Every finding on record at Robertsdale Rehabilitation & Healthcare CTR

Based on record review, interview, and facility policy review, the facility failed to notify the Ombudsman of hospital transfers in writing for three of three residents (Resident (R) 16, R38, and R93) out of a total sample of 35 residents reviewed for hospitalization . This had the potential for the residents to have no added protection if the residents were being inappropriately discharged or transferred so they could inform them of their rights and options. Findings include: Review of the facility's policy titled, Transfer and Discharge of a Resident (including AMA [against medical advice], revised 02/04, revealed no information regarding the facility's responsibility of notifying the Ombudsman of transfers and discharges. 1. Review of R16's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of a Departmental Note, provided by the facility and dated 07/24/24, revealed at 8:50 PM, R16's oxygen saturation (O2) was 60 percent (%). He was noted to be disoriented and projectile vomiting. The on-call physician was notified and gave an order to send the resident to the hospital for evaluation and treatment. There was no evidence in the medical record that the Ombudsman was notified of the transfer. The resident remained at the hospital. 2. Review of R38's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of a Departmental Note, provided by the facility and dated 05/30/24, revealed the resident was not able to be aroused and was unresponsive to commands. The physician was notified, and an order was received to send the resident to the hospital for evaluation and treatment. The resident was admitted to the hospital for respiratory failure. The resident was readmitted to the facility on [DATE]. Review of a Departmental Note, provided by the facility and dated 07/10/24, revealed the resident was noted to be lethargic, disoriented, and unable to complete full sentences. The resident was transported to the hospital. There was no evidence in the medical record that the Ombudsman was notified of either transfer. The resident was readmitted to the facility on [DATE]. 3. Review of R93's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of a Department Note, provided by the facility and dated 04/02/24, revealed upon entering the resident's room labored breathing was noted. An order was received to send the resident to the hospital for evaluation and treatment. The resident left the facility at 4:59 PM. The resident returned to the facility on [DATE] at 3:20 PM. At 4:23 PM the resident was having difficulty breathing and a new order was received to send the resident back to the hospital for evaluation and treatment. There was no evidence in the medical record that the Ombudsman was notified of the transfer. The resident was readmitted to the facility on [DATE]. During an interview on 08/08/24 at 1:10 PM, the Administrator confirmed no notices have been sent to the Ombudsman for transfers or discharges. He revealed they had not been doing that since COVID.

20064 27104 40847 Based on record review, interview, and facility policy review, the facility failed to protect the resident's right to be free from abuse for seven of nine residents (Resident (R) 48, R83, R267, R15, R117, R76, and R80) reviewed for abuse. This failure had the potential to affect resident safety. Findings include: Review of the facility policy titled, Administrative Policy, Subject: Abuse, Neglect and Exploitation, last revised ,d+[DATE], revealed Each resident of any facility .has the right to be free from verbal, sexual, physical, or mental abuse, neglect, exploitation, and misappropriation of his or her property. 1. a. Review of R12's undated ''Admission Record,'' provided by the facility revealed R12 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, psychotic disorder with delusions due to known physiological condition, dementia without behavioral disturbance, anxiety disorder, and major depressive. Review of R12's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated the resident was severely cognitively impaired. Review of R12's care plan, provided by the facility and dated [DATE], revealed exhibited following behaviors: attempted to bite staff, cursing and demeaning staff, and combative (hitting) at nursing staff. Refuses meds and BG's [blood glucose] DX. [diagnoses] Major Depressive Disorder: Psychotic diagnosis known psychological condition. Anxiety [DATE] hit another resident in response to that resident hitting her by accident, alteration in communication related to diagnosis of dementia. Residents have fragmented thought processes and slow processing, and resident was at risk for side effects from antidepressant medication use. b. Review of R48's undated ''Admission Record,'' provided by the facility, revealed R48 was admitted to the facility on [DATE] with diagnoses including dementia, moderate with psychotic disturbance, cognitive communication deficit, diffuse traumatic brain injury without loss of consciousness subsequent encounter, anxiety disorders, delusional disorders, and macular degeneration. Review of R48's quarterly MDS with an ARD of [DATE] revealed a BIMS score of nine out of 15 which indicated resident was moderately cognitively impaired. Review of R48's care plan, provided by the facility and dated [DATE], revealed at risk for medication side effects related to psychotropic medication use, diagnosis of macular degeneration, she requires adapting of activities and assistance secondary to visual impairments, has behaviors: inappropriate behaviors, paranoia, delusions, nightmares, swatting at nurse, grabbing at nurse, yelling at staff, and increased Sundowner's. Refuses meds at times, combative with staff during care and trying to care for others. Diagnosis: Dementia with Psychotic Features- gets into others faces r/t [related to] unable to see or hear; REVISED [DATE] combative with other residents. Review of the Facility Reported Incident, provided by the facility and dated [DATE], revealed R48 