Every finding on record at Pleasant View Care Center

Based on observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures, food palatable and appetizing for 4 of 15 residents reviewed (Residents #24, #42, #45 and #209). The facility reported a census of 56 residents. Finding Include: 1. Observation of meal service on 7/1/25 at 11:41 PM showed the lunch meal consisted of lemon chicken, garlic parmesan pasta, roasted caesar vegetables and garlic toast. a. The chicken appeared dry and burnt. The test tray temped immediately after plating showed: a. Lemon Chicken- 128.2 degrees Fahrenheit (F) b. Garlic parmesan pasta- 110.8 degrees F The test tray after the delivery of meal trays showed: a. Lemon chicken- 117.7 degrees F b. Garlic parmesan pasta- 98.8 degrees F c. Roasted caesar vegetables- 127.9 F In an interview on 6/30/25 at 1:49 PM, Resident #209 reported the food to always be cold and dry. Consumption of the test tray on 7/1/25 at 1:44 PM revealed the chicken difficult to cut, dry and burnt to taste. The warm garlic parmesan pasta started to lose shape and was mushy when chewed. In an interview on 7/1/25 at 2:47 PM, Staff D reported the chicken looked burnt and dry. Observation showed Staff D appeared to struggle when the chicken into bite size pieces. When asked if the chicken was hard to cut, Staff D stated, kind of but I'm getting an arm workout. In an interview on 7/2/25 at 12:42 PM, the Certified Dietary Manager (CDM) reported the dietary aide reported the test try failed to reach proper food temperatures. The CDM reported she would like food to be served at 165 degrees F but at least be above 135 degrees F. The CDM reported staff failed to follow the normal process by not placing food back into the oven but instead was placed on the hot cart. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #24 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. On 7/1/25 at 8:31 AM Resident #24 stated the meals could be warmer. Resident #24 stated the meals aren't cold but are not hot all the time. Resident #24 stated she wanted the food served warmer than it was being served at times. 3. The MDS dated [DATE] documented Resident #42 had a BIMS of 15 indicating no cognitive impairment. The MDS also indicated diagnosis of dependence on renal dialysis. On 7/1/25 at 8:48 AM Resident #42's daughter stated the meals are terrible at the facility. Resident #42's daughter stated the food is dry and difficult to eat at times. Resident #42's daughter stated her mother complained about the food frequently. On 7/1/25 at 3:20 PM Resident #42 stated the vegetables always seem over cooked. The Resident #42 stated the chicken at lunch on 7/1/25 was very tough and burned on the bottom. Resident #42 stated the chicken was cold as well for lunch on 7/1/25. Resident #42 stated she did not plan on eating the chicken because it was tough, so she did not ask for the lunch to be warmed up. Resident #42 stated the room trays were almost always cold. 4. The MDS dated [DATE] documented Resident #45 had a BIMS of 3 indicating severe cognitive impairment. The MDS also indicated diagnoses of dementia and heart failure. On 7/1/25 at 9:31 AM Resident #45's wife stated her husband had not complained about the food. Resident #45's wife stated sometimes the food is hot and sometimes it is not hot. Resident #45's wife stated the kitchen normally started on the front table but once it got to him it was not hot. An observation on 7/1/25 at 12:28 PM revealed Staff A, Dietary Aide brought food to the front dining room in a mobile steam table. The temperature of the food in the steam table was chicken 189 degrees, vegetables 176 degrees, noodles 164 degrees, puree vegetables 189 degrees, puree noodles 189 degrees, puree chicken 152 degrees, and ground meat 171 degrees. An observation on 7/1/25 from 12:56 PM - 1:10 PM revealed Staff A placed a piece of chicken intended for a room tray on the counter from 12:56 PM to 12:59 PM during the time Staff A obtained garlic bread per a resident's request and pizza for another resident. Staff A cut the chicken with a pizza cutter and placed the plate on the room tray cart at 12:59 PM. On 7/1/25 at 1:04 PM Staff A remade the plate for the room tray placed on the to go cart at 01:05 PM with the original tray used for the test tray. Test tray was intended for Resident #24 at the end of the hall and delivered at 1:09 PM. The test tray was brought back to the kitchen at 1:09 PM. The test tray's temperature was checked at 1:10 PM. The test tray's food temperatures were chicken 120 degrees, noodles 125 degrees and vegetables 133 degrees. Observation revealed Staff A struggled to get the temperature probe in the chicken on the steam table. Post lunch meal temperature for food on the steam table chicken 117 degrees, noodles 191 degrees and vegetables 168 degrees. On 7/1/25 at 1:12 PM Staff A stated the food on the steam table should have been at least 165 degrees. Staff A stated she would expect the temperature of the chicken on the steam table to be warmer than 117 degrees. Staff A acknowledged all the chicken was very dry and possible burned in spots. On 7/2/25 at 12:42 PM Staff B, Certified Dietary Manager (CDM) stated Staff A voiced the concern to her that the last plate did not have an appropriate temperature. Staff B stated some of the food did not go back into the oven yesterday. Staff B stated the food went straight onto the hot cart. Staff B stated her expectation was the food to come out of the kitchen to serve at 165 degrees. Staff B stated the chicken should have been a little warmer and noodles would have been a little harder to keep the temperature. Staff B stated If the food had a temperature under 135 degrees the food needed to be reheated back up to 165 before serving. Staff B stated her expectation was all food served to the residents to be a minimum of 135 degrees. Staff A acknowledged the meal was at the end of the 5 week course and was the first time they had cooked that meal. Staff B acknowledged the chicken looked a little dry. Staff B acknowledged the chicken appeared dry and tough. On 7/2/25 at 1:28 PM the Administrator stated usually she eats lunch and dinner at the facility and they are always monitoring that the meal is on time. Stated the chicken she was sure was dryer than normal because it was so much later service and in the oven longer. The Administrator stated she had eaten the chicken and thought it was good but she liked her chicken dry. The Administrator stated she was not sure if the one side of the steam table wasn't working and would investigate that. The Administrator stated the facility does food temperatures prior to and after meal service. The Administrator stated the survey team had a bad experience with meals yesterday because the steam table pans were not placed in the oven and the meal was served later than normal. The Administrator stated the facility expectation was the food temperatures in the steam table to be maintained at 135 degrees. Review of undated document presented by the Administrator, titled End Cooking Temperatures had written on the document holding temperature was 135 degrees.

Based on review of the planned menu, observations, staff interviews and facility policy review the facility staff failed to follow the planned menu for residents during the pureed meal preparation (Residents #16, #18 and #30) and for additional residents during meal service. The facility identified a census of 56 residents. Findings include: 1. Review of the menu identified the following items as part of the planned menu for the pureed and regular diet served at lunch on 7/1/25: a. Lemon Chicken b. Garlic Parmesan Pasta c. Roasted Caesar Vegetables d. Garlic Toast Observation of meal service on 7/1/25 at 11:41 AM, showed: a. Staff C, [NAME] prepared pureed meals for Residents #16, #18 and #30. Staff C placed four servings of chicken into a blender with one piece of garlic bread. When asked why Staff C used one piece of garlic bread, she replied, because it needed to be thickened. b. Staff C noted the pureed chicken would require #8 size scoop and #12 size scoop for a complete serving. Staff C obtained a pan for the two pureed diets in the east dining room and another pan for one pureed diet in the south dining room. Staff C appropriately placed #8 size scoops of pureed chicken into both pans. Staff C then placed two partial #12 size scoops into the pan for the east dining room, and used a #12 scoop with an approximate teaspoon of purred chicken for the south dining room. Staff C then placed tinfoil over both pans and wrote which location and to use a #8 and #12 size scoops for the servings of pureed chicken. As Staff C finished she stated, I don't even know why I'm writing the #12 on there, they won't have enough. Observation of the south dining room service on 7/1/25 at 1:25 PM showed Staff D, Dietary Aide failed to use the scoop sizes as written on the tinfoil covering the pureed chicken. Staff D served Resident #30 one #8 size scoop then used the same scoop to scrape approximately one teaspoon of the remaining pureed chicken from the pan. In an interview on 7/1/25 at 2:41 PM, when asked how many pieces of garlic bread Staff C should have used when pureeing 4 servings of chicken, Staff C replied, I usually puree the same number of garlic bread with the same number of chicken. I should have used 4 servings of garlic bread. I don't know why I didn't. When asked Staff C if she should have made enough pureed chicken to fill a #8 size scoop and #12 size for each pureed diet, she stated, Yes. I usually do but just didn't. I was already running late. In an interview on 7/1/25 at 2:47 PM, Staff D reported that she usually followed the scoop sizes as indicated on the tinfoil. When asked what happened if there isn't enough pureed food, Staff D stated, I usually call the cook and she' ll make more. In an interview on 7/2/25 at 2:42 PM the Certified Dietary Manager, (CDM) reported for pureed diets she expected staff to serve the correct portion sizes and correct number of servings of food as indicated on the menu. The CDM reported that she expected staff to puree additional food if needed. The CDM stated, we did not follow our normal process. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) score of 99 indicating Resident #16 was unable to complete the interview. The MDS also indicated diagnoses of dementia and heart failure. Review of EHR titled Physician Orders for Resident #16 documented a diet of mechanical soft with pureed meat. Review of EHR titled Care Plan for Resident #6 documented a diet of mechanical soft with pureed meat. Review of document titled, Pleasant View SS 2025, Week 1 Tuesday at noon documented a puree menu of 1 serving pureed lemon chicken, 1 serving pureed garlic parmesan pasta, 1 serving pureed roast Caesar vegetables, 1 serving pureed garlic bread and 1 serving pureed sugar cookie bar. An observation on 7/1/25 at 12:28 PM revealed Staff A, Dietary Aide brought food to the front dining room in a mobile steam table. On 7/1/25 at 12:36 PM an observation revealed Staff A utilized a size 8 and size 12 scoop to serve Resident #16's portion of meat. The observation revealed the size 12 scoop was less than 1/4 full. Resident #16 did not get the full portion of meat for lunch. On 7/1/25 at 12:53 PM an observation revealed Staff A served the first piece of garlic bread to the first table behind the medication cart. Staff A served 9 trays served without garlic bread. On 7/1/25 at 1:12 PM Staff A acknowledged the residents on the puree diet did not receive any garlic bread. Staff A acknowledged the cook probably forgot the garlic. Staff A stated she would look at the extended menu in the kitchen to know what the puree diet got for lunch. Staff A stated she looked at the extended menu for the puree meals today. Staff A acknowledged the puree diets did get garlic bread but the cook must not have made the bread. Staff A acknowledged she had enough meat to serve the first puree diet but the second puree did not receive most of the second scoop. Staff A stated she just gave Resident #16 what was left. Staff A acknowledged she did not serve garlic bread to the first 9 residents. Staff A stated she was very nervous and forgot until about halfway through the lunch meal about the garlic bread. On 7/2/25 at 12:42 PM Staff B, Certified Dietary Manager (CDM) stated she normally wants the cook to puree at least one extra serving in the whole process. The CDM stated Staff A, Dietary Aide acknowledged that she did not serve 9 residents garlic bread and she did not have enough pureed meat for both servings in both scoops. The CDM stated Staff A acknowledged she did not serve the puree diets garlic bread. The CDM stated her expectation was that the menu was completely followed. The CDM stated the facility's expectation was the garlic bread would have been served to all the residents. The CDM stated she would have expected that the garlic bread would have been pureed with the meat. The CDM stated the facility's expectation was the right amount of food would have been served to all residents on a pureed diet. The CDM stated if there was not enough then more should have been made. On 7/2/25 at 1:28 PM the Administrator stated usually she eats lunch and dinner at the facility and was always monitoring that the meal was on time. The Administrator stated the facility expected the menu would have been followed including the serving of garlic bread at lunch on 7/2/25 to all residents including the residents on pureed diets. The Administrator stated the facility's expectation was the staff would have served the appropriate amount to the resident that had a pureed diet. Review of a policy dated 2021 titled, Policy and Procedure Manual / Therapeutic Diets documented the facility would provide a therapeutic diet that is individualized to meet the clinical needs and desires of a resident. Available therapeutic diets should coincide with the therapeutic diets on the facility's menu extensions.

