Every finding on record at Pleasant Valley Rehabilitation and Nursing

Based on observations, interview, records review, and facility policy review, it was determined that the facility failed to ensure dish machine testing was completed per manufacturers recommendations for one of one kitchen. Specifically, the incorrect strips were utilized, and the instructions on the strips were not followed. Based on observations, interviews, records review, and facility policy review, it was determined the facility failed to ensure the dish machine testing was completed per manufacturer's recommendations for one of one kitchen. Specifically, incorrect testing strips were utilized, and the instructions on the testing strips were not followed. The findings include: During the initial kitchen tour and concurrent interview on 08/03/2026 at 10:45 AM, the Dietary Manager (DM) indicated the dish machine was a low-temperature dish machine and demonstrated the dish machine sanitizer testing process. This surveyor observed the DM cycle the dish machine, raised the walls/panels of the dish machine, removed a test strip from the available vial, swiped the test strip along the bottom edge of the front wall/panel (for 1-2 seconds, where the water was dripping), and compared the test strip to the color-coding range on the test strip vial. The DM indicated the reading to be at 50 parts-per-million (ppm), and the vial indicated the testing strips as Iodine testing strips, with the maximum reading on the color chart to be at 50 ppm. Review of the July and August 2026 Dish Machine logs on 08/03/2026 at 1:00 PM, revealed , all entries for test strip readings were recorded at 200 ppm. Review of the July and August 2026 Dish Machine logs; and concurrent interview on 08/05/2026 at 9:55 AM with the DM revealed the morning dish machine log for 08/05/2026 was recorded as 50 ppm and all other recordings were 200 ppm. The DM indicated the reason staff were recording 200 ppm when the maximum reading for the sanitizer reading was 50 ppm was because both iodine and chlorine testing strips were available for staff use in the wall holder, located in the holder on the wall across from the dish machine. In addition, the DM indicated the staff must have been using the wrong testing strips to measure the sanitizer, and they should have used the iodine strips which had a max reading of 50 ppm, and not the chlorine strips which had a max reading of 200 ppm. The DM indicated the dish machine was serviced a couple of months ago and the vendor must have given the facility the wrong testing strips. During an interview on 08/05/2026 at 10:46 AM, Dietary Aide (DA) #2 indicated the chlorine strips were the ones needed to be used now and not the iodine strips. The DM stated that the vendor-supplied lab strips must have been changed when the machine went from high temp machine to low temp machine and there was a chemical change at that time (which was a couple of months ago). During an interview on 08/05/2026 at 4:13 PM, the Dish Machine Vendor indicated he had been in this role and servicing the facility for approximately one and a half years; and the facility had a low-temp dish machine during that time. The Dish Machine Vendor indicated the staff should use chlorine test strips, and the acceptable range for testing should be between 50-100 ppm, and not 200 ppm as recorded on the July and August 2026 dish machine logs. During an interview and document review on 08/06/2026 at 9:10 AM, the test log was reviewed with DA #2. DA #2 indicated they had used the iodine strips to test the dish machine this morning and recorded the iodine test strip at 50 ppm. During an observation and interview on 08/06/2026 at 9:12 AM, this surveyor observed DA #2 perform a test on the dishwasher. DA #2 ran a cycle on the washer, raised the walls/panels of the washer, took an iodine test strip from the vial, swiped the bottom of the front wall/panel of the dishwasher (1-2 seconds) and compared the test strip to the color reference range on the vial, the results indicated the reading to be 50 ppm. DA #2 indicated she did not follow the instructions on the vial as followed: Dip strip into solution being tested for 60 seconds, without agitation, and while wet compare with color chart below During a follow up observation and concurrent interview on 08/06/2026 at 9:15 AM, this surveyor observed DA #2 run the dishwasher, raise the walls/panels of the washer, DA #2 used an iodine test strip and pressed the paper lightly to the bottom front wall/panel of the dishwasher and held it suspended into the drops coming from the bottom of the wall/panel. After approximately 60 seconds, the test strip was compared to the color chart on the test strip vial, and the reading was between 0-12 1/2 ppm. The DM and DA #2 indicated, 0-12 1/2 was too low. The DM and DA #2 discussed the process of dip strip into solution being tested for 60 seconds, as indicated on the vial of iodine testing strips. The DM used an iodine test strip to perform a test. The DM dipped the strip in the dishwasher with no agitation in the dishwasher's water reservoir for approximately 60 seconds and compared the test strip to the color chart on the test strip vial, the reading indicated the result was 50 ppm. During an interview on 08/06/2026 at 11:00 AM, the DM stated the dish machine vendor had been in the facility and conducted an in-service on the proper functioning and testing of the dish machine. The DM indicated they were now aware the staff need to use the chlorine test strips and not the iodine test strips. The DM also indicated a new wall poster reference was made available to staff. The wall poster reference observed instructions for dish machine testing using the test strips as follows: Take one test strip and dip into solution After dipping, let sit for at least 5 seconds but not more than 10 seconds before reading the strip Match the test strip to the color chart to determine chlorine concentration. During an interview on 08/06/2026 at 12:31 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) acting on behalf of the Administrator, indicated a result of the kitchen staff not testing the dish machine sanitizer appropriately could be residents getting sick and/or cross contamination. During an interview on 08/06/2026 at 1:43 PM, the DM indicated the 200 ppm readings on the July and August 2026 logs review represented the type of chlorine testing strips. During an observation and concurrent interview on 08/06/2026 at 1:38 PM, DA #5 indicated he was responsible for the dish machine testing and was observed washing dishes with the dish machine. DA #5 was observed to run a dish machine cycle, take a chlorine test strip, dip the strip quickly into the water reservoir and immediately compared the strip to the color chart. DA #5 and the DM indicated the reading was between 50-100 ppm, the DM confirmed the reading was correct. DA #5 and the DM were prompted by the surveyor to read the instruction on the Chloring vile strips, which read, dip and remove quickly, blot immediately with paper towel and compare to color chart at once. DA #5 indicated that he did not blot with a paper towel, as instructed on the vial. The DM stated they were not aware of the instructions regarding blot with paper towel. Both the DM and DA #5 indicated a result of not testing the dish machine appropriately would be residents getting sick. Review of an undated facility policy titled Diet, Sanitation, and Menu, indicated, a dish machine will be utilized in accordance with the manufacturer's instructions. Review of the dietary in-service provided on 08/06/2026 indicated the acceptable sanitizer concentration should fall between 50 ppm and 100 ppm.

Based on record review, interviews, and facility policy review, the facility failed to evaluate and revise the comprehensive care plan related to falls for 1 (Resident #3) of 1 sampled residents reviewed for accidents. Specifically, the facility failed to ensure appropriate fall prevention interventions were initiated after the resident had a fall with major injury. Based on record review, interviews, and facility policy review, the facility failed to evaluate and revise the comprehensive care plan related to falls for one (Resident #3) of one resident reviewed. Specifically, the facility failed to ensure appropriate fall prevention interventions was initiated after the resident had a fall with major injury. The findings include: Review of Resident # 3's admission Record revealed the facility admitted Resident #3 on 09/19/2024 with diagnoses which included hemiplegia affecting the left non dominant side. Review of Resident # 3's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/26 revealed Resident # 3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #3 was cognitively intact. The MDS also revealed Resident #3 required substantial/maximal assistance with functional abilities which included shower/bathing, and the resident was dependent for lower body dressing (the ability to dress/undress below the waist). Per the MDS, Resident # 3's active diagnoses included: osteoporosis, hip fracture, cerebrovascular accident (CVA) or stroke, and hemiplegia (weakness) to left nondominant side. Review of Resident # 3's Facility Incident and Accident Report (I & A), dated 06/01/26 revealed Resident # 3 had a fall in the shower room due to losing their balance while being assisted by one staff member. Review of Resident # 3's Care Plan, dated 05/01/26, revealed, Dressing: substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of Resident # 3's Care Plan, with a target date of 07/05/26, revealed the following: Dressing: Substantial/maximal assistance, Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Dressing: Weight bearing with assistance of one staff. Upper body/Lower body, putting on/taking off shoes. Shower/bathe self: Partial/moderate assistance with bathing. Fall Risk: 06/01/26, fall w/injury, Will have resident to sit down while dressing in shower. During an interview on 08/06/2026 at 10:04 AM, Certified Nursing Assistant (CNA) #3 revealed, Resident # 3 was always a two-person assist. CNA # 3 revealed that the care plan was where other staff members would verify this to care for Resident # 3 properly. CNA # 3 was unable to retrieve the care plan to verify. During an interview on 08/06/2026 at 10:12 AM, Resident # 3 revealed there was always two people in the shower with me to get me dressed. Resident # 3 revealed if there was not two people, I would tell them I need another person. During an interview on 08/06/26 at 10:46 AM, CNA # 4 revealed, to see how much care or assistance a resident required she would look at the care plan. During an interview on 08/06/2026 at 10:53 AM, Licensed Practical Nurse (LPN) #1 revealed, the care plan was where staff look to find out how to care for residents and determine how much assistance and care the resident required. During an interview on 08/06/2026 at 1:22 PM, Minimum Data Set, (MDS) LPN revealed that on the significant change MDS, dated [DATE] for Resident # 3, bathing assistance had been changed from partial to substantial assistance, no changes to the Care Plan ADLs had been made, and anyone looking at [the care plan] would not know [about the change]. The two-person assist was not in the I &A report, MDS LPN revealed it should have been on the I&A report During an interview on 08/06/2026 at 2:24 PM, Acting Administrator/Assistant Director of Nursing (ADON) revealed Resident # 3 was changed from partial/moderate to substantial moderate assistance on the significant change MDS following a fall. The ADON/Administrator revealed that on Resident # 3's care plan dated 07/05/26, the ADLs were changed from partial/moderate dressing to substantial assistance which could be just one person, and staff was to have Resident # 3 sit down while dressing. The ADON/Administrator revealed that the facility involved the resident in decision making regarding interventions on the care plan. The ADON/Administrator revealed Resident # 3 was okay with one person; The ADON revealed Resident # 3 would not need the assistance of two staff members for ADL care based on her level of function. During an interview on 08/06/2026 at 2:41 PM, The Director of Nursing (DON) revealed Resident #3's significant change MDS indicated substantial assistance for ADL's and Resident # 3 would sit down while dressing. The DON revealed the care plan changes included for Resident #3 to sit down while dressing. The DON revealed that Resident # 3 does not require a 2 person to assist. On 08/06/2026 at 4:18 PM, the DON revealed the facility did not have a Care Plan Policy. Review of the Facility's undated Fall Guideline revealed it was the charge nurse's duty to Implement intervention to prevent future injury and Update the Care Plan with new interventions

Based on observation of medication administration, interview, record review and facility document review, the facility failed to ensure an insulin pen was primed and the plunger was held down for a count of five (5) seconds after an administration of insulin, according to manufacturer's instructions for 1 (Resident #11) sampled resident reviewed for medication administration. The findings are: A review of a Living Well with Diabetes instruction document, provided by the Director of Nursing (DON), was reviewed and read in part Prime your pen; Step one (1): turn the dose knob clockwise, until the number two (2) is in the dose window. Step two (2): hold the pen, with the needle pointing up, and tap the cartridge to gently move air bubbles to the top. Step three (3): with the needle still pointing straight up, push the dose knob in while counting to five (5). When the dose knob stops, the number zero (0) will appear in the dose window. Take your shot; Step two (2): when the needle is under your skin, use your thumb to press the dose knob all the way in. Push the knob firmly and slowly, until it stops moving. Step three (3): hold the button while the needle is under your skin and count to five (5). Step four (4): you've gotten your full dose when you see a zero (0) in the dose window A patient package insert retrieved from the manufacturer ' s website provided by the DON, was reviewed and revealed Priming your pen Prime before each injection, priming your pen means removing the air from the needle and the cartridge that may collect during normal use, it is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, dial up to the number two (2) on the dial window, and with the pen pointed up, slowly depress the plunger. While continuing to hold the pen pointed up, count to five (5) slowly until a zero (0 is seen on the dial window. An Inservice Education Report dated 04/23/2025, provided by the DON, was reviewed, and revealed an in-service education related to How to use [brand name] Kwik pen with the signatures of seven (7) staff members. A review of Resident #11's Order Summary Report revealed Resident #11 had diagnoses that included: type II diabetes; with unspecified complications, immunodeficiencies, abnormal weight loss, vascular dementia, and Alzheimer ' s disease. A review of Resident #11 ' s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/2025 was reviewed and indicated that the resident had a Staff Assessment for Mental Status (SAMS) that indicated the resident had short and long-term memory problems and had Modified independence with daily decision making. A review of Resident #11's Order Summary Report, Active orders as of 04/21/2025 was reviewed and indicated the resident had physician's orders with a start date of 01/18/2024 of [brand name] Kwik Pen subcutaneous solution Pen-injector 100 unit/ml [milliliters] Inject 22 units subcutaneously one (1) time a day, related to diabetes mellitus, due to underlying condition with unspecified complications. During an observation, on 04/23/2025 at 9:29 AM, of medication administration of the insulin, via an insulin pen, with Registered Nurse (RN) #1 and the DON, RN #1 applied the needle cap to the insulin pen. RN #1 then dialed the dose in the window to 22 [units]. RN #1, without priming the pen prior to administering, entered Resident #11 ' s room, sanitized the skin of the resident ' s abdomen, applied the pen to the skin, depressed the plunger, then removed the needle without a count down, after the injection. During an interview on 04/23/2025 at 9:31 AM, RN #1 was asked how the insulin pen had been primed prior to dialing up the injection. RN #1 responded that the pen had been checked for air bubbles. When asked again if the insulin pen was primed prior to the injection, RN #1 responded with No . When RN #1 was asked how long the plunger had been held down after injecting the insulin, RN #1 did not respond. RN #1 was asked, when the insulin injection was administered, how long was the pen held to the resident ' s skin, prior to removing the needle. Again RN #1 had no response. During an interview with the DON on 04/23/2025 at 9:31 AM, (after an observation of medication administration at 9:29 AM, of insulin via an insulin pen) the DON, who observed the set up and delivery of the insulin pen dose, was asked how the insulin pen should have been primed. The DON responded that the pen should have been primed with 2 - 3 units. The DON was asked the purpose of priming the insulin pen. The DON ' s response was, we only have a couple of these pens in the building . The DON was asked if the nursing staff should know how to administer the insulin, via pens. The DON ' s response was, yes, they should know. The DON indicated the resident could have received an incorrect dose. During an interview, on 04/23/2025 at 1:30 PM, the Medical Director (MD) confirmed he was the Primary Care Provider for Resident #11. The MD confirmed Resident #11 had current orders for an insulin pen. In relation to the resident's insulin pen, the pen should be primed, prior to the actual dosage being dialed up. The MD confirmed he was aware that the insulin pen required priming, prior to each dose. The MD was asked, if the pen was not primed correctly, would there be a potential for the resident to not receive the ordered dose. The MD confirmed that there would be a potential to receive an inaccurate dose on insulin. The MD confirmed his expectation for the facility to follow the manufacturer recommendations related to administering insulin with an insulin pen.