was being pushed by Certified Nursing Assistant (CNA) 4 and R48 accidentally hit R12 as she was passing her in the hallway. R12 responded by hitting resident R48 in response. The residents were separated immediately, and CNA4 reported the incident to her charge nurse. The facility documented due to the cognitive status of both residents' intentional harm was deemed unlikely. During an interview on [DATE] at 4:42 PM, CNA4 stated R48 could not really see and did not intentionally hit R12. CNA4 stated R48 did swing her arm out to touch R12. CNA4 stated R48 was a touchy person, but her hand unintentionally landed wrong on R12. CNA4 stated R12 wasn't having a good day and struck R48 back in response. CNA4 stated she immediately pushed R48 away from R12 and told the charge nurse. CNA4 stated she checked on R12 to see if her day had gotten better and R12 did not have any memory or effects to the incident. 2. a. Review of R83's undated Face Sheet provided by the facility revealed the resident was readmitted to the facility on [DATE] with diagnoses of dementia, abnormal posture, and muscle weakness. Review of R83's annual MDS with an ARD of [DATE] located in the electronic medical record (EMR) under the MDS tab revealed the resident had a BIMS score of three out of 15 indicating the resident was severely cognitively impaired. b. Review of R269's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] with a diagnosis of dementia with other behavioral disturbances. R269 passed away while on hospice on [DATE]. Review of R269's quarterly MDS with an ARD of [DATE] revealed the resident's BIMS score was a nine out of 15 indicating she was moderately cognitively impaired. Review of a copy of the online form titled, Incident Reporting System, provided by the facility, revealed an incident occurred on [DATE] where R269 slapped R83 in the face in the sitting room by the nurses' station. R269 said she slapped her because it was her granddaughter, and she shouldn't move. R83 was noted with redness to the skin. Both residents were immediately separated. R269 was placed on one-on one until an order was obtained and she was sent to the hospital for evaluation where she was diagnosed with a urinary tract infection (UTI). Witness statements were obtained from staff and residents. R269 was readmitted to the facility and moved to another unit in an attempt to further separate the two residents. Since her re-admission there have been no further incidents. Given the incident was witnessed, abuse was substantiated. During an interview on [DATE] at 10:30 AM, R83 revealed she recalled she was slapped, and did not know why R269 slapped her. She confirmed she had not been abused previously or since the incident by any resident or staff member. During an interview on [DATE] at 2:25 PM, the Administrator confirmed the investigation showed the abuse happened to R83. He further confirmed there were no other incidents involving R269 or R83. 3. a. Review of R15's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] with a diagnosis of vascular dementia. Review of R15's quarterly MDS with an ARD of [DATE] (at the time of the incident) revealed a BIMS score of 11 out of 15 which indicated she was moderately cognitively impaired. Her quarterly MDS with an ARD of [DATE] revealed a BIMS score of 10 out of 15 which indicated she was moderately cognitively impaired. b. Review of R267's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] with a diagnosis of altered mental status. R267 passed away at the facility on [DATE]. Review of the facility's investigation, provided by the facility, revealed the incident between R15 and R267 occurred on [DATE]. R15 and R267 were roommates. Two nurses observed R15 slapping R267 and R267 retaliated by slapping her back. R267 sustained a skin tear. There was no serious bodily injury. R267's skin tear was assessed and treated. The residents were separated as they both continued to swing and yell at each other. R15 was discharged to a Senior Behavioral Health Hospital. Both residents were interviewed. R15 could not recall what was said that provoked the incident. However, R15 did say, she swung first so I hit her before she could hit me. R267 said she did not know why R15 came up to her and slapped her and did not know why she deserved it. Review of the conclusion of the investigation revealed R15 was separated from R267 and was sent to the Senior Behavioral Health Unit. It was determined she did have a UTI and was kept there for a three-day evaluation. R15 was readmitted to the facility on [DATE] and placed on the Rehab unit. Both women continued to be closely monitored, followed by the psych team, and remained in space away from each other. Interactions with other residents will be observed. The allegation was substantiated. During an interview on [DATE] at 10:30 AM, R15 revealed the resident did not recall the incident from five years ago. She revealed she had not been abused by any resident or staff member. During an interview on [DATE] at 2:30 PM, the Administrator revealed he was not employed at the facility five years ago when the incident occurred between R15 and R267. He confirmed the abuse did happen per the investigation. 