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food, and failed to prepare food in a sanitary manner. The facility identified a census of 56 residents. Findings included: The initial kitchen walkthrough on 6/30/25 at 11:35 AM revealed the following: a. East dining room kitchenette- refrigerator and freezer with dried liquid and various scattered food debris. b. [NAME] dining room kitchenette/dining area- white crust lime buildup found on ice machine, coffee machine and dishwasher. c. Drawers with utensils found with various food debris and dried liquid. Cupboards with small appliances found with various food debris. d. The main kitchen found a refrigerator with various food debris. Observation of meal service on 7/1/25 at 11:41 AM, showed: a. After pureeing pasta Staff C, [NAME] entered the dirty side of the kitchen in search of a measuring cup. Staff C touched the dishwasher handle and dish carts then returned to the clean side of the kitchen without completing hand hygiene. b. While placing a covered pan of pasta in the oven, Staff C dropped the pan on the floor, picked up the pan, and placed the pan over an open rack of garlic bread in the oven. c. Staff A, Dietary Aide made a salad, stacked containers of vegetables and ham in her arms then placed her face on the top bag to hold the stack steady in her arms. d. Staff D, Dietary Aide plated food, served the plate to residents then returned to the kitchen without performing hand hygiene. In an interview on 7/1/25 at 2:41 PM, Staff C reported she should have washed her hands when she left the clean side of the kitchen. Staff C also reported she wasn't thinking when she placed the pan that dropped on the floor in the oven over garlic bread. Staff C stated, I was nervous. The General Food Preparation and Handling policy last Policy & Procedure Manual dated 2021 identified food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep free of harmful organisms and substances. Procedure: 1. The kitchen will be kept neat and orderly. a. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. 2. Food Storage a. Food will be received, checked, and stored properly immediately following delivery. b. Time/temperature control for safety (TCS) food will be refrigerated or frozen except when being handled -Food will be covered for storage. -Food will be cooked as soon as possible after defrosting. c. Food in broken packages, swollen or dented cans, cans with a compromised seal, or food with an abnormal appearance or odor will be discarded 3. Food Preparation a. Meats, fish, and poultry will be defrosted using sale thawing practices: In the refrigerator in a drip proof container, and in a manner that prevents cross In the microwave if foods are cooked and served immediately after defrosting In the sink, submerging the item under cold water (less than 70° F) that is running fast enough to agitate and float off loose ice particles Thawing as part of a continuous cooking process. b. All meats will be cooked or heated to a safe minimum internal temperature. (Refer to the Resource: Minimum Cooking, Holding and Reheating Temperatures later in this chapter.) A meat thermometer will be used to check internal temperatures. Stuffing should be baked in separate pans. c. All cold meat/fish/poultry salads, potato/vegetable salads, egg salads, cream filled pastries and other TCS foods shall be prepared from chilled products and refrigerated below 41* F IMMEDIATELY after preparation. d. No raw eggs will be served; eggs must be cooked completely until all parts are firm. Pasteurized eggs are the exception (these may be served soft-cooked) e. Separate cutting boards for raw and uncooked food and for raw fruits and vegetables will be used. Prepared foods should not be cut on the same boards as raw food. Cutting boards should be of hard rubber construction (not wood) and must be dishwasher safe. Cutting boards should be cleaned and sanitized after each use, following the dish machine or 3 compartment sink method, and will be air dried before storing. f. Raw, unprocessed fruits and vegetables should be thoroughly washed under clean, potable, running water before use. g. Bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash hands prior to putting gloves on and after removing gloves. h. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Any utensil or serving dish must be thoroughly cleaned and sanitized prior to use. i. Tasting must be done with a tasting spoon. Follow proper tasting procedures: Remove the food with a serving spoon and transfer it to a tasting spoon. Always use clean spoons. j. Any food that is dropped on the floor must be discarded. k. Tops of canned foods should be washed before opening. l. The can opener will be cleaned and sanitized daily and/or as needed. 4. Food Service a. Foods that stand four or more hours at room temperature cannot be considered safe and free from contamination and cannot be made so by refrigeration, especially in warm temperatures. They must be discarded. b. Prepared food will be transported to other areas in covered containers. Individual portions of food once served will not be served again. · Single-service articles will be discarded after one use. d. Leftovers must be dated, labeled, covered, cooled, and stored (within ¼ hour after cooking or service) in a refrigerator. Leftovers must be cooled to less than 41° F within 4 hours (or cooled to 70 F within 2 hours and then down to 41° F within another 4 hours). Prior to re-serving, leftover foods must be reheated to a minimum internal temperature of 165° F for a minimum of 15 seconds. (Refer to the Resource: Minimum Cooking, Holding and Reheating Temperatures in this chapter.) Leftovers are no to be used as pureed food. Use leftovers within 7 days per Food Code or discard. Check state regulations for more detail. 5. Equipment a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. b. Plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of. c. Disposable containers and utensils should be discarded after one use. Only food-approved, dishwasher safe containers may be reused d. Flatware will be stored in such a manner to encourage contact with handles only e. Staff will handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with. f. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food Note: If individual patients/residents assist in food preparation and handling, the staff will assist and supervise to see that the above procedures are followed. In an interview on 7/2/25 at 12:42 PM, the Certified Dietary Manager (CDM) reported she expected the kitchen and kitchenettes to be clean and free of food debris. The CDM also reported that staff should use a cart or tray when transporting food, use hand hygiene when coming from the dirty side of the kitchen and should have covered the garlic bread in the oven.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 47. Findings include: On 8/13/24 at 8:42 AM, Staff F, Dietary Aide (DA) grabbed a milk gallon jug off the kitchenette counter and poured a cup. She stated it was for a resident. A temperature check of the milk revealed the temperature was 44.4 degrees Fahrenheit (F). On 8/14/24 at 12:40 PM, a temperature check of each lunch menu item after lunch service revealed the following results. a) Salisbury steak was 128 F. b) Pureed Salisbury steak was 115 F. c) Pureed green beans were 134.5 F. A policy titled Taking Accurate Temperatures dated 2021 indicated temperatures should be taken periodically to assure hot foods stay above 135 F and cold foods stay below 41 F during the serving process. On 8/15/24 at 12:50 PM, the Administrator stated staff should follow the temperature guidelines.

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to keep the kitchen food preparation area clean and by improperly handling food during meal service. The facility reported a census of 47 residents. Findings include: 1. On 8/12/24 at 5:28 PM, Staff C, Dietary Aide (DA) brought the steam table into the dementia unit and set it up for service. She used the tongs to poke through and remove the steam pan aluminum foil cover, picked up a sandwich with the same tongs, then laid the tongs on the cookie tray. She poured the stew into a bowl, moved the tongs, and placed the prepped plate where the tongs were. Another staff member took the plate to a resident. She used the tongs to plate another sandwich, laid the tongs on the cookie tray where the previous prepped plate was, and poured stew into a bowl on the plate and placed the plate on top of the tongs. She repeated this process for five (5) more plates. On 8/12/24 at 5:43 PM, Staff D, Activities Assistant, dropped a cup on the floor while serving dinner, picked it up with her bare hands and placed it on the bottom of the beverage cart. She opened a cabinet door, rummaged through a clear, plastic bag of plastic utensils, closed the bag and the cabinet door, grabbed a paper napkin with her right hand and a silverware spoon with her left hand and rolled the utensils in the napkin and gave it to a resident to use for dinner. She did not perform hand hygiene throughout the process. On 8/13/24 at 8:40 AM, Staff F donned gloves, placed a bowl on a plate, grabbed a disher, and placed a scoop of eggs with bacon on a resident's plate beside the bowl. She grabbed a piece of toast from the toaster, buttered it, then placed it on the same plate and took it to the resident. No hand hygiene or glove change was performed. On 8/14/24 at 11:50 AM, Staff E, cook, sprayed two (2) steam pans with non-stick spray and placed the can and steam pans on the food preparation counter. She picked up a steam pan and a disher (scoop), scooped pureed food from one steam pan into another one and placed the disher on the prep table where the steam pan had been. She picked up the other steam pan, grabbed the disher and scooped pureed food into the steam pan and placed the disher on the prep table where the steam pan had been. The disher was not cleaned throughout the process. A document titled General Food Preparation and Handling dated 2021 indicated food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. On 8/15/24 at 12:50 PM, the Administrator stated staff should not reuse a serving spoon after placing it on a dirty counter. She also stated they should not use tongs to touch non-food items. 44420 2. The initial kitchen walkthrough on 8/12/24 at 8:48 AM revealed the following: a. The shelf above the stove top showed a thick layer of grease with food splatter and a variety of food debris. b. A wheeled cart with clean dishes contained scattered food debris on all three shelves. c. The floor in the kitchen, walk-in fridge and freezer contained an accumulation of food debris and a variety of dried liquid. d. Food splatter and dried liquid splatter found in and on the cupboards in the kitchen area. e. All refrigerator and freezer units with food debris on the bottom of the unit. f. Toaster covered in grime and bread crumbs. g. Boxes of food found on the floor of the walk-in freezer. h. Mold found around the caulk and wall in front of the dishwashing sink. During the kitchen walkthrough Staff A, Head [NAME] reported she didn't have a chance to mop and sweep yesterday. When asked about the last time the floors were swept and mopped, Staff A reported she didn't know because kitchen staff had been short of help. When asked for the cleaning logs, Staff A stated, The logs are in the managers office and she's on leave. When asked about the location of today's cleaning logs, Staff A stated, I don't know. The General Food Preparation and Handling policy, dated 2021 indicated the kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. In an interview on 8/15/24 at 3:46 PM, the Administrator, and Assistant Director of Nursing (ADON) reported they expected the kitchen to be in clean and sanitary condition at all times. The ADON stated, We scrubbed and cleaned the kitchen yesterday.

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 47 residents. Findings include: On 8/13/24 at 8:59 AM, Staff H, Certified Medication Aide (CMA) escorted a resident to her room to apply a patch on her. She left her laptop open with 10 residents' Electronic Health Record (EHR) information visible and a sheet of paper with an identified resident's documented narcotic medication administration time. At 9:10 AM, she indicated she was normally assigned a different duty. A policy titled HIPAA / Privacy Complaints effective 11/28/16 indicated It is the policy of this facility to ensure the privacy of Protected Health Information (PHI) as well as to ensure that such information is used and disclosed in accordance with all applicable laws and regulations. On 8/15/24 at 1:12 PM, the Director of Nursing (DON) stated staff should secure the EHR medical record when they leave the cart.

Based on resident observations, record review, staff interview, and policy review, the facility failed to refer to a resident by name and failed to dress a resident appropriately for meal service 2 of 16 residents (#3 & #46) reviewed for dignity. The facility reported a census of 47. Findings include: 1. On 8/13/24 at 7:57 AM, Staff K, Licensed Practical Nurse (LPN) was standing in the dining room and stated the long table in the dining room was the feeder table for residents who required help feeding. Resident #46 was seated at the long table. The Minimum Data Set (MDS) dated [DATE] revealed Resident #46's Brief Interview for Mental Status (BIMS) score could not be determined due to the resident was rarely or never understood. It included diagnoses of Cerebral Palsy (CP), epilepsy, autistic disorder, and wheelchair dependence. It indicated the resident was dependent in all Activities of Daily Living (ADLs) and mobility. It also indicated the resident's ability to hear was adequate. 2. On 8/13/24 at 8:23 AM, Resident #3 was transported to the dining table with her briefs and upper left thigh exposed. Her pants were visible at her upper left thigh. On 8/13/24 at 8:30 AM, Staff J, Certified Nurse Aide (CNA) stated CNAs were responsible to dress and assist residents for dining. She stated Staff I, CNA and Staff L, CNA were assigned to Resident #3. The MDS dated [DATE] revealed Resident #3 had a BIMS score or 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of Adult Failure to Thrive (FTT), macular degeneration (blurred or lost central vision), and depression. It indicated the resident was dependent in all Activities of Daily Living (ADLs) and mobility. It also indicated the resident required corrective lenses. The Care Plan edited 6/21/24 indicated the resident required assistance with ADL's and would remain clean, dry, and appropriately dressed throughout the quarter. It directed staff to assist the resident with ADL's. On 8/13/24 at 2:50 PM, Staff I stated the resident's family member cut the back part of resident's pants for the resident's comfort. He stated that staff sometimes used a pad or sheet to cover a resident in like situations. He confirmed he had access to pads and sheets and should have used one for Resident #3. An undated document titled Long Term Care Community Coalition directed staff to avoid the use of labels for residents such as feeders and to assist the resident to dress in their own clothes appropriate to the time of day. On 8/15/24 at 1:12 PM, the Director of Nursing (DON) stated staff should verbally watch what they say and resident should be covered for dignity.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portions for one (1) residents (#16) who received pureed scalloped potatoes and failed to serve the therapeutic diet for two (2) residents (#6 & #51) who were ordered renal diets. The facility reported a census of 47 residents. Findings include: On 8/14/24 at 11:25 AM, Staff E, Cook, pureed scalloped potatoes for lunch service. She added three (3) 4-ounce disher servings of scalloped potatoes and milk to the blender and pureed them. She poured the contents into a pitcher and stated it was 3 1/2 cups total volume. She referenced the pureed disher conversion chart and stated it directed staff to use a #6 (5 1/3 oz) disher and a #8 (4 oz) disher. She wrote the disher numbers on the top of the steam pan aluminum foil cover. On 8/14/24 at 12:15 PM, continuous lunch service observation revealed Staff G, Dietary Aide (DA) used only the #6 (5 1/3 oz) disher to plate pureed scalloped potatoes for resident #16. On 8/14/24 at 12:40 PM, Staff G stated she forgot to use the #8 (4-oz) disher to serve the pureed scalloped potatoes. On 8/14/24 at 1:00 PM, a menu review directed staff to provide one (1) serving of scalloped potatoes for pureed diets and 4-oz of parsley noodles for residents who were ordered renal diets. An Electronic Health Record review revealed: a) Resident #16 was ordered a pureed diet without portion restrictions. b) Resident #6 was ordered a renal diet. c) Resident #51 was ordered a renal diet. On 8/14/24 at 2:02 PM, Staff E stated she did not make parsley noodles for lunch service. She indicated it was an oversight. A document titled (Therapeutic Diets) dated 2021 indicated diets will be offered as ordered by the physician or designee. On 8/14/24 at 12:50 PM, the Administrator stated staff should follow the scoop diagram (pureed disher conversion chart) and menu items.

