPN#1 went out to the van to assess the resident. Resident #1 was on the floor of the van with the wheelchair at her back. DON and ADON assessed Resident#1 without moving resident with no apparent injuries noted. Resident#1 rated pain 0 using a 0-10 pain scale. Ambulance service was notified at 2:43pm by the Charge Nurse. The van doors were shut and air turned up with DON and ADON at her side to ensure she was safe until the ambulance arrived. At approximately 2:50pm two ambulances arrived along with the fire department. Using three(3) person total assistance, the wheelchair was unlocked from its 4-point harness. Leg rests were moved outward and folded from the sides of the wheelchair. Wheelchair was gently moved backwards from the Resident#1. Resident#1 verbally stated she was okay. Emergency Medical Services(EMS) personnel transferred Resident#1 onto a sheet from the floor of the van with 4-person total manual lift. Resident#1 was brought to the local hospital and was evaluated by the emergency department provider. Resident#1 arrived back at the facility at 6:46pm by ambulance with no further orders at the time. Upon resident's arrival it was noted x-rays were not obtained at the emergency department. Medical Doctor(MD) was notified and x-rays were ordered for 23 views. Portable x-ray performed the x-rays. Report was sent over stat and no injuries were noted on x rays. On [DATE] Nursing and transportation staff were educated immediately requirements of having a CNA or nurse who is Cardiac Pulmonary Resuscitation(CPR) certified to provide non-emergency transport of residents and having two staff members who meet the requirements to transport residents. Education is ongoing with all nursing and transportation staff and will not work till completed. On [DATE] QA nurse met with the therapy director to put in place for all residents to be screened for appropriate mobility devices for transport. Emergency Q/A and safety meeting was held on [DATE] at 9:30am and [DATE] at 6pm and included the following persons: *Nursing Home Administrator *Medical Director *Director of Nursing (DON) * Assistant DON *QA/Infection Preventionist *Social Services *MOS Nurse *Medical Records Nurse *Staff Development Nurse *Treatment Nurse *Charge Nurse Topics addressed: *IJ Finding- F689 *Root cause analysis *Corrective action plan *Staff Education *Systemic Changes *Monitoring Plan The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy was reviewed. No revisions were required. On [DATE] 1 on 1 in-services on Abuse, Neglect, and Misappropriation, as well as, Requirements and Safety of Non-emergent Transportation were done with the Administrator by DON and ADON. A directive in-service was started on Saturday [DATE] by the [NAME] President of Clinical Operations on Resident safety during transport and Fall Response for all Nursing Staff. On [DATE] Staff who are allowed to transport residents were verified by checking to make sure they are on the company's insurance policy and CPR certified by the DON. The Q/A Nurse reviewed/monitored Resident#1's most recent MOS and most recent therapy screen for appropriate transportation on [DATE]. CONCLUSION: Based on the immediate corrective actions taken, staff education completed, systemic practice changes, and monitoring processes established, Pinecrest Guest Home alleges that the Immediate Jeopardy was abated as of [DATE]. Validation: The SA validated on [DATE] through interview and record review that all actions to remove the immediacy were completed on [DATE] and the IJ was removed on [DATE] prior to the SA exit.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when the facility failed to obtain immediate medical assistance for Resident #1 who sustained a fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van and was not assessed by licensed personal for approximately thirty (30) minutes during transport for one (1) of four (4) sampled residents (Resident #1). On [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06 PM without assistance from a nurse or Certified Nursing Assistant (CNA). At 1:49 PM on [DATE] the Administrator called Licensed Practical Nurse (LPN)#1 to inform her that Resident#1 had slipped from the wheelchair, but he stated she was not injured and was on the way back to the facility with the resident. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately 42 miles and arrived back at the facility at 2:40 PM. The facility's failure to ensure Resident #1 was properly secured and transported safely, under trained supervision, resulted in her fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately thirty minutes. This failure and a lack of immediate assessment by licensed personnel placed the resident in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when Resident #1 sustained a fall from a wheelchair in the facility van and was not assessed by licensed personal for approximately thirty (30) minutes during transport. The State Agency (SA) notified the Administrator of the IJ on [DATE] at 04:20 PM and provided an IJ Template. The SA validated the Removal Plan on [DATE], and determined that the IJ was removed on [DATE], prior to SA exit. Therefore, the scope and severity for CFR §483.12 Freedom from Abuse, Neglect, and Exploitation - F600 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Transportation Assistant Document, dated Copyright 2024, revealed, Position Purpose; Provides transport assistive services to assigned residents in accordance with care plans, facility policies and procedures and at the direction of supervisor(s); Required Qualifications . Certified Nursing Assistant in good standing with the state . Current CPR/BLS (Cardiopulmonary Resuscitation/Basic Life Support) certifications. A review of the facility's policy, Transporting a Resident (Facility Van), dated Copyright 2025, revealed, .It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments . 3.Facility will ensure that residents who require an escort to appointments due to cognitive or physical limitations have arrangements made ahead of time .6.Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie downs . Record review of the incident report dated [DATE] revealed Resident arrived at facility in facility van accompanied by facility employee. Resident positioned on buttocks, resting on bilateral footrests. Resident WC (wheelchair) foot pedals resting on van floor. WC secured with four floor harnesses. Tilted forward slightly. Lap seat belt buckled but not tightened across resident abdominal area. Pressure cushion tilted forward slightly and down towards floors at front edge of WC seat, resting against mid-thoracic region of back. Resident's left foot extended straight beneath back bench seat, sock intact. Right lower extremity extended forward slightly with knee flexed and right foot resting in front of pelvic region. Sock is intact to right foot. Does not recall how she came to be seated on bilateral WC footrests on van floor. On [DATE] at 3:49 PM, during an interview with the Resident Representative (RR) for Resident #1, she explained that the Director of Nursing Services (DNS) informed them that Resident #1 had fallen out of her wheelchair in the van during transport and was returned to the facility unsecured on the floor. She stated that the Administrator should have contacted emergency services and not transported the resident alone. She confirmed Resident #1 was admitted to a medical center on [DATE] due to Congestive Heart Failure, Urinary Tract Infection, and Septicemia. On [DATE] at 4:15 PM, during an interview with the Administrator, he explained he transported Resident #1 alone to an appointment approximately thirty-five (35) miles away. He stated the resident began scooting forward, fell to the floor of the van, and did not verbally respond after the fall. He confirmed he did not seek emergency assistance and drove back to the facility with the resident lying on the floor between the back of a van seat and the wheelchair. On [DATE] at 11:15 AM, during an interview with the Director of Nursing Services (DNS), she explained she was unaware that the Administrator transported Resident #1 alone and did not call emergency services after the fall. She described the resident's position as lodged between the wheelchair and van seat, with her legs extended and the seatbelt loose. Emergency services were contacted at 2:43 PM and arrived at 2:50 PM. The DNS confirmed the Administrator had not contacted them during the return transport. On [DATE] at 3:00 PM, during an observation, the Administrator demonstrated the resident's position on the van floor, confirming the resident was lodged between the wheelchair and a van seat with her legs extended and unrestrained. A record review of Resident #1's admission Record revealed an admission date of [DATE] with diagnoses including Major Depressive Disorder, Dementia, Lung Cancer, Panic Disorder, and Difficulty Walking. A record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition. The MDS identified Resident #1 as non-ambulatory and dependent on a wheelchair for mobility. The facility implemented the following plan to remove the Immediate Jeopardy: Incident on [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06pm with no assistance from nurse or certified nursing assistant(CNA). At 1:49 pm on [DATE] the Administrator called Licensed Practical Nurse (LPN)#1 to inform her that Resident#1 had slipped from wheelchair, but he stated she was not injured and was on the way back to the facility with the resident. Director of Nursing(DON) was notified by LPN#1 that the Administrator was on the way back to the facility with the resident in the transportation van. At 2:40 pm on [DATE], the Administrator arrived and DON, Assistant Director of Nursing(ADON), Quality Assurance(Q/A) nurse and LPN#1 went out to the van to assess the resident. Resident #1 was on the floor of the van with the wheelchair at her back. DON and ADON assessed Resident#1 without moving resident with no apparent injuries noted. Resident#1 rated pain 0 using a 0-10 pain scale. Ambulance service was notified at 2:43pm by the Charge Nurse. The van doors were shut and air turned up with DON and ADON at her side to ensure she was safe until the ambulance arrived. At approximately 2:50pm two ambulances arrived along with the fire department. Using three(3) person total assistance, the wheelchair was unlocked from its 4-point harness. Leg rests were moved outward and folded from the sides of the wheelchair. Wheelchair was gently moved backwards from the Resident#1. Resident#1 verbally stated she was okay. Emergency Medical Services(EMS) personnel transferred Resident#1 onto a sheet from the floor of the van with 4-person total manual lift. Resident#1 was brought to the local hospital and was evaluated by the emergency department provider. Resident#1 arrived back at the facility at 6:46 pm by ambulance with no further orders at the time. Upon resident's arrival it was noted x-rays were not obtained at the emergency department. Medical Doctor(MD) was notified and x-rays were ordered for 23 views. Portable x-ray performed the x-rays. Report was sent over stat and no injuries were noted on x rays. On [DATE] Nursing and transportation staff were educated immediately requirements of having a CNA or nurse who is Cardiac Pulmonary Resuscitation(CPR) certified to provide non-emergency transport of residents and having two staff members who meet the requirements to transport residents. Education is ongoing with all nursing and transportation staff and will not work till completed. On [DATE] QA nurse met with the therapy director to put in place for all residents to be screened for appropriate mobility devices for transport. Emergency Q/A and safety meeting was held on [DATE] at 9:30am and [DATE] at 6 pm and included the following persons: *Nursing Home Administrator *Medical Director *Director of Nursing (DON) * Assistant DON *QA/Infection Preventionist *Social Services *MDS Nurse *Medical Records Nurse *Staff Development Nurse *Treatment Nurse *Charge Nurse Topics addressed: *IJ Finding- F689 *Root cause analysis *Corrective action plan *Staff Education *Systemic Changes *Monitoring Plan The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy was reviewed. No revisions were required. On [DATE] 1 on 1 in-services on Abuse, Neglect, and Misappropriation, as well as, Requirements and Safety of Non-emergent Transportation were done with the Administrator by DON and ADON. A directive in-service was started on Saturday [DATE] by the [NAME] President of Clinical Operations on Resident safety during transport and Fall Response for all Nursing Staff. On [DATE] Staff who are allowed to transport residents were verified by checking to make sure they are on the company's insurance policy and CPR certified by the DON. The Q/A Nurse reviewed/monitored Resident#1's most recent MOS and most recent therapy screen for appropriate transportation on [DATE]. CONCLUSION: Based on the immediate corrective actions taken, staff education completed, systemic practice changes, and monitoring processes established, Pinecrest Guest Home alleges that the Immediate Jeopardy was abated as of [DATE]. Validation: The SA validated on [DATE] through interview and record review that all actions to remove the immediacy were completed on [DATE] and the IJ was removed on [DATE] prior to the SA exit.