4. Review of R117's Face Sheet located in the EMR under the Face Sheet tab, revealed R117 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, osteoporosis, difficulty in walking, not elsewhere classified, other lack of coordination, other abnormalities of gait and mobility, and anxiety disorder. Review of R117's Care Plan, dated [DATE] and located under the Care Plan tab of the EMR, indicated R117 had a history of episodes of psychosis, hallucinations, increased agitation, and going in and out of other resident's rooms. Interventions included encouraging resident's family to visit, involve resident in conversations, and psych consult as needed. Review of R117's record indicated she expired on [DATE] under the care of hospice services. Review of the facility investigation, provided by the facility and dated [DATE], revealed R117 was on the secure unit when another resident approached her, slapped her on the hand, cursed her, and told her to move. The residents were separated. R117 was assessed, and no injuries were noted. The facility staff attempted to interview R117, and the other resident involved. Neither resident was able to recall the incident and could not answer questions due to cognitive impairment. The facility substantiated abuse occurred. During an interview on [DATE] at 11:08 AM, CNA2 stated she did not remember R117 or any incident that occurred but knew to report any suspected abuse immediately. She stated she would tell the charge nurse or higher ups if nothing was done. During an interview on [DATE] at 11:16 AM, Licensed Practical Nurse (LPN) 7 stated she did not recall any incident related to R117 but would report any sort of abuse or suspected abuse immediately. She said CNAs reported any issues related to abuse or anything out of the ordinary to charge nurses. 5. Review of R76's undated Face Sheet in the EMR under the Face Sheet tab, revealed R76 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, mood disturbance, and depressed mood. Review of R76's quarterly MDS with an ARD of [DATE] located in the EMR under the MDS tab, revealed R76's BIMS score was three out of 15 which indicated the resident was severely cognitively impaired. R76 was documented as exhibiting behaviors, and required extensive assistance from one person for transfers, dressing and toilet use and limited assistance for personal hygiene. Review of R 76's Care Plan, last revised [DATE], located in the EMR under the Care Plan tab, indicated Resident experiences resisting care, combative with staff, and yelling at times. Interventions included observing resident for behavior triggers which might lead to combativeness, assess and approaches that worked with resident including tone of voice and mannerisms. Review of a facility reported incident, dated [DATE], indicated a nurse told R42 to shut up and go to his room. The facility investigated, took witness statements, and determined that R42 was nowhere around according to the witness statements. The nurse was speaking to R76 and told him to shut up and go to his room. The nurse was terminated. She denied saying anything to R42 or R76. The facility substantiated that verbal abuse occurred. During an interview on [DATE] at 11:08 AM, CNA4 stated she has been working at the facility seven years on the secure unit. She stated she recalled the incident related to R76. CNA4 stated she heard the nurse tell R76 to shut up and go to his room. She said it was reported R42 was the resident who was told to shut up and go to his room, but it was actually R76. She said neither resident remembered the incident and the nurse was terminated. 6. a. Review of R80's Face Sheet located in the EMR under the Face Sheet tab, revealed R80 was admitted on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances. Review of the quarterly MDS dated [DATE], noted R80 had a BIMS score of one out of 15 which indicated R80 was severely cognitively impaired. b. Review of R101's Face Sheet located in the EMR under the Face Sheet tab, revealed R101 was initially admitted [DATE] and readmitted [DATE] with diagnoses that included vascular dementia with behavior disturbances, restlessness, and agitation. Review of the significant change MDS, dated [DATE], noted R101 had a BIMS score of zero out of 15 which indicated R101 was severely cognitively impaired. Review of a facility investigation, dated [DATE], revealed R80 was physically struck by R101 on [DATE] at 7:30 PM. The incident occurred, on the secured dementia care unit, after R101 wandered into R80's room and R80 yelled at R101 to get out. R101 was reported to have struck R80 on her left shoulder. During an observation on [DATE] at 2:48 PM, R80 was seated in a wheelchair moving herself about the secured dementia care unit using her feet. During an observation on [DATE] at 2:43 PM R101 was in bed, with the bedcovers up to her chin. R101 said she was very tired. During an interview on [DATE] at 2:51 PM, with the CNA4 revealed R80 generally wandered about the unit in her wheelchair and R101 was often in bed due to a fracture following a fall on [DATE]. During an interview on [DATE] at 12:21 PM, the Director of Nursing (DON) revealed R101 had not had other incidents of physical abuse of a resident. R101 was identified to have various incidents of increased agitation and physical aggression of unit property including windows. During those instances, the DON said R101 was transferred out to a Geri-psych unit for an evaluation. R101 received Geri-psych consults weekly to bi-monthly for medication management. During an interview on [DATE] at 1:27 PM, the Administrator stated that the incident was substantiated because it was witnessed by staff and was reported as a Facility Reported Incident.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure four of six residents (Resident (R) 15, R83, R93, and R94) reviewed for pneumococcal vaccines out of total sample of 35 residents were either offered pneumococcal vaccines or offered additional pneumococcal vaccines per CDC guidelines. Additionally, the facility failed to obtain consents and provide the risks and benefits to the residents and/or responsible party (RP) prior to administering pneumococcal vaccines. Additionally, the facility failed to ensure R93 was offered an influenza vaccine. The failure of not offering/providing pneumococcal vaccines increased the risk for residents to contract pneumonia. The failure for not offering influenza vaccine increased the risk for the resident to contract influenza. Findings include: Review of the facility's policy titled, Influenza, Pneumococcal, COVID-19 and Respiratory Syncytial Virus (RSV) Vaccines with a most recent revised date of 10/23, revealed PURPOSE: The facility offers all residents the Influenza, Pneumonia .vaccines unless medically contraindicated or the resident has already received the vaccines. STANDARD: Influenza Vaccine: All resident will be