Based on observation, record review, staff interviews and policy review the facility failed to complete hand hygiene during medication administration for 2 out of 3 residents reviewed (Resident #25 and #33). The facility also failed to transport linen in a manner that prevented cross contamination. The facility reported a census of 51 residents. Findings include: 1. Observation on 8/14/24 at 8:48 AM showed Staff B, Registered Nurse (RN) assisted Resident #33 to sip water during medication administration. Staff B then picked up the cup of fluid by the rim, disposed of the cup, returned to the medication cart and touched the cart, mouse, and medications as Staff B prepared Resident #25 medications. Observation on 8/14/24 at 9:19 AM showed Staff B, RN entered Resident #25's room with a cup of water and a medication cup that contained pills. Resident #25 lifted the medication cup to her lips, placed the medications in her mouth, sipped water, and swallowed the medication. Staff B picked up both cups by the rim, discarded, exited the room then returned to the medication cart without performing hand hygiene. Staff B proceeded to touch the medication cart and mouse. In an interview on 8/14/24 at 9:26 AM Staff B, RN stated, the surveyor caught her not washing her hands after that last med pass. When asked if Staff B also recognized other times she failed to complete hand hygiene during the medication pass, Staff B replied, she did hand hygiene at her cart and she keeps the sanitizer in the drawer. When asked at what point should hand hygiene be completed, Staff B stated, after a certain number of times. When asked for clarification, Staff B replied, after a certain amount of residents, or is it after so many medications, she didn't know. She stated she would have to get that clarified for herself. The undated Medication Pass Policy identified safe procedures and correct techniques are followed and to promote efficiency on medication administration and to assist in optimizing treatment outcomes. The facility will follow the medication pass quality assurance audit form for proper technique and safe administration of medications. The Quality Assurance Audit For Medication Pass identified proper sanitation should used and appropriate hand hygiene. In an interview on 8/15/24 at 3:46 PM the Administrator and Assistant Director of Nursing (ADON) reported they expected hand hygiene to be completed between medication passes if the nurse touched something a resident touched, and staff should avoid carrying cups by the rim. 47079 2. On 8/13/24 at 8:32 AM, Staff I, Certified Nurse Aide (CNA) carried uncontained, soiled linen from a resident's room to the soiled utility room with gloves. The linen touched his uniform top and the gait belt hanging across his chest. On 8/14/24 at 4:45 PM, Staff J, CNA stated linen should be placed in a bag before it's carried to the soiled utility room. An undated document titled Linen Handling indicated linens need to be placed in plastic bag and taken to laundry bin. It also directed staff to never carry soiled linen against the body. On 8/15/24 at 1:12 PM, the Director of Nursing (DON) stated staff should discard linen per policy of linen removal.

Based on staff interview, chart review, and staff education review, the facility failed to ensure that residents were safe from accidents and hazards for 1 of 3 residents (Resident #33). A Certified Nurse Aide (CNA) failed to apply a gait belt before attempting to transfer Resident #33 from the shower chair to the wheel chair and the resident fell to the floor. The facility reported a census of 48 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #33 had a Brief Interview for Mental Status score (BIMS) of 8. She was at risk for falls and required extensive assistance with bathing. The Care Plan updated on 2/25/24, showed that Resident #33 was at risk for falling and had a history of falls. She was incontinent of bowel and bladder and was on 2 or more high fall risk drugs. She had impaired mobility and impaired cognition. A Nursing Note dated 1/09/2024 at 3:37 PM showed that Resident #33 fell in the shower room after getting a shower. The resident had stated that the floor was slippery and she fell . According to a Non-Pressure Skin Condition Report dated 1/9/24, the resident sustained a bruise on the top of her right hand that measured 10 centimeters (cm) x 8 cm. On 3/6/24 at 2:00 PM the Director of Nursing (DON) said they implemented an intervention after this fall to put a towel on the floor for the residents in the shower room after the bathes. She said that it was her understanding that the CNA used a gait belt when transferring the resident from the shower chair to the wheel chair. On 3/06/24 at 2:18 PM Staff C, Certified Nurse Aide (CNA) said that she provided a shower for Resident #33 on 1/9/24. After the shower, Staff C got the resident dressed while she was still in the chair, and she put gripper socks on her. Staff C said that she assisted the resident into the standing position to transfer her to the wheel chair, which was about two steps away, when the resident got weak, bent her knees and lowered to the floor. Staff C said that she assisted the resident with the transfer by grabbing the resident under her arm. She said that she had not put a gait belt on the resident. On 3/7/24 at 7:00 AM, Staff E, Registered Nurse (RN) remembered the fall that Resident #33 had in the shower room. She said that when the CNA came to get her, the resident was fully clothed, wearing gripper socks and sitting on the shower floor. The floor was wet, and the resident said that her wrist hurt. She said that while the resident was on the floor, Staff C applied the gait belt around the resident's waist at that time. On 3/07/24 at 7:21 AM, the DON said that she had just learned that Staff C hadn't actually used a gait belt to transfer the resident from the shower chair to the wheel chair. She said that the CNA would be re-educated and disciplined. The DON said that her expectation was that staff would always use a gait belt when transferring residents. She said she would expect staff to tell her if there were any staff that were not using the gait belts. According to an undated facility educational checklist titled: Transferring Resident from Bed to Chair or Chair to Bed, staff were to position a gait belt around the resident's waist before assisting them to a standing position and with both hands under the gait belt while they transferred.

Based on clinical record review and staff interview the facility failed to develop Care Plans to address opioid medication and antidepressant medication side effects to watch for 1 out of 5 sampled residents reviewed for comprehensive Care Plans (Resident #13). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of heart failure, hypertension, and Non-Alzheimer's Dementia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of the March Medications Administration History Report revealed the following orders: a. Escitalopram (antidepressant medication) daily for depression with a start date of 1/23/24 b. Hydrocodone- acetaminophen (opioid medication) as needed for pain with a start date of 11/21/23. Review of the MDS dated [DATE] revealed the resident was taking antidepressant medication in the review period. Review of the signed Physician Order Report dated 2/23/24 with a signature date of 2/24/23 revealed the following orders: a. Hydrocodone-acetaminophen as needed for pain with a start date of 11/21/23 b. Escitalopram daily for depression with a start date of 1/23/24 Review of the Care Plan with a revision date of 2/10/24 lacked information regarding the side effects of antidepressant medication and opioid medication. Review of the facility provided policy titled Care Plan Procedure undated revealed the Care Plan will include but not limited to medications that include antidepressants and pain medications. Interview on 03/06/24 at 12:53 p.m., with the Assistant Director of Nursing revealed the side effects should be listed on the Care Plan.

Based on observation, interview, and record review the facility failed to ensure that staff used adequate infection control practices to decrease the transmission of pathogens for 2 of 14 residents reviewed (Resident #1 and #34). Resident #34 required daily dressing changes for several wounds and staff failed to use proper hand hygiene during cares. Resident #1 required staff assistance with incontinence cares, they failed to use adequate hand hygiene when changing the resident. The facility reported a census of 48 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits). She was independent with rolling in bed and required supervision with transfers. Resident #34 had diagnoses that included urinary tract infections, renal insufficiency, and was at risk for developing pressure ulcers. The Care Plan updated on 2/24/24, showed that Resident #34 had the potential for pain/discomfort related to myalgia, multiple skin issues, and a history of skin yeast infection. The resident had a decline in functional ability, was unable to care for herself, and was at risk for impaired skin integrity related to fragile skin. She had unstageable pressure injuries on her bilateral heels, and a stage 3 ulcer on her spine. Staff were directed to keep her skin clean. On 3/04/24 at 10:33 AM, Resident #34 was in her bed on her back, she did not speak when addressed. A family member was in the room and said that the resident had just gotten out of the shower and was waiting for the nurse to come in and provide treatment to several wounds. With gloved hands, Staff A, Licensed Practical Nurse (LPN), applied betadine solution to the bilateral heels, wrapped the heals with a bandage, grabbed a marker and dated the dressing. She then applied a protective boot to the foot. Staff A failed to change her gloves. She then washed the right heel with saline solution, applied betadine to the right heel and wrapped it with a dressing. Without changing her gloves, she reached in her pocket for the marker, dated the bandage, and arrange the blankets on the bed without changing gloves. Staff A gathered trash and supplies and left the room without washing her hands. 2) According to the MDS dated [DATE], Resident #1 had a BIMS score of 9 (moderate cognitive deficits). She was at risk for developing pressure ulcers, but did not have any unhealed pressure ulcers at the time of the assessment. Diagnoses for Resident #1 included heart failure, anxiety disorder, schizophrenia, intellectual disabilities, and Down Syndrome. The Care Plan updated on 2/20/24, showed that Resident #1 had impaired decision making related to Down Syndrome and intellectual disabilities. She was at risk for pressure injury and impaired skin integrity due to incontinence of bladder and bowel. She required assistance with activities of daily living related to limited mobility. On 3/04/24 at 10:58 AM, Resident #1 said that she had a sore on her upper thigh that was causing her some pain, especially when she was sitting in the wheel chair. On 3/05/24 at 2:00 PM, Staff C, CNA and Staff D, CNA, moved Resident #1 to her bed and removed her brief. As they were checking her for skin issues, the resident said that she needed to use the bed pan. Staff D went to bathroom and got the bed pan, placed it under her and waited until she urinated. Staff D emptied the bed pan in the toilet and came back to the bed with a towel and a couple of wash cloths to clean her. With gloved hands, Staff D wiped the residents bottom several times. Staff C handed Staff D a 4x4 covering for an open sore on her upper thigh. With the same gloved hands, Staff C took a tube of barrier cream, squeezed some on the pad, spread it around on the 4x4, then applied the pad to the open sore. With the same gloved hands, Staff C then grabbed the blankets and pulled them over the resident. She gathered the trash that contained the soiled brief, grabbed the door knob, and exited the room with the trash with same gloved hands. On 3/06/24 at 3:13 PM, the Assistant Director of Nursing (ADON) and Infection Preventionist, said that she would expect staff to use hand hygiene, and glove changes whenever they were going from dirty to clean situations. She would expect them to wash their hands when entering and leaving a residents room. According to the facility policy titled: Infection Control Program, last reviewed 4/2/23, hand hygiene procedures would be followed by staff involved in direct resident contact.

Based on observations, facility policy review, clinical record reviews, resident, staff, and family interviews, the facility failed to ensure that all residents were free from physical abuse for 1 of 3 residents reviewed. Resident #6 reported that a Certified Nursing Assistant was rough with her during transfers resulting in bruising on her left and right arms. The facility reported a census of 47 Residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive ability. The resident required extensive assistance of one person for bed mobility, transfers, dressing and toilet use. The MDS section related to Behaviors indicated that the resident did not exhibit any behaviors of hallucinations, delusions, physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed toward others. The MDS continued to indicate that Resident #6 did not exhibit rejection of care. The Care Plan dated 7/22/22 showed that Resident #6 was admitted to Hospice services related to a diagnosis of Parkinson's disease with a decline in mobility and increase in dysphagia (difficulty swallowing). According to a facility investigation, on 12/10/22 at 9:45 PM the Director of Nursing (DON) received a call from Staff C, Licensed Practicing Nurse (LPN), regarding an incident between Resident #6 and Staff F, CNA. The resident alleged that Staff F was rough with her while getting her ready for bed. Staff B, LPN, assisted with the assessment. The resident told her that Staff F hit her on the arm as she pointed to bruising on her right arm. Staff B said that the resident had blood drawn three days prior, and that was the cause of the bruises. On 12/11/22 at 3:30 PM the DON assessed the resident and indicated that the resident had no apparent injury other than bruising from previous venipunctures. In an interview on 12/29/22 at 7:54 AM Resident #6 spoke with soft mumbled speech. She lifted the sleeves of her pajamas and did not have any visible bruising on her arms. She said that CNA Staff F barged into her room one night and started going through her closet. The resident said that she asked her what she was doing and the CNA said that she was going to get her ready for bed. She also went through her dresser drawers and the resident asked her to leave but she said I'm not leaving, I came in here to get you into bed. Resident #6 said that she had her pajama top on and wanted the bottoms but Staff F went to find a different top. She said that the CNA ripped the pajama top off of her and put her on the Sit to Stand. I was hollering for help, the door was closed, she tried to get me to shut up. She said that the CNA transferred her to the toilet. The hitting and grabbing started when she transferred her out of the wheelchair. The resident knew that Staff E and Staff C were in the building and she was hollering for them but they couldn't hear her. She said that while she was on the Sit to Stand and being transferred she let go a couple of times as she was swinging at Staff F. That was when the CNA grabbed her arm. After she got me into bed she put the green top on me. Shortly after she was put into bed, Staff C and Staff F came into the room. On 12/29/22 at 8:35 AM Resident #6's family member said that he got a call from the resident around 10:00 PM on 12/10/22. He said that was very unusual for her to call that late and she was very upset. He explained that it was difficult to understand what she was saying but she was very upset and told him I don't know who to get a hold of. He later talked to Staff E, LPN, who told him that the resident had been yelling at Staff F to get out of her closet and drawers. Then when the aide got her into the bathroom she was physical with her. The LPN told him that she had bruising on her arms but the bruising had been from blood draws a couple of days earlier. The family member said that he visited the next day and there were 3 large bruises on the right arm and one on the left arm. He said that she hadn't ever accused people of abuse before. At times she is not very happy but she doesn't accuse people of things. On 12/29/22 at 9:34 AM Staff F stated that when she went into the room of Resident #6 on 12/10/22, she started getting freaky with me so she left the room and went to get a nurse. Staff F then said that when she entered the resident's room she introduced herself and told her she was going to get her ready for bed. It was later that the resident got upset with her and told her to leave so that was what she did. She said that she got the resident transferred into bed and initially everything was okay, but then something happened, I don't know if it was my tone of voice or what, but the resident got upset and told her to leave. She said that the resident got upset when she was looking through her closet and drawers. In a second interview on 12/29/22 at 9:56 AM Staff F said that she transferred the resident to the toilet with the sit to stand lift and the resident was calm at that time. Once she got her into bed the resident started swinging at her. Staff F then said that she transferred the resident to the toilet and left her there while she went to get a hospital gown. When she came back the resident was yelling on the toilet that she had Parkinson's and she was yelling someone's name. She said that when she tried to put the gown on her while in bed, that's when the resident became resistive. Staff F denied grabbing the resident's arms but that she blocked the resident with her right arm when the resident tried to hit her. On 12/29/22 at 11:26 AM Staff G, LPN, stated that on 12/8/22 the Hospice nurse attempted two blood draws: one from the top of the left arm and one on the top of the right arm near the wrist. She said that she was able to get a blood sample with one try; just above the spot where the Hospice nurse attempted on the right arm. On 12/29/22 at 9:33 AM, Staff D, Hospice Nurse, said that on 12/8/22 she tried to draw blood from Resident #6 on the top of her right hand just above the right finger and in the left antecubital. She said that Staff G had not been in the room when she made these two attempts. Staff D watched as Staff G drew blood from Resident #6's right wrist. A review of pictures reported by the family to have been taken on 12/11/22 showed 6 areas of bruising. 1. One on the right hand, just above the ring finger 2. One on the right wrist 3. A much larger bruise on the lower right arm 4. A smaller bruise just above the large one on the right arm 5. A smaller bruise near the right antecubital. 6. One on the top of the left lower arm. According to a document titled: Non Pressure Skin Condition dated 12/10/22 the resident had three bruises; Area 1) Right lower arm closest to the wrist measured 4 centimeters (cm) x 3 cm Area 2) Right upper arm 4 cm x 3 cm Area 3) Left lower arm 3 cm x 2 cm. Each of the three areas were said to be dark purple with fading and noted that the resident had blood drawn on 10/8/22. On 12/29/22 at 2:50 PM Staff I, CNA, said that she got Resident #6 dressed on the morning of 12/9/22 and that she did not see any bruising on her arms. She looked at the picture of the bruising on the right arm and she said that she definitely would have remembered those bruises. On 12/29/22 at 2:59 Staff H, CNA, said that she remembered taking care of Resident #6 on the morning of 12/10/22. She said that she saw just one bruise on the resident's arm and it was in the crease of the elbow she did not see any other bruising on her arms. On 12/28/22 at 2:07 PM the Hospice Social Worker stated that she knew Resident #6 for many years. She said that while the resident can be negative and disagreeable at times, she hadn't ever known her to accuse anyone of abuse. The following additions were made to the resident's Care Plan after the incident: 1. On 12/27/22 a focus area of impaired skin integrity and indicated that the resident bruised easily. 2 On 12/18/22: a. The resident used aspirin and bruised easily. b. The resident exhibited verbal behaviors such as yelling and may make accusations toward staff. On 1/3/23 at 1:40 PM the DON provided statements from two staff that they witnessed bruising on the residents arms before 12/10/22. The statements did not include a description or location of those bruises. When asked why the skin assessment hadn't been initiated until after the alleged abuse, the DON responded in an email dated 12/29/22 at 7:49 PM that they do not track bruises under 3 cm and do not track bruises known to be caused by a blood draw. According to the facility policy titled: Abuse Prevention, Identification, Investigation and Reporting Policy last reviewed in October of 2022. The risk for abuse may increase when a resident exhibits behavior that provokes a reaction from staff such as verbal aggression or screaming or rummaging through property. Additional documentation provided by the facility on 1/4/23 via email included images of Resident #6's left and right upper extremities with comments for each bruise. 1. Right Upper Extremity from the elbow down includes four statements regarding the bruises to Resident #6's arm. a. Upper forearm Staff G reported that the bruise resulted from her tourniquet. b. Mid-forearm comment indicates an unexplained bruise - possibly from the hospice tourniquet location. c. Lower forearm - Staff G drew blood. d. Under lower forearm - Staff G reported that she did her blood draw above Staff D's venipuncture. 2. Left Upper Extremity from the elbow down includes documentation that the bruise measured 3 x 2 cm. The picture indicated that the bruising was unexplained but did not appear to be new.