F0812 F Based on observations and interview, the facility failed to ensure deep fryer was free of debris to prevent potential cross contamination, floor throughout the kitchen and wall air vent were free of grease, and stains, food items stored in the freezer or refrigerator were sealed, covered and dated, expired food items were promptly removed /discarded by the expiration or use by dates, and foods were dated as when received to ensure first in and first out usage to prevent the potential for food borne illness, 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition to prevent food and beverage contamination, staff washed their hands between dirty and clean tasks and before handling clean equipment to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 67 residents who received meals from the kitchen (total census 69), The findings are: 1. On [DATE] 09:03 AM The following observations were made in the kitchen: a. At the entrance door to the kitchen, the floor had a buildup of black stains on it. b. The floor by the ice machine was chipped exposing the cement. The area chipped had dirt on them. c. The floor below the counter where coffee, tea, and beverage machine were kept had wax buildup and brown stain. d. The floor in front of the steam table, by the 3-door freezer, in front of the food preparation counter by the vegetable freezer had brown and wax buildup around the corners of it. e. The floor the behind the deep fryer. f. Floor behind the oven. Floor between the oven and the deep fryer had grease buildup on them. g. The air vent between the 3-door and freezer was covered with debris. h. The floor in the storage room, floor by the milk refrigerator and by the food preparation where food processor was kept had stains on them. i. he floor under the food preparation sink, and the floor under the food preparation counter by the food preparation sink had stains on them. 2. On [DATE] at 09:10 AM The closed cabinet below the deep fryer had four pallets that were attached to the deep fryer. All 4 pallets had grease build up on them. The inside door of the closed cabinet had a buildup of grease on it. Th surveyor asked the Dietary Employee (DE) #1 How often they cleaned the bottom of the deep fryer and the pallets. DE #1 stated, We clean it once a week. 3. On [DATE] 09:20 AM An opened box of vegetable blend was on a shelf in the freezer. The box was not dated as of when opened. 4. On [DATE] at 09:23 am The following observations were made in the freezer: a. Two of 2 open bags of sausage in an opened box on a shelf freezer. The bags had no date on them. b. An opened box of biscuits on a shelf in the freezer. The bag has no date when opened. 5. On [DATE] at 9:29 AM There was an open bag of bread on the bread rack. The bag was not sealed. 6. On [DATE] at 09:34 AM The following observations were made on a shelf in the walk-in refrigerator: a. An opened bottle of nectar thickened liquid on a shelf in the walk-in refrigerator with no opened date on the bottle. b. An opened bottle of honey thickened liquid. The bottle has no open date on it. c. An opened box of bacon. The box was not covered or sealed. Either the bag or box has opened date. d. An opened bottle of grape jelly. The bottle has no open dated on it. e. An opened bottle of mayonnaise. The bottle has no opened date on it. f. Two of 2 opened containers of honey mustard. The containers have no open date on them. g. An opened gallon of enchilada sauce. There was no opened date on it. h. An opened gallon of medium picante sauce. There was no opened date on it. i. An opened container of salad with a by date of [DATE]. J. An opened bottle of dill pickle. There was no date on it. k. A carton of Hiland Vitamin-D with an expiration of [DATE]. 7. On [DATE] at 09:48 AM The following observations were made on a shelf in the storage room: a. An opened imitation vanilla. b. There was no date on the bottle. b. An opened box of graham crumbs. The box was not covered or sealed. There was no opened date on the box. c. An opened box of plain breadcrumbs. The box was not covered or sealed. There was no date opened date on the box. d. Ten of 10 boxes of malt-o-meal on a shelf had an expiration date of [DATE]. Dietary Employee (DE) #1 stated, We don't even use it. e. An opened container of Greek all-purpose seasoning. There was no opened date on the container. 8. On [DATE] at 09:55 AM The following observations were made on a spicy shelf in the storage room: a. An opened container of rubbed sage has no open date on it. b. An opened container of ground mustard has no open date on it. c. An opened contain of dill seed has no date on it. d. An opened container of Montreal chicken has no date on it. e. An opened container of Mediterranean style, ground oregano. f. An opened container of ground nutmeg has no date on it. g. An opened container of lemon and pepper seasoning has no date on it. h. Ground cinnamon has no date on it. i. An opened containers of onion powder and garlic powder had no date on them. 9. On [DATE] at 10:09 AM The ice machine panel had wet brown residue on it. Surveyor asked the Dietary Employee (DE) #1 to wipe the panel of the inside of the ice machine. He used a tissue to wipe the panel inside of the ice machine which had a brown substance on it that had easily transferred from the ice machine onto the tissue. Surveyor asked Dietary Supervisor to describe the residue found inside the ice machine that showed on the tissue. Who uses the ice machine from the machine and how often do you clean it? He stated, [NAME] dirt, We use to fill beverages served to the residents at mealtimes. 10. On [DATE] at 10:12 A The following observations were made on a shelf in the 3-door freezer: a. An opened box of turkey sausage. The box has no date when it was opened. b. An opened box of hamburger patties. The box was not covered or sealed. The box has no open date on it. c. An opened box of steak fingers. The box was not covered or sealed completely. 11. On [DATE] at 10:15 AM The ice scoop holder on the wall close to the ice machine on the 400 Hall had wet grayish residue on it. The ice scoop was resting directly in contact with the grayish residue. The surveyor asked the Dietary Employee (DE) #1 [NAME] to wipe the wet grayish residues observed. He did, and the wet grayish residues easily transferred to the paper towel. The surveyor asked the Dietary Employee (DE) #1 [NAME] to describe what was observed in the scoop holder. He stated, It was nasty. The surveyor asked the Dietary Employee (DE) #1 [NAME] who uses the ice from the machine. He stated, That's the ice the CNAs) Certified Nursing Assistants) use to fill the water pitchers in the resident's rooms. On [DATE] at 11:10 AM The surveyor asked the maintenance man Colbey [NAME] how often the ice scoop holder was cleaned. He stated, Every week. 12. On [DATE] 11:27 AM Dietary Employee (DE) #2 turned on the hand washing faucet on and washed his hands, dried his hands with paper towel, turned the water off with paper towel, and then used the same paper towel to dry his hands, contaminating his hands, without washing her hands, she picked cups by their rims and placed them on the trays. When he was about to pour beverages into the cups. The surveyor immediately asked DE #2 what should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 13. On [DATE] 11:47 AM Dietary Employee (DE) #3 opened the refrigerator and removed fresh tomatoes from a box and placed it on the cutting board. Without rinsing the tomatoes. He sliced the tomatoes and placed them on the plates that container shredded lettuce to be served to the residents who requested for salad with their lunch meal. The surveyor immediately asked him what you should have done before processing fresh tomatoes. He stated, I should have rinse them. 14. On [DATE] at 10:51 AM Dietary Employee (DE) #4 lifted ice machine lid with her gloved hand. Contaminated the gloves. Without Changing gloves and washing her hands, she used her contaminated gloved hand to push ice cubes into the glasses for the residents to use in eating their lunch meal. 15. A facility titled Handwashing and gloves usage in food service provided by the Dietary Supervisor on o[DATE] at 01:20 PM documented, A. Before starting work. b. After cleaning table or busing dirty dishes. C. After touching anything else such as dirty equipment, work surfaces or cloths.

Based on observation and interview the facility failed to ensure a safe environment for 1 (room [ROOM NUMBER]) room on the 200 Hall. This failed practice had the potential to affect 3 (Resident #13, #42, & #53) residents who were ambulatory on the 200 Hall, and the facility failed to ensure the residents were provided a homelike environment for 5 (room [ROOM NUMBER], room [ROOM NUMBER], Room112, room [ROOM NUMBER], and room [ROOM NUMBER]) rooms on the 100 Hall . The findings are: 1. On 02/04/2024 at 09:24 AM the shower in room [ROOM NUMBER]'s bathroom lacked on/off knobs (exposed metal posts 2 1/2 inches long) on the hot and cold water handles. 1A. On 02/04/2024 at 01:03 PM the shower lacked on and off knobs in room [ROOM NUMBER], leaving metal posts exposed 2 1/2 inches long. 1B. On 02/05/2024 at 08:27 AM the Surveyor observed exposed metal posts 2 1/2 inches long in room [ROOM NUMBER]'s shower. 1C. On 02/04/2024 at 12:48 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Does the resident use this bathroom? CNA #1 stated Yes, but they don't shower in here. The Surveyor asked, Do other residents wander and go into other resident's rooms? CNA #1 stated, Yes, they do. The Surveyor asked, Does this look safe to you? CNA #1 stated, No, it doesn't. 1D. On 02/06/2024 at 02:04 PM the Surveyor asked CNA #3, Does the resident use this bathroom? CNA #3 stated, Yes, but [resident] doesn't go into the shower. The Surveyor asked, Does this look safe to you? CNA #3 stated, I really don't know. 1E. On 02/07/2024 at 10:51 AM the Surveyor observed foam covers placed over the cold and hot shower posts in room [ROOM NUMBER]'s shower. The Surveyor asked Maintenance, When were these applied? Maintenance stated, I put those on yesterday after I heard about it. The Surveyor asked, Was this safe prior to the foam being applied? Maintenance stated, No, I don't think so. 1F. On 02/07/2024 at 11:01 AM the Surveyor asked the Director of Nursing (DON), Please describe the shower knobs for me. The DON stated, There are foam covers over them, but I know they were just put on yesterday. The Surveyor asked, Was this safe prior to the foam covers being applied? The DON confirmed it was not safe. 2. On 02/04/2024 at 9:25 AM the bathroom in room [ROOM NUMBER] had a loud urine odor. The trash can was filled with water. Resident #50 was asked, Can you tell me why the water is in your trash can? Resident #50 stated, I use it to flush the toilet. My toilet is messed up. Resident #50 was asked, How long has your toilet been messed up? He stated, A few days, but I'm going to fix it. I just need the supplies to fix it. 2a. On 2/04/2024 at 9:34 AM a raised toilet seat in room [ROOM NUMBER] had a brown substance on the raised toilet seat. There were brown substances on the fixed toilet and stains coming down the sides of the toilet, and trash on the floor. 2b. On 02/04/2024 at 9:35 AM room [ROOM NUMBER]'s bathroom floor was dirty. 2c. On 02/04/2024 at 9:50 AM the wall was peeling behind the bed in room [ROOM NUMBER]B. 2d. On 02/06/2024 at 10:20 AM room [ROOM NUMBER]'s bathroom had a strong odor. The toilet was full of tissue and the water was brown. The surveyor asked Resident #50, Did you get your toilet repaired? Resident #50 stated, No, it hasn't been fixed yet. 2e. On 02/04/2024 at 10:15 AM the floors were dirty in room [ROOM NUMBER]A. Resident #5 was asked, How often is your room cleaned? Resident #5 stated, They clean the rooms maybe once a week. 2f. On 02/07/2024 at 11:00 AM the Maintenance Director was asked, How long had the toilet been out of order in room [ROOM NUMBER]? The Maintenance Director stated, It was out for a couple of hours on Monday. I believe it's completely fixed now. It was the handle and a valve that had to be connected. The Surveyor asked, Can you tell me what's wrong with the wall in room [ROOM NUMBER]? The Maintenance Director stated, It needs to be painted. 2g. On 02/08/2024 at 10:06 AM the Administrator was asked, How often are the rooms cleaned? The Administrator stated, Daily and deep cleaned once a month. The Surveyor asked, How many housekeepers are assigned for the weekends? The Administrator stated, It should be 3 housekeepers and a laundry personnel. The Surveyor asked, Can you tell me why there was only one housekeeper this past Sunday? The Administrator stated, We were short on Sunday. I think we had 2 call ins. We were trying to get additional staff, but they couldn't come in. The Surveyor asked, Do you know how long the toilet was out of order for room [ROOM NUMBER]? The Administrator stated, No I don't. 2h. A document provided by the Administrator on 02/08/2024 at 10:04 am titled, Accident Hazards Prevention 42 C.F.R. S 483.25 documented, .the environment will be free from accident hazards as is possible . 48483

Based on observation, interview and record review the facility failed to ensure the state survey results were posted in a place readily accessible to residents. The findings are: On 2/06/24 at 3:02 PM a resident council meeting was conducted. The residents were asked if they knew were the state inspection results were located, and if they could get them without having to ask staff for them. There were 10 (Resident #3, Resident #5, Resident #7,Resident #14, Resident #34, Resident #43, Resident #45, Resident #47, Resident #55, and Resident#66) residents in the resident council meeting that did not know where the survey results information was located. On 2/06/24 at 3:30 PM there were a binder located on the wall at the beginning of the 100 that had Survey Results written on it. The Annual survey results for 2023 was not in the binder. On 2/06/24 at 3:35 PM the surveyor asked the Director of Nurse (DON), Can you show me where the 2023 Annual Survey results are located? She looked in the survey results binder that was located on the wall at the beginning of the 100 hall. She stated, They aren't in here. She was asked, Should the survey results information be located in a place where the residents can reach it without having to ask for it? She stated, Yes it should. On 2/06/24 at 3:50 PM the DON came in the conference room holding the 2023 survey results. She stated, I have them now, and I'm getting ready to put them in the binder. A form titled, Resident Rights and Responsibilities .documented, .Examination of survey results. Resident/Elders may examine the results of the of the most recent survey of the nursing facility conducted by Federal or State surveyors. This will include any plan of correction in effect. The nursing facility will make the results of the most recent survey available for examination in a place readily accessible to Resident/Elders. A notice of the availability of survey results will be posted . On 2/08/24 at 10:11 AM the administrator was asked, Should the survey results be available for the family and residents at all times? He stated Yes.

Based on interview the facility failed to ensure isolation laundry was handled correctly to prevent the spread of infection. This failed practice had the potential to affect 15 (Resident's #1, #6, #7, #11, #20, #21, #25, #27, #36, #37, #42, #50, #53, #54, #64) sample mix residents who depend on the facility to provide laundry services according to a list provided by the Social Services Director on 2/7/24 at 3:48pm. The findings are: On 02/05/24 at 01:37 PM, the Surveyor asked Housekeeper (HKP) #1 What jobs do you perform? HKP #1 stated I'm a housekeeper, but I do laundry too. The Surveyor asked How do you wash isolation laundry? HKP #1 stated The aides on the floor bring the laundry to us. I pick up the outside of the bag that they bring it to us in and shake it out into the washer. The Surveyor asked Do you wear Personal Protection Equipment (PPE) when you do isolation laundry? HKP #1 stated No, I've never been told to wear PPE while doing isolation laundry. I don't know why a person would need to. On 02/05/24 at 01:43 PM, the Surveyor asked the District Manager of Housekeeping (DMH) Is PPE required when washing isolation laundry? The DMH stated Yes, instructions are posted in the dirty room beside the PPE. It should be being used properly. The Surveyor asked When was the last In-Service held for isolation laundry? The DMH stated I don't remember off the top of my head, but there will be one done today. On 02/05/24 at 03:00 PM, the DHM provided the Surveyor with an in-service for HKP #1 on Laundry PPE that showed, .laundry workers must wear the proper personal protective equipment when handling soiled linen .wear the following: gloves, gown, eye protection, and face shield .never handle isolation laundry without PPE . On 02/08/24 09:07 AM, the Surveyor asked the Director of Nursing (DON) How should isolation laundry be handled by the laundry staff? The DON stated My staff should be putting it in the water soluble and yellow laundry bags and it should be taken straight back to laundry. I assume housekeeping would do it the same way. The Surveyor asked Should laundry staff be using PPE when handling isolation laundry? The DON stated Yes.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 5 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 02/08/2024 The findings are: 1. On 02/04/24 at11:34 AM DE #1poured the pureed vegetable into a pan. He covered the pan with foil and placed it in a pan of hot water on the stove. The consistency of the pureed vegetable blend was not smooth. There were pieces of carrots in the mixture. 2. On 02/04/24 at 11:38 AM Dietary Employee (DE) #1 used a #8 scoop to place 6 servings of rice pilaf into a blender, added broth and pureed. At11:40 AM DE# 1 poured the pureed rice into a pan. The consistency was gritty, sticky and not smooth. 3. On 02/04/24 at 12:08 PM A pan of pureed bread to be served to the residents who required pureed diets was on the steam table. The consistency of the breadcrumbs was lumpy and not smooth. 4. On 02/04/24 at 12:37 PM Dietary Employee (DE) #3 placed 10 servings of carrot cake into a blender, added whole milk and pureed. At 12:39 PM DE #3 used a # 8-scoop to place pureed carrot cake into 5 bowls. The consistency of the pureed carrot cake was not smooth and was a little thick. There were pieces of carrots visible in the mixture. 5. On 02/04/24 at 12:46 PM The surveyor asked the Dietary Supervisor to describe the consistency of the pureed foods served to the residents who required pureed diets. She stated, Pureed pork roast and pureed rice, pureed carrot cake and pureed bread have little lumps in them, and not pudding consistency.

Based on interview and record review the facility failed to ensure 1 (Resident #35) of 5 (Residents #13, #21, #35, #42, #66) sample mix residents that were reviewed for unnecessary medications received a diagnosis prior to receiving an anti-depressant medication. The findings are: Resident #35 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 showed a Brief Interview for Mental Status (BIMS) of 99. A Staff Assessment for Mental Status (SAMS) was completed that showed short term and long-term memory problems. The resident is taking an antidepressant. The diagnoses showed type 2 diabetes mellitus; anxiety disorder; cerebral infarction; heart failure; stiffness of right hand; contracture of right hand, right knee, and left knee. No diagnosis observed in the resident's chart for depression. The Physician's Order Summary showed Remeron Oral Tablet 30 milligrams (mg) (Mirtazapine) Give 30 mg by mouth in the evening for Depression with an order date of 5/1/23 and a start date of 5/2/23. The Care Plan showed the resident uses antidepressant medication. Nursing staff are to administer antidepressant medications as ordered by the physician. On 02/07/24 at 01:01 PM, the Nurse Consultant (NC) provided a Pharmacy Medication Regimen Review (MRR) for antidepressants dated 11/8/2023. The MRR showed Escitalopram Oxalate (Celexa) Oral Tablet 10 mg 1 tablet by mouth 1 time a day. Additional antidepressant of Remeron 30 mg every night with an original start date of 5/2/23. Pharmacy recommendation was to decrease Celexa to 5mg. The consultant pharmacist notes showed an indication for depression. The physician's recommendation was to decrease Celexa to 5mg (discontinued 11/12/23). Depending on how the resident does, I will consider discontinuing. I am seeing the resident this month. On 02/07/24 at 01:07 PM, the Surveyor asked the Director of Nursing (DON) Can you show me in Resident # 35 chart the diagnosis for depression? The DON stated There is no diagnosis for depression. The Surveyor asked Can you show me what antidepressant medication the resident is on? The DON stated they are on Remeron for weight loss. Not depression. The Surveyor asked Should there be a diagnosis for depression? The DON stated If they had a diagnosis for depression. The Surveyor asked Does the resident have a diagnosis for depression? The DON confirmed Resident # 35 does not have a diagnosis for depression. On 02/08/24 at 09:15 AM, the DON stated I spoke with Resident # 35's Dr. yesterday and they said that they did not want to diagnose the resident with depression until they spoke with and evaluated them.

Based on observation and interview the facility failed to ensure a homelike environment for 1 (room [ROOM NUMBER]) room on the 200 Hall. The facility also failed to ensure residents meals were removed from serving trays in the dining room to de-emphasize the institutional character of the setting to promote dignity and respect. This failed practice had the potential to affect 2 (Resident's #21 & #42) sample mix residents who received a tray on the 200 Hall during lunchtime Sunday 2/4/24 according to a list provided by the Nurse Consultant on 2/7/24 at 1:01pm. The findings are: 1. On 02/04/24 at 11:01 AM, the Surveyor observed 2 holes approximately 1 inch each side by side in room [ROOM NUMBER]'s bathroom wall by the commode. 1A. On 02/05/24 at 08:34 AM, the Surveyor observed 2 holes approximately 1 inch each in the wall by the commode where a toilet paper holder would be placed. 1B. On 02/06/24 at 10:47 AM, the Surveyor observed 2 holes approximately 1 inch each in the wall by the commode of room [ROOM NUMBER]'s bathroom. 1C. On 02/07/24 at 10:55 AM, the Surveyor asked Maintenance Please describe the bathroom wall to me. Maintenance stated There is no toilet paper holder and there are 2 holes in the wall. Maintenance measurements were as follows, left hole 7/8 high x 1 1/8 wide and the right hole was 1 high x 1 3/8 wide. The Surveyor asked Do you consider this homelike? Maintenance stated, No. 1D. On 02/07/24 at 11:02 AM, the Surveyor asked the DON Will you please describe the bathroom wall to me. The DON stated There are a couple of holes in it. The Surveyor asked Do you consider this homelike? The DON confirmed it was not homelike. 2. On 02/04/24 at 12:33 PM, the Surveyor observed 12 Residents served lunch in the secure unit dining room. The residents' meals and drinking glasses were not removed from the serving trays. 2A. On 02/04/24 at 12:53 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 Are the meals always served on the trays in the dining room? CNA #1 stated I have always left the meals on the trays. The Surveyor asked Would it be considered homelike to eat a meal still on the serving tray? CNA #1 stated No, I didn't think about it like that. 2B. On 02/04/24 at 12:56 PM, the Surveyor asked CNA #2 Do you leave the meals on the trays when they are served in the dining room? CNA #2 stated I usually remove them from the trays and stack the trays on top of the cart. The Surveyor asked Are the meals left on the tray today? CNA #2 confirmed the lunch meal was left on the serving trays in the dining room. 2C. On 02/08/24 at 09:04 AM, the Surveyor asked the DON How should a meal be served in the dining room? The DON stated the staff should offer hand sanitizer and then remove the items from the tray. They should assist the residents with opening items and cutting up food. The Surveyor asked Should a meal ever be served on a serving tray in the dining room? The DON confirmed a meal should not be served on a serving tray in the dining room unless preferred by a resident.