offered an influenza vaccine October 1 through March 31 annually, unless the vaccine is medially contraindicated or the resident has already been vaccinated during this time. Pneumonia Vaccine: All residents will be offered a pneumonia vaccine unless the vaccine is medically contraindicated, or the resident has already been vaccinated. There are multiple Pneumonia vaccines approved for use in the US [United States]. Prevnar 13 (PCV 13), Prevnar 15 (PCV15), Prevnar 20 (PCV20), and Pneumovax 23 (PPSV23). The vaccine will be administered based on the age of the resident and previous pneumonia vaccines administered. As an alternative, based on assessment and practitioner recommendation, a second pneumonia vaccine may be given after 5 years following the first vaccine, unless medically contraindicated or the resident or legal representative refused the second immunization .PROCESS: a) Upon admission and annually in September of each year the facility will send a letter to each resident, sponsor, or legal representative inform them that vaccinations are about to be administered to the residents. The letter will include a consent form and educational information, including benefits and potential side effects of the vaccinations . d) The resident or legal representative will have the opportunity to refuse vaccines and document the refusal on the Resident Acceptance/ Declination Form. e) The consent form for the vaccines will be made available for the resident or resident's legal representative. Benefits and potential side effects of the vaccines will be explained on the consent form. The consent form will be stored in the resident's medical record. Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22 and located at https://cdc.gov/vaccines/chp/acip-recs/vacc-specific/pneumo.html, indicated .CDC recommends pneumococcal vaccination for all adults [AGE] years or older .For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you .Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 .If PCV15 is used, this should be followed by a dose of PPSV 23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak .If PCV20 is used, a dose of PPSV23 is NOT indicated .For adults [AGE] years or older who have only received a PPSV23, CDC recommends you .May give 1 dose of PCV15 or PCV20 .The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you .Give PPSV23 as previously recommended .For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . 1. Review of R15's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. Diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease (COPD). Review of R15's Physician Orders List, provided by the facility and dated 04/21/21, revealed the resident was ordered Prevnar 13 pneumococcal vaccine and it was administered on 04/21/21. There was no evidence in the medical record that a consent was obtained by the resident's RP prior to administering the Prevnar 13 pneumococcal vaccine or that risks and benefits were explained to the RP. Additionally, per CDC guidelines, there was no evidence R15 received one dose of PCV20 or PPSV23 at least one year after PCV13. 2. Review of R83's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. The Face Sheet also indicated R83 was given a pneumococcal vaccine, however, there was no date, or any indication of which vaccine was given. Additionally, there was no evidence the RP signed a consent for the vaccine or that the risks and benefits were explained to the RP. 3. Review of R93's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. There was no evidence in the resident's medical record that she was offered the influenza or pneumococcal vaccine. 4. Review of R94's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE] and was [AGE] years old at the time of admission. There was no evidence in the resident's medical record that he was offered a pneumococcal vaccine. During an interview on 08/08/24 at 1:00 PM, the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) confirmed the above findings regarding pneumococcal vaccines for R15, R83, R93, R94, as well as R93 not being offered an influenza vaccine. During an interview on 08/08/24 at 1:54 PM, the Director of Nursing (DON) revealed she was not sure why the four residents were not offered the pneumococcal vaccines or why R93 was not offered an influenza vaccine.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 83) observed for dining out of 35 sample residents was positioned to ensure the resident could access their food without difficulty and at a comfortable position. This had the potential for the resident to have a decline in nutritional status and a negative dining experience. Findings include: Review of the facility's policy titled, Dining Services with the last revision date of 10/17, revealed Meal service is provided for all residents in a safe and sanitary environment and in a manner that preserves the dignity and respect of each resident .Every effort is made to provide a homelike environment in the dining room .During meal service: 3. b. Residents shall be positioned by nursing staff to enable the resident to consume food served in the safest, most efficient, and more comfortable manner possible. Review of R83's undated Face Sheet provided by the facility revealed the resident was readmitted to the facility on [DATE] with diagnoses of abnormal posture and muscle weakness. Review of R83's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/24 located in the electronic medical record (EMR) under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. She was noted to be independent with eating after set-up. During an observation on 08/05/24 at 11:30 AM, R83 was in the dining room at a table eating her lunch. She was in a chair that was in a reclined position. She was not sitting in an upright position. She had to lean forward and reach above her head to reach her utensils and the food on her plate. The resident's chin was level with the table. During an observation on 08/06/24 at 12:05 PM, R83 was in the dining room eating her lunch in the same chair