Based on observation, interviews and record review the facility failed to maintain a safe and clean environment related to a leaking roof, damaged ceiling tiles, and thick, black, wet biological growth in air vents for two (2) of three (3) days of observation Findings included: On 12/10/2024 at 10:30 AM, during an observation and interview, Resident #35's room was observed to have a leaking roof near the entranceway, with a blanket draped on the floor. Resident #35 reported that the ceiling was leaking from the light fixture in the entranceway to his room but stated the leaks were not near his bed or where he sits to watch TV. On 12/10/2024 at 10:37 AM, during a facility-wide observation, leaks were observed at various spots throughout the ceiling. Black biological growth was visible in the air vents throughout the facility. On 12/11/2024 at 11:42 AM, during an interview with the Maintenance Director, he acknowledged that the roof was actively leaking throughout the facility and reported that the roof had been leaking for about a year. The Maintenance Director stated his department had been patching areas here and there and confirmed the presence of black biological growth in the air vents, which he attributed to moisture in the ceiling. He reported plans to clean the air vents to remove the biological growth and stated that the Chief Operating Officer (COO) had planned for a new roof for the facility. On 12/11/2024 at 12:00 PM, during an interview, the Administrator acknowledged that the facility had active leaks throughout the building and confirmed the visible presence of black biological growth in the air vents. She stated that the COO had arranged for a roofing company to install a new roof on the building. The Administrator explained that she planned to consult with the roofers before cleaning the air vents because the moisture would persist until the roof was repaired. On 12/11/2024 at 12:14 PM, during an interview, the COO acknowledged that the roof had been leaking for about a year. He reported that the facility had applied for state grant funding to repair the roof but was denied. He stated this was the reason for the delay in roof repairs. The COO confirmed that the facility would now fund the repairs independently and reported speaking with a local roofing company in a nearby town to replace the roof but noted that a date for the roof replacement had not been determined. On 12/12/2024 at 10:12 AM, during a follow-up interview, the Maintenance Director reported that a roofing company was at the facility to patch and caulk areas above Resident #35's room. He confirmed that the company arranged by the COO would still replace the roof but was unable to provide a confirmed date for the replacement. A record review of Resident #35's Admission Record revealed the facility admitted the resident on 01/11/2021. The resident's diagnoses included Unspecified Dementia and Chronic Obstructive Pulmonary Disease (COPD). A record review of Resident #35's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and policy review, the facility failed to resolve resident council members' complaints regarding the lack of hot water in a timely manner for one (1) of two (2) halls. Findings included: A review of the facility's policy titled, Conflict Resolution and Resident Complaint and Grievance Process, dated 09/06/2022, revealed, It is this facility's commitment to safe, respectful, and high-quality care, all concerns brought to the organization's attention by residents/legal representatives shall be reviewed in a timely manner. This organization shall respond to such concerns in a timely, reasonable, and consistent manner. Concerns regarding care received shall include, but not be limited to, concerns over perceptions related to premature discharge . All grievances shall receive immediate priority and must be investigated with efforts made toward resolution within 24 hours. If a grievance cannot be resolved within 24 hours, the grievance shall be referred as described below. This organization shall make every attempt to provide a response within seven (7) days of receiving a grievance . If a grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated within the seven (7) day timeframe, the facility shall send a response to the resident stating that the facility continues to work to resolve the complaint and the facility shall follow-up with another response within 24 hours . A review of the facility's policy titled, Residents' Rights, dated 2020, revealed, The residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The resident has the right to a safe, clean, comfortable, and homelike environment, including receiving treatment and supports for daily living safely . Grievances: The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal . b. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. A record review of the Resident Council's Comments/Concerns/Suggestions, dated 10/29/2024, revealed residents complained that the hot water took too long to get hot, sometimes running for more than 30 minutes and only getting a little warm. Documentation on 11/26/2024 indicated the complaint was resolved. On 12/10/2024 at 10:50 AM, during an initial tour of the facility, Resident #21 requested that the hot water in her bathtub be turned on so the water in her sink would warm. The resident stated she had been complaining about the water not getting hot for the last three months. She explained she was wheelchair-bound, unable to transfer without assistance, and could not turn on the bathtub water herself. She reported having to wash her hands, face, and body in cold water. On 12/11/2024 at 9:00 AM, during an interview, Certified Nursing Assistant (CNA) #1 confirmed she had to retrieve hot water from the soiled utility room to provide incontinent care for residents on the west wing. She reported that staff had informed maintenance about the issue several times with no resolution. CNA #1 stated residents had to wash their hands and face in cold water and confirmed she had to turn on the bathtub water before the sink water would get warm. On 12/11/2024 at 10:00 AM, during a meeting with the resident council members, residents explained all concerns had been resolved except for the issue with the hot water taking a long time to get warm. Resident #21 stated staff had to turn on the bathtub water in her bathroom before the sink water would warm, which she could not do herself. She reiterated having to wash her hands, face, and body in cold water. On 12/11/2024 at 11:30 AM, during an interview, the Activity Director confirmed residents on the west wing had complained about the water not getting hot. She explained she documented the issue as resolved because Resident #21 did not attend the November Resident Council Meeting, and no other residents brought up the concern. She acknowledged she did not confirm with residents that the issue had been resolved. On 12/12/2024 at 9:00 AM, during an observation with Licensed Practical Nurse (LPN) #1, the hot water in Resident #21's room ran for 15 minutes without getting warm. LPN #1 explained that staff had to retrieve hot water from the soiled utility room to assist residents with warm bed baths. She confirmed the water in the residents' rooms barely got warm, even when it eventually warmed. On 12/12/2024 at 10:30 AM, during an observation of water temperature checks and interview, the Maintenance Director confirmed he was aware the hot water was not getting hot on the west wing. He stated he notified a plumbing company on 12/05/2024, which identified a sticking water pump outside the hot water heater. He reported that the facility had ongoing issues with hot water for two to three months and admitted he had not yet called the plumber for further repair. The Maintenance Director stated he turned up the water temperature in an attempt to fix the problem and would turn on Resident #21's bathtub water each morning to ensure warm water for her. The Maintenance Director verified the water temperature in the sink at 80 degrees Fahrenheit. On 12/12/2024 at 11:00 AM, during an interview, the Director of Nursing (DON) confirmed she was aware of the hot water issue and assumed the Maintenance Director had resolved the problem. On 12/12/2024 at 12:15 PM, during an interview, the Administrator confirmed she was aware of the complaint about the hot water not getting hot on the west wing. She stated she believed the Maintenance Director resolved the issue by increasing the water temperature. She was unaware that residents had to turn on the bathtub water to get hot water in the sink and stated she would contact the plumber immediately.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide the appropriate care and services to ensure a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections for one (1) of two (2) residents reviewed with indwelling catheters. Resident #44 Findings include: On 8/08/23 at 10:47 AM, an observation revealed Resident #44 sitting up in his recliner with an indwelling drainage catheter bag attached to the bed. The drainage bag was empty, the tubing was not attached to the resident and was lying on the floor. On 8/08/23 at 12:00 PM, an observation of Resident #44 revealed the resident continued to sit in his recliner, with the indwelling catheter bag attached to the bed and the drainage tubing lying on the floor, unattached to the resident. On 8/09/23 at 11:06 AM, during an observation and interview with Licensed Practical Nurse (LPN) #1 providing suprapubic catheter care for Resident #44, LPN #1 revealed that the tubing should never be on the floor when the resident is switched to a leg bag as this could possibly cause an infection. On 8/09/23 an 11:36 AM, in an interview with Registered Nurse (RN) #3/Infection Preventionist, she explained she spot checks catheter care weekly. RN #3 revealed to prevent infection, catheter drainage bags and the catheter tubing should not touch the floor. Record review of the Order Summary Report with active orders as of 8/8/23, revealed a physician order dated 8/7/23 revealed, DRAINAGE BAG FOR SUPRA PUBIC CATHETER WHEN IN BED. KEEP BELOW WAIST AND HAVE PRIVACY BAG IN PLACE . and another physician order dated 8/7/23 revealed, FOLEY LEG BAG AT HIS REQUEST WHEN OUT OF BED. KEEP LEG BAG BELOW WAIST . Record review of the Admission Record for Resident #44 revealed the facility admitted the resident on 6/28/23, with diagnoses that included Retention of Urine, Muscle Weakness, and Urinary Tract Infection. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/11/2023, Section H revealed the resident had an indwelling catheter. 47873