Based on observation and interview the facility failed to ensure a vial of long-acting insulin was properly labeled with an open date. This failed practice had the potential to affect 1 (Resident #12) sample mix residents according to a list provided by the Nurse Consultant on [DATE] at 1:01pm. The findings are: On [DATE] at 02:41 PM, the Surveyor observed Hall 300 cart with one 10 milliliter (mL) multi-dose vial of Insulin Glargine (Lantus) 100 Units/mL with an expiration date of ,d+[DATE] with no open date listed on the vial. On [DATE] at 03:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 When opening a new vial of insulin what should be done? LPN #1 stated It should be dated. The Surveyor asked What could happen if it is not dated? LPN #1 stated You could give expired medication. On [DATE] at 03:05 PM, the Surveyor asked the Director of Nursing (DON) Should insulin be dated when opened? The DON stated Yes. The Surveyor asked What could happen if it is not dated? The DON stated It may not work correctly. The Surveyor asked Is this vial of insulin dated? The DON confirmed the insulin vial did not have an open date. On [DATE] at 02:36 PM, the Surveyor requested a Medication Administration Policy for Insulin. On [DATE] at 03:49 PM, the Nurse Consultant stated We do not have a policy.

Based on record review and interview, the facility failed to ensure an injury of unknown source/origin was reported to the Office of Long-Term Care (OLTC) and other agencies in accordance with state and federal laws for 1of 1 (Resident #2) of 3 sampled residents. This failed practice had the potential to affect 73 residents that reside in the facility. The findings included: Review of Resident #2's progress notes dated 09/11/2023 showed the following: a. A diagnosis of severe dementia with agitation. b. A nursing progress note dated 08/21/2023 at 4:19 PM showed the nurse was informed Resident #2 was experiencing pain when the left leg is moved. The nurse assessed Resident's left leg and noted an open area to the LLE (left lower extremity). The Advanced Practice Nurse was notified, and a X-ray of Resident #2's LLE was performed. The X-ray finding was an acute femoral intertrochanteric (hip) fracture. Record review of an Office of Long-Term Care (OLTC) DMS (Division of Medical Services) /7734 Form showed the date & time of discovery as 08/21/2023 at 3:50 PM and the date incident reported to OLTC as 08/22/2023 at 4:50 PM. During interview on 09/11/2023 the Surveyor asked the Administrator when was the fracture incident of Resident #2 reported to OLTC? The Administrator stated, This was reported as an unusual occurrence and I did not suspect abuse, that's the reason it was not submitted in the 2-hour period. The following interviews occurred on 09/12/2023: a. At 10:09 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 how did Resident #2 obtain a fracture of the hip? CNA #1 stated, I don't know. b. At 10:35 AM, the Surveyor asked the Social Worker (SW) how did Resident #2 obtain a fracture of the left hip? SW stated, I do not know. c. At 11:00 AM, the Surveyor asked the Director of Nursing (DON) how did Resident #2 obtain a fracture of the left hip? The DON stated, I do not know. The Surveyor asked was Resident #2's reportable incident reported to the state office within the 2 hours? The DON stated, I don't know. The Surveyor asked, who is responsible for reporting to the state office? The DON stated, The Administrator. d. At 11:26 AM, the Surveyor asked the Administrator how did Resident #2 obtain a fracture to the left hip? The Administrator stated, The doctor thought it was non-traumatic. The Surveyor asked, did anyone observe how the fracture happened to Resident #2's left hip? The Administrator stated, It was unwitnessed. The Surveyor asked, was Resident #2 able to tell you what happened? The Administrator replied, No. The Surveyor asked, was Resident #2's reportable incident reported to the state office within the 2 hours? The Administrator replied, We reported that as an unusual occurrence. Review of facility's policy titled Abuse, Neglect, and Maltreatment Investigation and Reporting provided by Administrator #2 on 09/11/2023 at 10:25 AM showed the following: a. The facility will protect residents from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, and misappropriation of resident property. The resident has the right to be free from physical or mental abuse. b. Facility staff shall comply with Section 1150 B of the Social Security Act, and report reasonable suspicion of abuse or serious injury to a resident immediately, but not later than two hours.

Based on observation, interview, and record review, the facility failed to ensure it was free of any significant medication errors as evident by failing to administer scheduled insulin according to the Physicians Orders for Resident #5 and administering scheduled Alprazolam at a higher dose than the Physician Orders for Resident #6. The findings are: 1. Resident #5 was admitted to the facility on [DATE] with diagnosis of Encounter for Attention to Ileostomy and Diabetes Mellitus with other skin ulcer. a. Review of the Physician's order with a start date of 6/2/23 and an end date of 6/8/23 revealed an order for Levemir 100 units at bedtime related to Type 2 Diabetes Mellitus. Levemir is a type of insulin. b. Review of the Physician's order with a start date of 6/8/23 revealed an order for Levemir 10 units at bedtime related to Type 2 Diabetes Mellitus. c. The Care Plan with an initiation date of 06/19/23 documented, . [Resident #5] has Diabetes Mellitus . Interventions include diabetes medication as ordered by the doctor. d. The June Medication Administration Record (MAR) documented resident did not receive the ordered Levemir 100 units on 06/03/23, 06/04/23, and 06/07/23 and documented Resident #5 received the ordered Levemir 100 units on 06/05/23 and 06/06/23. Licensed Practical Nurse (LPN) #2 stated in her interview she did not administer the Levemir on 06/05/23 and 06/06/23 it was documented incorrectly. e. On 06/21/23 at 11:01am, the Surveyor asked the Director of Nursing (DON), On Resident #5 it is documented she had an order for Levemir 100 units at bedtime. Did she receive that medication? The DON stated, No. LPN #3 documented on two days that she did not give the medication because the resident refused. LPN #2 documented on two days that she administered the medication. The Surveyor asked, Did she administer it? The DON stated, No It was signed off incorrectly. When she (LPN #2) put in the blood sugar, she (LPN #2) put it down, but she did not give the medication. The order was put in late Friday evening, and it was wrong. I corrected 10 units on 06/08/23. We pulled the medication list from the hospital and when the order was pulled it was put into our system incorrectly. The Surveyor asked, Was the Nurse Practitioner notified? The DON stated, Yes. The Surveyor asked, Did the resident ever receive 100U (Units) of Levemir? The DON stated, No. The Surveyor asked, Did you tell LPN #2 to go ahead and administer the 100 units as it was ordered? The DON stated, No, I told her to verify the order based on the records from the hospital. The Surveyor asked, Do you have any documentation regarding what occurred? The DON stated, Yes, I put it in a medication error for the transcription error. I have it in my office. I need to go get it. f. On 06/21/23 at 11:19 am, the Surveyor asked the DON, Did Resident #5 get any Levemir on those 5 days where the order was incorrect? The DON stated, No, she did not. The Surveyor asked, Why did it take five days to verify the order? The DON stated, LPN #3 called the on-call number and on call did not return her call. We normally verify orders of new admissions on the following day and we were going to meet on that Monday since she admitted on Friday, but we had a Surveyor come in on Monday and we put that on the back burner. The Surveyor asked, So the resident went without her Levemir for five days? The DON stated, Yes, but her blood sugar during that time remained within her baseline. g. On 06/21/23 at 11:44am, the DON provided a form labeled, Medication/Transcription Error Report. The form was completed on 06/09/23 stating, Levemir 100U/ml [units/milliliter] order entered in as give 100 ml . h. On 06/21/23 at 3:35pm, The Surveyor asked, LPN #2, How long have you worked here? LPN #2 stated, Since April. The Surveyor asked, Are you familiar with Resident #5? LPN #2 stated, Yes. I must give her a lot of attention. Her [family member] is in the room with her, and they both need a lot of attention. The Surveyor asked, Did you know she had an order for Levemir 100 units? LPN #2 stated, Yes, I am very aware of that because I am the one that reported to the APRN [Advanced Practice Registered Nurse] and the DON on Wednesday. They were together at the same time when I informed them. She [Resident #5] came in on a Friday and I left early, and another nurse came in. I finished my med [medication] pass, and the nurse took over for me. I am the type of nurse that I will tell you everything I am going to do. I asked the resident when I checked her blood sugar and it never went above 200, how many units do you normally take? Because the reason I am asking is because the order was for 100 units. The resident did not know what she took. If her blood sugar was higher around 500, I would have given it to her but not under 200. This was on Monday. I called Monday and they did not respond to my call and her blood sugar was still within limits. On Wednesday I went to APRN and the DON on 200 Hall and asked them to look at the resident's order for Levemir. The APRN wanted me to get labs on her and she stated she will further investigate why it was 100. The DON told me to give it and I refused to give it because it did not sit well with me. I went over to 300 Hall and APRN came and told me it was supposed to be 10 units not 100 units. I promise I did not give her 100 units of insulin. I was not properly trained on how to use the system. I did not know that I was marking that I gave it. I was just trained on the system to get by basis and not how to deep dive training. I am just being honest with y'all. I always let my patients know what I am going to do or not do. I told her on both those days that I was not comfortable giving that amount of insulin. I did not follow the orders. If something doesn't look right, I am not going to do it. If something is wrong, I am going to report it. I am a new nurse, and I am not going to lose my license. I wasn't properly trained on [Facility Electronic Medical Record]. I told her it was a mistake in the system. I felt a lot better with 10 units. Her blood sugar has never been over 200 with me. The Surveyor asked the LPN #2, So on those three days, did the resident get any Levemir? LPN #2 stated, On Wednesday I gave her 10 units because as soon as APRN told me about it. I didn't confirm the order on Friday. When I came back on Monday the orders were already in. I don't know how to put in orders. I went ahead and did it on Wednesday. I knew the order had been changed from 100 to 10. 2. Resident #6 was admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis, Fibromyalgia, Hereditary, and Idiopathic Neuropathy. a. The Care Plan with an initiation date of 11/07/22 documented, uses anti-anxiety medications anxiety disorder . [Resident #6] has Multiple Sclerosis . Interventions include, administer anti-anxiety medications as ordered by the physician. b. A review of the Order Recap Report for the period of 6/18/23 to 6/30/23 revealed the Alprazolam 1 milligram (mg), three times per day for generalized anxiety order was discontinued on 6/19/23. The Alprazolam 0.5 mg three times per day had an order start date of 6/19/23. c. On 06/21/23 at 1:42 pm, the Surveyor asked the Nurse Consultant, Did Resident #6 have a Methadone overdose and go to the hospital? The Nurse Consultant stated, Yes. [Medical Director] came in on Monday and decreased her Xanax because of the emergency room visit. She was taking Xanax 1mg [milligram] three times a day and he decreased it to 0.5mg three times per day and he thinks it may be Xanax. d. On 06/21/23 at 1:47pm, the Nurse Consultant provided a copy of the order change on the Alprazolam from 1mg three times per day to 0.5mg three times per day. The new order was to start on 06/19/23. (pg. 1) e. On 06/21/23 at 3:27 pm, the Nurse Consultant and LPN #1 did a medication card audit on Resident #6 Xanax with the Surveyor present. LPN #1 removed the Xanax card, and it was labeled 1mg three times a day. The Surveyor asked, LPN #1, Do you have any other cards of Xanax in your narcotic box? LPN #1 stated, No. The Surveyor asked, What dose is the Xanax? LPN #1 stated, 1 milligram. The Surveyor asked, Did you give any of the 1 mg Xanax today? LPN #1 stated, Yes. The Surveyor asked, How many have you given today? LPN #1 stated, Two doses. The Surveyor asked, Did you know the order changed on the 19th? LPN #1 stated, No. The Surveyor asked, What is your process for changing medications out when there is an order change? LPN #1 stated, We should have got a new card and I would have given this one to the DON. f. On 06/21/23 at 3:32 pm, the Nurse Consultant provided a copy of the Narcotic Book for Alprazolam 1mg, and it documented where the resident received 5 doses of the 1mg instead of the 0.5mg from 6/19/23 to 6/21/23. g. On 06/21/23 at 4:13pm, the Surveyor asked the Nurse Consultant, Did you tell me the resident's order for Xanax changed on Monday? The Nurse Consultant stated, Yes it was Monday at approximately 1:35pm. The Surveyor asked, What is your process for changing medications out when there is an order change? The Nurse Consultant stated, The nurse that took the order should have obtained a hard script and immediately pulled the 1 milligram card off the med cart. The Surveyor asked, How does the pharmacy know there was an order change? The Nurse Consultant stated, When the order is put into [Electronic Medical Record] it goes to the pharmacy and the nurse that took the order would have faxed the script over to the pharmacy. The Surveyor asked, Who did the Medical Director give the new order to? The Nurse Consultant stated, [Name] the DON. h. On 06/21/23 at 4:13pm, the Nurse Consultant provided a copy of resident #6's MAR (Medication Administration Record). The MAR documented that Resident #6 had received the new dose 0.5mg of Xanax starting on 06/19/23 at 4:00 PM. The facility did not have 0.5 mg dose of Xanax in the building. i. On 06/21/23 at 4:13pm, The Nurse Consultant provided a copy of the Medication/Transcription Error Report. The report documented, Describe concern using Factual Terms: On 06/19/23 new order for Alprazolam oral Tablet 0.5 mg (milligram) TID (Three times per day) was ordered. Order for Alprazolam oral tablet 1mg was D/C'D (Discontinued). Medications given 1 mg was given on 06/19/23 1600 [4:00pm] 06/20/23 0800 [8:00], 06/20/23 1200 [12:00], 06/21/23 0800 [8:00], 06/21/23 1200 [12:00] .LPN #1 Medication pass check off to be completed . The nurse consultant provided a copy of the same medication/transcription Error Report for another nurse that gave 1mg instead of 0.5mg as the Doctor ordered. j. The facility policy titled, Preparation and General Guidelines HA2: Medication Administration-General Guidelines provided by the Nurse consultant on 06/22/23 at 8:58am documented, .5) The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medications and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container had not already been flagged indicating a change in direction, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. When medication order is changed and the current supply can continue to be used, the container should be flagged right away and the order change communicated to the provider pharmacy so that the next supply of medication is labeled with the current directions .D. Administration: .2) Medications are administered in accordance with written orders for the prescriber. 3) If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to administration of the medication or if necessary, contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate .HA7: Controlled Substances: Policy, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulation .E. Accurate accountability of the inventory of all controlled drugs is maintained at all time. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record) 3) Remaining quantity (Accountability Record) 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record).

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented to prevent the development of communicable diseases and infections as evidenced by failure to sanitize hands between residents during medication administration. The findings are: a. On 06/22/23 at 7:12am, the Surveyor observed LPN #4 provide a resident medication then exited the resident's room. She did not sanitize her hands when she exited the room. LPN #4 started preparing medications for Resident #14. She entered the room and administered medications to Resident #14, then. exited the room and went to her medication cart and documented the medication administration. She did not wash or sanitize her hands. LPN #4 prepared the medications for Resident #13. She crushed the medications and mixed them with pudding. She locked her medication cart and dropped her keys on the floor. She picked up keys from the floor and placed the keys in her shirt under her bra strap. LPN #4 did not wash or sanitize hands. LPN #4 entered Resident #13's room and administered the medication in pudding orally. She walked over to the door, placed a glove on her right hand, and then administered eye drops in each eye of Resident #13. LPN #4 removed her glove and placed glove and medication cup in the trash can. She went to her medication cart and did not wash or sanitize her hands. LPN #4 started preparing medications for Resident #5. She entered Resident #5's room and administered the medications orally. She exited Resident #5's room and went to her medication cart and did not wash or sanitize her hands. b. On 06/22/23 at 7:51am, the Surveyor asked LPN #4, When should you wash or sanitize your hands? LPN #4 stated, If the resident is in isolation, I should wash after I leave their room. I guess I should sanitize hands after every resident. The Surveyor asked, Why do you wash or sanitize between each resident? LPN #4 stated, To prevent cross contamination. The Surveyor asked, Did you sanitize your hands between those three residents that you gave mediations to? LPN #4 stated, I did not but I will. LPN #4 walked over to the hand sanitizer on the wall and sanitized hands. c. On 06/22/23 at 7:57am, the Surveyor asked Assistant Director of Nursing (ADON), When should you sanitize your hands during medication administration? The ADON stated, Before doing your medications, before going into the room, and when you come out and if you touch something before doing your next meds then obviously you should sanitize your hands again. The Surveyor asked, Why do you sanitize your hands? The ADON stated, Infection control so that I am not passing germs onto other residents and cross contaminate them. d. On 06/22/23 at 8:17am, the Surveyor asked the Director of Nursing (DON), When should you sanitize your hands during medication administration? The DON stated, Between Residents, before and after residents. The Surveyor asked, Why do you sanitize your hands? The DON stated, It is protocol, standard of practice, Infection control. e. The facility policy titled, Preparation and General Guidelines HA2: Medication Administration-General Guidelines, provided by the Nursing Consultant on 06/22/23 at 8:58am documented, Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .2) Hand washing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass; prior to handling any medication; before and after administration of ophthalmic .9) Hands are washed before putting on examination gloves and upon removal from administration of topical, ophthalmic .medications . f. The facility policy titled, Hand Hygiene, provided by the Assistant Administrator on 06/22/23 at 9:19am documented, Guidance: All staff will perform proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors .Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. @ [at] Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60 to 95% [percent] alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the resident .Between Residents .Before preparing or handling medication .After handling items potentially contaminated with blood, body fluid, secretions or excretions . g. The facility policy titled, Infection Prevention and Control Program, provided by the Assistant Administrator on 06/22/23 at 9:19am documented, Guidance: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with and organism that could be transmitted during providing resident care services. B. Hand Hygiene shall be performed in accordance with our facility's established hand hygiene guidance. C. All staff shall use personal protective equipment (PPE) according to established facility guidance governing the use of PPE. D. Licensed staff shall adhere to safe injection and medications administration practices, as described in relevant facility policies .