that was in a reclined position. R83 reached up over her head and had to lean forward in order to reach her iced tea so she could drink it. She was observed to reach above her head to reach her utensils and her plate of food. R83 leaned forward to reach her cranberry juice and spilled some as she was trying to bring it closer to her mouth. She was observed to feed herself her lunch, however had to lean forward to reach it. During an interview on 08/06/24 at 12:05 PM, Licensed Practical Nurse (LPN) 6, who was in the dining room at the time of the observation, confirmed the table was too high for the resident to comfortably reach her food to feed herself. LPN6 said she tried to get R83 to move to a lower table, however the resident insisted on sitting at her current table with her friends. LPN6 confirmed other alternatives should be attempted so the resident could reach her utensils, plates, and beverages without leaning forward and reaching above her head so she could continue to sit at the table of her choosing. LPN6 then got a pillow and placed it behind R83's back so she was closer to the table. R83 thanked her and said it was much better and she could reach her food easier. During an observation on 08/08/24 at 12:13 PM, R83 was sitting at her usual table, in her chair that was reclined back. No pillow was observed behind the resident or any other assistive device so she would be positioned closer to the table to make it more comfortable. She again was having to reach above her head to reach her food and beverages. At the time of the observation the Speech Language Pathologist (SLP) was sitting at the table with R83. The SLP confirmed the resident was seated too low and she was struggling to see and reach her food. She confirmed she fed herself independently, however, could use some device so she was up higher and/or something behind her back, so she didn't have to lean forward to see her food and reach her utensils and beverage cups. The SLP confirmed R83 wanted to be at this particular table with her friends and said, so we need to figure out what adaptive devices we can use to make her more comfortable when she is eating.

Based on observations, record review, interview, and job description review, the facility failed to ensure two of four residents (Residents (R) 5 and R 37) reviewed for activities of daily living received adequate assistance with shaving. This failure had the potential to negatively impact the quality of life and self esteem for the affected residents. Findings include: 1. Review of R5's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia, anxiety, urinary tract infection, abnormal posture, and history of stroke. Review of R5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/24 and located in the EMR under the MDS tab, indicated he had a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated the resident had intact cognition. R5 required extensive assistance by one staff member with personal hygiene. Review of R5's Care Plan, located in the EMR under the Care Plan tab, most recently revised on 05/31/24, revealed the resident had a self-care deficit related to his diagnoses of weakness and paraplegia, a required assistance with activities of daily living (ADL) including personal hygiene. During an interview on 08/05/24, at 10:58 AM, R5 was in his room in bed, he was alert and able to answer questions. He stated he was doing okay in the facility but needed a shave and was usure when he was last shaved. His face had approximately one-half inch long whiskers at that time. During an observation on 08/06/24 at 2:14 PM, R5 was in his room. He had whiskers on his face. During an observation on 08/07/24 at 10:07 AM, R5 was in his room in his wheelchair, his face was unshaven. During an interview on 08/07/24 at 11:08 AM, Certified Nursing Assistant (CNA) 2 stated she did not shave residents unless as needed. During an interview on 08/07/24 at 11:11 AM, CNA1 (assigned to R5) stated she did not shave residents and was not sure who was responsible for shaving residents. During an interview on 08/07/24 at 11:12 AM, Licensed Practical Nurse (LPN) 2 stated CNAs should have been shaving residents every other day and more often as needed. During an interview on 08/07/24 at 11:12 AM, LPN7 said CNAs should have been shaving residents every other day and more often as needed. During an interview on 08/07/24 at 2:20 PM, the Director of Nursing (DON) stated CNAs should have been shaving the residents. 2. Review of R37's undated Face Sheet located in the EMR under the Face Sheet tab, indicated he was admitted on [DATE] with diagnoses of left above the knee amputation (AKA), history of stroke, osteoporosis, and reduced mobility. Review of R37's quarterly MDS with an ARD of 05/24/24 and located in the EMR under the MDS tab, revealed a BIMS score of nine out of 15 which indicated the resident had moderately impaired cognition. R5 required substantial/ maximum assistance with personal hygiene. Review of R37's Care Plan, located in the EMR under the Care Plan tab, most recently revised on 05/24/24, revealed the resident had a self-care deficit related to his diagnoses of weakness, required assistance with activities of daily living including personal hygiene. During an observation and interview on 08/05/24 at 3:05 PM, R37 stated he needed a shave; he stated it took a week after you asked to be shaved. During an observation on 08/06/24 at 2:15 PM, the resident was in room in bed, unshaven. During an observation 08/07/24 at 10:15 AM, the resident was in room in bed awake watching TV, unshaven. During an interview on 08/07/24 at 11:58 AM, the DON stated CNAs should have shaved the residents on shower days and upon request. During an interview on 08/08/24 at 3:52 PM, the Administrator stated he did not have a policy on ADLs. He provided a policy titled Nursing Assistant Job Description, dated May 2003 which revealed Essential Job Functions: Personal Care Functions- Duties: Assist with daily bath, dressing, grooming, dental care, bowel and bladder functions.