Based on observation, interviews, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for one (1) of 12 sampled residents. Resident #12 Findings include: A review of the facility's policy, Infection Prevention Control, with a revision date of 6/8/23 revealed, Policy: This facility has established and maintains am infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .5. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with CDC (Centers for Disease Control and Prevention) guidelines . A review of the facility's policy, Perineal/Incontinent Care, revised 9/15/22 revealed, .Policy Explanation and Compliance Guidelines: 1. Hand Hygiene 2. Gather Supplies . 9. Expose perineal area keeping resident covered as much as possible. 10. Hand Hygiene 11. Apply Gloves . On 8/09/23 at 3:07 PM, during an observation of Certified Nurse Aide (CNA) #1 providing perineal care for Resident #12, revealed CNA #1 performed hand hygiene and applied gloves prior to assisting the resident from the wheelchair to the bed and pulling the privacy curtain. However, prior to beginning perineal care, CNA #1 did not remove the soiled gloves, perform hand hygiene, and apply clean gloves. On 08/09/23 at 3:25 PM, in an interview with CNA #1, she stated she should have removed her gloves and washed her hands before beginning perineal care. She confirmed she had contaminated her gloves when she had assisted the resident out of the wheelchair and closed the privacy curtain. On 08/10/23 at 10:15 AM, in an interview with Registered Nurse (RN)/Charge Nurse, she confirmed CNA #1 should have changed her gloves and performed hand hygiene at appropriate times during the care, as her actions could cause the resident to develop an infection. On 08/10/23 10:43 AM, in an interview with Director of Nursing (DON), she stated CNA #1 should have set everything up properly, provided privacy, and washed her hands and applied clean gloves before beginning care. The DON confirmed the actions of CNA #1, while performing perineal care, had the potential to cause the resident to develop an infection. The DON explained she expects the CNAs to follow procedures and guidelines when providing care. A record review of the Admission Record for Resident #12 revealed the facility admitted the resident on 5/30/23, with diagnoses that included Unspecified Dementia, Chronic Kidney Disease, Essential (Primary) Hypertension and Vitamin B12 Deficiency Anemia. A record review of the Admission Minimum Data Set (MDS) for Resident #12, with an Assessment Reference Date (ARD) of 6/7/23, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment.

Based on observations, record review, staff interviews, and review of the facility protocol entitled, Coronavirus Screening Form, the facility failed to screen accordingly one (1) of one (1) visitor, who entered the facility and had access to 38 of 38 residents and facility staff. The failure occurred during a COVID-19 pandemic. The findings include: During a concurrent observation and interview on 09/22/2020 at 3:00 p.m., Screener #1 who was located in the main lobby gave the visitor a coronavirus screening form to be completed. Upon receipt of the completed screening form from the visitor, the screener allow visitor access pass the main lobby, into the resident care areas. Further review of the screening form revealed the screener allowed access without clarifying or addressing, Have you been in contact with someone with or under investigation for COVID-19 - Yes? On 09/23/2020 at 12:30 p.m., Screener #2 screened the same as aforementioned and allowed visitor access pass the main lobby, into resident care areas, without addressing, Have you been in contact with someone with or under investigation for COVID-19 - Yes? Both screeners were aware of the COVID-19 pandemic. During an interview on 09/23/2020 at 1:15 p.m., the Infection Control Nurse stated that she expected the screeners to adhere to the COVID-19 screening protocol. Review of facility records provided by the facility, revealed, 27 residents tested positive for COVID-19, since the start of the coronavirus pandemic. Review of the facility's screening protocol, revised on 09/10/2020, revealed, several screening questions to assess one's whereabouts, to include the question that read, Have you been in contact with someone with or under investigation for COVID-19 - Yes/No?

Based on observation, record review, staff interview, and facility policy review, the facility failed to accurately document a physician's order as prescribed, for one (1) of 20 resident records reviewed, Resident #24. Findings include: Review of the facility's Medical Record, Medication, Discharge, Verbal and Written Orders policy, with a revision date of 11/28/2017, revealed, medical records of residents shall be maintained according to regulations and laws regarding proper documentation and privacy. A review of Resident #24's physician orders, dated 12/05/2019, revealed an order was written to discontinue [MEDICATION NAME] 20 milligrams (mg) daily, and start [MEDICATION NAME] 10 mg daily for Depression. Review of the Note to Attending Physician/Prescriber, dated 12/05/2019, revealed the physician signed to reduce Resident #24's dosage of [MEDICATION NAME] 20 mg daily to [MEDICATION NAME] to 10 mg daily. Review of Resident #24's printed Physician Orders for February 2020, revealed an order for [REDACTED]. On 02/12/2020 at 3:30 PM, during an interview, the Director of Nursing (DON) revealed the current physician orders for Resident #24 should match the MAR and medication card to ensure the resident was receiving the right medication and right dosage. The DON revealed Resident #24's current physician orders should have been changed to reflect the right dosage. On 02/12/2020 at 3:50 PM, during an observation and interview with Licensed Practical Nurse (LPN) #4, revealed Resident #24's medication card and Medication Administration Record (MAR) documented [MEDICATION NAME] 10 mg. LPN #4 revealed the resident was currently receiving [MEDICATION NAME] 10 mg.

Based on observation, record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to Respiratory Care, for one (1) of 20 MDS assessments reviewed, Resident #21. Findings include: Review of the facility's Comprehensive Assessment and Re-Assessment policy, revealed the assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the resident population. The Registered Nurse (RN) Resident Assessment Coordinator, using the quarterly review instrument specified by the state, must assess each resident no less frequently than every three (3) months. Each healthcare professional who completes a portion of the assessment shall sign and certify the accuracy of that portion of the assessment relative to the resident's condition and discharge or entry status. A record review of Resident #21's Quarterly MDS assessments, with an Assessment Reference Date (ARD) of 8/21/2019 and 11/18/2019, revealed, Section O100 (Special Treatments and Programs), was left unchecked for oxygen therapy while a resident in the facility. Record review of Resident #21's Medication Administration Record [REDACTED]. Review of Resident #21's Care Plan revealed, a problem to address use of required Oxygen at 2 liters per nasal cannula related to [MEDICAL CONDITION], with an onset date of 3/06/2019. On 2/11/2020 at 11:34 AM, during an observation, Resident #21 was noted wearing Oxygen per nasal cannula and running at 2 liters per concentrator. During an interview, on 02/12/2020 at 10:18 AM, Licensed Practical Nurse (LPN) #1/MDS Care Plan Nurse confirmed Resident #21 was on continuous Oxygen at 2 liters per minute via nasal cannula. LPN #1 revealed Resident #21 quarterly assessments were suppose to indicate oxygen therapy, but the documentation in the nurses notes did not support the look back period. LPN #1 confirmed Resident #21's Medication Administration Record [REDACTED]. LPN #1 confirmed the MDS assessment should match the resident's current status, which would include oxygen, therefore, the MDS was not correct.