Based on observation, interview, and record review, the facility failed to ensure the drainage bag of an indwelling catheter was below bladder level to prevent cross contamination and possible infection for 1 (Resident #7) of 3 (Resident #7, #8, #12) sampled residents. The findings are: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses of Other Cerebrovascular Disease, Personal history of Urinary Tract Infections and Peripheral Vascular Disease. a. The Care Plan, last revised on 09/20/23 documented, Resident #7 has an indwelling urinary catheter related to urinary retention, with interventions to include, position catheter bag and tubing below the level of the bladder. b. On 06/19/23 at 11:07am, Resident #7 was sitting in his Geri-chair in the Day Room. He had an indwelling catheter and the bag was next to him in the chair. The bag was not below the bladder. c. On 06/22/23 at 8:17am, the Surveyor asked the Director of Nursing (DON), When a resident is in a Geri chair where should the catheter bag be placed? The DON stated, On the side of the Geri chair, there is a spot for them. The Surveyor asked, Is ok for the bag to sit in the chair beside the resident? The DON stated, No. d. On 06/22/23 at 9:37am, The Assistant Administrator stated, We do not have a policy on foley catheters.

Based on observation, record review, and interview, the facility failed to maintain sufficient staffing to ensure provision of timely care for 4 (Residents #2, #3, #4, and #6) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents who indicated call lights are not answered in a timely manner, and resident bathing is not completed on a regular basis. The findings are: 1. Resident #2 had diagnoses of Multiple Sclerosis and Neuromuscular Disorder of the bladder. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/23 documented the resident received a score of 15 (13-15 indicates cognitively intact), on a Brief Interview of Mental Status (BIMS), and required two-person total physical assistance with bed mobility, transfer and toileting. a. Resident #2's Bathing Task sheet for 5/17/23 through 6/13/23 documented the resident received a shower on 5/17/23, 5/22/23, 5/29/23, 6/1/23 and 6/5/23 and a whirlpool bath on 5/31/23. b. The care plan for Activities of Daily Living (ADL) self-care deficit, last updated on 11/1/22 revealed Resident #2 requires total assist with two staff for bathing. c. On 06/13/23 at 3:30 PM, Resident #2 told the Surveyor, They work short all the time. We are supposed to get a bath three times a week, but it rarely happens. See my bed? It hasn't even been made yet. Resident #2's bed was unmade with no linens on it. While talking to Resident #2, a CNA came into the room with linens and stated, I will be back to make your bed. 2. On 06/13/23 at 12:00 PM, observed the call light from room [ROOM NUMBER] lit and an audible sound noted at the Nurse's Station. The light was on continuously until 12:45 PM, when a staff member took a lunch tray into the room and the call light was turned off. The Surveyor asked the Director of Nursing (DON) Are you short staffed today? The DON stated, No. The Surveyor asked, During meal service, who is responsible for answering call lights. The DON stated, Some Certified Nursing Assistants (CNAs) serve lunch in the Dining Room and there is a CNA that remains on each hall to answer call lights. 3. On 06/13/23 at 1:00 PM, the Surveyor met with the Ombudsman who was in the facility on a visit. She related that she had received concerns pertaining to staffing and a linen shortage. 4. Resident #3 had a diagnosis of Multiple Sclerosis. The Quarterly MDS with an ARD of 04/13/23 documented a score of 15 (13-15 indicates cognitively intact) on a BIMS, no refusal of care behavior and was dependent on two people physical assistance with bed mobility, transfers and bathing and toileting. a. Resident #3's Bathing Task sheet for 5/17/23 through 6/13/23 documented the Resident received a bath on 5/22/23, 5/29/23 and 6/2/23. No refusals were documented. b. The care plan for ADL self-care performance deficit, last updated on 10/31/22 revealed Resident #3 is totally dependent on staff for bathing and requires two staff for assistance. 3. Resident #4 had a diagnosis of Dementia, The Quarterly MDS with an ARD of 03/26/23 documented a score of 13 (13-15 indicates cognitively intact) on a BIMS, with no rejection of care exhibited and required physical help of one person with bathing. a. Resident #4's Bathing Task sheet for 5/17/23 to 6/13/23 documented the Resident received a tub/whirlpool bath on 5/23/23 and 6/8/23. b. The care plan for ADL self-care performance deficit, last updated on 10/3/22 revealed Resident #4 requires extensive assistance by one staff for bathing, and a bed bath should be provided if a full bath or shower cannot be tolerated. 4. Resident #6 had diagnoses of muscle wasting and atrophy and dysuria. The Quarterly MDS with an ARD of 05/17/23 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), and no behavior problems were exhibited. Two-person extensive assistance required for bed mobility, transfer, and toileting. a. On 06/13/23 at 3:21 PM, observed Resident #6 lying in her bed in mid position, with a fall mat bedside the left side of her bed. She held out her hand motioning the Surveyor to come to her bedside. When the Surveyor approached, she moved the sheet and showed the Surveyor that the adult brief that she had worn was soaked with urine, the bed under pad was thoroughly soaked with urine, and was dripping onto the fall mat and the floor. The Surveyor immediately asked the DON to accompany to Resident #6's room. The Surveyor asked the DON to look under the sheet and describe what she saw. The DON stated, Oh we need to get them cleaned up. I know they take Resident #6 to the bathroom after lunch before they lay her down. I think that's her bowels. Five call lights were going off on the 100 Hall during this time. The DON stated, There are two CNA's who work this hall, one has gone to the laundry to get some linen, let me get someone down here to help. b. The care plan for ADL self-care performance deficit, last updated on 9/20/22 revealed Resident #6 requires substantial/maximal assistance of 2 staff with bathing and showering and bed mobility. 5. On 06/13/23 At 3:52 PM, the Surveyor asked LPN #2 if the nursing home worked short staffed very often? LPN #2 stated, Quite a bit, at times The Surveyor asked if residents had gone without baths or call lights answered during those times. LPN #2 stated, They may not get a bath, but call lights are always answered, I've answered call lights myself a lot when we are short. 6. On 06/13/23 at 9:36 AM, the Surveyor asked CNA #1, How often do you have to work short? CNA #1 responded, Not very often. We were short with only one CNA on the hall Wednesday, Thursday and Friday of last week. The Surveyor asked, What happens when this occurs? CNA #1 stated, I take care of my residents and will get help from one of the other halls if 2 people are required, such as transfers. She went on to say two staff members had to leave today. 7. On 06/13/23 at 9:49 AM, the Surveyor asked CNA # if they had to work short very often. She stated that no they did not, especially on the secure unit. The Surveyor asked if CNA#2 knew if the floor had to work short. CNA #2 stated that if they did, they were the bath assistant in the secure unit and they would go out and help with baths if needed. CNA #2 stated we all help each other out. 8. On 06/13/23 at 9:51 AM, CNA #3 stated they work short on the floor at times, but everyone helps each other to get patient care done. The Surveyor asked how many staff are normally on the secure unit. CNA #3 stated that they normally have two CNAs and one bath assistant. 9. On 06/13/23 at 1:03 PM, the Surveyor asked, LPN #1 if they had to work short very often. LPN #1 stated, Sometimes, yes. The Surveyor asked, Do residents go without receiving a bath or must wait for care? The response was, No. 10. The Resident Council Minutes provided by the Administrator on 06/12/23 at 10:00 AM, documented, A concern from residents about the length of time it takes to get their call lights answered during the March, April and May 2023 meetings. The Minutes from the March, 2023 meeting noted showers are not given when there are only two CNA's on the hall.

Based on interview, and record review, the facility failed to ensure the confidentiality of resident's records when they sent another resident medication card containing personal identifiable information home with one (Resident #3) of 2 (#2 and #3) sampled residents that went home on a leave of absence in the last 3 months. The findings are: a. On 05/24/23 at 1:40 PM, the Surveyor asked the Administrator, Are you aware of any resident going on a leave with family and another resident's medication card being sent home with that resident? The Administrator stated, Yes. I had a family member speak with me and they said they had some concerns. I asked them if they would like to have a care plan meeting and they said that they would, but they wanted to wait until the next day because more family members wanted to come. The next day when we were having the care plan meeting, they told me that another residents medication card had been sent home with their family member. I asked them to please bring the medication card back. The next day when they brought their family member back to the facility, they brought me the medication card. The Surveyor asked, Who was the resident who went home on leave with family? The Administrator stated, The resident was (Resident #3). The Surveyor asked, Did the family bring the medication card back? The Administrator stated, Yes. The next day when they brought the resident back, they brought the card back and gave it to me. The Surveyor asked, What resident did the medication card belong to? The Administrator stated, When the family member gave it to me, I took it immediately to the nurse on the floor and gave it to her to make sure it got back to the correct resident. I did not look at the name on the card. The Surveyor asked, Do you know which nurse you gave the medication card to? The Administrator stated, No. I do not remember who I gave it to. The Surveyor asked, Should a medication card belonging to another resident have been sent home with (Resident #3)? The Administrator stated, No. The nurse should have caught that and have been more in tuned with what she was sending home. The Surveyor asked, Would sending another residents medication card that included the residents name and information regarding the medication the resident was taking be considered a breach of confidentiality? The Administrator stated, Yes. It could be. I was concerned with whether the resident whose card got sent with (Resident #3) had been receiving their medication and checked with the nurse's. I was told that they had gotten the residents medication from the Emergency drug box so that she did not miss any medication. The Surveyor asked, Was there anyone else at the care plan meeting that might know who the medication card that was sent home with (Resident #3) belonged to? The Administrator stated, The Director of Nursing (DON) was at the meeting, but she no-longer works here. The Surveyor asked, Was anything done to ensure the this does not happen again? The Administrator stated, The DON said that she would have two nurses to sign out for the medications when a resident goes home on leave to make sure this does not happen again. The Surveyor asked, Do you have an in-service to show that the DON implemented this change in process? The Administrator stated, I am not sure I will have to check. b. On 05/24/23 at 3:30 PM, the Surveyor asked the Administrator, Were you able to find an in-service regarding having two nurses check medications when a resident goes home on leave to be sure the correct medications are sent with the resident? The Administrator stated, No, but we have started an in-service now to ensure two nurses reconcile the resident's medications before they are sent home with the Do you have a policy on confidentiality? The Administrator stated, I will check and see. c. The facility policy titled Confidentiality, (Revised 2022) provided by the Administrator on 05/24/23 at 3:40 PM, documented, .It is the policy of this facility to carefully protect the confidentiality of . our Elders . and business information associated with our facility. Employees are prohibited from disclosing confidential and/or sensitive information to unauthorized persons without proper authorization. Information pertaining to the health status or medical conditions of any Elder at the nursing home is confidential and cannot be discussed with any individuals outside the nursing home except for purpose of providing for the Elders' care of operation of the facility . d. The Inservice Education Report provided by the DON on 05/24/23 at 3:55 PM documented, .When a resident is being discharged or LOA (Leave of Absence) .Make sure you are looking at the name on the card and the medication .Make sure the name on the card matches the Name of the resident, medication, dose and directions .

Based on observation, interview, and record review the facility failed to ensure weekly skin audits were reported to ensure the residents received treatment and care in accordance with professional standards of practice for one resident (R #1) of 6 sample mix (#1, #2, #3, #4, #5, #6) residents. This failed practice had the potential to affect all 77 residents as documented on the facility Census and Condition provided by the Administrator on 03/22/23. The findings are: Resident (R) #1 had diagnoses of Alzheimer's, Dysphagia, and Autistic Disorder. The Annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 02/18/23 documented a Staff Assessment for Mental Status (SAMS) of 3 [3 indicated severe cognitively impaired]. R #1 required extensive assistance of 2 people for transfer and toileting. Section M0150 of the MDS documented the resident was at risk for developing a pressure ulcer/injury. a. R #1 was admitted on [DATE]. Record Review of the R #1's weekly body audits did not have documentation for 02/15/23, 02/22/23, 03/01/23, and 03/08/23. b. The Care Plan documented, .The resident is at risk for Impaired Skin Integrity r/t [related to] incontinence with brief usage Date Initiated: 03/09/23 .Resident's risk for impaired skin integrity will be minimized through plan of care .Conduct body audit weekly .has a Stage 3 pressure ulcer to the left greater Trochanter Date Initiated: 03/10/23 .Assist with turning and repositioning as needed. Minimize amount of time resident is placed on area of current pressure ulcer location . c. The Skin and Wound Evaluation form documented, . 03/10/23 . A 1. Describe . 15. Pressure . 15 a. Stage 3: Full-thinness skin loss . 22. Location Left Trochanter . 23 . In-house Acquired . 24 . 2. Exact date . 24 a. 03/10/23 .) d. On 03/27/23 at 10:40 am., the Surveyor asked the Director of Nursing (DON), How often are skin audits done? She said, Weekly. The Surveyor asked, Are they being done weekly? She said, They were not being done. The Surveyor asked, Do you have a policy? She said, No.

Based on observation, interview, and record review the facility failed to ensure 1(Resident #2) of 3 (Residents #1, R #2, R #3) sampled residents always had water available. The facility failed to ensure 1(Resident #2) of 3 (Residents #1, R #2, R #3) sampled residents always had their call light within reach. Resident #2 had a diagnosis of CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, CONSTIPATION, UNSPECIFIED, PERSONAL HISTORY OF URINARY (TRACT) INFECTIONS, and REPEATED FALLS. The Admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of October 11, 2022, documented the resident scored 15 (13-15 Indicates Cognitively Intact) on a Brief Interview for Mental Status (BIMS). She required limited one person assistance for bed mobility; Set up assistance with eating, and total dependence with one person for toilet use. a. On 12/16/22 at 10:45 AM, Resident #2 was in bed and was leaning toward the edge of the bed. Her pillow and call light were on the floor. Resident #2 stated, can you get me up? I was supposed to have been up a long time ago. I want to get in my wheelchair, and I have on a shitty diaper, which I don't like. All they do is play games and watch TV. The Surveyor asked Resident #2, can you push your call light? Resident #2 stated, I can't because I can't reach my call light. I tried getting it with my grabber, but I can't get it. The Surveyor asked resident #2, when was the last time staff checked on you? She stated, Three hours ago. There was no pitcher, or water in Resident #2 room. The Surveyor asked Resident #2, how often do the staff give you water? She stated, 'they don't give me any. The Surveyor asked Resident #2, do you like water? She stated, I love water. b. On 12/16/22 at 10:55 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, can you tell me why Resident #2 doesn't have any water available? She stated, I'm not her assistant. I'm just helping. I'm not sure about water. The Surveyor asked CNA #1, Should a resident's call light be within reach at all times? She stated, Yes. c. On 12/16/22 at 11:07 AM, the Surveyor asked the Director of Nurse (DON), who's responsible for passing out water and ice for the residents? She stated, the CNAs on the hall. The surveyor asked the DON, Should a resident's call light be within reach at all times? The DON stated, Yes. The Surveyor asked the DON, can you tell me why Resident #2 didn't have ice or water in her room? She stated, I cannot I'll have to find out. d. On 12/16/22 at 11:35 AM, the Surveyor asked CNA #2, Is there a reason why Resident #2 don't have water, or a pitcher in her room. She stated, I did the ice this morning and I thought she had water in her room. The Surveyor asked CNA #2, Should the call light be within reach at all times? CNA #2 stated, Yes, it should be. e. On 12/16/22 at 11:48 AM, the Surveyor asked Licensed Practical Nurse LPN #1, who's responsible for passing out water and ice for the residents? She stated, the assistants, but anybody can do it if the aides can't get to it. The Surveyor asked LPN #1, Should a resident's call light be within reach at all times? She stated, Yes. The Surveyor asked LPN #1, can you tell me why Resident #2 didn't have ice or water in her room? She stated, The assistant was on the hall passing ice. I thought she had some.

Based on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before they handled clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 83) as documented on a list provided by Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 11:14 AM, during the initial tour of the kitchen with the Dietary Manager the dry storage room contained the following: a. A flat of 12 cans of chicken noodle soup with no received date. 2. On [DATE] at 11:39 AM, the following on a metal bread shelf on wheels: a. A bag of Hawaiian rolls not dated b. 2 loaves of sliced white bread not dated 3. On [DATE] at 11:44 AM, the following were in the Refrigerator & and Freezer on the 200 Hall (Unit). The Surveyor asked, What items are from the kitchen? The Dietary Manager stated, None of this is from the kitchen. a. A can of Sports Drink had no name or date. b. 4 bottles of water had no name or date. c. A plastic bottle of cranberry juice had no name or date. d. A plastic bottle of Fruit Punch had no name or date. e. 3 small plastic cups of reddish-orange thick liquid had no name or date. f. A tv dinner had no name or date. g. A frozen cup of applesauce had no name or date. h. The Surveyor asked, How do staff know which food items are for the residents? The Dietary Manger asked Certified Nursing Assistant (CNA) #1 who stated, Some are Activities, some are for the residents, and some are staff. The Surveyor asked, When a new Certified Nursing Assistant comes to cover the hall, how do they know whose items they are? The Dietary Manager stated, They would not. They would have to ask someone that is usually here. i. On [DATE] at 1:16 PM, The facility policy for Storage of Food and Beverages Brought by Visitors documented, .Food or beverage brought in from the outside will be monitored by nursing staff for spoilage, contamination, and safety .Foods or beverages brought into the facility by guests or visitors will be labeled with the specific resident's name, room number, and dated with the current date the item is brought into the Facility for storage outside the resident's room . 4. On [DATE] at 8:58 AM, The following were in the refrigerator on the 200 Hall (Unit). a. An opened box of honey ham, the box was not covered. b. One carton of yogurt had an expiration date of [DATE]. 5. On [DATE] the following hand hygiene observations were made in the kitchen: a. At 10:07 AM, Dietary Employee #1 turned on the hand washing sink and washed his hands, then turned off the faucet. He pushed on the lever of the paper towel dispenser with his bare hands, dispensed a paper towel, dried his hands. He picked up a tray of leftover juice glasses and placed it on the dirty side of the machine. He did not wash his hands, he picked up glasses by the rims and stacked them up, then picked up plates and placed them on the plate warmer, his fingers touched the interior surfaces of the plates. b. At 10:18 AM, Dietary Employee #1 turned the hand washing sink on and washed his hands. He turned off the faucet. He used his bare hand to press down on the paper towel dispenser handle. He used the paper towel to dry his hands and contaminated his hands. He pulled his hair net down, did not wash his hands, picked up more glasses by the rims, placed them on the trays, and poured water in them. c. On [DATE] at 11:37 AM, Dietary Employee #1 picked up an object from the floor and placed it in his pocket. He did not wash his hands, he picked up utensils by the tips and wrapped them up in individual napkins for the residents use. d. On [DATE] at 11:39 AM, Dietary Employee #1 washed his hands, turned off the faucet, used his bare hand to press down on the paper towel dispenser handle. He used the paper towel to dry his hands which contaminated his hands. He picked up glasses by the rims and placed them on the trays. He pushed a cart that the contained glasses towards the ice machine. As he filled the glasses with a scoop, he used his hand to wedge and push ice into the glasses to be served to the residents. e. At 1:17 PM on [DATE], The Surveyor asked Dietary Employee #1, what should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 6. The Hand Washing Policy provided by the Dietary Supervisor on [DATE] at 4:10 PM documented, Food handlers must wash their hands after touching anything else such as dirty equipment, work surfaces or cloth.