Based on staff interviews, clinical record reviews, and facility policy review, the facility failed to follow their policy regarding the designation of code status (full code or do not resuscitate) with not using the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Without the proper form the facility could not ensure the use of a clear and documented code status form used to notify the receiving facility of a resident's code status if necessary to transfer to a resident to a higher level of care for two of two residents reviewed for correct code status documentation in a sample of 13 residents (Resident (R) 12 and R38). Due to the facility's failure to recognize the lack of clarity for a resident's code status and the lack of using the POLST form if a resident required to be transferred to a higher level of care resulted in an Immediate Jeopardy for the potential of all residents. The facility reported a census of 44. The survey determined the Immediate Jeopardy began on [DATE] when the survey team identified the inaccuracy of the residents' code statuses. On [DATE] at 10:00 AM the survey team notified the Administrator, the Director of Nursing (DON), and Assistant Director of Nursing (ADON) of the Immediate Jeopardy at F578 (Request/Refuse/Discontinue treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The facility's policy titled, Advance Directive Policy, dated [DATE], revealed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It is the policy of this facility to provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place. The facility's policy titled, Hospital Transfer Policy, dated [DATE], revealed .When a Resident is transferring to a higher level of care facility the nurse will send the following information with the resident: .Residents Code Status. The facility's Emergency Transfer Paperwork Process, undated, revealed Code Status Signed Sheet in Resident Chart - Make Copy. [to send with resident when transferred to higher level of care]. 1. R12's undated Face Sheet revealed an admitted [DATE]. The Face Sheet included medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The top of the face sheet indicated code status as FULL CODE/DNI (do not intubate). R12's admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, indicating severe impaired cognition. R12's paper chart and electronic medical record (EMR) lacked documentation about the resident's or the resident's representative's (RR) choice of do not intubate (DNI). R12's paper chart and EMR lacked documentation of a POLST form to indicate their code status. R12's Do Not Resuscitate/DNR Request Order, dated [DATE], located in their paper chart medical record revealed R12's RR signed the form. In the middle of the form, above the RR's signature was printed Patient must initial statement: Next line read, I (box) DO (box) DO NOT want a DO NOT RESUSCITATE (DNR) order. On the form in R12's paper chart the box checked was the DO NOT box and initiated by the RR, indicating R12 was to be a full code, and not a DNR. At the bottom of the form, printed in bold were the words DNR PHYSICIAN ORDERS. Under the title was the statement: This directive is the expressed wish of the above patient. This is followed by a box [to be checked by the physician] DO NOT RESUSCITATE in the event of an acute cardiac or respiratory arrest, no cardiopulmonary resuscitation (CPR) would be initiated. Below the statement is a line for the physician to place their signature, phone number, and date signed. The form in R12's chart had the box checked and signed by the physician with phone number and undated, indicating R12 was to be a DNR. During an interview on [DATE] at 4:23 PM, Licensed Practical Nurse (LPN) 1 reviewed R12's Face Sheet in the paper chart and expressed confusion when he read the top of the face sheet FULL CODE/DNI. He was unsure if the resident was a FULL CODE or a DNR based on the face sheet information. LPN1 reviewed the form in R12's paper chart titled Do Not Resuscitate/DNR Request Order, and expressed confusion about the wishes of the resident for FULL CODE or DNR. LPN1 confirmed if R12 had transferred to a higher level of care, the form titled, Do Not Resuscitate/DNR Request Order would be the form sent with the resident. LPN1 stated due to the signature on the bottom of the form and box checked for DNR, if R12 did stop breathing or their heart stopped, the higher level of care facility may not do CPR, even though R12 actually did wish to have CPR. During an interview on [DATE] at 4:35 PM, when asked the question if R12 was a FULL CODE or DNR, the Director of Nursing (DON) opened the paper chart, the first page, viewed the Face Sheet and seeing DNI at the end of the top line (pointed to it with her finger) stated R12 was a DNR and proceeded to look at the second page titled Do Not Resuscitate/DNR Request Order, seeing the box checked and the signature on the bottom of the page again confirmed R12 code status was DNR. Further the paper chart revealed a green dot sticker on the spine of the chart and then the DON realized R12 was a FULL CODE, not a DNR. 2. R38's undated Face Sheet revealed an admitted [DATE]. The Face Sheet included medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's quarterly MDS dated [DATE], revealed a BIMS score of four out of 15, indicating severe cognitive impairment. R38's paper chart lacked documentation of the POLST to indicate code status for the resident. R38's Do Not Resuscitate/DNR Request Order, dated [DATE], located in the resident's paper chart medical record, revealed R38's RR signed the form. In the middle of the form, above the RR signature was printed Patient must initial statement: Next line read, I (box) DO (box) DO NOT want a DO NOT RESUSCITATE (DNR) order. On the form in R38's paper chart the box checked was the DO box and initiated by the RR, indicating R38 was to be a DNR, At the bottom of the form printed in bold were the words DNR PHYSICIAN ORDERS. Under the title a statement the words: This directive is the expressed wish of the above patient. This is followed by a box [to be checked by the physician] DO NOT RESUSCITATE in the event of an acute cardiac or respiratory arrest, no cardiopulmonary resuscitation will be initiated. Below the statement is a line for the physician to place their signature, phone number, and date signed. The form in R38's chart the box was not checked, and it was signed by the physician with a phone number and dated [DATE]. During an interview on [DATE] at 4:23 PM, LPN1 reviewed R38's Face Sheet in the paper chart and confirmed R38 code status was a DNR/DNI. LPN1 reviewed the form in R38's paper chart titled Do Not Resuscitate/DNR Request Order, and confirmed the wishes of the resident for DNR. LPN1 confirmed if R38 had transferred to a higher level of care this was the form being sent with the resident and due to the signature on the bottom of the form without the box checked for DNR. LPN1 confirmed that if R38 did stop breathing or their heart stopped, the higher level of care facility may perform CPR due to the incomplete form lacking a mark confirming the order of DNR. During an interview on [DATE] at 4:35 PM, when asked the question if R38 was a FULL CODE or DNR, the Director of Nursing (DON) opened the paper chart, the first page, viewed the Face Sheet and seeing DNR/DNI at the end of the top line stated R38 was a DNR and proceeded to look at the second page titled Do Not Resuscitate/DNR Request Order. Seeing the box not checked and the signature on the bottom of the page the DON confirmed R38 code status was DNR. The DON verified that with the box not checked the form was incomplete and did not clearly indicate R38's code status of DNR. With the unclear form, this could confuse the higher level of care facility if R38 stopped breathing or heart stopped. During an interview on [DATE] at 9:55 AM, the Administrator expressed concern that there could be other residents in the facility with their Do Not Resuscitate/DNR Request Order forms not correctly completed and expressed a need to audit all the resident paper charts for correct completion of the form. The survey team validated the facility's removal plan on [DATE] at 12:15 PM through the following actions: A. Completed POLST form for R12 and R38 with resident representative and physician signatures confirming code status. B. An audit of all resident charts for accurate completion of the code form, six more resident records were identified and corrected with an up-to-date POLST form with resident representative signatures and physician signatures. C. Revised the current Transfer Policy and Emergency Transfer Paperwork Process flowsheet to include current POLST form. D. Education of staff about the use of the new POLST form clarifying each resident's code status. The facility received notification that the Immediate Jeopardy was removed on [DATE] at 12:15 PM. After the immediacy was removed, the noncompliance remained at a lower scope and severity level for more than minimal harm that was not Immediate Jeopardy.

Based on clinical record reviews, facility policy review, Pharmacist Consultant, and staff interviews the facility failed to document a clinical rationale for using multiple medications from the same pharmacological class for one resident (Resident (R) 40) of five residents reviewed for unnecessary medication use. This failure had the potential to place the resident at greater risk for adverse consequences. Findings include: The facility's policy titled, Monthly Drug Regimen Review, dated 1/7/17, indicated, During this review the pharmacist will identify excessive doses (including duplicate drug therapy). R40's Face Sheet revealed R40 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)]. R40's Physician Order Report revealed the following orders for antidepressant medications: 5/23/21 [MEDICATION(S)] [[MEDICATION(S)]] (an antidepressant) 150 mg (milligrams) once a day for depression; 6/3/22 [MEDICATION(S)] (an antidepressant) 300 mg once a day for depression; 12/15/21 [MEDICATION(S)] (an antidepressant) 300 mg at bedtime for [CONDITION(S)]. R40's July 2022, August 2022, September 2022, and October 2022 Medication Administration History revealed the nursing staff administered the above-mentioned medications as ordered by the physician. During an interview on 11/1/22 at 4:29 PM, the Assistant Director of Nursing (ADON) stated, He likes his medications. He is on several antidepressants but that's what he likes. He will not let anyone change them. When asked if the pharmacist reviewed the duplicative therapy, the ADON was unable to provide an answer. During an interview on 11/3/22 at 12:42 PM, the Pharmacy Consultant reported that he had not identified R40's duplicative therapy in regard to antidepressant medications.