Based on observation, facility policy review, and staff interview, the facility failed to ensure the possible spread of infection by not following proper hand hygiene procedures during resident care tasks for four (4) of seven (7) resident care observations: Resident #5, Resident #25, Resident #37, and Resident #42; and the improper handling of linens for one (1) of (3) days of observations. Findings include: A review of the facility policy titled, Infection Control Policy, no date, revealed that it is the policy of this facility to maintain an infection control program to help prevent the development and transmission of disease and infection. The facility policy also stated that the infection control program will be over seen by the Infection Control Nurse (ICN) and the Director of Nursing (DON). A review of the facility policy titled, Hand Washing Policy, dated 11/02/2016, revealed that it is the policy of this facility that hand washing will be done by all staff frequently throughout their shift. The facility policy stated that hand washing will be done to reduce the transmission of organisms from resident to resident, from nursing staff to the residents, and from residents to the staff. The facility policy stated that hand washing will be done before and after providing resident care, and after any direct contact with another person. A review of Facility Policy titled Handling Clean Linens Policy, revealed, It is the policy of this facility that clean linens will be handled as follows: Employees hands should be clean during linen transport, linens are not to be held close to your body during transport, and linens may be placed in the individual residents room (once linen are placed in a room they can be used only in that room). A review of Facility Policy titled, Female Incontinent Care,dated 11-16-15, revealed incontinent care will be provided to insure that all incontinent residents will receive appropriate treatment and services to prevent Urinary Tract Infections and promote good skin integrity. The Procedure is to remove gloves, wash hands and apply new gloves after washing resident. Resident #42 During an observation, on 04/02/2019 at 7:10 PM, of the personal care task for Resident #42, Certified Nursing Assistant (CNA) #1 failed to change her gloves or wash her hands after she removed a soiled brief and incontinent pad, and before she applied a clean brief and clean incontinent pad. The observation also revealed that upon completion of the personal care task for Resident #42, CNA #1 removed her gloves and left the resident's room without washing her hands. During an interview, on 04/02/2019 at 7:20 PM, Registered Nurse (RN) #1 confirmed that CNA #1 should have washed her hands after handling the dirty linens, and before touching the cleans linen. RN #1 stated that the CNA should have also washed her hands after removing her gloves, and before she left the resident's room. During an interview, on 04/02/2019 at 7:35 PM, the DON confirmed that it would be an infection control problem if any CNA did not wash their hands after providing care, after removing their gloves, or as they leave any resident's room. During an interview, on 04/02/2019 at 7:55 PM, CNA #1 confirmed that she did not wash her hands when going from dirty to clean linen, or after she took off her gloves, or as she left the resident's room. During an interview, on 04/03/2019 at 4:28 PM Licensed Practical Nurse (LPN) #2/ Infection Control Nurse, stated it is considered an infection control concern if you fail to wash your hands between the removal of dirty linen and the addition of clean linen during incontinent care, and after you remove your gloves. LPN #2 stated, The CNAs know about handwashing. Resident #25 During an observation on 04/02/19 at 06:13 PM, with CNA #2 and CNA #3, checked Resident #25's brief. Resident #25's brief was wet and the cotton padding inside the brief appeared to be dark brown and coming apart as visualized thru the outside of the brief. Resident #25 was uncovered to change her brief, and two (2) linen saver pads were noticed under Resident #25 buttocks. Resident #25 had a Duoderm dressing intact on the coccyx and right buttock. During incontinence care, CNA #3 and CNA #2 washed their hands and gloved. During care, CNA #3 pulled her gloves off, exited the room to get a clean gown and did not wash her hands. CNA #3 then re-entered Resident #25's room, not washing her hands. CNA #3 re-gloved and continued to assist CNA #2 with incontinence care. After finishing with incontinence care on Resident #25, CNA #2 and CNA #3 kept their dirty gloves on and placed a clean gown and clean brief on the resident. Both CAN #2 and #3 removed their gloves after applying the clean gown and clean brief on the resident, and discarded them into a dirty trash bag with the soiled brief. Both CAN #2 and #3 exited the room without washing their hands. Resident #5 An observation on 04/02/19 at 06:21 PM, revealed CNA #2 and CNA #3 entered Resident #5's room. CNA #2 and CNA #3 gloved and began to gather supplies to perform peri-care. RN #1 was ask to enter Resident #5's room. After washing hands and gloving, CNA #2 and CNA #3 began incontinence care on Resident #5. Resident #5 had two (2) linen saver pads under her. Resident #5's brief was visibly wet. CNA #2 removed the wet brief while CNA #3 assisted turning Resident #5 from side to side. CNA #2 and CNA #3 did not change gloves nor wash their hands after removing Resident #5's wet brief. CNA #2 and CNA #3 continued with peri-care, applying a clean brief, with dirty gloves. Resident #37 An observation on 04/02/19 at 06:38 PM, revealed CNA #2 and CNA #3 entered Resident #37's room. CNA #2 and CNA #3 washed their hands and gloved. RN #1 was present in the room. CNA #2 removed Resident #37's brief. Resident #37's brief was wet as well as soiled with Bowel Movement. CNA #3 removed her gloves and exited the room, without washing her hands, to get some bags. CNA #3 re-entered Resident #37's room and did not wash her hands upon re-entrance, and before gloving. CNA #2 folded the soiled brief over and placed the soiled brief back under Resident #37's buttocks. CNA #2 stated this was done because the resident had not finished having the BM. CNA #3 removed her gloves and exited the room again to get a clean gown for Resident #37, without washing her hands. CNA #3 re-entered the room with the gown in her hand (linen not covered), without washing her hands, and before re-gloving. CNA #3 re-gloved and assisted with turning Resident #37 for peri-care and applying the gown. CNA #2 wiped Resident #37's bottom, cleaning away the BM and then applied a clean brief, without changing gloves. CNA #3 assisted CNA #2 with applying the clean gown, with the same gloves as she had on to assist in turning the resident for peri-care. An interview on 04/02/19 at 07:35 PM, with CNA #2 revealed, I realized that I didn't wash my hands or change my gloves after doing incontinence care and before applying a clean gown and a clean brief on Resident #5, Resident #25, and Resident #37. Not washing my hands and changing gloves between doing pericare and before providing clean care to a resident is an infection control issue. Especially with the resident having two (2) pressure wounds. I realized I didn't wash my hands and change my gloves as soon as I finished care to the residents. An interview on 04/02/19 at 07:38 PM, with CNA #3, revealed, Yes I do remember not washing my hands when I left the room and when I came back into the room. I remember not changing my gloves after providing peri-care and before putting a clean gown on the resident. I agree it is an infection control issue An interview on 04/02/19 at 07:40 PM, with RN #1, revealed, I saw they didn't wash their hands or change gloves after providing peri-care on Resident #5 and Resident #37, and before providing a clean brief to both residents and a clean gown to Resident #37. She stated, I noticed CNA #3 leaving the room and not washing her hands and re-entering the room and not washing her hands before she re-gloved. RN #1 stated that CNA #2 and CNA #3 came to her and said they forgot to wash their hands and change their gloves after providing peri-care, and before applying a clean brief or gown. She stated there is an infection control problem with both CNA #2 and #3 not washing their hands and not changing gloves between cleaning a resident up and applying clean briefs or gowns. During an interview on 04/03/19 at 02:50 PM, the Director of Nursing (DON) revealed it is not a standard practice for a CNA not to wash her hands or change her gloves when going from dirty to clean. It is not acceptable at all for them not to wash their hands and change gloves. She stated, We just had our check-offs in (MONTH) and that was part of the check-off. In an interview on 04/03/19 at 04:35 PM, LPN #2 QA /Infection Control Nurse revealed, It is not a Standard of Care for a CNA or any professional to not wash their hands or put on clean gloves especially in preventing decubitus or preventing the spread of infections. LPN #2 was informed of the failure of CNA #2 and CNA #3 to wash their hands and put on clean gloves during incontinence care. LPN #2 stated I can name numerous things in what you've described that took place with CNA #2 and CNA #3 in incontinence care that was wrong. They know better than not to wash their hands or glove appropriately. It is definitely an infection control issue. LPN #2 QA/Infection Control Nurse also stated, You don't go down the hall with exposed linen. You cover it. It is an infection control issue. An observation on 04/02/19 at 09:53 AM, revealed Maintenance #1 came down the hall holding a privacy curtain in his hands and up against his clothing (uncovered, no bag). Maintenance #1 entered Resident room [ROOM NUMBER] and came back out, still holding the privacy curtain against his clothing. He stood in the hall and looked up and down the hall. Maintenance #1 stated, I'm going to replace this curtain in room [ROOM NUMBER]. Maintenance #1 walked down the hall and entered room [ROOM NUMBER] (still holding the privacy curtain). In an interview on 04/03/19 at 04:45 PM, (regarding Maintenance #1 bringing the clean privacy curtain down the hall uncovered, against his clothing and going in and out of a resident's room before going into the correct residents room) LPN #2 QA/Infection Control Nurse stated, You don't carry clean privacy curtains from room to room. You don't bring a clean privacy curtain down the hall uncovered, and you certainly don't carry it into one (1) residents room and then bring it back out into the hall, and then enter into another resident's room. You never hold clean linen or even a privacy curtain against your clothing. You cover it.