Complaint # (AR 564) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure a resident who was at high risk for elopement was properly monitored on an unlocked unit to prevent potential for accident and or injury for 1 (Resident #1) of 1 resident who was high risk for elopement. This failed practiced resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who wandered from the facility and was found walking on a busy street, two miles from the facility and had the potenital to cause more than minimal harm to 17 residents who were at risk for elopement, according to a list provided by the Administrator on 10/01/2020. The facility removed the Immediate Jeopardy and corrected the failed practice on 09/26/2020 prior to the survey. The Administrator was notified of the Past Immediate Jeopardy on 10/01/2020. The findings are: 1. Resident #1 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The entry Minimum Data Set (MDS) documented the resident scored 2 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS). a. The Interim Care plan dated 9/25/2020 documented, .resident wanders in and out of quarantine room . b. The Wander Collection Tool dated 9/25/2020 documented Has the resident wandered? Did the resident wander at home, in previous living setting, family/significant others voiced concerns? response: Yes.Is a wander/elopement risk . and .Resident is a high risk for wandering. Res (Resident) ambulates independently, is confused (and) A&O x1 (alert and oriented times one). Res is also non-complaint with respiratory/droplet isolation x2 weeks. Res is currently on a quarantine hall and is unable to be on dementia (secure) unit for wandering. Staff is aware of res' wandering and will continue to monitor . c. On 9/25/2020 at 6:17 pm, an admission/readmission note documented, .resident admitted from (Facility in Arkansas). Report from RN (Registered Nurse) stated some confusion, that she was found wandering in neighborhood with hallucinations and delusions . d. On 10/1/20 at 1:14 pm, the Administrator was asked about an incident which occurred on 09/26/2020, What time was the resident observed to be missing? The Administrator stated, Resident asked for toilet paper around 5:15 pm and the Certified Nursing Assistant (CNA) made resident rounds at 5:30 pm and observed another resident in her room and then realized resident was missing. An as needed CNA called the facility around 6:15 or 6:30 and stated she seen resident walking by (local Mexican Restaurant). The resident recognized the CNA and got in the car with the CNA. The CNA returned the resident to the facility. I personally called the police at 6:27 pm. When I got to the facility, the (RN) completed a body audit on the resident. The (Police Officer) came into the facility and laid eyes on the resident. The resident was placed on 1 on 1 monitoring until she was moved to the dementia unit. The RN and I went around and checked all the windows in the resident rooms. We then completed in-services for staff on wandering residents. The Administrator was asked, What was put in place to prevent this from happening again? The Administrator stated, We checked all windows, checked to ensure all residents were accounted for, checked residents with Wanderguards, and completed assessments for all residents at risk for elopement. The Administrator was asked, How often do staff make rounds? The Administrator stated, Every two hours and we monitored her quite a bit. e. On 10/1/20 at 4:24 pm, Licensed Practical Nurse (LPN) #1 was asked, What time did you find out the resident was missing? LPN #1 stated, I don't remember. I was counting narcotics to finish my shift. We started looking for the resident then about 10 minutes later we got a call that she was walking down the road. LPN #1 was asked, How did the resident leave the building? LPN #1 stated, The window was open, and the screen was down. The screen slides up and down easy. LPN #1 was asked, Were you still there when the resident returned? LPN #1 stated, Yes, I did a body audit and she did not have any bruising or injuries. LPN #1 was asked, How was the resident's mood when she returned? LPN #1 stated, She was happy when she came back. f. On 10/1/20 at 4:39 pm, Registered Nurse (RN) #1 was asked, What time were you notified? RN #1 stated, I was notified by the Administrator about 6:15 -6:30 pm. RN #1 was asked, What time was the resident found to be missing? RN #1 stated, Around 5:15 the resident asked for toilet paper and the CNA was making rounds at 5:30. The resident was not in her bed. The CNA noticed the screen was up on the resident's window. The resident arrived back at the facility between 7:15 and 7:30 pm. LPN #1 completed a census check and a full body audit. The resident did not have any injuries. We placed a CNA with her to be one on one. At 7:30 pm, I went and did a body audit myself to verify there were no injuries. I spoke to the resident, and she stated she wanted to go for a walk. RN #1 was asked, What was put in place to prevent this from happening again? RN #1 stated, We in-service the staff on elopement and we completed an elopement risk assessment on all residents at risk. We did one on one for this resident. The Administrator and myself checked all window [MEDICATION NAME] and windows to make sure they were secure and working properly. g. On 10/1/20 at 4:57 pm, CNA #2 was asked, Can you tell me what happened on Saturday night? CNA #2 stated, I was riding down (a busy street) and I seen the resident walking by (the Mexican Restaurant). I went to my friend's house and called the facility. They told me the resident was missing. I told them I seen her, and I would go back to pick her up. I drove back to (the Mexican Restaurant) where the shopping center is at and the resident got in the car with me. I took her back to the facility. I walked her to her room on the 400 Hall. CNA #2 was asked, Was there any injuries with the resident? CNA #2, No, she was happy and walking without difficulty. h. On 10/1/20 at 5:03 pm, CNA #1 stated, I was working 400-hall. I was doing rounds about 5:15-5:30 and another resident was in (Resident #1)'s room. I took that resident back to her room and started looking for (Resident #1) since she was not in her room. I went up and down the hallway looking for her. I notified the nurse to let her know, I could not find the resident. I went to the front to see if anyone had seen her go out the front door. I then went to the laundry room out back and she was not there. We realized her window was up, (Nurse) and I went outside looking for her. I jumped in my car and went up and down Hinson Road. I took a left on(NAME)and did not see her. We had everyone at the facility doing a sweep of the facility. CNA #1 was asked, How long was the resident out of the building? She stated, Probably about an hour. i. The Resident Elopement Policy and Procedure provided by the Administrator on 10/1/2020 at 11:22 am documented, .All residents will be assessed for behaviors and conditions that put them at risk for elopement . 2. The facility initiated corrective action immediately after the incident on 9/26/2020 by implementing the following: .a. Resident #1 was observed in room with 1/1 observation with no negative findings noted. b. Body audit was completed with no negative findings c. Window checked and intact/secured d. Census count had been completed e. All windows and doors were checked with no negative findings noted. f. Inservice on Abuse and Neglect, Elopement policy and procedure started g. Interviews started h. Wandergaurd ordered and placed on resident i. Residents wander risk assessments reviewed and updated with changes/as needed. Immediately identified 17 residents at risk for wandering. Completed 11 of wandering risk assessments 9/27/2020. Completed remaining 6 wandering risk assessments on 10/1/2020. j. Administrator/designee will begin monitoring 3 x week until compliance is achieved to ensure residents that are at risk for wandering remain in a safe environment. Any negative findings will be corrected immediately, and Administrator/Designee notified. On 09/27/20: a. Inservices on Abuse/Neglect and Elopement continued b. Resident was transferred to Secured Dementia unit c. Maintenance checked windows x 2 to ensure all windows were functioning properly .

Complaint # (AR 072) and Complaint # (AR 077) were substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure there was adequate visibility through a window in the door to the Secured Unit to prevent potential accidents for 1 (Resident #17) of 1 sampled resident who was at risk for falls on the secured unit. The failed practice resulted in actual harm for Resident #17 who was struck by a door by an employee resulting in a humeral condyle fracture, and had the potential to cause more than minimal harm for 11 residents who resided on the Secured Unit, according to a list provided by the Nurse Consultant on 7/14/2020 at 11:53 a.m. The Administrator was notified of the Actual Harm situation on 7/14/2020 at 11:53 a.m. The findings are: a. Resident #17 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 4/9/2020 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required limited one person physical assistance for bed mobility; required limited one person physical assistance for transfer; was independent for walking in room per setup help only; was independent for walking in corridor per setup help only; was independent for locomotion on unit per setup help only; was independent for locomotion off unit per setup help only; required extensive one person physical assistance for dressing, toilet use, and personal hygiene; and had no falls since prior assessment. b. A Care Plan with a revised date of 6/22/2020 documented, .I have a fracture to my left elbow . Administer my medications as ordered . Order for sling as tolerated to LUE (Left Upper Extremity) . F/U (Follow-up) with ortho dr. (Orthopedic Doctor) in one week . 7/1/2019 . I am at risk for falls r/t (related to) wandering and unsteady gait . Refer me for Therapy screen as appropriate . 6/1/2020 . In-service staff on being careful when entering the retreat area . 6/22/2020 . X-ray to left elbow . elbow is fractured . c. A Nurses Note dated 6/1/2020 at 9:28 a.m. documented, .At 1415 (2:15 p.m.) the resident was hit by the door of the unit as it was opened causing her to stagger a few steps backwards and land on her butt. The CNA (Certified Nursing Assistant) working on the unit was entering the locked door w/ (with) supplies and didn't see her through the window d/t (due to) resident crouching down . Res (Resident) paces up and down the hall all day and often pauses and rests at the end with the doors just out of sight from the other side if you're looking through the windows on either door. Res. witnessed staggering back and falling to the ground by CNA that was entering the unit. Assessed by myself and Day Shift Nurse. No injuries noted or c/o (Complaints Of) pain. Cont. (Continued) amb (Ambulating) w/o (without) difficulty after assisting off of the ground. Res. had amb (ambulated) to the end of the hall and was in the Dining Room by the time I left the unit and came back w/ (with) a v/s (vital sign) machine. No visible limp or change in gait noted. BP (Blood Pressure) 113/67, P (Pulse) 76, R (Respirations) 18, T (Temperature) 96.8. APN (Advanced Nurse Practitioner) notified @ (at) 1437 (2:37 p.m.) and no new orders rcv'd (received). DON (Director of Nursing) @ facility and made aware @ 1449 (2:49 p.m.). Res.'s (Resident's) son called @ 1620 (4:20 p.m.) and msg (message) left to call facility. Res.'s daughter called and notified of incident @ 1623 (4:23 p.m.) and appreciative for notifying her . d. A Resident Incident Report dated 6/1/2020 at 4:49 p.m. documented, .Narrative of incident and description of injuries .At 1415 (2:15 p.m.) the resident was hit by the door of the unit as it was opened causing her to stagger a few steps backwards and land on her butt. Res. (Resident) Witnessed staggering back and falling to the ground by CNA that was entering. Assessed by myself and Day Shift nurse. No injuries noted or c/o (complaint of) pain. Cont. (continued to) amb. (ambulate) w/o (without) difficulty after assisting off the ground . Immediate Post-Incident Action . Had staff in-service reminding them to use caution and pause and look through the windows prior to opening the door and entering the unit . e. A facility In-Service Form dated 6/1/2020 documented, .When entering the retreat be careful and cautious of the residents behind the door . f. A facility Resident Incident Report dated 6/20/2020 at 10:33 a.m. documented, .Narrative of incident and description of injuries . Resident was walking near the door in the hallway when a CNA was walking into the door. Resident was hit by the door, falling to the floor on her left side. Resident was able to ambulate on her own away from the door. Some swelling and decreased movement in her left forearm . Immediate Actions Taken . Resident was moved to a safer area, assessed for injuries. DON (Director of Nursing) and APN (Advanced Practice Nurse) notified. Vital signs taken and pain medication given . Immediate Post-Incident Action . Asked CNAs to be more cautious when entering doors on the 200 Hall . Narrative of Investigation . Resident was behind entry doors on retreat entry. She is small stature and difficult to see when she is standing by door. Staff entered in the door and resident fell on her left side. She had swelling to her left forearm and facial grimacing when movement was noted. Initial x-ray showed no injury however the following day resident had increased swelling and new x-ray was done to elbow showing fracture. She was sent to ER (emergency room ) for eval (evaluation). She has order for sling to left arm. Today she is showing signs of increased difficulty walking. New x-ray was ordered and PT (Physical Therapy) to screen . g. A Nurses Note dated 6/20/2020 at 3:07 p.m. documented, .Resident was walking in the hallway on 200 (Hall) near the door. As a CNA entered, resident was hit by the door causing her to fall onto her left side. Some swelling and decreased movement in her left forearm. Vitals (vital signs) stable, pt. (patient) still able to ambulate as before. X-Ray ordered for left forearm and Tylenol given for pain . h. A Fall Risk assessment dated [DATE] documented, .Total Score (Total Score of 10 or above represents High Risk) . Grand Total . 11 . i. A (Radiology) x-ray digital image dated 6/20/2020 documented, .Forearm Left (2V (views)) AP (anteroposterior), LAT (lateral) .Findings . Views of the left forearm show bony architecture to be Osteopenic. No definite bone or soft tissue abnormality is seen . Impression . No acute injury . j. A physician's orders [REDACTED].Mon (Monday) Sling LUE (Left Upper Extremity) as tolerated . k. A Nurses Note dated 6/22/2020 at 6:35 p.m. documented, .Rad. tech (Radiology Technician) @ (at) facility to x-ray L (left) elbow around 3pm (3:00 p.m.). Report rcv'd (Received) @ 1547 (3:47 p.m.) . Acute Lateral Humeral Condyle Avulsion Fx (fracture). APN (Advanced Practice Nurse) @ facility and copy of report given. V.O. (Verbal order) rcv'd @ 550 (3:50 p.m.) to send to ER (emergency room ) of family's choice . Daughter called @ 1601 (4:01 p.m.) and notified of fx (fracture) and stated she wanted res. (resident) sent to (Hospital) ER (emergency room ). MEMS (Metropolitan Emergency Medical Service) called, and transport requested @ 1607 (4:07 p.m.). Report called to ER @ 1610 (4:10 p.m.) .Nurse stated they're on diversion d/t (due to) no open rooms and a full waiting room and that they may not accept. MEMS @ facility @ 1625 (4:25 p.m.) and left @ 1628 (4:28 p.m.) . l. A (Radiology) Digital x-ray dated 6/22/2020 documented, .Elbow Left (2V) (2 Views) AP (Anteroposterior) LAT (Lateral) .Findings . Frontal and lateral views left elbow submitted. No prior studies. Acute Lateral Humeral Condyle Avulsion Fracture. Lateral view is oblique, cannot assess for joint effusion. The Unotrochlear and Radiocapilellar joints are with mild [MEDICAL CONDITION] changes. Osteopenia . Impression . Acute Lateral Humeral Condyle Avulsion Fracture . m. A Nurses Note dated 6/22/2020 at 6:49 p.m. documented, .Report rcv'd from RN (Registered Nurse) (at) (Hospital) ER (emergency room ) (at) 1840 (6:40 p.m.) . Fx (fracture) verified to L (left) elbow. Will be in sling. Wear as tol (tolerated). Rx (Prescription) for [MEDICATION NAME] and will need to f/u (follow-up) w/ (with) ortho (Orthopedics). Res. (Resident) coming back by MEMS (Metropolitan Emergency Medical System). APN (Advanced Practice Nurse) notified and given okay to send Rx (prescription) to pharmacy and give as directed . n. An Advanced Practice Registered Nurse (APRN) Progress Note dated 6/26/2020 documented, .Today she is being seen following a Fall. Has left elbow pain with limited movement. She cannot complain but limited or no movement obvious. 6/22/2020 X-ray . Acute Lateral Condyle Avulsion Fracture . Assessment / Plan . 1. Closed Fracture of Condyle of Humerus . Send to ortho (Orthopedic Doctor) for further eval (evaluation) . o. A (Radiology) Digital Image dated 7/2/2020 documented, .Pelvis (1 to 2V (one to two views) AP (anteroposterior) . Impression . No acute abnormality . p. On 7/13/2020 at 10:10 a.m., Resident #17 was sitting in a wheelchair in the Day Room with her feet flat on the floor. There was no assistive devices or sling on the resident's left arm. q. On 7/13/2020 at 11:45 a.m., Resident #17 was propelling herself down the hallway returning from taking a shower. The resident's left arm was resting in her lap and no assistive device was in place. r. On 7/13/2020 at 11:48 a.m., a sign hanging on the outside and inside of the door of the Retreat Unit documented, .Retreat . Please be cautious when opening this door for everyone's safety . Thank You . s. On 7/13/2020 at 3:36 p.m., Registered Nurse (RN) #1 was asked if he was familiar with (Resident #17). He stated, Yes. He was asked if he remembered an incident involving the resident. He stated, Yes. The resident was knocked down by the door when a staff member came through it. The resident got up and walked. She did not have any injuries. t. On 7/14/2020 at 1:56 p.m., Certified Nursing Assistant (CNA) #4 was asked if she was familiar with (Resident #17). She stated, Yes. I remember the resident falling at the beginning of June (June 2020). I was bringing supplies to the hall. I am tall and could still not see through the little window. The resident was crouched behind the door. I did see the resident fall. I bumped the resident with the door. The nurse was at the beginning of the hall and came to look at resident. We had an in-service to make sure we look through the window. I do not know who did the fall at the end of June (June 2020). After the second fall, I do not know why the resident was not walking. She had pain in her hip. u. On 7/14/2020 at 2:15 p.m., the Director of Nursing (DON) was asked if she was familiar with (Resident #17). She stated, Yes. The incident that happened towards the end of June (June 2020) happened on a weekend. I instructed the weekend staff to be cautious when entering the unit and to distract residents away from the doors. From June 22nd (6/22/2020) through June 25th (6/25/2020) the resident was not ambulating. The resident had hip pain post fall, but we had the staff keep her occupied and away from the doors. A Nurse does stay on the hall during meal service. We did an in-service on being cautious when entering the unit. v. On 7/14/2020 at 3:47p.m., RN #2 was asked if she was familiar with (Resident #17). She stated, Yes. She stated she does remember the resident falling. She stated, The resident would pace the hallway. She is short and she would get down behind the door. The CNA did not see the resident when she opened the door. I am the RN Supervisor and was not on the hall at the time of the incident. (RN #3) told me of the incident. I did assess the resident and did the Incident Report. The resident was non-verbal, she not moving her left arm as much, and she was holding her arm. An x-ray was ordered. (RN #3) called the doctor. The rest of the shift I checked on the resident frequently. I tried to get her vital signs, but I couldn't get them. The resident would not allow it. The resident continued to wander. We did finally have the resident sit in the office and was able to give her pain medication and she allowed the x-ray to be done. I was not there when the x-ray results came back. I did tell the DON of the incident. She told me to tell the CNAs to be more cautious when entering the unit. There was a sign on the door going in and coming out alerting us to be cautious. w. On 7/15/2020 at 10:10 a.m., CNA #5 was asked if she was familiar with (Resident #17). She stated, I have worked the Retreat Unit since starting here. I am familiar with (Resident #17). The resident had a fall about a month ago. The resident was ambulating well. She would stand up and would constantly walk up and down the hallway. The resident never sat in any activities. The resident would stop for a few minutes, rub her hands together, and would then continue to walk. The resident would stand by the doors. I was on the hall on the day of the incident. It was me and another aide (Certified Nursing Assistant). We were pushing residents to the Dining Room. I did not witness the fall. I heard someone saying a faint 'Hey, hey'. I then saw resident on the floor behind the doors. The resident will stand in the corner behind the doors. I do not remember who came through the doors. We went to get the nurse. The nurse assessed the resident. The resident started limping and was rubbing her arm. The resident's arm was swollen. We did get the resident to go to the MDS (Minimum Data Set) office for her x-ray to be done. The resident has been in a wheelchair ever since the fall. We are always being told to watch the door when we enter the Unit and to be careful. We have had a repeat in-service since the fall to be cautious when entering the Unit. There has been a sign on the door instructing us to be careful when entering the Unit. This sign has been there since the Retreat Hall was started. The resident is now more stationary. She is now in a wheelchair. x. On 7/15/2020 at 10:31 a.m., CNA #6, was asked if she was familiar with (Resident #17). She stated, Yes. I work on the Retreat Unit 80% of the time. The resident was ambulatory prior to her fall. She does now walk a few times. The last time that she walked she was a little clumsy. The resident used to pace constantly. The fall happened 2 to 3 weeks ago. I can't remember if I was here on the day of the fall. I am only aware of the resident having one fall. The shower aide pushed the door open and the resident fell backwards. There has been a sign on the door ever since the doors were closed making it into a Retreat Unit. We have had a few in-services telling us to be careful when we open the doors to the Unit. y. On 7/15/2020 at 11:21 a.m., CNA #7 was asked if she was familiar with (Resident #17). She stated, Yes. The resident was a walker, walked up and down the hall. I know that resident would stand behind the doors. The resident would walk to the door, stand there for a while, then turn around, and repeat the same behavior. She's always had that behavior. Walking and wandering. I am not aware of the resident falling at the beginning of June (June 2020). I am aware of the fall towards the end of June (June 2020). I was pushing the hall trays onto the Unit. I could not see through the glass. I couldn't see anyone back there, even if I looked through the glass. I could not see resident. She was in the corner by the door. I did look through the door window before I opened it. The door hit the resident as I was pushing the cart (tray cart) onto the Unit. I had one hand on the cart and one hand on the door. It was a cart full of trays. As I pushed the door, it hit the resident. I got the nurse. She was on the hall and she checked her out. Later we had an in-service. It was before the end of the shift that day, to be cautious when going through the door. I did write a statement and the Staffing Coordinator, she educated me on how to open the doors real slow. About six months ago they put out an in-service when the doors were first locked to be careful when we go through the doors. I was pushing the (tray) cart and holding the door at the same time. The door tapped the resident and she lost her balance and fell . I saw the resident as I was entering but she was already falling. I had my back turned as I was going through the doors. There was a nurse right there close to the door. She was passing meds (medications). There has been a sign on the doors for a long time, more than a month, telling us to be careful when we open the doors. z. On 7/15/2020 at 1:38 p.m., RN #3 was asked if she was familiar with (Resident #17). She stated, Yes. I am usually assigned to the 200 Hall and a few residents on the 300 Hall. I do remember one Saturday that the resident fell and sustained a fracture to her elbow. The resident was behind the door. The CNA did not see resident behind the door and knocked her down. I was not on the Unit at the time of the incident. I was passing meds (medications) on the 300 Hall. The CNA came and told me about the fall. I did assess the resident and an x-ray was ordered of her arm. If an in-service was done about the incident, I know nothing about it. I have worked on the Unit since April (April 2020). There has been a sign on the door instructing us to be cautious when going through the doors ever since I have been working the Unit. I know nothing about the fall earlier in June (June 2020). The resident did use to pace up and down the hallway and would stand behind the door. The staff are aware of the sign on the door. I always practice caution when entering the Unit.