Based on interview, record review, and facility policy review, the pharmacist failed to report irregularities and the facility failed to respond to a pharmacy recommendation of a gradual dose reduction (GDR) for [CONDITION(S)] medication use (any drug that affects brain activities associated with mental processes and behavior) for one of five residents (Resident (R) 40) reviewed for unnecessary medication use. Findings include: The facility's policy titled, Monthly Drug Regimen Review, dated 1/7/17, indicated, It is the facility's policy to have a monthly drug review by a licensed pharmacist to ensure irregularities are identified and reported to the physician, medical director, and the director of nursing. The facility's policy further revealed, During this review the pharmacist will identify Medication irregularity (e.g., including, but not limited to, unnecessary drug criteria); and review psychoactive medications to recommend gradual dose reductions per federal guidelines. R40's undated Face Sheet revealed R40 was admitted to the facility on [DATE] with a diagnoses of [CONDITION(S)] and [CONDITION(S)]. R40's Physician Order Report revealed the following order for [CONDITION(S)] medications dated 5/23/21: [MEDICATION(S)] (an antidepressant) [[MEDICATION(S)]] 150 milligrams (mg) once a day for depression. R40's July 2022, August 2022, September 2022, and October 2022 Medication Administration History revealed the nursing staff administered the above-mentioned medications as ordered by the physician. R40's electronic medical record (EMR) revealed the absence of pharmacy recommendations for [MEDICATION(S)] except for one recommendation dated 9/21/22. R40's Note to Attending Physician/Prescriber, provided to the survey team by facility staff and dated 9/21/22, the pharmacist recommended a GDR of the [MEDICATION(S)]. The physician did not respond to the recommendation. During an interview on 11/1/22 at 4:29 PM, the Assistant Director of Nursing (ADON) stated, The only pharmacist recommendation that we have is the one from September. The doctor hasn't responded yet because we let the psychiatrist respond and he comes every other month. He couldn't come for October and won't be here until December. The ADON confirmed there was only one pharmacy recommendation for R40 in over a year. During an interview on 11/2/22 at 5:19 PM, the ADON confirmed R40 originally got the order for [MEDICATION(S)] in May 2021. During an interview on 11/3/22 at 12:42 PM, the Pharmacy Consultant stated, I do the recommendations for the [CONDITION(S)] medications as a group and that is done every six months and I will bounce back and do another one [recommendation] the next month if a new medication is ordered. The Pharmacy Consultant stated he did not have any additional recommendations for R40 related to his [MEDICATION(S)]. The Pharmacy Consultant stated, Since he started the medication in May 2021, there should have been recommendations done in October 2021, March 2022, and then September 2022. The Pharmacy Consultant confirmed he had not received a response from the physician for his September 2022 recommendation. During an interview on 11/4/22 at 12:36 PM, the Medical Director stated, Pharmacy recommendations related to [CONDITION(S)] drugs, usually the psychiatrist responds unless I am acquainted with that resident. I don't know this particular resident so that would have been left up to the psychiatrist.

Based on observations, staff interviews, Pharmacy Consultant interview, Medical Director interview, clinical record reviews, and facility policy review, the facility failed to ensure controlled medications records were maintained and accounted for. In addition the facility failed to ensure Schedule II through V controlled substances were doubled locked for one of three medication carts. These deficient practices had the potential for residents' medications to be diverted and not be identified by the facility. Findings include: During an observation and interview on 11/1/22 at 12:00 PM of the medication administration pass on the 400 Hall and medication cart three, revealed the OPUS (a small cassette with seven days worth of medication) box which contained [MEDICATION(S)] (a Schedule IV controlled substance used to treat pain) was stored in a single locked drawer and not double locked. Registered Nurse (RN) 2 stated, [MEDICATION(S)] is not considered a controlled substance here. On 11/2/22 at 4:30 PM the observation of medication cart three with RN1 revealed the medications of [MEDICATION(S)] (a Schedule IV controlled substance used to treat anxiety), [MEDICATION(S)] (a Schedule IV controlled substance used to treat anxiety), [MEDICATION(S)], and [MEDICATION(S)] (a Schedule IV controlled substance used to treat anxiety) were all located in a singled locked compartment and not double locked. Additionally, there were no reconciliation records for the medications. During an interview on 11/2/22 at 4:35 PM, RN1 stated, those medications, [[MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]] are not double locked or tracked in the narc [narcotic] book. During an interview on 11/2/22 at 4:50 PM, the Assistant Director of Nursing (ADON) stated, We lock and log narcotics. We have not ever double locked or tracked any other controlled substances. During an interview on 11/3/22 at 11:26 AM, the Pharmacy Consultant (PC) stated he was unaware it was necessary to double lock any controlled medications other than narcotics. After he reviewed the regulations, he stated it did say controlled substances schedule II through V were required to be double locked and audited. The PC stated he had not performed an audit or reconciliation on the controlled substances that were dispersed from the main area of the cart. During an observation on 11/2/22 at 4:40 PM a Certified Medication Aide (CMA) 1 gave [MEDICATION(S)] to the prescribed resident, from one of the top drawers of medication cart three. During an interview on 11/3/22 at 4:30 PM with the DON and ADON, the DON stated again, We only lock and track narcotics, we had no idea we were supposed to be locking and tracking all controlled substances. The ADON stated, I looked up the regulation, I just did not know. During an interview on 11/4/22 at 12:30 PM, the Medical Director stated he was unaware that controlled substances were not being properly stored or reconciled.

Based on observations, staff interviews, and clinical record reviews, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice, by specifically failing to change oxygen tubing for one (Resident (R) 42) of three residents reviewed for respiratory care in a total sample of 13 residents. This failure had the potential for the resident to receive care that was not in line with professional standards. Findings include: R42's undated Face Sheet revealed R42 was admitted to the facility on [DATE]. The Face Sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's quarterly MDS (Minimum Data Set) dated 9/6/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. During observations on 10/31/22 at 10:59 AM, 11/1/22 at 11:26 AM, and on 11/2/22 at 10:09 AM, R42's oxygen tubing was dated 9/24/22. During an interview on 11/2/22 at 10:09 AM, R42 stated the last time the oxygen tubing was changed was in September. R42 further stated, A couple of weeks ago, somebody left me some extra tubing and put it in that pouch right there but then somebody came and got it and I guess used it for another resident. R42's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not reveal when R42's oxygen tubing should be changed. R42's Care Plan located under the RAI then Care Plan tab, revealed the following oxygen interventions: 1. Assist me with organizing my oxygen and tubing. 2. The Pharmacy will maintenance my oxygen concentrator. 3. Nursing will monitor oxygen saturation as needed and address it with PCP [primary care physician] as needed. 4. Assist me with managing tubing and assess the need for oxy ears as needed. During an interview on 11/2/22 at 10:09 AM, Registered Nurse (RN) 2 stated, Oxygen tubing is changed and dated on night shift. I think monthly it [tubing] gets changed. RN2 confirmed R42's tubing was dated 9/24/22. RN2 stated, That should be changed. I will go change that now. During an interview on 11/2/22 at 11:20 AM, the Assistant Director of Nursing (ADON) stated, the Pharmacy changes tubing and maintains filters. Oxygen tubing is changed every other week by the pharmacy. For R42 the ADON expected that his tubing would have been changed so don't know why it is dated for September. I will check the last time the pharmacy was here. The ADON further stated, Oxygen tubing is not something that nursing takes care of unless it falls on the floor and gets dirty. We don't have any policies; I would just expect nurses to know what needs to be done and a care plan to be followed. R42's Oxygen Equipment Follow Up dated 10/13/22, provided to the survey team by the ADON, revealed the Pharmacy was in the facility on 10/13/22 and checked R42's concentrator and filter. The document further revealed supplies left was a cannula. Other options for supplies left include humidifier, seven foot tubing, twenty-five foot tubing, fifty foot tubing, water trap, distilled water, O2 [oxygen] mask, and oxy ears (foam padding to protect the ears). These items were not checked on the document as left for R42. An interview was conducted with the ADON at the time that she brought the document. The ADON stated the document was used as a tracking log for billing purposes to show the services the pharmacy provided. The ADON stated because the cannula was checked on the form, which meant the pharmacy changed the resident's tubing. The ADON was unable to answer why R42's tubing was dated 9/24/22. The ADON was unable to provide any other previous Oxygen Equipment Follow Up documents for R42. During an interview on 11/3/22 at 12:42 PM, the Pharmacy Consultant stated, We provide oxygen services to the facility. We check the concentrator and filter. When asked if the pharmacy changed resident tubing, the Pharmacy Consultant stated, We don't change oxygen tubing, but we do leave the supplies that are needed like the tubing. During a follow-up interview on 11/3/22 at 1:00 PM, the ADON stated We do not have any oxygen policies, but we go by the Clinical Nursing Skills book. The Clinical Nursing Skills Basic to Advanced Skills book 7th edition, copyright 2008, provided by the facility, revealed the following: pages 1390-1391 Caring for Oxygen Equipment - wash long tubing weekly. Replace monthly.

Based on observations, staff interviews, and clinical record reviews, the facility failed to ensure a resident received appropriate treatment and services to increase or to prevent a decline in range of motion for one of one resident (Resident (R) 23) sampled for limited range of motion (ROM) in a total sample of 13 residents. This failure had the potential for the resident to have a decline in range of motion. Findings include: R23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/31/22 at 10:00 AM, observed R23 seated in a Geri-chair (medical recliner, is a large, padded, comfortable reclining chair), with her fingers clenched into her palms on both hands. R23 had no rolled washcloths observed at that time in either of her hands. During an additional observation on 11/1/22 at 11:24 AM, observed R23 seated in her Geri-chair, in the dining room with both of her hands in a clenched position with no rolled washcloths noted that time. During an additional observation on 11/1/22 at 2:21 PM, observed R23 in her bedroom, lying in bed awake with both of her hands in a clenched position without rolled washcloths noted at that time. R23's undated Face Sheet revealed R23 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R23's quarterly MDS (Minimum Data Set) located in EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 8/30/22 revealed R23's Brief Interview for Mental Status (BIMS) could not be assessed due to resident rarely understood. During an interview on 11/2/22 at 9:21 AM, Certified Medication Aide (CMA) 2 stated she had noticed that R23 sometimes did not have the rolled washcloths in her hands. CMA2 stated, She bites at them, so I guess she doesn't like them. CMA2 stated R23 should have the rolled washcloth in both hands when R23 is awake. During an interview on 11/2/22 at 11:55 AM, Restorative Aide (RA) 1 stated, I have noticed there are times that she comes to restorative and does not have the washcloths in her hands. When that happens, I just wash her hands and follow the procedure. During an interview on 11/2/22 at 2:29 PM, the Assistant Director of Nursing (ADON) stated, If there is a nursing order in the chart, I expect it to be followed.

Based on observations, staff interviews, and clinical record reviews, the facility failed to ensure a resident assessment accurately reflected the resident's status for two of 13 sampled residents (Resident (R) 23 and R40). This failure could result in the residents' needs, strengths, and areas of decline to be not addressed. Findings include: 1. During an observation on 10/31/22 at 10:00 AM, observed R23 seated in a Geri-chair, with her fingers clenched into the palms of both of her hands. R23's hands were observed in the same position on 11/1/22 - 11/4/22 at various times during the survey period. R23's undated Face Sheet revealed R23 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 11/2/22 at 2:19 PM, Restorative Aide (RA) 1 stated R23 was unable to open her hands on her own. During an interview on 11/2/22 at 3:47 PM, Occupational Therapist (OT) 1 stated, R23 had limited range of motion in both hands. R23's quarterly MDS (Minimum Data Set) dated 8/30/22 documented that R23 had no impairment in the upper extremities (shoulder, elbow, wrist, hand). During an interview on 11/3/22 at 12:03 PM, the Director of Nursing (DON) stated she was responsible for completing the range of motion portion of the MDS. The DON stated she coded R23 as zero impairment in her upper extremities because staff could open R23's hands. 2. R40's undated Face Sheet revealed R40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's July 2022, August 2022, September 2022, and October 2022 Medication Administration History revealed R40 received [MEDICATION(S)] daily. The quarterly MDS dated [DATE] documented R40 had not received antipsychotic medications since admission. During an interview on 11/3/22 at 12:00 PM, the MDS Coordinator (MDSC) stated R40 received antipsychotics daily and the MDS was coded incorrectly. During an interview on 11/3/22 at 3:25 PM, the DON stated the facility did not have a MDS policy. The DON stated the facility followed the RAI manual.