Based observation, staff interview, record review, and facility policy review, the facility failed to follow the manufacturer's guidelines regarding inhalers for (1) of (27) medication administration opportunities. Resident #16. Findings include: A review of [MEDICATION NAME] Inhaler Manufacture's Pharmacy Guide revealed, After inhalation, the patient should rinse the mouth with water without swallowing. Swallowing and not rinsing the [MEDICATION NAME] can cause [MEDICAL CONDITION][MEDICATION NAME] Infection of the oral cavity. A review of the facility's Physicians order, dated 01/22/2018, revealed orders for [MEDICATION NAME] aerosol 160-4.5 mcg (microgram)/AER([MEDICATION NAME]-[MEDICATION NAME]) two (2) puffs, inhale orally two (2) times a day, related to [MEDICAL CONDITION]. Rinse mouth with water after use. A review of the facility's policy titled, Administering Medication, not dated, revealed medication must be administered in accordance with the orders, including required time frame. A review of Resident #16's Medication Administration Record [REDACTED]. During an observation on 4/2/2019 at 09:00 AM, of the facility's morning Medication Pass, License Practical Nurse (LPN) #1 gave Resident #16 two (2) puffs from the [MEDICATION NAME] Inhaler. LPN #1 offered Resident #16 water to rinse his mouth out after inhaling the medication. Resident #16 swallowed the water after each puff. LPN #1 failed to educate Resident #16 on the importance of not swallowing the water. During an interview on 4/2/2019 at 03:00 PM, LPN #1 said she did not know the resident should spit the water out. LPN #1 said she knew the resident should rinse with water because of the medication, but didn't know why. During an interview on 4/3/2019 at 1:50 PM, The Director of Nursing (DON) confirmed that the facility failed to follow the Manufacturer's Prescribing Guidelines by allowing Resident #16 to swallow the water mouth after inhaling the [MEDICATION NAME]. Review of Physician orders [REDACTED].#16 on 08/24/2017, with diagnoses, which included [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION] Fibrillation. A review of Resident #16's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/22/2019 , revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement the care plan regarding care for three (3) of 19 care plans reviewed. Residents #5, #25, and #37. Resident #25 for incontinent care, turn/reposition, and offer fluids every two (2) hours; Resident #5 for; Resident #37 for Findings include: A review of Facility Policy titled, Total Care Plan, not dated, revealed It is the policy of this facility that the Interdisciplinary Care Plan will be done to identify problems that affect the resident and his/her needs. It also identifies the discipline responsible for performing the intervention. A review of Facility Policy titled, Comprehensive Care Plan dated 2-15-18, revealed the Interdisciplinary Care Plan will be completed to identify the interventions related to specific problems. A review of Facility Policy titled, Female Incontinent Care, dated 11-16-15 revealed incontinent care will be provided to insure that all incontinent residents will receive appropriate treatment and services to prevent Urinary Tract Infections and promote good skin integrity. Incontinent residents will be checked at least every two (2) hours for incontinent episodes. Resident #25 A review of Resident #25's current Care Plan, initiated 2/13/19, revealed Resident #25 is incontinent of bowel and bladder and at risk for pressure ulcers and Urinary Tract Infection [MEDICAL CONDITION], with interventions of incontinent care and applying skin protectant to skin after bath/incontinent care. The care plan also included interventions to offer fluids and turn/reposition the resident every two (2) hours. An observation on 04/02/19 at 06:13 PM, with Certified Nursing Assistant (CNA) #2 and CNA #3 (Orientee), revealed Resident #25 was in bed. When entering the room, a strong smell of urine was noticed at the entry into the room. When asked if Resident #25 was her assigned resident, CNA #2 stated she was assigned to the resident. Because of the strong urine odor, CNA was asked if she had performed any kind of incontinence care on Resident #25 since she had been at work. CNA #2 stated No. CNA #2 and CNA #3 checked Resident #25's brief. Resident #25's brief was wet and the cotton padding inside the brief appeared to be dark brown and coming apart as visualized through the outside of the brief. CNA #2 stated she had been at work since 3:00 PM, but had not changed Resident #25. She stated, I didn't have time; they had to get the board together (assignments) when I got here, and then I had to push other residents to the dining hall and help feed. Resident #25 was uncovered to change her brief and two (2) linen saver pads were noticed under Resident #25's buttocks. Resident #25 had a Duoderm dressing intact on her buttocks. The CNA had not provided care to Resident #25 for over three (3) hours. Resident #5 A review of Resident #5's current Care Plan, initiated 1/16/19, revealed Resident #5 is at risk for pressure ulcers related to incontinence of both bowel and bladder, with the intervention of incontinent care every two (2) hours and as needed (PRN). An observation on 04/02/19 at 06:21 PM, revealed CNA #2 and CNA #3 entered Resident #5's room. When asked if she had provided incontinence care to Resident #5 since she came on duty at 3:00 PM, CNA #2 stated, I am assigned to Resident #5, but no, I have not changed the resident since I came to work at 3:00 PM. She stated, Like I said earlier, I can only be so many places and after they did the board (assignments) I had to get residents to the dining room and then help feed. I just didn't have time. CNA #2 and CNA #3 gloved and began to gather supplies to perform peri-care. RN #1 was asked to enter Resident #5's room to discuss CNA #2 stating that she had not changed the resident since clocking in for work, and to witness if Resident #5's brief was wet. After washing hands and gloving, CNA #2 and CNA #3 began incontinence care on Resident #5. Upon pulling back bed covers, Resident #5 had two (2) linen saver pads under her. Resident #5's brief was visibly wet. The CNA had not provided care to Resident #5 for over three (3) hours. Resident #37 A review of Resident #37's current Care Plan, initiated 2/28/19, revealed Resident #37 is at risk for pressure ulcers related to incontinence of bowel and bladder, with an intervention of incontinence care. The care plan revealed the resident required total assistance with toilet use. The Care plan revealed Resident #37 is at risk for UTI related to incontinent of bowel and bladder with an intervention of incontinent care. An observation on 04/02/19 at 06:38 PM, revealed CNA #2 and CNA #3 entered the room to provide peri-care on Resident #37. CNA #2 and CNA #3 washed their hands and gloved. RN #1 was present in the room. CNA #2 removed Resident #37's brief. Resident #37's brief was wet as well as soiled with Bowel Movement (BM). The CNA had not provided care to Resident #37 for over three (3) and one-half (1/2) hours. An interview on 04/02/19 at 06:37 PM, with RN #1, revealed, We are low on CNA's. You can look at the schedule and see that. It's hard for them to work short and be in several different places at one time. I saw the brief was wet on both Resident #37 and Resident #5, and soiled with BM on Resident 5. An interview on 04/04/19 at 02:04 PM, with LPN #6, Care Plan Nurse, revealed, When I create a care plan it is a plan of care for the nurse or CNA to follow. I expect them to follow the care plan.

Based on observation, record review, facility policy review, and staff interview, the facility failed to provide privacy during the personal care for one (1) of seven (7) residents observed for a personal care task, Resident #42. Findings include: A review of the facility policy titled, Privacy and Confidentiality Policy, no date, revealed that it is the policy of this facility that the resident has the right to personal privacy. The facility policy noted that personal privacy included personal care. The facility policy noted, as a reminder, that the cubicle curtain, window curtains or blinds, and the door should always be closed before rendering treatment or care. During an observation, on 04/02/2019 at 7:10 PM, of the personal care task for Resident #42, Certified Nursing Assistant (CNA) #1 failed to close the door to Resident #42's room when providing personal care to the resident. Resident #42 was exposed from her waist to her feet while CNA #1 was changing her brief. The privacy curtain was not in use and Resident #42 could be seen from the hallway. During an interview, on 04/02/2019 at 7:20 PM, Registered Nurse (RN) #1 stated that CNA #1 should have closed the door to Resident #42's room before starting care, to provide Resident #42 with privacy. During an interview, on 04/02/2019 at 7:35 PM, the Director of Nursing (DON) stated that closing the resident's door should always be done before providing resident care. During an interview, on 04/02/2019 at 7:55 PM, CNA #1 confirmed that she did not close the door of Resident #42's room prior to providing personal care to the resident. CNA #1 stated that she should have closed the door before she changed Resident #42's brief and pad, so that the resident had privacy. A review of the facility document titled, CNA Orientation Checklist, dated 02/02/2019, revealed that Certified Nursing Assistant (CNA) #1 was checked off as having completed the Orientation Training for Privacy Reinforcement (ex. Knock before Entering, Pulling Privacy Curtains and Etc.), as was indicated by the initials of the Orientation Staff Member and CNA #1. Review of the Face Sheet revealed Resident # 42 was admitted by the facility on 05/21/2015, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2019, revealed that Resident #42 had a Brief Interview of Mental Status (BIMS) score of 6, indicating severely impaired cognition.

Based on staff interview, record review, and facility policy review, the facility failed to issue a written notification of transfer and discharge to an acute care hospital for one (1) of four (4) residents with transfer to the hospital, Resident #41. Findings include: A review of the document, Hospital Transfer /Return Form Policy, not dated, revealed the Hospital Transfer Nurses Notes and the Hospital Return Notes forms will be utilized on any resident who is transferred to, or returned from, the hospital. Documentation included that the Hospital Transfer Form/Return Form will be maintained in the medical records as the Nurse's note. The form does not take the place of the transfer form which accompanies the resident to the hospital. Record review revealed Resident #41 had two (2) hospital stays in the past six (6) months. Dates included: 12-05-18 thru 12-10-18, and 12-31-18 thru 1-4-19, with no letter of notification of transfer on either hospital visit. An interview on 04/04/19 at 12:55 PM, with Medical Records personnel revealed, We do not send a letter out to the resident or resident representative when the resident goes out to the hospital. An interview on 04/04/19 at 12:56 PM, with Social Services revealed, We do not send a letter to the resident or resident representative when the resident goes out to the hospital. We do a verbal with the family. A phone interview with Resident #41's Representative on 04/04/19 at 1:01 PM, revealed, The facility did call and notify me when she went to the hospital. There was no documented evidence there had been a written notification of the hospital transfers. An interview on 04/04/19 at 1:06 PM, with the Director of Nursing (DON), revealed the facility had no letter that was sent out to the resident/resident representatives regarding residents going to the hospital to her knowledge.