Based on observations, interviews, and record review the facility failed to ensure staff were providing appropriate and timely urinary catheter care for one of four residents (Resident (R) 5) reviewed for catheters and urinary tract infections of 35 sample residents. This failure placed the residents at risk for infection to the urinary tract and urethral trauma. Findings include: Review of R5's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia, anxiety, urinary tract infection, abnormal posture, and history of stroke. Review of R5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/24 and located in the EMR under the MDS tab, revealed he had a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated the resident had intact cognition. R5 required extensive assistance by one staff member with personal hygiene. Review of R5's physicians orders, located in the EMR under the Orders tab, indicated: provide catheter care every shift and as needed. Review of R5's Care Plan, located in the EMR under the Care Plan tab, most recently revised on 05/31/24, revealed the resident had alteration in elimination related to incontinence of bowel and bladder functions. He had a Foley catheter inserted for urinary retention. The care plan included R5 had a history of chronic urinary tract infections (UTIs) and received a maintenance dose of antibiotics. The goal was R5 would not be hospitalized due to a UTI through the next review. He was at risk for infection related to the Foley catheter. Approaches were to position catheter and tubing to facilitate proper drainage, provide catheter care every shift and as needed. During an observation and interview on 08/5/24 at 10:58 AM, R5 was in his room in bed, he was alert and able to answer questions. He had a Foley catheter in place. He stated he was unsure of why he had the catheter. During an interview on 08/07/24 at 11:08 AM, Certified Nursing Assistant (CNA) 2 stated she did not do catheter care. She stated she only emptied the drainage bag. During an interview on 08/07/24 at 11:11 AM, CNA1 stated she did not provide catheter care. She stated the nurses did catheter care and she only emptied the drainage bag and documented the amount of urine. During an interview on 08/07/24 at 11:12 AM, Licensed Practical Nurse (LPN) 2 stated CNAs should have been doing catheter care every shift. During an interview on 08/07/24 at 11:16 AM, with LPN7 stated CNAs should have been providing catheter care every shift and more often if the resident had a bowel movement and needed cleaning up. During an observation of catheter care on 08/07/24 at 3:05 PM provided by CNA1 and CNA2 revealed supplies were gathered. Staff Development (SD) was in the room during the catheter care. CNA2 cleaned tubing near penis, turned resident on right side leaving drainage bag attached to bed on the left side of the bed causing tension and pulling. SD told the CNAs to make sure they moved the drainage bag with the resident, they then moved it up in the bed close to the resident's head (above the bladder). SD told the CNAs to move the drainage bag. They moved it to the right side of the bed, they continued the catheter care, and turned the resident on his side causing tension to the tubing. During an interview on 08/07/24 at 4:45 PM when asked about the catheter care provided for R5 the SD stated CNAs needed to be aware of the catheter placement when providing care. SD stated the CNAs needed more training. Review of the Personal Hygiene Roster, provided by the facility, indicated R5 was provided catheter care on 08/01/24, 08/03/24, and 08/06/24. There was no evidence catheter care was provided every shift as ordered.

Based on observation, interview, and facility policy review, the facility failed to ensure ceiling vents did not drip condensation onto the tray line and scoops were stored appropriately. This deficient practice had the potential to affect 100 of 113 residents who received meals prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Supplies and Equipment, dated 11/08, revealed Equipment will be ready for use at all times day or night to serve the resident's needs. Review of the facility's policy titled, STORAGE OF CANNED AND DRY FOOD, revised 11/23, revealed Dry lbod [food] products such as flour, commeal [cornmeal], sugar, etc [etcetera], that are stored in bins are removed from their original packaging. These bins are cleaned and sanitized according to facility cleaning schedule. Scoops are stored in covered containers and not in thc [the] storage bin unless hanging on a hook and out offood [of food] product. 1. The tray line was observed on 08/07/24 from 11:14 AM through 12:53 PM. Two ceiling vents above the steam table were observed to drip condensation onto the shelf where meals were being prepared for delivery to residents. No condensation was observed to drip into food. The Dietary Manager (DM) and three Dietary Aides (DA1, DA2, and DA5) confirmed the dripping. During an interview on 08/08/24 at 10:45 AM, the Registered Dietitian (RD) stated that she inspected the kitchen once a month without being aware of the condensation from the ceiling vents. On 08/08/24 at 10:55 AM, the two ceiling vents were confirmed by the DM, RD, and Maintenance Director (MD), to drip onto the steam table. 2. During a tour of the kitchen on 08/05/24 at 9:25 AM, with the DM, a scoop was observed inside the flour container; a scoop was observed inside the cornmeal container; and an uncovered scoop was observed on top of the sugar container which had food particles on top. The observations were confirmed by the DM who stated, they know better, I'll have to remind them to put the scoops in the bags as expected.