Based on observations, clinical record reviews, and resident and staff interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents and injury for 1 of 32 residents reviewed. On 10/4/17, a resident fell out of the facility's wheelchair van when one of the van drivers on staff released Resident #17's wheelchair from the hooks in the van, and she unlocked her brakes and backed up, as was her usual practice. However, the lift platform had been already been lowered prematurely rather than kept level with the van floor to ensure a smooth transition surface in order to lower the resident safely to the ground. Although the van driver attempted to keep the resident and her wheelchair from falling from the van, both the driver and resident tumbled to the ground. Both were injured; the resident bumped her head and momentarily lost consciousness, fractured ribs, and experienced pain. This situation constituted Immediate Jeopardy (IJ) to resident health and safety at the time of the investigation. The facility identified a census of 72 residents. Findings include; 1. According to the Minimum Data Set (MDS) assessment tool dated 8/29/17, Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicated the resident remained cognitively intact. The MDS recorded the resident required total physical assistance of 2 staff for transfers and had [DIAGNOSES REDACTED]. The MDS documented the resident required [MEDICAL TREATMENT] ([MEDICAL TREATMENT]), a process that compensates for impaired renal function. When the kidneys are damaged, they are no longer able to remove wastes and excess fluid from the bloodstream efficiently. [MEDICAL TREATMENT] uses a machine and a filter to remove waste products and water from the blood. The Care Plan dated 6/19/17 recorded Resident #17 experienced mobility problems due to a [MEDICAL CONDITION] on the left side. The Care Plan documented the resident required [MEDICAL TREATMENT] three times weekly, and directed staff to encourage the resident to attempt any dressing and undressing tasks and assist as needed to complete anything she was unable to do. The Care Plan also instructed staff to monitor lab work related to kidneys and watch for either insufficient fluid intake or fluid overload. The Interdisciplinary Team Notes dated 10/4/17 documented Resident #17 went to [MEDICAL TREATMENT]. The Facility's Incident Report dated 10/4/17 at 11:00 AM identified the resident fell while being assisted from the facility van. Staff D, Maintenance worker and van driver pulled the resident backwards in her wheelchair, and unhooked Resident#17 after the door and ramp opened. The report revealed Resident #17 unlocked wheelchair brakes and pushed herself back, which caused an alarm to sound. When the alarm activated, Staff D tried to stop Resident #17 from falling, but she continued to push back. Staff D and Resident #17 fell out of the van because the ramp had been lowered to the ground rather than kept level so the resident could wheel herself out of the van. The Radiology Report for a chest CT with contrast completed 10/4/17 at 12:06 PM documented Trauma as the reason for the procedure. Findings: There are non-displaced fractures that manifest as slightly angulated deformities without displacement involving the anterolateral left 2nd, 3rd, 4th, 5th. 6th, 7th, and 8th ribs. There is no underlying lung abnormality. The Trauma Surgery History and Physical dated 10/4/17 at 1:24 PM documented Resident #17 transported by Helicopter and presented due to a fall during transportation to [MEDICAL TREATMENT]. The patient fell backwards out of a wheel chair and struck her head. She experienced loss of consciousness for less than 1 minute, with an initial Glasgow Coma Scale of 8 ( GCS is a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment. A GCS of 8 or less indicates severe injury, score 9-12 moderate injury, and a score of 13-15 is obtained when the injury is minor). At the time of the helicopter transport was arranged and prior to patient's transport, her GCS had risen to 15. When she presented at the hospital, the patient continued to demonstrate a GCS equal to 15, remained fully lucid, answered all questions appropriately, and followed all commands correctly. She complained of neck pain and mid back pain with no head ache, shortness of breath, abdominal or pelvic pain or extremity pain. Resident #17 presented with [MEDICAL CONDITION] on right lower extremity with no other visible skin changes or lacerations. Outside CT head,, C-spine, chest, abdomen/pelvis done and CD transported with patient. Report showed Left minimally displaced rib fractures 2-8. The hospital staff admitted Resident #17 to the ICU (Intensive Care Unit) and consulted internal medicine as well as nephrology. Plan was to observe and control pain with aggressive [MEDICAL CONDITION] hygiene. The Hospital Summary signed electronically by the physician 10/10/17 at 8:27 AM documented Resident #17 as a [AGE] year old female admitted for multiple rib fractures on 10/4/18. Medical history significant for type 2 diabetes, end stage [MEDICAL CONDITIONS], hypertension, and [MEDICAL CONDITION]; presented after a fall with loss of consciousness. Initially her GCS equaled 8 and she sustained multiple left sided mildly displaced rib fractures #2 through #8 and required 3 liters of oxygen (home requirements 1.5 liters). Home medications were restarted. The hospital staff managed her pain via PCA (patient controlled [MEDICATION NAME]) pump of [MEDICATION NAME] (a narcotic to treat moderate to severe pain) and [MEDICATION NAME] (narcotic) initially and weaned down to Tylenol (an [MEDICATION NAME]). Overnight she developed acute respiratory distress requiring [MEDICAL CONDITION] (Bi-level Positive Airway Pressure) on 10/5/18 and 10/6/18 and became quite agitated. Staff initiated a Precedex drip (Sedative, used in intensive care units for sedation) on 10/8/18 and then weaned her from it. The summary revealed Resident #17 breathed comfortably on 1 liter of oxygen after weaning from sedation. The Interdisciplinary Team Notes dated 10/11/17 identified Resident #17 returned to the facility at 4:50 PM via the facility transportation in wheelchair. During assessment, abdomen appeared swollen related to the rib fractures with light bruising present. At 9:00 PM, Resident #17 used call light and reported she did not feel right because her head and chest felt different. Staff notified the Resident's primary physician and gave a condition update. The doctor stated he would stop by the facility to assess her. The notes documented when the physician arrived, he sent the resident to ER (emergency room ) due to a new onset [MEDICAL CONDITION] Fibrillation. Call returned to facility from ER, the Resident returning to facility due to normal sinus rhythm while at the Hospital. The Interdisciplinary Team Notes dated 10/11/17 reported that Resident #17 returned to the facility via facility transportation at 11:45 PM from ER. The Interdisciplinary Team Notes dated 10/12/17 at 2:15 AM revealed Resident #17 complained of rib pain at 9 out of 10. Staff gave [MEDICATION NAME] and Tylenol for pain. The Interdisciplinary Team Notes dated 10/12/17 at 8:00 AM contained a late entry for 10/4/17 at 11:00 AM that revealed Resident #17 sustained a fall outdoors in [MEDICAL TREATMENT] parking lot and was transferred to the hospital and admitted for observation with [DIAGNOSES REDACTED]. During an interview on 04/12/18 at 08:48 AM with the Administrator, when asked to provide documentation for driver training, instructions for the lift, and any repair bills, the Administrator explained they have not had instructions for the lift as long as she has been at the facility for over 3 years. During an interview on 04/11/18 at 10:03 AM, Resident # 17 explained she had not done anything different the day she fell from the van. She reported she had to rock back and forth to get unhooked from the wheel holders. Resident # 17 also reported she and Staff D saw the light activate, but did not hear the horn. She said she did not know why the lift had been down on the ground, but she had started to roll back; Staff D tried to stop her, but the two fell to the ground. She added this happened on a Friday, but she did not remember anything that had happened before the following Monday. She added Staff D broke his neck at the time they fell . In an interview on 4/12/18 at 7:54 AM, Staff D (when asked about Resident #17's) fall he explained it had been a busy day, but loaded Resident #17 as usual and transported her to [MEDICAL TREATMENT]. Staff D further explained he lowered the lift to back Resident #17 out of the van. Staff D stated it happened so fast, but apparently he did not leave the lift up to the van floor level. Staff D reported once they hit the bar in the back of the van, it had alerted him something was wrong. Staff D saw Resident #17 as she turn around and look over her shoulder in her wheelchair to see about the alarm sounding. Staff D stated he had tried to hang onto Resident #17, but the momentum threw him out along with the resident. This surveyor asked about the van that day and Staff D explained he did not think anything went wrong with the van that day, but the facility took the van for repairs afterward. Staff D reported the Administrator came down to the incident and ran the lift up and down several times that day. During an observation of the reenactment of the incident on 4/12/18 at 10:02 AM, the Housekeeping Supervisor parked the facility van in front of the facility, opened the back of the van, and lowered the lift to the van floor level. Upon request, Staff F hooked the front and back hooks from inside the van. A surveyor sat in the wheelchair and then asked if Staff D, who drove the van the day of the incident, could be present to demonstrate what he had done that day. During that time the Administrator. said that Resident #17 turned to the side and went out side ways. Staff D approached and explained he opened the door, and must have lowered the lift all the way to the ground by pushing in the button and holding down. Staff D then got into the van to undo the straps that held the wheelchair in place. Staff D reported at that time, Resident #17 unlocked the wheelchair brakes and started to move; the light and the alarm activated so she turned around and looked over her shoulder to check what happened. Staff D acknowledged at that time he noticed the lift had been lowered all the way. He reported he the tried to hold Resident #17 back by grabbing the front of the wheelchair, but with the momentum they both fell out of the van onto the ground. He stated a van driver from a different facility noticed them on the ground and summoned assistance. During the demonstration, bot van drivers had unhooked the wheelchair from inside the van in front of the wheelchair without checking the lift position before pushing the wheelchair. During the observation, the following instructions had been noted on the lift. The instructions were as follows: Warning 1) Improper use of lift can result in personal injury. User must read and follow operation instruction in Owner Manual. Additional copies of owner's manual are available from Ricon Corporation 7900 Nelson Rd, Panarana City CA. 2) Do not exceed rated load capacity. 3) Prior to use inspect wheelchair lift for proper function, required maintenance or damage if a problem exist do not use return to an authorized service technician for repair. Operation Instructions Deploy Lift 1) Open door fully 2) Use pendent switch to apply power to pendant 3) Press down hold deploy button to unfold platform and lower it to vehicle floor level 4) Press and hold down button to lower platform to ground level. Enter Vehicle 1) Place wheelchair in center of platform facing outward if possible. Lock wheelchair brakes 2) Fasten occupant restraint belt 3) Press and hold up button to raise platform to vehicle floor level 4) Release wheelchair brakes and enter vehicle Exit Vehicle 1) Fasten occupant restraint belt 2) Place wheelchair in center of platform facing outward if possible. Lock wheelchair brakes 3) Press and hold down button to lower platform to ground level. 4) Release wheelchair brakes and exit platform Stow lift 1) Press and hold stow button to fold platform and return to stowed positron 2) Turn pendant switch off 3) Close doors During an interview on 4/12/18 at 10:44 AM with the Administrator while she supplied documents for the investigation, she acknowledged human error accounted for the lift to be lowered all the way down to the ground. The Administrator provided a training form for Staff D that showed he had been trained by a former driver via check list. A training form for Staff F showed he had been trained by a current employee also using the same check list. The inspection sheet dated 9/27/17 for the van contained no information related to checks for the lift operation. The facility abated the IJ on 10/13/17 when they implemented the following: 1. Implementing weekly van inspections completed by the driver, which included exterior, interior, tires, mechanics, wheelchair restraint, lift equipment and safety equipment. 2. A van inspection was performed by a certified mobility company. 3. The van was removed from service from 10/4/18 to 10/12/18 lift equipment inspected by professional certified dealer. 4. The van was inspected by certified dealer on 10/12/17 and all items pertaining to the accident worked properly. The dealer concluded it was user error that caused the accident. 5. Main van driver was trained on 10/13/18, and other drivers trained before they operated the van again. ***The scope and severity level of the deficiency was lowered from a J to a D after it the facility abated the Immediate Jeopardy. II. Based on observation, interview and record review, the facility failed to provide direct supervision of medications ready to administer for 1 of 32 residents reviewed (Resident #48). The facility reported a census of 72 residents at the time of the survey. According to the Medication Flowsheet for Resident #48 received the following medications and supplements the morning of 4/11/18: Aspirin 81 mg (milligrams); [MEDICATION NAME] 112 mcg (micrograms); [MEDICATION NAME] 7.5 mg; Prevagen ES 20 mg ; [MEDICATION NAME] 50 mg; [MEDICATION NAME] (Calcium, Vitamin D3 and Vitamin K); Fish oil 1000 mg; Preser Vision (a vitamin supplement); Senna-S 8.6-50 mg; [MEDICATION NAME] 25 mg. ; During observation on 4/11/18 at 7:46 AM of the northwest hallway, the medication cart sat in the dining room area and a cup containing 11 medications sat on top of the medication cart. The observation revealed Staff A, Registered Nurse (RN) down the hallway looking inside a laundry cart. Staff A noticed the surveyor and stated she could see her medication cart. The laundry cart sat approximately 58 feet down the hallway to the north (counting 29 two foot by two foot ceiling tiles) and there were several residents in the dining room at the time. Staff A walked up the hallway and reported he had been looking for something and stated the medications were for Resident # 48. During interview on 4/11/18 at 08:45 AM with the Director of Nursing (DON), she stated she would expect a nurse to not even turn their back on a medication cart with a cup full of medications on top, let alone be all the way down the hallway. On 4/11/18 at 1:14 PM, the DON stated 5 cognitively impaired and mobile residents lived on the Northwest hallway.

Based on record review, observations and interviews, the facility failed to provide an environment free from accident hazards and failed to provide nursing supervision for the prevention of avoidable accidents for 1 of 7 sampled residents. (Resident #1) The facility reported a current census of 82 residents. Findings include: According to the MDS (Minimum Data Set) assessment dated [DATE], Resident #1 ' s brief interview for mental status (BIMS) score of 9 represents moderate cognitive impairment, The MDS identified Resident #1 required extensive assistance of one staff member for transfers, toilet use, dressing and limited assistance of one staff member for personal hygiene and ambulating in room and the corridor. Balance for all activity was listed as not-steady and uses walker and wheelchair. The MDS indicated Resident #1 as frequently incontinent of bladder and continent of bowel. Resident #1 ' s [DIAGNOSES REDACTED]. The MDS documented Resident #1 experienced falls prior to admission. Review of the Fall Risk Assessment form dated on 6/30/15 revealed an assessed score of 16, that indicated Resident #1 was at risk of falling. Review of the Care Plan with identifying date in upper right corner of 7/2/15 revealed Resident #1 at risk for falls and to follow the ADL (Activities of Daily Living) Care Plan. According to the ADL Care Plan, dated on 6/30/14, Resident #1 required assistance of one for transfers and assistance of one for ambulation. Alarms identified on the Care Plan for Resident #1 included a personal alarm on the bed, chair/recliner, wheelchair and an motion detector to be on when Resident #1 was in his/her room. Review of the Incident Report for Resident #1, dated 7/30/15 at 1900 (7:00 p.m.), revealed Resident #1 found on the floor next to his/her bed, the personal body alarm was attached to Resident #1 ' s clothing and to the wheelchair. The alarm failed to sound and Resident #1 failed to activate the call light. Resident #1 claimed to hit his/her head during the fall. According to the incident report staff initiated a neurological assessment. The report documented no injuries as a result of the fall. Review of the Nursing Home to Hospital Transfer Form dated 7/31/15 (no time documented) for confusion, nausea, a blood pressure of 220/100 and a statement of a fall on 7/30/15 that included hitting his/her head. According to the Record of Admission form for the Burgess Hospital in Onawa, dated 7/31/15 for Resident #1, revealed an initial [DIAGNOSES REDACTED]. According to the Radiology Report dated on 7/31/15 at 0753 (7:53 a.m.) revealed a [DIAGNOSES REDACTED]. During observation of Resident #1 on 9/9/15 at 10:07 a.m., Staff A and Staff C, both certified nursing assistants (CNA) assisted Resident #1 into the shower chair leaving Resident #1's feet off of the floor at least 6 inches, placing Resident #1 at risk for falling forward. Both of the CNA ' s spoke to Resident #1 about the shower chair being new and wider for his/her comfort. During an interview on 9/8/15 at 5:10 p.m., Staff B Licensed Practical Nurse (LPN) stated she work 7/30/15 and was in the hall passing medications when she heard a loud noise coming from the room of Resident #1. Staff G CNA, entered the room first and Staff B LPN entered soon after, finding Resident #1 on the floor with his/her head under the edge of the bed. Resident #1 talked to them like normal and exhibited no signs or symptoms of injury. Resident #1had reported hitting his/her head during the nurse ' s assessment. Staff B LPN stated she began neurological assessments right away. Staff B LPN further stated that, after working in the facility for over a year, she was unaware Resident #1would self-transfer as she had that night. Staff B LPN stated Resident #1 was able to be in his/her room alone prior to this fall. She stated she reported this fall to Resident #1's primary care physician. There was no reason to send Resident #1 into the emergency room , based on her assessment. During an interview on 9/9/15 at 5:20 p.m., Staff H, Registered Nurse (RN) stated she worked the night shift 7/30/15 following Resident #1 ' s fall. Staff H stated Resident #1 appeared fine, no signs or symptoms of an injury until 5:30 a.m. Staff H stated Resident #1 had put on his/her call light, Staff H answered it and Resident #1 stated he/she didn't feel right, then went unresponsive for a few seconds then became incoherent, patting self on the head. Staff H stated she asked Resident #1 if his/her head hurt and Resident #1's response was yes. Staff H stated she called Resident #1 ' s primary care physician right away and sent Resident #1 out to the hospital. Staff H stated she assessed Resident #1 until after 2:00 a.m., and just looked in on Resident #1, until the call light needed answered. Resident #1 had a normal night, watched television until around 11:00 p.m., went to the restroom and went to sleep. Resident #1 appeared fine. Staff H stated she was shocked at this. Review of a letter written by Resident #1's primary care physician dated August 20, 2015 documented it is unknown when the hemorrhagic stroke occurred. It may have contributed to the etiology of Resident #1 ' s fall or it may have been a result of the fall. During an interview on 9/21/15 at 5:00 p.m., Resident #1's primary care physician stated he had been called about Resident #1's fall on 7/30/15. He cannot remember if he had been informed about Resident #1 hitting his/her head but his standard is to question enough before feeling comfortable about his resident. He stated he can't say if the stroke occurred before the fall or if that caused the fall. He stated a spontaneous hemorrhagic stroke occurs from a cause, trauma or something, it just does not occur. It more likely was a tiny bleed that bled all night and resulted symptomatically the next morning.