CI MS # Based on interview, record review, facility policy review, and facility investigation review, the facility failed to protect Resident #1 from abuse when Certified Nursing Assistant (CNA) #1 was observed hitting Resident #1 multiple times on the arm and Resident #1 reported to the nurse that CNA #1 thumped him in the eye for (1) of four (4) residents reviewed for abuse. (Resident #1) Findings include: The facility policy, titled, Resident's Prevention from Abuse Policy, undated, read, It is the Policy of this Facility that all residents will be free from physical, mental and verbal abuse. This policy also documented that once an allegation of abuse is made, the Director of Nursing (DON) and Administrator must be notified immediately. Review of the facility's investigation revealed that Resident #1 complained that his CNA (CNA #1) thumped him in the eye. It was reported the Nurse on duty, that Licensed Practical Nurse (LPN) #1 heard Resident #1 yelling and saying, She hit me, she hit me, and indicated by thumping his fingers in the air. LPN #1 did not follow policy and notify the DON or the Administrator immediately but left a note underneath the DON's door. CNA #1 was not sent home immediately pending the investigation. An interview with Resident #1 was attempted on 7/12/18 at 1:10 PM, and when asked about the allegation of abuse, Resident #1 responded, I don't know. Resident was confused at this time and unable to answer questions. In an interview on 7/12/18 at 4:40 PM, LPN #1 stated she heard Resident #1 call her name and was saying, She hit me, she hit me. LPN #1 stated she went into Resident #1's room and CNA #1 was leaning across the over-bed table with her arms crossed and was saying to Resident #1, Stop saying that I hit you. LPN #1 stated she asked CNA #1 to leave the room but the resident made the statement in front of her and he was using his pointer finger and middle finger to poke in the air with his right hand and kept saying she hit me. LPN #1 confirmed she did not see CNA #1 hit the resident and CNA #1 denied hitting him. LPN #1 stated she notified administration by leaving a note underneath the DON's door and stated it would be investigated the next day. LPN #1 did not suspend the CNA at that time. In an interview on 7/12/18 at 3:40 PM, CNA #2 stated she walked in on CNA #1 hitting Resident #1 on the hand. CNA #2 stated he had his hands crossed over his stomach and was yelling and she was hitting him really hard on his arms telling him to hush. CNA #2 stated she observed CNA #1 hit Resident #1 about four (4) times. CNA #2 stated she did not tell anyone that day because, I didn't feel comfortable, and felt like CNA #1 would lie on her if she reported anything that night. CNA #2 confirmed she observed CNA #1 watching television and talking on the phone in other resident's rooms and told the Nurses when she saw this. In an interview on 7/12/18 at 10:40 AM, the DON revealed an investigation into the allegation of abuse for Resident #1 revealed a report from LPN #1 that Resident #1 was hollering and saying, She hit me, she hit me, and said she hit him in the eye. The DON stated that LPN #1 said it was the way Resident #1 said it when CNA #1 walked out that made her believe it. The DON stated that CNA #2 reported that she witnessed CNA #1 hit Resident #1 on the arm but was afraid to say anything at the time. The DON stated that LPN #1 and CNA #2 both got written up for not reporting the abuse immediately, and in-serviced everyone again. The DON confirmed that CNA #1 was terminated for abuse. The Face-sheet documented the facility admitted Resident #1 on 10/28/15, with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 4/12/18, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 8, which indicated Resident #1 was cognitively impaired. CNA #1 was called on 7/12/18 at 3:15 PM by two (2) contact numbers that was provided and messages were left on both numbers to return the call and there was no response. An attempt was made to interview the Responsible Party (RP) for Resident #1 on 7/12/18 at 3:20 PM, with no answer and the voicemail had not been set up. In an interview on 7/12/18 at 12:30 PM, with Resident #2, revealed CNA #1 was rude and yelled often. Resident #2 stated CNA #1 was just mean. He stated she also would come into his room to watch the news and talk on the phone. Resident # 2 stated CNA #1 was supposed to change him every two (2) hours but would wait till the last round and then change him, changing him only once per shift. Resident #2 stated he was also Resident Counsel Vice President. Resident #2 stated he was going to keep CNA #1 from coming into his room. In a record review of Resident #2's MDS with the ARD of 4/26/18, revealed Resident #2's BIMS score was 15, which indicated he was cognitively intact.

CI MS # Based on interview, record review, facility policy review, and facility investigation review, the facility failed to follow the Plan of Care for Resident #1 when Certified Nursing Assistant (CNA) #1 was observed hitting Resident #1 multiple times on the arm and Resident #1 reported to the nurse that CNA #1 hit him for (1) of four (4) residents reviewed for Care Plans. (Resident #1) Findings include: The facility policy, titled, Comprehensive Care Plan Policy, dated 2/15/18, read, The facility will identify problems that affect the resident, identify interventions related to specific problems and must be based on comprehensive person-centered care. The review of Resident #1's Plan of Care revealed the intervention to approach the resident warmly and positively at all times with the onset date of 4/19/18, related to the resident is at risk for increased cognitive loss related to the [DIAGNOSES REDACTED]. Review of the facility's self-reported incident investigation revealed that Licensed Practical Nurse (LPN) #1 heard Resident #1 yelling and saying, She hit me, she hit me, and indicated it was Certified Nursing Assistant (CNA) #1. Resident #1 also indicated by thumping his fingers in the air the way CNA #1 hit him. In an interview on 7/12/18 at 4:40 PM, LPN #1 stated she heard Resident #1 call her name and was say, She hit me, she hit me. LPN #1 stated when she went into Resident #1's room that CNA #1 had her arms crossed and was saying to Resident #1, Stop saying that I hit you. LPN #1 stated Resident #1 was using his pointer finger and middle finger to poke in the air with his right hand and kept saying she hit me. In an interview on 7/12/18 at 3:40 PM, CNA #2 stated Resident #1 had his hands crossed over his stomach and she observed CNA #1 hitting him really hard on his arms, telling him to hush. CNA #2 stated she observed CNA #1 hit Resident #1 about four (4) times on his arms really hard. CNA #2 stated she had observed CNA #1 watching television and talking on the phone in other resident's rooms. In an interview on 7/12/18 at 10:40 AM, the Director of Nursing (DON) revealed the conclusion to the investigation into the allegation of abuse for Resident #1 was substantiated. The DON stated that LPN #1 said it was the way Resident #1 described the occurrence when CNA #1 walked out of the room that made her believe what the resident had alleged. The DON stated that CNA #2 had also reported that she witnessed CNA #1 hit Resident #1 on the arm, but was afraid to say anything at the time. In an interview on 7/13/18 at 11:10 AM, the Director of Nursing (DON) stated Resident #1 had an intervention to approach resident warmly and positively at all times and confirmed when CNA #1 hit Resident #1 and was accused of hitting and yelling at him that she was not following his Plan of Care. The Face-sheet indicated the facility admitted Resident #1 on 10/28/15, with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 4/12/18 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 8, which indicated Resident #1 was cognitively impaired.

Based on record review, staff interview and facility statement, the facility failed to provide written documentation related to annual nurse competencies for five (5) of 5 nursing employee records, as indicated by the facility assessment. Findings include: Review of the facility assessment that was completed in (MONTH) (YEAR), revealed the facility had reviewed and evaluated competencies for the staff. Review of the Facility's Assessment, page 7 of 12, revealed that staff competencies were reviewed and adequate. Skills and competency reviewed for licensed nurses was checked as completed. Review of the Facility's Employee Personnel Files, revealed an Employment Verification Checklist, and Employee In-service Log for Registered Nurse (RN) #2, Licensed Practical Nurse (LPN) #4, LPN #5, LPN #6 and the Director of Nursing (DON). The employee personnel files did not reveal a nurse's skills checklist for the nurses. Review of RN #2's employee file revealed she was hired on 03/08/17. Review of LPN #4's employee file revealed she was hired on 08/29/17. Review of LPN #5's employee file revealed she was hired on 04/24/17. Review of LPN #6's employee file revealed she was hired on 03/30/17. Review of the DON's employee file revealed she Review of the DON's employee file revealed she was hired on 02/15/17. Review of the Director of Nurses (DON)'s job description revealed she is responsible for directing the overall operations of the Nursing Service Department in accordance with the state and federal regulations which govern the facility. The DON's duty is to maintain or assist with the maintenance of current nursing employee files. Review of the Facility's letter dated 02/08/18, confirmed the facility does not have a policy in place for nurse competencies or annual requirements for check-offs of their skills. Interview with LPN #10, on 02/07/18 at 4:10 PM, revealed she has been employed at this facility for three (3)years and has not had an annual nursing skills check-off during her employment. On 02/08/18 at 4:20 PM, upon review of the facility assessment, which included the section related to staff competency and staff skills, the Administrator was unable to comment. Interview with the Director of Nursing (DON), on 02/07/18 at 4:30 PM, confirmed she is responsible for ensuring all clinical staff receive annual staff competency check-offs. Said she gives new nurses a Nurse Orientation Checklist to have completed by another facility nurse. The DON said she has not followed up with the newly hired nurses to ensure their nursing skills have been checked off by another nurse of the facility or to ensure the staff competency check-off forms have been completed. The DON stated that the facility assessment was a lie after reviewing the section related to competencies. Review of the Facility's letter and interview with the DON, on 02/08/18 at 11:07 AM, confirmed the facility does not have a policy to entail the DON or the Administrator's role in ensuring all clinical staff receive annual staff competencies.