Complaint # (AR 014) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure the facility van restraint system was not easily released by a resident during transport for 1 (Resident #3) of 3 (Residents #3, #1, and #2) case mix residents who were transported in a wheelchair via the facility van. This failed practice resulted in Immediate Jeopardy, which caused or could have likely caused serious harm, injury, or death to Resident #3, who moved her foot off the wheelchair pedal touching the restraint system release button on the floor of the van resulting in the restraint loosening and the resident's wheelchair tilting during transport, causing shoulder and foot pain, and had the potential to cause more than minimal harm to 53 residents who were transported via wheelchairs in the facility van, as documented on a list provided by the Assistant Director of Nursing (ADON) on 1/13/20. The Administrator was informed of the Immediate Jeopardy condition on 1/3/20 at 12:40 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 10/10/19 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, required extensive two-plus persons assistance for transfers, was totally dependent on one person physical assistance for locomotion off unit, had functional limitation in range of motion of the upper extremities on one side, required a wheelchair and walker for mobility, required [MEDICAL TREATMENT] three times per week, and had no falls since admission or prior assessment. a. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 12/17/19 at 10:45 a.m. documented, .Type of Incident . Neglect 11:30 a.m. Director of Nursing notified Administrator that transportation driver called the facility and reported an incident in the transportation vehicle. CNA (Certified Nursing Assistant) reported that Resident was fastened in her wheelchair in the back of the bus on the left / driver side. When driver was turning left, resident's wheelchair tilted onto it's right side . Resident was noted in wheelchair with q-restraints attached to wheelchair frame and shoulder/lap belt still latched. Resident denied pain or discomfort when Driver CNA asked at that time. Driver and passenger CNA transferred resident to bus seat while readjusting wheelchair to proper positioning. Transferred resident back to wheelchair, fastened wheelchair in back on the right/passenger side of bus. According to passenger .Resident requested to go to appointment . Steps Taken to Prevent Continued Abuse or Neglect During the Investigation . Upon resident returning to facility, nurse noted resident complaining of bil (bilateral) ankle pain and right arm pain. No visible injuries noted. X-Ray results are negative.Van taken out of service and checked by Maintenance and an outside vendor. Seat belt to left / driver side noted to be unlatched at the base. Van will remain out of service until Maintenance and outside vendors inspection are complete and all negative findings are corrected . Abuse and Neglect in-service started . Competency check off completed for driver CNA on 10/25/19 . New competency check off completed for driver CNA on 12/17/19 . Competency check off completed for passenger CNA on 12/1/19 . In-service given to Administrator and Director of Nursing on Van policy and procedure . Maintenance Director and Administrator inspection reveals that shoulder strap located on left / driver side was not latched to the base . CNA doesn't recall it being unlatched initially. 4-Point q-straint is properly working on left / driver side and right / passenger side. Right / passenger side safety straps have no negative findings noted . Investigation reveals that resident can move BLE (bilateral lower extremities) and possible hit red switch with left foot causing restraint to retract and loosen . Checked current driver list and all competency checks are up to date with no negative findings . Will observe and complete competency check offs again for list of drivers . Will monitor proper fastening of wheelchair 5 (times) (per) wk (week) (times) 1 wk, then 3 (times) (per) week (times) 8 wks (weeks) . b. A witness statement form dated 12/17/19 and signed by Certified Nursing Assistant (CNA) #1 documented, .I made a left turn out of Crystal [NAME]. (Resident #3's) wheelchair tipped over to the right towards the lift, with her still in the chair . When I observed (Resident #3), her seatbelt was still on and all four lock hooks were still connected to the wheelchair I called the facility phone (telephone) and (talked) to (Director of Nursing (DON)) . c. A witness statement form dated 12/17/19 and signed by CNA #2 documented, .I was riding in the van. (CNA #1) was turning through the light and I heard something, and I turned around and saw (Resident #3's) chair turned to the right side of the floor . Her seatbelt and everything was still strapped in . d. A Vendor Compliance Officer Statement dated 12/19/19 documented, .(Name) Maintenance Supervisor was in our facility today in a 2012 Ford E-350 Bus . Vin # . for in-service training . The Braun wheelchair lift . and securement system are in proper working order . e. On 1/2/20 at 11:15 a.m., Resident #3 was asked, What can you tell me about what happened to you in the van? She stated, My wheelchair fell over when we made a turn. It was on a Wednesday, but I don't remember the date. We were on the way to the doctor when it happened. She was asked, Who was with you in the van? She stated, It was just me and the girl that usually does it, the one with short hair. She was asked if she buckled her in as she usually does. She stated, Yes. She was asked if that had ever happened before to her. She stated No. She was asked, what did she (CNA #1) do when she fell over. She stated, She pulled over to the side of the road as soon as she could and came back there and checked me over and over. The resident was being transported to a doctor's appointment at the time of the incident. Resident #3 stated, The girl (CNA #1) told the doctor what happened, and the doctor checked me over. She was asked what the facility did when she got back. She stated, The nurse checked me over and they did x-rays to make sure I was ok. f. On 1/2/20 at 12:20 p.m., CNA #1 was asked, What happened that day that the resident's wheelchair turned over in the van? She stated, I was at the light at (Street Name) and I made a left turn. (Resident #3) doesn't like to keep her feet on the pedals, so she has them down on the floor. The latches are on the floor that release the straps that hold the (wheelchair) wheels down and secure them. When I made that left turn, she (Resident #3) tilted to the right and I heard the wheelchair fall. I put on my emergency lights and pulled over. I asked if she was ok and everything was locked and secured on her. The seatbelt was still latched, and the wheel locks were secure on her chair (wheelchair). She stated she was fine, and I helped her get up and sat her in the van seat. I checked her over. Then she stated her left foot was hurting, the top of her left foot. I asked her if she wanted to go back to the facility to be checked or onto her doctor's appointment. She stated she was fine and wanted to go to the appointment which was a swallow study test at (hospital). Once I got her back in her wheelchair and the wheelchair locked back down, I called the facility to speak with (DON) to tell her what had happened. I dropped her (Resident #3) off at her appointment and came back to the facility . CNA #1 stated, One of the buckles (on the facility van) was at fault. The mechanic said it was. g. On 1/2/20 at 12:54 p.m., the Administrator provided one of the retractors that fit in the van to secure the wheelchairs. (The Surveyor took a photograph of the retractor at this time.) The Administrator demonstrated how it worked and how easy it is to release. He was asked if any other incidents like this had taken place where the wheelchair wasn't secure in the van. He stated not since he's been here (6/10/19). He was asked, what about having the resident's feet on the pedals? He stated, If the doctor prescribes that and wants their feet up on the pedals, then they need to be up on the pedals. He reiterated that the van drivers were re-in-serviced on all the vans after this incident and that it should be in the investigation file provided. h. On 1/2/20 at 3:19 p.m., CNA #1 was notified by telephone. She was asked if she remembered making sure (Resident #3's) straps were locked when she was strapped in. She stated Yes ma'am. Because it makes a 'click-in' noise when you have it locked in. And all four straps were still on her wheels when she tilted over. i. On 1/3/20 at 10:04 a.m., CNA #3 demonstrated the wheelchair restraint system without a resident present. (The Surveyor took a photograph of the restraint system at this time.) CNA #1 was asked, What position was the wheelchair in after the turn happened? She stated, It was just tilted to the right. She was never on the floor. The front left seatbelt was loose, and her (the resident's) left (wheelchair) foot pedal was up on her chair. She was asked if anyone else was on the van. She stated, We always have two people if there are two or more residents. The facility van restraint system was checked with two residents who were going to appointments. The Surveyor observed that the resident could put their foot out and press on / reach the release and potentially cause the restraint to be loosened. (The Surveyor took a photograph of this.) j. On 1/3/20 at 11:40 a.m., the DON was asked what (CNA #1) had told her about the wheelchair when she called in after the incident. She stated, She said it (the wheelchair) was tilted on its side. k. The Immediate Jeopardy was removed, and the scope / severity reduced to D on 1/3/20 at 1:50 p.m. when the facility implemented the following Plan of Removal: 1.) On 12/17/19 the Maintenance Director and Administrator documented, .I examined all restraint system on the facility's bus. When tested all retractors were working properly. I did note that the stop on the shoulder strap (driver's side) was missing. I did find the stop that had come off on the bus. Also was noted that the shoulder strap was not connected to the seat belt properly . 2.) A facility form titled Monitoring of Daily Van Inspections was initiated on 12/17/19. The Daily Van Inspections will be performed daily for one week, then three times per week for 8 weeks. The Daily Driver Pre-Trip Inspection form will be utilized during this inspection process. 3.) On 12//18/19 CNAs #1 and #2 were in-serviced and checked-off by use of a facility form titled Transportation Drivers Competency Checklist by the Administrator and Maintenance Director. 4.) A statement provided by the Administrator on 1/3/20 documented, .Upon notification by OLTC that the facility was receiving an immediate jeopardy (IJ) concerning the securing system on the transport van, the van was immediately removed from service .