Based on interviews and review of Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing's job descriptions, the Administrator and Director of Nursing, responsible for the overall day to day operations of the facility and nursing department, failed to provide monitoring and oversight to ensure outbreak testing for COVID-19 was performed as directed by the Centers for Medicare & Medicaid Services (CMS) and the facility's policy. This deficient practice placed all residents currently residing in the facility in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 2/6/2021 at 4:25 PM, the Administrator and Director of Nursing were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Administration, F835. Findings include: The facility failed to consistently conduct outbreak testing for 13 of 16 sampled staff, when it was indicated. Rapid identification and isolation of new cases is critical in stopping further COVID-19 [MEDICAL CONDITION] transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every three to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The facility's Infection Preventionist (IP) stated the facility has had four COVID-19 outbreaks in the facility since September 2020. The most recent outbreak began on 12/1/2020 and the facility has not gone 14 days without any new confirmed cases of COVID-19 among residents and/or staff. Refer to F886 The BALL HEALTHCARE SERVICES, INC. ADMINISTRATIVE PROCEDURE with a subject of Novel Coronavirus Prevention and Response dated October 2020 documented . POLICY INTERPRETATION AND IMPLEMENTATION 1. The Infection Preventionist/Director of Nursing will assess facility risk associated with COVID-19 . The unsigned . DIRECTOR OF NURSING SERVICES JOB DESCRIPTION documented General Purpose: To plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current federal, state and local standard governing the facility . In an interview on 2/9/2021 at 1:15 PM, EI #2, the Director of Nursing and Infection Preventionist (IP) acknowledged that while she was aware of the lack of testing, she had not developed a concrete plan of resolution to address the lack of staff COVID-19 testing. When asked how residents could become exposed to the COVID-19 virus when they are not leaving the facility or having visitation, EI #2 replied, it would have to be the staff. When asked what the potential harm could be to residents if staff are not tested according to outbreak testing guidelines, EI #2 replied there could be an increased risk of transmission. According to EI #2, there have been four residents, Resident Identifier (RI) #12, RI #19, RI #20 and RI #21, to expire after testing positive for COVID-19. The unsigned . FACILITY ADMINISTRATOR JOB DESCRIPTION documented General Purpose: The position of Facility Administrator is responsible to the overall management and daily operations of the facility. To plan and direct the operations of the facility to ensure quality and appropriateness of resident/patient care meets or exceeds the company and regulatory standards. Responsible to ensure the well-being and good health of each resident and to ensure compliance with applicable federal, state, and local regulatory standards and regulations governing the facility . In an interview on 1/30/2021 at 11:50 AM, EI #1 stated he has been the facility's Interim Administrator since 12/1/2020. When asked what his responsibilities included, EI #1 replied, overall management, day to day operations, and supervision of the facility. When asked about who was responsible to ensure COVID-19 testing was done per the guidelines, EI #1 stated ultimately, he was. EI #1 explained at least once a week, the facility's tracking system should be checked to verify each staff member that required testing was tested . In a follow-up interview on 1/30/2021 at 2:40 PM, EI #1 denied having knowledge that COVID-19 testing was not being done according to the testing guidelines. According to EI #1, there has been no communication, other than today (1/30/2021) that there was a gap/delay in staff COVID-19 testing. When asked should he have known, EI #1 replied yes. EI #1 was asked to explain the facility's COVID-19 tracking system. EI #1 replied, the system identifies all staff that are tested ; the DON reviews and maintains the system and should communicate to EI #1 if testing was not done. When asked if he reviews the tracking system, EI #1 stated he did not that it was maintained by the DON. When asked why (outbreak) testing had not been consistently done, EI #1 stated he did not have a reason, it should have been. EI #1 explained there should have been a plan developed to ensure testing was completed and there was no situation where it was okay that testing was not done. On 2/2/2021 at 11:45 AM, EI #1 acknowledged he provided oversight of the DON, EI #2. When asked as the Administrator should he have known the staff was not consistently tested for the COVID-19 virus as outline in the Centers for Medicare & Medicaid (CMS) guidelines and the facility's policy, EI #1 answered yes. ************************* On 2/8/2021, the facility submitted an acceptable Removal Plan which documented . As of February 1, 2021, the administrator and Director of Nursing / Infection Preventionist had been trained in the process of monitoring staff testing by the Director of Quality Assurance. The Administrator and Director of Nursing