Based on record review, staff interview and facility statement, the facility failed to provide skills and competency training as well as supportive documentation for nursing staff for five (5) of 5 nursing employee records reviewed and eight (8) of 8 nurses interviewed. Findings include: Review of the Facility's letter, dated 02/08/18, confirmed the facility does not have a policy in place for nurse competencies or annual requirements for check-offs of their skills. Review of the Facility's Employee Personnel Files, revealed an Employment Verification Checklist, and Employee In-service Log for Registered Nurse (RN) #2, Licensed Practical Nurse (LPN) #4, LPN #5, LPN #6 and the Director of Nursing (DON). The employee personnel files did not reveal a nurse's skills checklist for the nurses. Review of RN #2's employee file revealed she was hired on 03/08/17. Review of LPN #4's employee file revealed she was hired on 08/29/17. Review of LPN #5's employee file revealed she was hired on 04/24/17. Review of LPN #6's employee file revealed she was hired on 03/30/17. Review of the DON's employee file revealed she was hired on 02/15/17. Review of the Director of Nurses (DON)'s job description revealed she is responsible for directing the overall operations of the Nursing Service Department in accordance with the state and federal regulations which govern the facility. Another of her duties is to maintain or assist with the maintenance of current nursing employee files. Interview with LPN #10, on 02/07/18 at 4:10 PM, revealed she has been employed at this facility for the past three (3) years and has not had an annual nursing skills check-off during her employment. Interview with the Director of Nursing (DON), on 02/07/18 at 4:30 PM, confirmed she is responsible for ensuring all clinical staff receive annual staff competency check-offs. The DON stated she gives new nurses a Nurse Orientation Checklist to have completed by another facility nurse. The DON said she had not followed up with the newly hired nurses to ensure their nursing skills had been checked off by another nurse of the facility or to ensure the staff competency check-off forms have been completed. Review of the Facility's letter and interview with the DON, on 02/08/18 at 11:07 AM, confirmed the facility does not have a policy to entail the DON or the Administrator's role in ensuring all clinical staff receive annual staff competencies. Review of the facility assessment that was completed in (MONTH) (YEAR), revealed the facility had reviewed and evaluated competencies for the staff. In an interview, on 02/08/18 at 4:20 PM, and upon review of the facility assessment, the Administrator was unable to comment on the section related to competencies and skills for staff. Interview on 02/08/18 at 4:30 PM, with the DON, revealed she completed the facility assessment and stated, it was a lie, after reviewing the section related to competencies.

Based on observation, record review, staff interview, and facility policy review, the facility failed to follow professional standards related to administering medication injections for one (1) of two (2) injections observed, Resident #46. Findings include: A review of the policy titled, Medication Set-up, Administration and Documentation Policy, not dated, revealed the policy did not cover injection procedures. A review of an in-service titled, Injection Safety, dated 3/31/17, revealed LPN #7 attended the in-service. The in-service covered Center for Disease Control (CDC) guidelines for syringe use for injections. The in-service indicated to change syringes with each puncture of the medication bottle. A review of the Mississippi Board of Nursing Practice Law revealed , Nursing practice: includes, but is not limited to, administration, teaching, counseling, delegation and supervision of nursing, and execution of the medical regimen, including the administration of medications and treatments prescribed by any licensed or legally authorized physician or dentist. During an observation, on 02/02/18 at 8:29 AM, Licensed Practical Nurse (LPN) #7 diluted [MEDICATION NAME] into [MEDICATION NAME] by a needle/syringe for Resident #46. LPN #7 failed to change her needle/syringe and cleanse the top of the multi-dose [MEDICATION NAME] and single dose [MEDICATION NAME] bottle after she had previously punctured the bottles to mix the two (2) medications. An interview, on 02/02/18 at 8:50 AM, with LPN #7, confirmed she forgot to change the needle/syringe and cleanse the bottle of [MEDICATION NAME] and [MEDICATION NAME] prior to drawing for the second time. She stated she didn't have enough [MEDICATION NAME] for the medication to mix and drew another milliliter (ml). She said the policy was to cleanse the top of the bottle and change syringes. During an interview on 02/06/18 at 3:30 PM, the Director of Nursing (DON) said they did not have a specific policy for injections. The DON said she had not been doing the check off skills list with the nurses since she was hired in (MONTH) (YEAR), and would have to look for the in-services prior to her hiring. An interview with the DON on 02/07/18 at 10:36 AM, revealed the concern with failing to change the syringe and wiping the bottles after puncture, was infection control. The DON acknowledged it was incorrect procedure for injection practices. In an interview on 02/07/18 at 12:00 Noon, the Quality Assessment (QA)/Infection Control Nurse said the Pharmacist would randomly select nurses to follow during medication pass and would write in a report that would be sent back to the facility. LPN QA/Infection Control said there was no other competency lists that she knew was done. An interview, on 02/07/18 at 1:48 PM, with the QA/Infection Control Nurse, confirmed the Pharmacist's reports only showed two (2) months, (MONTH) (YEAR) and (MONTH) (YEAR), where the documentation revealed a nurse was followed/observed during medication pass. In an interview on 02/07/18 at 2:30 PM, LPN #7 said she was hired in (MONTH) (YEAR). She said she had orientation with another LPN. LPN #7 said the DON at the time came to her and told her she was doing good and then she was put on the medication cart alone. LPN #7 said she did have in-services on narcotics and injection safety. LPN #7 said she was observed by the Pharmacy Consultant once in the past year. A review of a Medication Pass Observation, provided by the Pharmacist, dated 04/04/17, revealed the Pharmacist observed LPN #7 during medication administration. A review of the Pharmacist's monthly reports, provided by the facility since last survey, revealed documentation she had followed a nurse during medication pass on (MONTH) 8, (YEAR) and (MONTH) 5, (YEAR).

Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection for an injection during medication pass for one (1) of two (2) injections observed, Resident #46. Findings include: The policy titled Medication Set-up, Administration and Documentation Policy, without a date, revealed the policy did not cover injection procedures. An interview on 02/06/18 at 3:30 PM, with Director of Nursing (DON), revealed the facility did not have a specific policy for injections related to infection control. In an observation on 02/02/18 at 8:29 AM, Licensed Practical Nurse (LPN) #7 diluted [MEDICATION NAME] into [MEDICATION NAME] by a needle/syringe for Resident #46. LPN #7 failed to change her needle/syringe and cleanse the top of the multi-dose [MEDICATION NAME] and single dose [MEDICATION NAME] bottle after she had previously punctured the bottles to mix the two (2) medications. An interview on 02/02/18 at 8:50 AM, with LPN #7, confirmed she forgot to change the syringe/needle and to cleanse the bottle of [MEDICATION NAME] and [MEDICATION NAME] prior to drawing the medication for the second time. She stated she didn't have enough [MEDICATION NAME] for the medications to mix and drew another milliliter (ml). LPN #7 said the policy was to cleanse and change needles/syringes. In an interview on 02/07/18 at 10:36 AM, the DON said the concern with failing to change syringe and wiping the bottles after puncture, was an infection control issue. The DON acknowledged incorrect procedure for injection practices by LPN #7. Record review of an in-service titled, Injection Safety, dated 3/31/17, revealed LPN #7 attended the in-service. The in-service covered Center for Disease Control (CDC) guidelines for syringe use for injections. The in-service said to change syringes with each puncture of the medication bottle.