Complaint # (AR 153) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure the environment was free of accident hazards as evidenced by the facility's failure to thoroughly assess entrapment risks when side rails were placed on beds with low air loss mattresses and adequate supervision was provided in monitoring for gaps between side rails and mattresses for 3 of 3 (Resident #1, 2 and 5) case mix residents who used a low air loss mattress and side rails. This failed practice resulted in Immediate Jeopardy which caused or could have caused harm, injury or death to Resident #1 who was found with her head lodged between the side rails and low air mattress and did not have any vital signs, and placed Resident #2 and #5 at risk for entrapment due to gaps between the side rails and low air mattress. This failed practice had the potential to affect 5 residents who had side rails/assist bars according to the Nurse Consultant on [DATE]. The Administrator was informed of the Immediate Jeopardy on [DATE] at 12:20 p.m. The findings are: 1. The Invacare Manufacturer's Operating Instructions for the Half Bed Rails were received from the Administrator on [DATE] at 8:25 a m. The Operating Instructions documented, .Replacement mattresses and bed rails with dimensions different than the original equipment supplied or specified by the bed manufacturer may not be interchangeable. Variations in bed side rail design, thickness, size or density of the mattress could cause entrapment. Use only authorized Invacare replacement parts The Liberty Series Section B: Assist Devices Optional Assist Bar Installation - Head End Only (received from the Administrator) documented, .Warning when assessing the Risk of Entrapment, consider the bed, mattress, headboard, footboard, assist devices (i.e. rails and assist bars) and other accessories as an entire system. All bed systems are evaluated for full compliance to the FDA/CDRH 'Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment' guidelines . The User's Manual for the Supra CXC Low Air Loss and Alternating Pressure Release Mattress Replacement System did not address the use of side rails in conjunction with the air loss mattress. The Bed Entrapment Zones received from the Administrator on [DATE] documented, .Zone 4 Under the Rail at the Ends of the Rail. The gap between the mattress and the lowermost portion of the rail presents risk of neck entrapment. *Recommended space: less than 2 ,[DATE] inch 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 6 (,[DATE] indicates cognitively impaired) on the Brief Interview for Mental Status, required extensive assistance of two or more people for bed mobility, and bed rails were not used as a restraint. a. The Care Plan documented, Problem Onset: [DATE] - I utilize ,[DATE] rails to aid with turning and repositioning to help define boundaries and help me feel secure and comfortable with bed environment. Approaches: Check ,[DATE] rails as needed to ensure good working order. Evaluate quarterly and as needed for appropriateness and need. Educate me/family as needed on potential injuries r/t (relate to) usage. Notify maintenance as needed of any loose fitting or malfunctioning rails for repair. b. The [DATE] physician's orders [REDACTED]. c. The I/A (Incident and Accident) Report dated [DATE] at 7:00 a.m. documented, This nurse called to resident room, observed resident sitting on floor w (with)/back to bed w/right arm on bed rail asked resident what happened? Resident stated, I fell out of bed, assessed resident from head to toe no injury found at this time, this nurse and CNA (Certified Nursing Assistant) assisted resident back into bed resident denies pain at this time. d. The Side Rail assessment dated [DATE] documented the question, Does the resident have a history of falls? The Evaluation sheet documented no. e. The DMS (Division of Medical Services)-762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, dated [DATE] at 5:00 a.m. documented, (Resident #1) was found unresponsive in room at approximately 5 a.m. by CNA staff members (CNA #1 and CNA #2) who immediately notified charge nurse (LPN #1). (LPN #1) initiated CPR (Cardiopulmonary Resuscitation). EMS (Emergency Medical Services) contacted (Ambulance Services), Police and Fire/Rescue responded. EMS, discontinued CPR and Coroner was contacted by Police. (Resident #1) body was released to funeral home. Incident reported to Administrator/DON (Director of Nursing) resident was found positioned with knees on floor mat and head resting against mattress and chin pointed toward rail. Full investigation was conducted and completed on [DATE]. CNA and LPN stated reenactment of incident. Incident reenactment was conducted by DON, Administrator and Staff. Charge Nurse (LPN #1) reports that (Resident #1) was not wedged and they simply moved her to a supine position to perform CPR. Charge Nurse (LPN #1) reported there were no visible markings on resident to indicate there was entrapment. Resident had low air loss mattress on bed and padded rail and fall mat beside bed with bed in low position. Findings indicate resident may have pulled herself to side of bed due to possible distress and collapsed, slid to knees with head resting against mattress and chin pointed toward side rail. Facility was notified by Coroner on [DATE] that private autopsy was requested by family for questionable cause of death. Facility is reporting incident at this time due to preliminary autopsy reading postural asphyxiation. Coroner will return on [DATE] to conduct investigation with staff to help determine cause of death. 1) A witness statement dated [DATE] at 5:00 a.m. written by CNA #2 documented, At 5 am went into resident's room with another CNA and saw Bed B (Resident #1's) head caught between the upper bed rail and mattress. Resident was half on floor mat from waist down, and head caught in rail. On [DATE] at 9:26 a.m., CNA #2 stated, (Resident #1) could not move her right arm. She required two people to assist her with care because she can be combative at times. She could not roll herself over in bed, it took two people to turn her. She used a wedge for repositioning. If you didn't have the bed up just right she would move when she scratched if the head of the bed was too high. She would lean to the left toward the wall. She was total care with bed mobility, confused, and a mat was on floor.at that time of the incident, (CNA #1) called me in the room. I was shocked how her head and neck was between the rail and the mattress. Her body was limp. That night I was on another hall. I'm usually down there but that night (CNA #1) was down there. When I work with (Resident #1), I've not noticed any problem with the side rail or the air mattress. I had never noticed gaps or side rails being loose. CNA #2 was asked if she had attended or had been trained on monitoring for gaps in the side rails or entrapment zones between the side rail and the air mattress and CNA #2 stated, No, 2) A witness statement dated [DATE] at 5:00 a.m. written by CNA #1 documented, At the start of my shift I did rounds to check on everybody about 11:15 residents were fine and sleeping. At 1:30 a.m., I changed (Resident #1) she went back to sleep after. Every time I went pass I looked in on her. I did another round at 3:30 a.m. When I went back at 5 a.m. I found her on the floor with her head on the side rail with rest of her body on the mat. I called for the nurse to come. On [DATE] at 10:15 a.m., CNA #1 stated, We did everything for her. She would move around a little bit in bed. Some times she would tilt over if the head of the bed was elevated to high. She would wiggle down, we would have to pull her back up. We have never caught her with her leg off of the bed. But I'm sure if she had time to wiggle that much I'm sure she could. CNA #1 stated that the staff did the majority of the turning and repositioning. CNA #1 stated, I had been up and down the hall all night. Between 3:15 a.m. and 3:20 a.m., I had checked on the hall and (Resident #1) had been asleep all night. At 5:00 a.m., I went down to get her up, she was on the floor. She wasn't moving. I called (LPN #1), he came immediately. (LPN #1) told me to call 911. I left. CNA #1 was asked if she could remember whether or not there was anything wrong with the side rail such as being too loose, gaps between the side rail and air mattress and CNA #1 stated, It never crossed my mind. But now I would be more conscious of that. She was asked if she had attended or had been trained on monitoring for gaps in the side rails or entrapment zones between the side rail and the air mattress and CNA #1 stated, No, f. The nurse's notes dated [DATE] at 7:53 a.m. and written by LPN #1 documented, at 5:00 am on [DATE] (CNA #1) requested this (LPN #1) to assess resident. As I entered the room, (Resident #1) was off her knees on her fall mat and head resting on the side of bed, chin resting on side rail. Resident was non responsive, slight blue colored skin around the lips, slightly cool to touch, Repositioned resident to her back, assessed for pulse and tried a sternal rub with no response. Around this time (CNA #2) and (LPN #2) entered the room. I called out to call 911, (LPN #2) repeated order and (LPN #2) called for the crash cart. I started chest compressions, when the cart arrived the ambu bag and oxygen were hooked up. CPR continued between the three of us, still not getting pulse. When EMS, Fire, and Police arrived, I briefly explained situation, working with responders the residents chart was checked and identified resident as a DNR (do not resuscitate). At this point, emergency response stopped . On [DATE] at 10:42 a.m., LPN #1 stated, When the CNAs notified me to come to (Resident #1's) room I didn't dislodge her (from between the mattress and side rail), there was no problem getting her on her back. LPN #1 also stated that he had worked twice since the incident on [DATE] and there had been no inservicing regarding identifying entrapment zones or gaps between the mattress and side rails. g. On [DATE] at 6:20 a.m., CNA #3 stated Resident #1 could not reposition herself in the bed. We always had two people with bed mobility. CNA #3 was asked if Resident #1 had side rails and CNA #3 stated, Yes, we had written in the maintenance log they had been loose at one point. CNA #3 was asked if Resident #1 needed the side rails and she stated, Yes and no. She would not use them herself to reposition. She would maybe grab to hold when we turned her. The morning the incident happened ([DATE])afterward me and another CNA went back into the room. The bed was at it lowest position. You know the side rails are straight up and down. Well, her side rail was loose. It concerned me. You could just tell it, you could pull on it a little bit. The maintenance log was reviewed and no maintenance request were found for loose side rails. h. On [DATE] at 10:16 a.m., the Maintenance Supervisor stated he looked at the side rail after the incident and stated it looked like a typical side rail. He also stated, I don't think that anyone had messed with the bed or the side rail and no one had reported any issues with the side rail not working properly. The Maintenance Supervisor stated he had not been told to monitor the side rails on a routine basis for proper functioning or entrapment zones. He stated the mattress Resident #1 was using at the time was rented, so it did not come with the bed. The Maintenance Supervisor stated he only checked the rooms over when residents were moved out of the rooms. He stated, I have a checklist I go by. The checklist did not specifically list side rail functioning, or monitoring gaps between mattresses with side rails. i. On [DATE] at 6:56 a.m., Licensed Practical Nurse (LPN) #3 stated she was off that night ([DATE]). She stated, (Resident #1) was total care. She had a bad rash that scratched to the point you could see blood under her fingernails. When she was in the bed she didn't move much. She leaned to the left side more. She has fallen out of the bed before. It's been about 2 months ago. (Resident #1) had side rails. The bed was up against the wall and had one side rail in use on the right side. LPN #3 was asked if Resident #1 could use the side rails and LPN #3 stated, No, I never seen that. I am not sure she could grab the side rail. She would try to move to turn from side to side. LPN #3 stated she had not been inserviced on identifying and monitoring beds with siderails for entrapment zones. j. On [DATE] at 8:32 a.m., CNA #4 stated he occasionally took care of Resident #1. CNA #4 stated, (Resident #1) was confused at times, incontinent, and was total care. Staff had to reposition her in bed, help her roll over. She could not reposition herself. She wasn't aware of her movements. She had a real bad skin disease. She would scratch frequently. Her scratching a lot would cause her to wiggle and move about somewhat in bed. We would have to reposition her. She had small rails. He was asked if the resident used the rail at all and CNA #4 stated, Sometimes she was able to use the rail, we would have to que her to hold it. I just know that when I have repositioned her. I would leave and come back and see that she is in a different position. I've had to reposition her because her legs were hanging on the side, looked like she was going to fall out of the bed. The CNA was asked, Did you ever notice gaps between the mattress and side rail? CNA #4 stated, No. The CNA was asked, Did she use the side rail as a restraint? CNA #4 stated, I don't think they were used as a restraint. I don't think the side rail was used to keep her in bed. He was asked why were the side rails in use and CNA #4 stated, Well, I guess they were then (used as a restraint). They were used to keep her safe. k. On [DATE] at 8:51 a. m., CNA #5 stated, (Resident #1) pulled onto the rail. She would help if she wasn't in her way like having anxiety, combative or calling names. But it was related to her pain from the skin disease she had. The side rails were not used as a restraint. I assume they were used to help her roll. To my knowledge there was no issue with the side rail. She would wiggle herself down lower than the side rail. She would wiggle herself down and lean toward the right side of bed. Her head would be leaning against the rail sometimes. l. On [DATE] at 9:11 a.m., CNA #6 stated, I helped assist with (Resident #1) from time to time. When it came to scratching she would scratch so bad. She would wiggle so much to get to the areas to scratch, she would not be aware she was scooting about in the bed. (Resident #1) would need two people to help reposition her in bed . We would reposition her and leave then come back 20 minutes later she had wiggled down in the bed. We had to reposition her again. m. On [DATE] at 11:35 a.m., CNA #7 stated, I took care of (Resident #1). She was total care and scratched a lot. Because of her scratching, she would be agitated . she couldn't move really. She needed us to adjust her in bed.she did have side rails. CNA #7 was asked why she had side rails and he stated, I don't know, maybe just in case to prevent her from falling. She only used her hand to scratch with that's about it. He stated that he had no idea why the side rail was up because she never used them to pull over with. CNA #7 was asked if he had attended any training or inservices since the incident ([DATE]) regarding monitoring gaps in side rails or identifying entrapment zones between the mattress and side rails and he stated, No, the next day I came to work, there were no more side rails in the building. n. On [DATE] at 11:05 a.m., the Coroner stated, We initially weren't told of any of this, that there were any problems. If we had known there was any question or concern surrounding the death, we would have done an investigation right then, but then (physician who conducted the autopsy) called me. He said I need to turn this case back over to you. Apparently someone tipped the family off that the resident was found hanging and died . The family hired (Doctor) for a private autopsy and he told me he found something in the autopsy that would support this. His preliminary finding is Positional Asphyxia. Now, I will do my report and give it to him and he could change his findings, but right now he's leaning toward that because of what he found. The Coroner also stated that when interviewing (LPN #1, CNA #1 and CNA #3), We got three totally different stories from the three employees. o. On [DATE] at 2:43 p.m., the Administrator was asked, Based on the staff interviews, staff indicated there was no inservice conducted after the incident occurred on [DATE]. Has there not been a formal inservice to inform staff of the entrapment zones and monitoring gaps between the mattresses with side rails? The Administrator stated, It was not done. As far as entrapment zones, paperwork was not given out. p. On [DATE] at 3:14 p.m., the Administrator provided the 2009 FDA (Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment documented, Zone 4 is defined as This space is the gap that forms between the mattress compressed by the patient, and the lower most portion of the rail, at the end of the rail. Factors that may increase the gap size are: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. The space poses a risk for entrapment of a patient's neck. It may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The space may increase, decrease, become less accessible, or disappear entirely. Thus, in some positions, the potential for entrapment in this zone may still exist when the deck is articulated. q. The Coroner ' s Report prepared by the physician and faxed to the Office of Long Term Care on [DATE] documented, This [AGE] year old white female died of positional asphyxia. Investigation of the circumstances of death revealed that the decedent was a patient at Pleasant Valley Nursing & Rehabilitation where, reportedly, she was wheelchair bound due to a remote cerebral aneurysm which resulted in a cerebral infarction. She was reportedly found with her head trapped between the upper bedrail and the mattress.Autopsy demonstrated petechial hemorrhage involving the face and left conjunctivae. Petechial hemorrhage were also present on the right hand and laryngeal mucosa. 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive assistance from two or more staff for bed mobility, and side rails were not used as a physical restraint. a. A Resident Incident Report dated [DATE] at 7:45 p.m. documented, At 1945 (7:45 p.m.) CNA yelled out resident is on the floor, observed resident lying on the floor mat in fetal position on her left side beside her bed, alarm sounding . b. The Care Plan updated on [DATE] documented in the Problem section, I am at risk for falls. The Approach section documented, Fall mat . Low bed with assist rail . Bolsters added to air mattress [DATE]. c. A Side Rail Evaluation dated [DATE] documented, Evaluation Factors . Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes . Is the resident able to get in/out of bed? Yes. Is the resident able to get out of bed safely? No. Does the resident have a history of falls? Yes. Is the resident having problems with balance or poor trunk control? Yes . Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? Yes . Is there a risk to the resident if side rails are used? No. Do the side rail alternative/interventions create more risks than side rail use? No Based off of Summary Findings: Side Rails - none. Half Rails - None. d. On [DATE] at 10:40 a.m., the resident was in bed curled up in a fetal position. The resident was on a low air loss mattress with winged sides (bolster mattress) and a padded assist bar was on the right side of the bed. There was a gap between the air mattress and the assist bar. e. On [DATE] at 9:30 a.m., the resident was in bed curled up in a fetal position. The resident was on a low air loss mattress with winged sides and a padded assist bar was on the right side of the bed. A gap was between the air mattress and assist bar. When the surveyor mashed down on the side of the mattress, the gap became much larger. f. On [DATE] at 9:45 a.m., CNA #2 was asked if the resident could move about on her own in bed. She stated, Yes. She can come out of the bed. g. On [DATE] at 10:13 a.m., CNA #1 was asked if the resident could move about on her own in bed. She stated, Yes. A lot. h. On [DATE] at 2:00 p.m., the Maintenance Director measured the gap between the mattress and assist rail as approximately 1 ,[DATE] inches. When pressure was put on the edge of the mattress, the gap size increased to 5 inches. 4. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, was totally dependent with two or more staff for bed mobility, and side rails were not used as a physical restraint. a. A Side Rail Evaluation dated [DATE] documented, Evaluation Factors . Does the resident have fluctuations in levels of consciousness or cognitive deficit? Yes . Do the side rail alternative/interventions create more risks than side rail use? No . Based off of Summary Findings: Side Rails - none. Half Rails - none. b. On [DATE] at 8:41 a.m., 10:45 a.m., and on [DATE] at 8:35 a.m., there was a gap between the air mattress and assist rail. c. On [DATE] at 9:45 a.m., CNA #2 was asked if the resident could move about on her own in bed. She stated, Yes, she can scoot. We have to reposition her in bed all the time. d. On [DATE] at 10:13 a.m., CNA #1 was asked if the resident could move about on her own in bed. She stated, Oh yeah. She will surprise you. e. On [DATE] at 11:35 a.m., the Maintenance Director measured the gap between the air mattress and assist rail as approximately 5 inches. When pressure was put on the edge of the mattress, the gap size increased to approximately 7 ,[DATE] inches. 5. On [DATE] the Immediate Jeopardy was removed and the scope/severity reduced to H when the facility implemented the following plan of removal: 1) On [DATE] at 12:45 p.m. and ending at 1:45 p.m. on [DATE] - All residents with side rails will be identified by observation by Director of Nursing or Designee. 2) On [DATE] at 12:45 p.m. and ending at 1:45 p.m. on [DATE] - All residents with side rails were assessed for need of side rails and entrapment zones by Director of Nursing or Designee and any negative findings were corrected immediately. 3) On [DATE] at starting at 12:45 p.m. and ending at 1:45 p.m. - All beds in facility were assessed for entrapment for the seven entrapment zones and the proper dimensions for each any negative findings were corrected immediately. 4) On [DATE] at 12:45 p.m. and ending at 1:45 p.m. on [DATE] - An in-service was conducted for clinical department head staff, by Administrator on proper side rail assessments to include determining the need for rails and entrapment zones to include the 7 entrapment zones and proper dimensions to prevent entrapment. 5) On [DATE] starting at 1:50 p.m. an in-service was conducted by QA (Quality Assurance) Nurse or designee to all direct care staff on proper side rail assessments and the seven entrapment zones and proper dimensions for each to prevent possible entrapments. No direct care employee will be allowed to return to work until inservice is complete. 6) Starting on [DATE] monitoring will be conducted by DON or designee to ensure that all beds are free from entrapment zones and side rail assessments are completed to ensure need for side rail. Five beds a day will be assessed five times a week until compliance is determined by OLTC (Office of Long Term Care).

Complaints # (AR 048), # (AR 026) and # (AR 028) substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure a cognitively impaired resident with a history of recent falls was adequately supervised during toileting to prevent falls and injury for 1 (Resident #2) of 5 (Residents #1, #2, # 3, #7 and #8) case mix residents who had a history of [REDACTED]. This failed practice resulted in actual harm to Resident #2, who fell after being left unattended on the toilet and sustained a right femur fracture, and had the potential to affect 37 residents who had a history of [REDACTED]. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 12/29/15 documented the resident scored 6 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, required extensive assistance of one person for transfers, did not walk, required limited assistance of one person for locomotion on and off the unit, used a wheelchair for locomotion, was not steady when moving on and off the toilet - only able to stabilize with staff assistance, and had experienced one fall with injury since admission or prior assessment. a. The Care Plan dated 12/2/15 documented, .Problem onset 12/2/14 I require assistance for all ADL's (activities of daily living) . Approaches . I require assistance with transfers to the toilet . The Incident Report dated 12/8/15 2:10 p.m. documented, .Location of Incident . (Resident #2's) room . Narrative if incident and description of injuries: Resident roommate came out of the room calling to help stating that (Resident #2) has fallen. Upon entering resident room charge nurse noted resident sitting on floor in front of her w/c (wheelchair) in the restroom . Intervention: Staff inserviced to assist resident to the bathroom after every meal to help reduce the risk of falls . The Incident Report also documented, .Medical risk factor related to incident . fall history (checked) . confusion/disorientation (checked) . A Care Plan updated dated 12/8/15 documented, .fall on 12/8/15 . Approaches . Remind me to ask for assistance for all ambulation. I use a chair alarm while in chair . CNA (Certified Nursing Assistant) to offer toileting after each meal (12/8/15) . b. A fall assessment dated [DATE] documented, .Yes, Resident score is 10 or higher and is at HIGH RISK for falls . Grand Total: 12 . c. The Incident Report dated 1/31/16 at 7:21 p.m. documented, .Location of Incident . (Resident) room . Narrative if incident and description of injuries: Floor nurse and (Certified Nursing Assistant (CNA) #2) went to resident room due to alarm sounding and resident was found in bathroom standing from being in w/c (wheelchair) fixing to transfer self onto toilet. Floor nurse assisted resident onto toilet and as usual resident was oriented to pull cord for call light. CNA pulled w/c out of bathroom into room. Another CNA called for floor nurse to let floor nurse know that resident was on the bathroom floor. Resident was found in sitting position on bathroom floor sitting with leg underneath resident. Resident leg was found laying pretty much flat side ways on floor. Immediate action taken: floor nurse asked resident if she was hurt and resident stated yes. Resident was sitting on top of left leg and with resident and floor able to bring left leg out in front and resident was able to move left leg but right leg was found laying inwards towards floor. Another came into room and was with resident while this floor nurse called (Emergency Medical Services). Another emergency response team was already in facility directed to resident room and assessed resident and helped put resident on stretcher. Vitals signs . Physician and Family notified . The hospital admission report dated 1/31/16 documented an admitting [DIAGNOSES REDACTED]. Under hospital course, the report documented, The patient is an [AGE] year-old white female who is in a nursing home for dementia . She fell out of wheelchair, sustained a right intertrochanteric femur fracture. d. A care plan update dated 1/31/16 documented, .fall on 1/31/16 . Inserviced aides and floor nurses to stay with (Resident #2) and to not leave her unattended (2/2/16). An inservice dated 1/31/16 documented for CNA's and floor nurses to stay with resident during toileting and to not leave resident unattended. There was no other documentation on the inservice that staff were to provide the same interventions for other residents who were at risk for falls and required assistance of staff for toileting. e. On 3/8/16 at 12:30 p.m., CNA #1 was asked if she knew how much assistance Resident #2 required for toileting and if the resident had a history of [REDACTED]. f. On 3/8/16 at 12:35 p.m., CNA #2 was asked if she knew how much assistance Resident #2 required for toileting and if the resident had a history of [REDACTED]. I look at the care plan. g. On 3/9/16 at 8:45 a.m., the Director of Nursing was asked if, having a history of falls and requiring bed and chair alarms, the resident should have been left unattended on the toilet. She stated, No.