Based on clinical record review, observation and staff interview, the facility failed to ensure appropriate nursing supervision was provided for 1 of 5 resident records reviewed (Resident #1). The facility identified 81 current residents. Findings include: 1. According to the MDS (minimum data set) dated 5/6/14 identified Resident #1 ' s cognition as severely impaired on the Brief Interview for Mental Status (BIMS). Resident #1 required extensive assistance with bed mobility, transfers and toilet use. Resident #1 had [DIAGNOSES REDACTED]. The care plan dated 5/8/14 identified the resident at risk for falls and directed staff to provide a personal alarm on the residents bed, chair/recliner and wheel chair. The intervention discontinued on 7/9/14. The care plan dated 7/16/14 revealed no direction for alarm use for the resident. Observation on 7/23/14 at 1:00 p.m. revealed the resident in the wheel chair with alarm intact. Review of the Interdisciplinary Team Notes dated 7/2/14 at 2:20 p.m. directed to see the Incident Report. At 3:10 p.m. Resident #1 was transported to the hospital by ambulance. Review of the Incident report dated 7/2/14 at 2:20 p.m. revealed the resident found on the floor in the resident's bathroom beside the commode. Resident #1's left leg was noticed to be shorter than the right leg with outward rotation and complaints of discomfort. Three staff members assisted Resident #1 up from the floor using an EZ Lift mechanical lift back to bed. The ambulance was notified after communication with the physician. The immediate intervention included to tell the CNA (certified nursing assistant) to never leave the resident anywhere alone. Review of the Radiology Report dated 7/3/14 revealed the resident had a moderately displaced fracture of the femoral neck on the left. During an interview with the DON (Director of Nursing) on 7/22/14 at 2:00 p.m. she stated that the facility went over and over again that staff members are not to leave residents alone in the bathroom if needed an alarm or staff assistance. She stated that on 6/17/14 they had went over alarms and to not leave resident's alone in the bathroom when toileting. She further stated that the resident came back from the hospital on hospice. He/she had improved back to pre-hospital status and the alarms had not been added to the care plan yet. During an interview with Staff D, Activity Aid on 7/22/14 at 3:15 p.m. she stated that between 2:00 and 2:30 p.m. Resident#1 attended an activity and requested to use the toilet. Staff D, took Resident#1 to the nurse ' s station and Staff A, CNA (certified nursing assistant) took the resident to the bathroom and then back to the activity. During an interview with Staff A, CNA on 7/22/14 at 3:50 p.m. Staff A, stated that she assisted Resident#1 to the toilet. She had been the only CNA for that unit due to the other CNA was assigned to the dementia unit to cover from 2:00 p.m. to 3:00 p.m. The nurses on that unit had been doing report so she went to the hallway to check for call lights or alarms. She came back to the bathroom and saw the resident fall from the toilet. She also stated that the resident did not have an alarm on the wheel chair that day. Staff A stated she did not recall the directive for staff not to leave residents alone when on the toilet. During an interview with Staff C, LPN (Licensed Practical Nurse) on 7/22/14 at 2:30 p.m. stated that at a little after 2:00 p.m. she observed Staff A, CNA and Staff B, LPN with Resident #1 at the nurse ' s station. She assisted the other afternoon nurse with another resident in the DON's office. Staff B, LPN then stated Resident #1 fell out of the wheel chair. Staff C went to the room and observed the wheel chair next to a bed and identified Resident #1 on the bathroom floor. Staff C stated she could tell there may be a fracture and called the ambulance. Staff C stated that Staff A, CNA reported she left Resident #1 alone. Staff C checked the resident's wheel chair and no alarm present and noted to still be on the bed. Staff C commented that Staff A was the only CNA on the floor during the shift because the other CNA went to cover the dementia unit. Staff C stated staff members know not to leave resident's unattended. During an interview with Staff B, LPN on 7/22/14 at 5:00 p.m. stated she was at the nurse ' s station to finish charting for the day shift (6:00 a.m. to 2:00 p.m.) The afternoon nurses had another resident to take care for and went to the DON's office. Staff A, CNA called out that she needed help and Resident#1 was on the floor. Staff B told the resident's afternoon nurse (Staff C, LPN) and Staff A went to the room. Staff B grabbed the vital machine and went to the room and observed Resident #1 on the floor in the bathroom. Staff B stated that staff members know not to leave the resident's alone and always educated on this in meetings. Staff B stated that all staff answers call lights. During an interview with the DON on 7/23/14 at 9:30 a.m. stated staff members cover the dementia unit infrequently. She stated they may cover for staff that called in or could be scheduled due to some CNAs scheduled 2:00 p.m. to 10:00 p.m. and some 3:00 p.m. to 11:00 p.m. She stated that during this time all nurses answer call lights. Other staff members in the building answer call lights and many are active CNAs including housekeeping and activity staff. She further stated that the 2 afternoon nurses had brought another resident to the DON's office. The day nurse was still at the nurse ' s station charting for the day. The day nurse was still on the clock and answers call lights. All staff members know the requirement. Staff B would have verbally told Staff A when she had finished and clocked out for the day.