CI MS # Based on observation, record review, staff interview and policy review, the facility failed to implement the Action portion of the facility's Abuse, Neglect, or Exploitation Policy by allowing Certified Nurse Aide (CNA) #1 to complete her shift after she neglected Resident #2. This was evident by CNA #2 transferring the Resident #2 manually without the use of a Total Lift and two (2) staff as care planned. This is for one (1) of four (4) residents reviewed (Resident #2). Findings include: Resident #2 Review of an incident reported by the facility revealed that on 2/4/13 at approximately 4:20 p.m., revealed that Certified Nurse Aide (CNA) #1 transferred Resident #2 from her wheelchair to the bed. During the transfer the "resident's left foot got caught in a ? side rail that was down on left side of bed. Bedrail was raised by nurse and Resident #2's foot was removed from between rail. On initial examination of left foot by the nurse Resident #2 could move foot up and down, wiggle toes, no broken skin or redness was noted to her foot. Resident #2 did complain of pain and was given a [MEDICATION NAME] 5/500 mg. (milligrams) 1 tab (tablet) po (by mouth) which she already had as a prn (as necessary) order, M.D. was notified and informed of incident, new order received for x-ray of left ankle on 2/5/13 at ... (local hospital) ... Resident #2 was transported to ... (local hospital) 2/5/13 when the x-ray was done as ordered by M.D. X-ray report showed a fracture of tibia and fibula with [MEDICAL CONDITION]. Resident #2 was transferred to ... (another hospital) for further evaluation and treatment. " Observation of Resident #2 on 3/13/13 at 4:14 p.m., revealed that the resident was in the bed in her room. Certified Nurse Aide #2 assisted in the observation of this resident's left foot revealing a purple below the knee cast in place on the left leg with an ace wrap around the ankle and heel area. Record review for Resident #2 revealed that she was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 12/11/12 Minimum Data Set assessment for Resident #2 revealed that for the Brief Interview for Mental Status (BIMS) Resident #2 scored 15, indicating that the resident was cognitively intact. Review of Resident #2's care plan revealed that on 12/18/12 the problem of "Resident requires extensive assist with bed mobility ... total assist with transfers x 2 (two staff) with total lift" was identified. Review of the Resident ADL (Activities of Daily Living) Record and Care Plan with the starting date of 12/23/12 and continuing to the present revealed that the Resident #2 was to be transferred with a Total Lift and 2 CNAs. Interview on 3/14/13 at 1:25 p.m. with Licensed Practical Nurse (LPN) #1, who was assigned to Resident #2 the evening of the incident, confirmed that the Resident #2's left leg had become caught in the side rail when CNA #1 had transferred her manually from the wheelchair to the bed without the use of a total lift and the assistance of another staff. LPN #1 stated that she stresses the use of ADL Care Plan and that CNA #2 had neglected Resident #2 by not using a Total Lift and a second staff. LPN #1 stated that CNA #2 continued working in the facility until the completion of her shift at 11:00 p.m. on 2/4/13. Interview on 3/14/13 at 2:45 p.m. with CNA #1, confirmed that she had transferred Resident #2 as reported and had not used a Total Lift and had not had another staff to assist. CNA #1 confirmed that she had continued working that evening until the completion of her shift. Interview on 3/14/13 at 1:45 p.m. with the Director of Nursing (DON) of the facility, confirmed that CNA #1 did complete her shift on the evening of 2/4/13 and that the CNA #1 was suspended the next morning (2/5/13). Review of the facility Abuse, Neglect, or Exploitation Policy with the effective date of 1/1/08 revealed the following: "DEFINITIONS" "NEGLECT The failure of a caretaker to supply for the vulnerable adult the food, clothing, supervision, or other services which are necessary to maintain his/her mental or physical health." "ACTION" "Any employee suspected of abuse, neglect, or exploitation shall be placed on suspension."

CI MS # Based on observation, record review, and staff interview, the facility failed to ensure that Resident #2 was provided care consistent with her plan of care resulting in a [MEDICAL CONDITION] tibia and fibula. This was for one (1) of four (4) residents reviewed (Resident #2). Findings include: Resident #2 Observation of Resident #2 on 3/13/13 at 4:14 p.m. revealed that the resident was in the bed in her room. Certified Nurse Aide (CNA) #2 assisted in the observation of this Resident #2's left foot revealing a purple below the knee cast in place on the left leg with an ace wrap around the ankle and heel area. Record review for Resident #2 revealed that she was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 12/11/12 Minimum Data Set assessment for this resident revealed that for the Brief Interview for Mental Status (BIMS) the Resident #2 scored 15, indicating that the resident was cognitively intact. Review of Resident #2 s care plan revealed that on 12/18/12 the problem of " Resident requires extensive assist with bed mobility ... total assist with transfers x 2 (two staff) with total lift " was identified. Review of the Resident ADL (Activities of Daily Living) Record and Care Plan with the starting date of 12/23/12 and continuing to the present revealed that the resident was to be transferred with a Total Lift and 2 CNAs. Review of the 2/4/13 Nurses' notes for Resident #2 revealed that "4:35 p.m. Observed resi (resident's) left ankle between the bed and rail of her bed Ankle was released from area. Assessment: Resi able to move left ankle up/down, wiggle toes. Resi c/o (complained of) pain. PRN (as necessary) [MEDICATION NAME] administered RP (responsible party) and MD notified. Resi left ankle will be futher (further) monitor. Left ankle/rt (right ankle elevated." Interview on 3/14/13 at 1:25 p.m. with Licensed Practical Nurse (LPN) #1, who was assigned to Resident #2 the evening of the incident, confirmed that the Resident #2's left leg had become caught in the side rail when CNA #1 had transferred her manually from the wheelchair to the bed without the use of a total lift and the assistance of another staff. LPN #1 stated that she stresses the use of the ADL Care Plan. Interview on 3/14/13 at 2:45 p.m. with CNA #1, confirmed that she had transferred Resident #2 on 2/4/13 and had not used a Total Lift and had not had another staff to assist and that the Resident #2's left leg had gotten caught in the bed rail. Review of the 2/5/13 x-ray report of the left tibia and fibula revealed "Left tibia fibula 3 views History: Trauma to leg with fractures. Posterior splint placement with 3 views of the left tibia and fibula are submitted and compared with earlier ankle x-rays of the same date. An overlying splint now obscured bone detail. There is some diffuse osteopenia with a recent mildly overlapping spiral [MEDICAL CONDITION] shaft and metaphysis of the tibia. There is a mildly separated oblique fracture involving the proximal metaphysis and shaft of the fibula. Impression: 1. Osteopenia with recent fracture proximal fibula and recent fracture distal tibia. Overlying splint."

CI MS # Based on observation, record review and staff interview, the facility failed to provide adequate supervision to ensure Resident #2 was transferred with a Total Lift and two (2) staff resulting in a fracture of the resident's left tibia and fibula. This is for one (1) of four (4) residents reviewed (Resident #2). Findings include: Resident #2 Review of an incident reported by the facility revealed that on 2/4/13 at approximately 4:20 p.m. Certified Nurse Aide (CNA) #1 transferred Resident #2 from her wheelchair to the bed. During the transfer the "resident's left foot got caught in a ? side rail that was down on left side of bed. Bedrail was raised by nurse and Resident #2's foot was removed from between rail. On initial examination of left foot by the nurse Resident #2 could move foot up and down, wiggle toes, no broken skin or redness was noted to her foot. Resident #2 did complain of pain and was given a Lortab 5/500 mg. (milligrams) 1 tab (tablet) po (by mouth) which she already had as a prn (as necessary) order, M.D. was notified and informed of incident, new order received for x-ray of left ankle on 2/5/13 at ... (local hospital) ... Resident #2 was transported to ... (local hospital) 2/5/13 when the x-ray was done as ordered by M.D. X-ray report showed a fracture of tibia and fibula with osteoporosis. Resident #2 was transferred to ... (another hospital) for further evaluation and treatment. " Observation of Resident #2 on 3/13/13 at 4:14 p.m. revealed that the Resident #2 was in the bed in her room. Certified Nurse Aide (CNA) #2 assisted in the observation of this Resident #2's left foot revealing a purple below the knee cast in place on the left leg with an ace wrap around the ankle and heel area. Record review for Resident #2 revealed that she was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 12/11/12 Minimum Data Set assessment for this resident revealed that for the Brief Interview for Mental Status the resident scored 15, indicating that the resident was cognitively intact. Review of Resident #2 ' s care plan revealed that on 12/18/12 the problem of " Resident requires extensive assist with bed mobility ... total assist with transfers x 2 (two staff) with total lift " was identified. Review of the Resident ADL (Activities of Daily Living) Record and Care Plan with the starting date of 12/23/12 and continuing to the present revealed that the resident was to be transferred with a Total Lift and 2 CNAs. Review of the 2/4/13 Nurses ' notes for Resident #2 revealed that " 4:35 p.m. Observed resi (resident's) left ankle between the bed and rail of her bed Ankle was released from area. Assessment: Resi able to move left ankle up/down, wiggle toes. Resi c/o (complained of) pain. PRN (as necessary) Lortab administered RP (responsible party) and MD notified. Resi left ankle will be futher (further) monitor. Left ankle/rt (right ankle elevated. " Interview on 3/14/13 at 1:25 p.m. with Licensed Practical Nurse (LPN) #1, who was assigned to Resident #2 the evening of the incident, confirmed that the resident ' s left leg had become caught in the side rail when CNA #1 had transferred her manually from the wheelchair to the bed without the use of a total lift and the assistance of another staff. LPN #1 stated that she stresses the use of the ADL Care Plan. Interview on 3/14/13 at 2:45 p.m. with CNA #1, confirmed that she had transferred Resident #2 on 2/4/13 and had not used a Total Lift and had not had another staff to assist and that the Resident #2's left leg had gotten caught in the bed rail. Review of the 2/5/13 x-ray report of the left tibia and fibula revealed "Left tibia fibula 3 views History: Trauma to leg with fractures. Posterior splint placement with 3 views of the left tibia and fibula are submitted and compared with earlier ankle x-rays of the same date. An overlying splint now obscured bone detail. There is some diffuse osteopenia with a recent mildly overlapping spiral fracture of the distal shaft and metaphysis of the tibia. There is a mildly separated oblique fracture involving the proximal metaphysis and shaft of the fibula. Impression: 1. Osteopenia with recent fracture proximal fibula and recent fracture distal tibia. Overlying splint."