Complaint # is substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure the footrests on wheelchairs used for van transports were in good repair for 1 (Resident #2) and the residents were placed on the S-Series Personal Use Van Lift as recommended per manufacturer's operator guidelines prior to engaging the lift for entrance to access the van for 2 of 2 residents (Resident #2, and #4) who required the use of the van for transport. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Resident #2 who was placed in a defective wheelchair prior to placement on the lift and whose left foot was trapped between the lift and the van bumper when the lift was engaged causing a probable nondisplaced fracture of the distal fifth metatarsal, possible nondisplaced fracture of the distal fourth metatarsal and a nondisplaced fracture of the medial malleolus and was likely to affect 58 residents who were eligible to be transported via wheelchair in the van according to a list received from the Administrator on 12/14/11/ at 12:12 p.m. The Administrator was notified of the Immediate Jeopardy on 12/13/11 at 10:50 a.m. The findings are: 1. The Ricon S-Series Personal Use Lift Operator Manual documented, "1. Entering Vehicle: a. Deploy platform-Push and hold deploy switch until platform completely unfolds from vehicle and stops at floor level. b. Lower Platform-Do not stand on inboard rollstop as platform lowers. Push and hold down switch until lift contacts ground and rollstop opens completely. 1) Carefully place wheelchair centrally on platform, FACING OUTWARD away from the vehicle, and lock wheelchair brakes. 2) Be certain wheelchair is safely within platform perimeter and does not interfere with operation of platform rollstop. c. Raise Platform-Push and hold up switch until platform raises and stops automatically at vehicle floor level. Release wheelchair brakes, carefully board passenger into vehicle and secure wheelchair." The Skill Form-Transporting by Van dated 7/2/10 documented satisfactory completion of "b.) Load resident into the van. Follow the manufacturers recommended guidelines for use of the lift." This document was signed by Certified Nursing Assistant (CNA) #1 and the evaluator. 2. Resident #2 was admitted on [DATE] at 2:24 p.m. and had a [DIAGNOSES REDACTED]. a. The Nurse's Notes dated 11/23/11 at 2:45 and signed by LPN #1 documented, "Resident admitted to (facility) skilled bed for dx (diagnosis) left hip replacement from (hospital). Transported by facility van. Upon admission van driver (CNA #1) reports that when loading resident on van, resident's left foot was caught between lift and van. Upon admission resident noted with bruising to top lt (left) foot and ankle. No swelling noted. Resident moves toes to lt foot without difficulty. Also able to move foot around in a circular motion. Resident c/o (complained of) foot pain. Order per APN (Advanced Practice Nurse) to give Hydrocodone 5/325 i po (by mouth) now x (times) 1 dose and get stat x-ray of left foot and ankle. Resident has 2 daughters present and both informed of incident, as well as, APN orders. Resident A & O (alert and oriented) x 3. O2 (oxygen) at 2 l/m (liters per minute) per nc (nasal cannula) for dyspnea. Speech clear. Partial wt (weight) bearing with 2 person assist. Total assistance with personal care. Multiple bruises to rt (right) forearm. No s/s (signs or symptoms) skin breakdown. Surgical wound to left hip. No sutures/staples present. Edges approximated. No drainage. Resident assisted to bed per this nurse and CNA. VS (vital signs) 138/70 (blood pressure)-82 (pulse)-23 (respirations)-98.0 (temperature)." On 12/13/11 at 9:46 a.m., Licensed Practical Nurse (LPN) #1 stated, "I was the admitting nurse for (Resident #2) on 11/23/11. As soon as she got here, she was complaining that the van driver closed her foot in the space between the van and the lift. I took her sock off and looked at her left foot. It was swollen and bruised. She was able to move her toes. She had bruising on the top of her foot to her ankle. She was requesting pain medication. The Advanced Practice Nurse gave an order to x-ray her foot. She had oxygen on. (CNA #2) or the daughter mentioned the foot rest swinging outward. I did nothing about the wheelchair. I gave her a Hydrocodone out of the emergency box (as ordered by the APN)." b. The Physician order [REDACTED]. Get x-ray of left foot and ankle stat." c. The Skilled Daily Nurses Note dated 11/23/11 at 4:30 p.m. and signed by LPN #2 documented "R (resident) moved to room 404-b. R's daughter concerned about R foot x-ray. Explained to daughter that (mobile x-ray service) has 2 hours to arrive for a stat order and it had not yet been an hour. Daughter states she does not want to wait anymore and would like for her mother to go to (hospital) for x-ray. (Ambulance Service) notified. Report called to (hospital's) ER. (Ambulance Service) arrived at approximately 1700 (5:00 p.m.). R's foot bruised and swollen." On 12/14/11 at 9:40 a.m., LPN #2 stated, "I was working the afternoon (Resident #2) was admitted . I was not told about the faulty wheelchair. I called the APN and let her know of the family's decision to transfer (Resident #2) to the emergency room . The whole foot was bruised and swollen." d. The diagnostic imaging of the left ankle dated 11/23/11 documented, "the bones are generally demineralized". The impression for left foot and ankle was documented as "Nondisplaced fracture of the distal fifth metatarsal-probable, nondisplaced fracture of the distal fourth metatarsal-possible and nondisplaced fracture of the medial malleolus." e. The emergency room Physician documented a [DIAGNOSES REDACTED].#2 to the hospital. f. The OLTC Incident and Accident Report-DMS 7734 dated as submitted 11/25/11 at 10:45 documented "On Wednesday, November 23, 2011 at approximately 2:45 p.m., (facility) van driver (CNA #1) and (CNA #2) loaded (Resident #2) on our van to transport her to (facility) for admission. (Resident #2) was seated in her wheelchair with both her feet on the footrests and her legs and feet covered with a blanket. As (CNA #1) attempted to raise the lift, he realized that (Resident #2's) foot had slipped off of her foot rest and gotten caught between her chair and the lift. This was not immediately evident because of the blanket covering her feet and legs. (CNA #1) and (CNA #2) immediately lowered the lift and checked (Resident #2's) foot, lifted her chair into place on the van and proceeded to the facility. Upon arrival at the facility, (CNA #1) immediately reported the incident to (Director of Nursing)." g. The DMS-762 Section III-Findings and Actions Taken section documented, "(Director of Nursing) notified (APN) for (Attending Physician) and obtained an order for [REDACTED]. X-ray was obtained. Resident's daughters were present in the facility upon (Resident #2's) arrival and were immediately notified of accident. (Resident #2) was sent back to the hospital for further evaluation. (CNA #1 and #2) were immediately counseled on transfer of residents on and off van safely. Inservice also done 11/23/11 on 'Van Transport Safety' with emphasis on blanket placement to not block staff's line of sight to resident appendages. Both CNA's performed return demonstrations showing knowledge of van lift safety. Quality Assurance monitor put into place to observe van transfers 3 times weekly for 3 weeks to ensure safe techniques are being used by staff. Van was inspected by administrator at approximately 4:00 p.m. on 11/23/11. All belts, safety restraints and the lift were in good working order. Van had also been inspected by Corporate Maintenance Director on 11/21/11 with no negative findings. (Resident #2's) family chose not to complete her admission to (facility). Results from mobile x-ray performed on (Resident #2's) left foot on 11/23/11 showed "a probable nondisplaced fracture of the distal fifth metatarsal, possible nondisplaced fracture of the distal fourth metatarsal and a nondisplaced fracture of the medial malleolus." h. The Van Transport Safety Inservice 11/23/11 documented as presented to CNA #1 and CNA #2 documented the content as "Demonstration by DON (Director of Nursing) of loading wheelchairs onto van and securing into place: move the wheelchair to the appropriate place in the van for securing, lock the wheels of the wheelchair, using the straps provided, strap the front wheels of the wheelchair to the floor brackets, cinch the straps as tight as possible, using the straps provided, strap the back wheels of the wheelchair to the floor brackets, wiggle the wheelchair and make sure straps are as tight as possible and chair is secure, use the seatbelt provided place the end of the seatbelt through the arms of the resident and buckle. Demonstration by DON of raising and lowering lift safely. Return demonstration of using the van lift performed by CNA's. Emphasis on chair placement on lift (not too far forward or back on floor of lift). Emphasis on making sure any blanket or covering over resident does not block line of sight of appendages to ensure resident safety during lift procedure." i. A calendar dated December 2011 documented the Director of Nursing observed transfer onto the van and lift used safely on 12/1/11, 12/5/11, 12/6/11, 12/7/11 and 12/8/11. The calendar documented that the Administrator observed transfer onto the van and lift used safely on 12/9/11. j. On 12/12/11 at 2:31 p.m., CNA #2 stated, "Me and (CNA #1) went to (Hospital) (on 11/23/11 to pick up two new residents. One of them was (Resident #2)... She was in a wheelchair with leg rests. She was alert and oriented... She was on the lift facing the front of the van. (CNA #1) was on the lift with her. She screamed 'my foot'. She said her foot got caught on something. We examined her left foot. She said 'I think my foot is broken.'...She complained during the trip of the 'bumpy ride' but did not complain of pain. Once we got in the building, her daughter was sitting up front. (Resident #2) said to her daughter 'The ride was horrible. They tried to kill me.' The Director of Nursing came up there. I told the Director of Nursing that her foot was hurting. Later, I pushed her to her room. The Director of Nursing looked at her foot. The foot rest would not lock, it was loose. She had propped one foot on the other on the foot rest... I reported the broken wheelchair to (Licensed Practical Nurse (LPN) #1)." k. On 12/12/11 at 3:00 p.m., CNA #1 stated, "Me and (CNA #2) went to (Hospital) to pick up two residents (on 11/23/11). One was (Resident #2). When I had her on the lift, when I started raising the lift, her foot got caught in between the lift and the van. She screamed. I let the lift down. The left (wheelchair) pedal was loose. She had both feet on the right pedal. One foot got hurt. She said 'I think my foot is broke'. She asked for a pain pill. When we got to the facility, she told her daughter that I hurt her foot on the van. I went and told the Director of Nursing that her foot got caught between the van and the lift and that the foot pedal was loose... The Administrator asked me to show her how it happened. I lowered the lift and showed her." As soon as the interview was completed, CNA #1 and this Surveyor went to the front of the building and was joined by the Corporate Registered Nurses (RN). This Surveyor got in a wheelchair to replicate how the resident placed her left foot on top of the right foot on top of the footrest. CNA #1 demonstrated loading onto the lowered van lift. He rolled the wheelchair with this Surveyor onto the lift facing the front of the van. There was a gap between the van's bumper and the end of the lift of approximately six inches. As CNA #1 engaged the lift the gap became smaller and smaller. With the left foot on top of the right foot during this demonstration, considering the placement of the occupied wheelchair by the CNA on the lift, this Surveyor's left toes could have become easily trapped between the lift and the bumper as the lift rose. On 12/13/11 at 9:40 a.m., the Maintenance Director measured the opening between the deployed lift top nearest the van and the bumper. He stated the measurement was "four inches". l. On 12/12/11 at 4:10 p.m., the Administrator stated, "I do not know anything about a broken footrest on (Resident #2's) wheelchair during the transport. That's why I did not investigate it. I did not know that she was using one footrest for both feet. If a piece of equipment such as a wheelchair is broken, I expect it to be taken out of use until repaired by maintenance. I did not talk to (LPN #1) regarding the wheelchair." m. On 12/14/11 at 12:00 p.m., the Director of Nursing was asked if she had an awareness of the incorrect loading of Resident #2 onto the lift prior to her transport on 11/23/11 and further incorrect placement of residents on the lift by the transport personnel. The Director of Nursing stated, "I was not aware. I thought so but I have learned that it wasn't (being performed correctly)." The Director of Nursing was asked if she knew that the left footrest on (Resident #2's) wheelchair was swinging back and forth during the 11/23/11 transport. She stated, "I was told that the footrest did not work properly. I do not know what happened to the footrest or wheelchair." 3. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/15/11 documented the resident had a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive to total assistance of 1 or more person for activities of daily living and a wheelchair was used for mobility. a. The Physician order [REDACTED]. b. On 12/13/2011 at 8:15 a.m., the resident was in her wheelchair in her room. The resident stated she was waiting to be taken to the Wound Clinic. c. On 12/13/11 at 8:42 a.m., the resident was taken to the facility transport van via wheelchair by CNA #1. CNA #1 rolled the wheelchair onto the transport van lift platform that was flat on the pavement. CNA #1 placed the resident on the platform facing the back of the van, locked the wheelchair brake, raised the platform to the level of the van flooring and then went to the passenger's side of the van, entered the van and placed the resident's wheelchair into the locking mechanism. During the lift process this Surveyor was standing at the back of the van. This Surveyor observed the signage affixed to the right side of the frame of the lift mechanism. The sign contained three illustrations. The first illustration depicted a wheelchair placed on the flat surface of a lift platform with the wheelchair facing the van, a red circle on the outer edge of the illustration, and a red line crossing the illustration from approximately the 10 o'clock position to the 4 o'clock position. The second illustration depicted a wheelchair placed on the flat surface of a lift platform with the wheelchair facing away from the van, the wheelchair moved forward to near the front edge of the lift platform, a red circle on the outer edge of the illustration, and a red line crossing the illustration from approximately the 10 o'clock position to the 4 o'clock position. The third illustration depicted the proper placement of the resident on a lift by showing a wheelchair placed on the flat surface of a lift platform with the wheelchair facing away from the van, the wheelchair moved backward as close to the van as possible, and a green circle on the outer edge of the illustration. e. On 12/13/11 at 8:42 a.m. after the resident was placed in the transport van, the resident was asked if she was always transported and placed on the lift in the same manner. The resident stated,"Yes, I'm always placed just like I was now." f. On 12/13/11 at 8:47 a.m., CNA #1 was asked, "Is that the way you always load residents into the van with the resident always facing the back of the van?" CNA #1 stated, "Yes, that's the way that I was taught by the previous van driver." CNA #1 was asked if he had ever transported any resident by placing the resident on the platform different from the procedure he had used on 12/13/11 at 8:42 a.m. CNA #1 stated he had always placed the resident on the platform facing the van. He further stated, "I've always done it the way I was taught." 4. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 12/13/11 at 3:10 p.m. when the facility implemented the following Plan of Removal: a. Twenty-nine residents were transported in the van in the last 30 days. These were identified by using the van appointment book. Four of those residents have been discharged from the facility leaving 25 residents. Twenty-three of those 25 residents were assessed by ADON (Assistant Director of Nursing/designee to ensure they had no injuries sustained from improper van transport on December 13, 2011 by 1:00 p.m. The remaining 2 residents will be assessed upon return to facility. b. Van transport equipment was assessed on December 13, 2011 at 10:00 a.m. by the corporate nurse and the corporate maintenance director to ensure it was in proper working order. There were no negative findings. c. A copy of the lift manufacturer's guidelines was placed in the van for reference on December 13, 2011 at 11:00 a.m. by the corporate nurse. d. Transport van was taken out of service on December 13, 2011 at 9:15 a.m. until all transport staff on duty at the time were inserviced by corporate nurse on van safety and manufacturer's guidelines for lift use. Van was put back into service at 9:50 a.m. Administrator will be inserviced by 5:00 p.m. on December 13, 2011. The DON and other transport staff will be inserviced by corporate nurse/designee on or before their next scheduled shift. e. All 72 wheelchairs in facility were inspected by the maintenance director to ensure they were in proper working order on December 13, 2011 by 11:45 a.m. Seven wheelchairs were repaired immediately. One wheelchair was taken out of service and removed from building until repairs can be made. Inservice was begun on December 13, 2011 to all staff on equipment safety, removing equipment in need of repair immediately and reporting equipment to maintenance supervisor. All staff will be inserviced on equipment safety on or before their next scheduled shift. f. Monitoring for lift/van safety will be conducted by Administrator/DON/designee daily Monday through Friday for 3 weeks, then 3 times for 2 weeks, then weekly. All negative findings will be corrected immediately. Any negative findings will be brought to the QA (Quality Assurance) Committee weekly by DON/designee for review/recommendations. g. Monitoring of wheelchairs for disrepair will be conducted by maintenance supervisor/designee 3 times per week for 3 weeks, then 2 times per week for 2 weeks, then weekly. All negative findings will be corrected immediately. Any negative findings will be brought to the QA Committee weekly by DON/designee for review/recommendations."