Based on observation, record review, and staff interview, the facility failed to plan for and direct nursing care and services to ensure four (4) of (4) residents received adequate supervision from hazards (Residents #1, #3, #2 and #4.) The facility used a pad chair alarm to alert staff when Resident #1 and Resident #3 attempted to stand or self- transfer. Record review established Resident #1 had frequent attempts to stand unassisted and on [DATE], the alarm pad did not sound to alert staff of Resident #1 trying to get up. Resident #1 fell and fractured his/her hip and shoulder. The facility used a 45 day alarm pad device however staff interviews revealed no one knew how old the alarm pad was for Resident #1 and staff gave inconsistent reports of when the alarm pad device should be changed. The facility had an alarm checklist which lacked consistent documentation and the alarm pad was not tested appropriately the morning of [DATE] before the resident fell . Resident #3 fell and sustained several skin tears when his/her seat alarm did not sound. Record review and staff interview identified the facility staff failed to safely transfer Resident # 2 according to his/her care plan. The facility reported a census of 81 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 7 on the Brief Interview for Mental Status (BIMS) cognitive test indicating he/she had cognitive impairments. Resident #1 required one staff to physically assist with activities of daily living (ADL's) including transfers, dressing, and with personal hygiene; and required two staff to assist with toilet use. Resident #1 required limited assistance with ambulation. The assessment identified Resident #1's balance as not steady and only able to stabilized with staff assistance when walking, when moving from seated to standing position, when turning around, when moving on and off the toilet, and during surface to surface transfer. Resident #1's [DIAGNOSES REDACTED]. The Cognitive Loss Care Area Assessment (CAA) dated [DATE] documented Resident #1 attempted to stand up from the wheelchair several times per ID (interdisciplinary) notes [DATE], and at times needed 1 to 1 for supervision. Resident #1 could be quite anxious and attempt to stand on his/her own. The Behavioral Symptoms CAA dated [DATE] documented Resident #1 could get anxious/restless and attempt to stand on his/her own and get out of the recliner or wheelchair. Resident #1 required assistance. Staff observed (the resident) 1 to 1 at times. The Fall CAA dated [DATE] documented Resident #1 had a history of [REDACTED]. A Falls Risk assessment dated [DATE] scored Resident #1 at 17 with a score of 10 or above indicating a high risk for falls. An Interdisciplinary Team Note dated [DATE] documented Resident #1 restless, trying to get out of the recliner. An Interdisciplinary Team Note dated [DATE] documented Resident #1 sitting in his/her recliner, attempting to get out of the recliner. An Interdisciplinary Team Note dated [DATE] documented Resident #1 very restless, attempting many times to stand by him/her(self). An Interdisciplinary Team Note dated [DATE] documented Resident #1 in his/her recliner, restless and trying to get out of the recliner. A facility form titled, " Check PA's (alarms) at the beginning of your shift to make sure all sound when triggered. Mark at the end of your shift that all are on the resident's that need them," dated [DATE] to [DATE] identified staff did not document checking Resident #1's alarm on [DATE] on the ,[DATE] or ,[DATE] shifts, the 2 shifts preceding the fall with fractures. The form also revealed no documentation on [DATE] on the ,[DATE] shift or [DATE] or [DATE]. The Care Plan dated [DATE] identified Resident #1 with impaired physical mobility related to a history/risk of falls and the approaches included to follow the ADL cares PVCC (Pleasant View Care Center Protocol) related to toilet use/mobility/pain/skin, and update the resident communicator as needed. The ADL Care Plan last updated on [DATE] directed staff to use a seat alarm when out of bed, AMAP (as much as possible) at night. On [DATE], the ADL Care Plan added a new seat alarm to Resident #1's chair. Staff to continue to check alarms every shift to assure working. A facility report dated [DATE] at 8:45 a.m. documented Resident #1 had an incident in the dining room. The report documented Resident #1 sat in the wheelchair in the dining room and tried to stand up and fell to the floor on his/her right side. The alarm did not go off at the time of the fall, but worked when Resident #1 put in the wheelchair. The new intervention was to put a new seat alarm in the chair. An Interdisciplinary Team Note dated [DATE] ,[DATE] documented Resident #1 complained of leg pain, would not put weight on the right leg, and had a large bruise to the right upper extremity. The facility received an order to transport to the hospital. The hospital emergency room staff advised the facility Resident #1 had a right hip fracture and transported to another hospital for surgical repair. A hospital Discharge Summary documented Resident #1's admission on [DATE] and discharge on [DATE]. The document identified Resident #1 had been admitted to the hospital after a fall (at the nursing home) with a fracture of the neck of the femur. Resident #1 underwent a right hip hemi-arthroplasty surgery. Resident #1 had post op complications with blood loss, anemia and received blood transfusions. Resident #1 had a waxing and waning level of consciousness and probably postoperative delirium. Resident #1 tolerated physical therapy well, but the decision had been made to transfer him/her back to the nursing home. Resident #1 had a urinary tract infection and started antibiotic for that. Resident #1 received intravenous fluids (IV) for renal failure. Resident #1 developed acute metabolic [DIAGNOSES REDACTED] secondary to postoperative course, urinary tract infection, and advanced Alzheimer's disease. Resident #1 did not cooperate with speech therapy and kept NPO (nothing by mouth) on IV fluids. The case was discussed in detail with the family and they decided on hospice care with only comfort measures. Resident #1 started Roxanol and a Clonidine patch for blood pressure as he/she did not tolerate any oral foods. Resident #1's [DIAGNOSES REDACTED]. The facility Admit Orders dated [DATE] documented Resident #1's new [DIAGNOSES REDACTED]. A Non-Pressure Skin Condition report dated [DATE] documented Resident #1 had a right hip fracture surgical incision with 28 staples, and a right arm bruise 29 centimeters (cm) by 17 cm. The report documented Resident #1 expired [DATE]. During an interview on [DATE] at 8:16 a.m. Staff B Licensed Practical Nurse (LPN) stated she worked the day Resident #1 fell but was not assigned to his/her hall. She walked toward the dining room from the 100 hall and caught the fall from the corner of her eye. She saw it from the corner of her eye, she really didn't see it, she wasn't in there. She started the initial fall assessment and called Staff C Registered Nurse (RN) back from break. Resident #1 complained of his/her arm hurting during the assessment. The alarm did not sound. She did not do any investigation in to why the alarm did not go off. During an interview on [DATE] at 8:50 a.m. Staff A Certified Nursing Assistant (CNA) stated she worked the day Resident #1 fell . She got Resident #1 up. She went to Resident #1's room. She removed the pad cord from the alarm box and the box beeped, so she knew it worked. She rolled Resident #1 over and removed the pad and put it in the wheelchair and put the cord back in. When she finished getting Resident #1 ready, she transferred him/her to the wheelchair and out to the dining room. Staff A stated Resident #1 was very anxious that morning, trying to crawl out of bed. Resident #1's alarm did not sound when doing this, she figured he/she was not completely off of the pad. She said Resident #1 would sit and rock in his/her chair. Staff A stated she reported to the charge nurse about Resident #1 being anxious and trying to crawl out of bed. Staff A said during breakfast she saw Staff B take a room tray. Staff B walked up one hall and Staff A walked down the other hall away from the dining room. Staff A heard something and looked back and saw Resident #1 standing and trying to take a few steps and fall. She did not see Resident #1 go from a seated to a standing position. The alarm did not sound. She said Resident #1 also gagged, and vomited on the floor after falling. Staff A stated she had witnessed Resident #1 try to transfer him/herself before when anxious. During an observation on [DATE] at 8:50 a.m. Staff A obtained an alarm box and pad like Resident #1 used. She pulled the alarm cord from the alarm box and it beeped. She also put pressure on the alarm pad with the cord plugged in to the box and it alarmed when pressure removed. She pushed the reset button several times and silenced the alarm. During an interview on [DATE] at 9:20 a.m. Staff C RN stated she was assigned to Resident #1's hall the day he/she fell . Staff C went to break and off the floor about 5 minutes. She thought Staff A was in the dining room, and Staff B in the area. When called back, Staff A and Staff B were both there. During the assessment, Staff C found out the alarm did not sound. She thought Staff B hit the test button and it worked, so they put Resident #1 back on the same alarm pad. Resident #1 had someone with him/her until they transferred him/her to the recliner and put a new sensor pad under him/her, with the same alarm box. She didn't know if the pad they removed had a date on it, or what the dates meant. Staff C stated that morning they did report Resident #1 tried to get out of bed. She said Resident #1 had phlegm, and they got him/her up. Staff C stated she would not call Resident #1 anxious. He/she was mobile up and down the hall in the wheelchair, not abnormal for Resident #1. Staff C stated someone always helped Resident #1 with meals, but didn't know who. Resident #1 did have an emesis while on the floor. She said Resident #1 could answer yes/no questions, but couldn't necessarily tell them if something was wrong. She said they needed to have staff in the dining room during breakfast. During an interview on [DATE] at 10:28 a.m. Staff D LPN stated the majority of the alarm pads were dated, but some were not. She thought they replaced them every 30 days. During an interview on [DATE] at 10:39 a.m. the MDS Coordinator stated they dated the alarm pads when they applied them and changed them out every 45 days. She said the CNA's would let the nurse's know. During an interview on [DATE] at 10:40 a.m. Staff A stated she didn't think the alarm pad Resident #1 had when he/she fell had a date on it. She said some alarm pads were dated and some were not. She didn't know why they were dated. During an interview on [DATE] at 11:25 a.m. the Director of Nursing (DON) and the Administrator stated they did not see the alarm pad Resident #1 had when he/she fell , so they didn't know if it had a date. The DON stated they used the 45 day (alarm) pads and replaced them after 45 days. The Secure Personal Accident Deterrent System (P.A.D.S.) chair sensor instructions included the alarm and sensor pad should be checked prior to each use for proper functioning. When staff removed user from the pad for whatever reason the alarm would sound. To silence the alarm press the test/reset button per the alarm's instruction. The alarm pad must be tested each time used with a patient to make sure it functioned properly. The caution identified the product was designed as a monitor, alerting staff when a resident had risen from their bed or chair. The instruction sheet identified the Personal Safety Corporation warranty the product to be free from factory defects in material and workmanship for a period of 45 days from the date of first use. The instruction sheet documented it's use as a 45 day pad and left a line for the user to write the date of first use. During an interview on [DATE] at 1:15 p.m. a representative of the Personal Safety Corporation (company where the facility obtained their alarm pad/P.A.D.S stated they had 45 day pads. She said the 45 day pad had a warranty for 45 days from the date of first use. They guaranteed it would work for 45 days or they would replace it. She said they did not tell facilities they had to stop using the pad after 45 days but it needed to be tested every time they used it. She said to test the pad you put weight on the pad then removed the weight and the alarm would sound if the sensor pad functioned. Removing the pads cord from the alarm box was not an appropriate way to test the sensor pad. During an interview on [DATE] at 8:17 a.m. Staff A confirmed she pulled the pin of the alarm pad from the alarm box when testing Resident #1's alarm the day he/she fell and fractured. She did not test it (alarm pad) by putting weight on it and removing it. The alarm pad remained unplugged when she rolled Resident #1 off of it. Staff A stated she always tested the alarm for functioning that way. During an interview on [DATE] at 10:00 a.m. the DON stated she had always thought putting pressure on the alarm pad to test it. The facility had no policy on Alarms. 2. According to the MDS assessment dated [DATE], Resident #3 scored 8 on the Brief Interview for Mental Status (BIMS) cognitive test indicating he/she had cognitive impairments. Resident #3 required assistance from two staff with activities of daily living (ADL's) including transfers and walking in his/her room; and one staff assistance with bed mobility. Resident #3 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, when walking, when turning around, when moving on and off the toilet, and when surface to surface transfers. The MDS documented Resident #3 frequently incontinent of bladder. Resident #3's [DIAGNOSES REDACTED]. A Falls Risk assessment dated [DATE] scored Resident #3 at 11 with a score of 10 or above indicating high risk for falls. The ADL Care Plan for Resident #3 directed a seat alarm AMAP dated [DATE], and call light within reach. A facility report dated [DATE] at 3:40 a.m. documented staff found Resident #3 on the floor at 3:40 a.m. The CNA's heard Resident #2 yell for help. The seat alarm did not sound, and the CNA stated it was not connected. The call light remained connected to Resident #3's chair out of Resident #3's reach. Resident #3 stated falling on the floor when trying to get him/her(self) out of bed. Resident #3 did not like asking for help. Resident #3 reported he/she had pain in his/her spine, both knees, and both right and left hips. Staff noted bruising to both knees and a skin tear to the right elbow. A Telephone Orders sheet dated [DATE] documented Resident #3 had open skin tears to the right arm/elbow area from a fall during the night. The areas measured: a. Area #1, 9.3 by 3.2 centimeter (cm). b. Area #2, 3 by 2.8 cm. c. Area #3, 2.6 by 0.8 cm. The physician okayed an order for [REDACTED]. The hospice Chart/Clinical Notes dated [DATE] documented they received a call from the facility stating Resident #3 fell during the night and requested a visit from the nurse. Resident #3 had the bilateral lower arms wrapped as he/she sustained several skin tears with the fall. Resident #3 denied hitting his/her head and staff did neuro checks which were within normal limits. Resident #3 had bilateral hip pain and both he/she and his/her spouse refused evaluation at the hospital. Resident #3 also had a lot of pain in the abdominal area. Resident #3 just wanted to stay at the facility. The physician okayed starting MSC (Morphine) 2 times a day for pain control. A hospice Chart/Clinical Notes dated [DATE] documented they received a call from a nurse at the facility stating Resident #3 not doing well and spouse struggling with his/her condition. The hospice nurse spoke to the spouse first and discussed Resident #3's condition. They talked of Resident #3's fall and things quickly went down since then. A hospice Chart/Clinical Notes dated [DATE] documented a facility nurse requested the hospice nurse visit Resident #3 while at the facility. The nurse stated Resident #3 took a turn for the worse since his/her fall, with pain in the right hip area with palpation only. A hospice Chart/Clinical Notes dated [DATE] documented Resident #3 passed away at the facility at 5:30 p.m. During an interview on [DATE] at 12:03 p.m. Staff E LPN stated she worked the night Resident #3 fell . She said Resident #3 put the call light on if he/she needed anything. Staff E stated she always made sure everyone got checked on, but Resident #3 did not get checked that night. Staff E knew Resident #3 used an alarm. Resident #3 did not have the alarm or the call light that night. Resident #3 told Staff E he/she looked at the clock when he/she fell and it was 2:21 a.m. Resident #3 laid on the floor over an hour. She said she worked 6:00 p.m. to 6:00 a.m. that night. She said the ,[DATE] staff put Resident #3 to bed without the alarm or the call light, and the ,[DATE] staff did not check on him/her. During an interview on [DATE] at 10:14 a.m. Staff F CNA stated Staff G CNA heard a noise, went down the hall, opened the door and found Resident #3 on the floor. She yelled for a nurse. Staff F stated they were told prior to that (night) they were not to disturb Resident #3. She said the alarm pad was in the wheelchair, and the call light on the recliner. She said the ,[DATE] shift put Resident #3 to bed. She had not normally checked Resident #3 at night. She said she was informed after the fact Resident #3 had been a little sick, but she had not received new information on Resident #3. She said typically Resident #3 would put the call light on. Normally Resident #3 had the door closed at night. She said she did not know Resident #3 had an alarm. It was not on the sheets they filled out (alarm checklist). A facility form titled, " Check PA ' s at the beginning of your shift to make sure all sound when triggered. Mark at the end of your shift that all are on the resident ' s that need them, " identified Resident #3's alarm had not been added to the checklist until [DATE] (after he/she fell ). During an interview on [DATE] at 10:22 a.m. Staff G CNA stated they did not bother Resident #3 unless he/she put the call light on and that was very rare. She said she did not know Resident #3 used an alarm. During an interview on [DATE] at 4:10 p.m. the Director of Nursing (DON) stated Resident #3's alarm did not get on the alarm check list, but staff still should know he/she had it and checked it. Staff received written warnings. During an interview on [DATE] at 9:24 a.m. a Hospice RN stated Resident #3 started extended release Morphine on [DATE] for hip and abdominal pain. The hip pain would be a result of the fall. During an interview on [DATE] at 1:12 p.m. another Hospice RN stated Resident #3 did have pain and was banged up from the fall. They did start Morphine the next day for hip pain, and abdominal pain from [DIAGNOSES REDACTED]. Resident #3 had previously been on Hydrocodone. 3. According to the MDS assessment dated [DATE], Resident #2 demonstrated long and short term memory problems and moderately impaired skills for daily decision making. Resident #2 required two person assistance with activities of daily living (ADL's) including transfers and toilet use. Resident #2's [DIAGNOSES REDACTED]. A Falls Risk assessment dated [DATE] scored Resident #2 at 16 with a score of 10 or above indicating high risk for falls. The ADL Care Plan for Resident #2 directed the use of the EZ stand with 2 assist with transfers dated [DATE], discontinued [DATE]. The ADL care plan noted Hoyer transfer [DATE]. A facility report dated [DATE] documented the writer heard a CNA (Staff I) ask for someone for a nurse. When finished in the room, the nurse went immediately to Resident #2's room. She found Resident #2 in the EZ stand, and the report indicated the resident's legs had gone weak and the resident had been held up by the chest strap. The report revealed the leg strap had not been on, and the butt strap missing a buckle. The nurse and the CNA (Staff I) supported the resident ' s legs and another nurse supported the resident's torso as they laid the resident in bed. The immediate intervention was to re-educate the CNA's on the EZ stand protocol. During an interview on [DATE] at 12:55 p.m. Staff I CNA stated on [DATE] she transferred Resident #2 with the EZ stand alone. She said normally they had 2 staff with his/her transfer, but they were behind that day and she had done the transfer herself before. Staff I reported the transfer went fine until she lifted Resident #2. Resident #2 hung from the sling, not putting weight on his/her legs. Staff I called for help. Staff I reported it took a minute for help to arrive, but they were able to transfer Resident #2 to bed without falling. Staff I stated she didn't know what Resident #2 had on the care plan for transfer with the EZ stand, but also thought other staff had done the transfer before with 1 staff. During an interview on [DATE] at 2:56 p.m. the Director of Nursing (DON) stated Resident #2 transferred with assist of 2 and the EZ Stand (mechanical lift) and the CNA received a written warning for doing it herself and the nurse received a written warning for not for not being on top of the CNA's. 4. According to the MDS assessment dated [DATE] Resident #4 scored 14 on the Brief Interview for Mental Status (BIMS) cognitive test indicating no cognitive impairments. Resident #4 required the assistance of two staff with activities of daily living (ADL's) including transfers and toilet use. Resident #4 was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #4's [DIAGNOSES REDACTED]. The Interdisciplinary Team Notes dated [DATE] documented Resident #4 admitted [DATE] after hospitalization for repair of a right hip fracture from a fall at home. The ADL Care Plan for Resident #4 directed call light within reach. The Activities of Daily Living sheet for Resident #4 directed assist of 1 or 2 for transfers. The Skilled Daily Nurses Note dated [DATE] for ,[DATE] shift documented Resident #4 remained skilled care for therapy. Resident #4 needed assist of 1 with pivot transfers. A facility report dated [DATE] at 2:20 p.m. documented after end of shift report the nurse and a CNA found Resident #4 sitting on the floor. Resident #4 stated he/she tried to get the foot of the chair down and couldn't so he/she scooted his/her butt down to the end of the chair and fell out of the chair. The call light was not within reach, so Resident #4 could not call for help. The Interdisciplinary Team Notes dated [DATE] at 3:00 p.m. documented Resident #4 and his/her family member requested an x-ray of his/her right hip/leg. The physician gave orders to transport per ambulance to the hospital for x-rays. At 5:15 p.m. the hospital nurse called and stated no changes from the previous x-ray. Resident #4 returned at 6:30 p.m. The Skilled Daily Nurses Note dated [DATE] documented Resident #4 moved with assist of 2 during the shift with pivot transfers. Resident #4 appeared weaker, and stated a fear of falling. During an interview on [DATE] at 10:28 a.m. Staff D LPN stated the call light was not in Resident #4's reach when in the chair. Staff D reported the call light was way over on the couch. She stated Resident #4 always used the call light when he/she needed something. The Care Center's Protocol Regarding Daily Approaches for Residents included positioning the call light within reach.