will ensure that COVID-19 testing . is conducted according to CMS guidelines and facility policy during the COVID-19 Pandemic. They were both provided education on February 1, 2021 regarding the process of monitoring staff . testing. The education was provided by the Director of Clinical Services and Quality Assurance . When testing is required twice weekly, nursing department employees who work twelve hour shifts on Wednesday and Thursdays will be tested on Sunday and Wednesdays of each week and nursing department employees that work twelve hour shifts on Monday, Tuesday and Friday will be tested on Monday and Friday of each week. When weekly testing is required, nursing department employees will be tested on Mondays and Wednesdays. Other department employees will be tested Mondays and Wednesdays of each week depending on the required testing frequency. Each week on Friday, the upcoming week testing frequency and testing schedule will be posted at the time clock. All staff will be educated on the testing requirements by February 8, 2021. The education will be provided by the Administrator/designee. Any employees that have not completed the education by February 8, 2021 will not be allowed to work until the education is completed. On February 1, 2021, the Administrator and Director of Nursing were provided education regarding testing requirements and monitoring of testing. The education was provided by the Director of Clinical Services and Quality Assurance. The facility request that the IJ be removed effective February 8, 2021 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a F level on 2/8/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 036.

Based on interviews, review of the Centers for Medicare & Medicaid Services QSO (Quality, Safety & Oversight)-20-38-NH, the facility's policy titled Novel Cornovarius Surveillance and Testing Policy, a complaint received by the State Survey Agency and various facility documents, the facility failed to consistently conduct outbreak testing for 13 of 16 sampled staff, when it was indicated. Rapid identification and isolation of new cases is critical in stopping further COVID-19 [MEDICAL CONDITION] transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every three to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The facility's Infection Preventionist (IP) stated the facility has had four COVID-19 outbreaks in the facility since September 2020. The most recent outbreak began on 12/1/2020 and the facility has not gone 14 days without any new confirmed cases of COVID-19 among residents and/or staff. This deficient practice placed all residents currently residing in the facility in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 2/6/2021 at 2:30 PM, the Administrator and Director of Nursing were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of COVID-19 Testing - Residents & Staff, F886. Findings include: On 1/25/2021, the State Agency received an anonymous complaint which alleged the facility was not testing staff as they should. The anonymous caller stated Employee Identifier (EI) #9 who works full time on the 7:00 PM to 7:00 AM shift has not been tested since 12/23/2020. Other staff not tested included: EI #19, EI #25 and EI #28. The Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group Ref: QSO-20-38-NH dated 8/26/2020, documented . Memorandum Summary . facilities are required to test residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 based on parameters set forth by the HHS (Health and Human Services) Secretary. This memorandum provides guidance for facilities to meet the new requirements. GUIDANCE FOR F886 Testing of Nursing Home Staff and Residents To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set for by the HHS Secretary . Testing of Staff and Residents in Response to an Outbreak An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission . Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result . Documentation of Testing Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: . Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests . The BALL HEALTHCARE SERVICES, INC. ADMINISTRATIVE PROCEDURE with a subject of Novel Coronavirus Surveillance and Testing Policy revised October 2020, documented PURPOSE: This facility will ensure that residents and HealthCare Personnel (HCP) are tested for COVID-19 as required by state and federal requirements . PROCEDURE: 1. Perform COVID-19 [MEDICAL CONDITION] and/or [MEDICATION NAME] testing for residents and HCP based on testing requirements by the Centers for Medicare and Medicaid Services (CMS), to include: . b. Outbreak Testing: Test all staff and residents in response to an outbreak (any single new infection). Continue to test all staff and residents that tested negative every 7 days until 14 days have passed since the most recent positive result . In an interview on 1/29/2021 at 4:00 PM, EI #2, the Infection Preventionist (IP) stated the facility has had four COVID-19 outbreaks in the facility since September 2020. The most recent outbreak began on 12/1/2020 and the facility has not gone 14 days without any new confirmed cases of COVID-19 among residents and/or staff. EI #9's timecard revealed EI #9, a CNA, worked in the facility on 12/23/2020, 12/24/2020, 12/26/2020, 12/27/2020, 12/30/2020, 12/31/2020, 1/2/2021, 1/5/2021, 1/6/2021, 1/7/2021, 1/11/2021, 1/12/2021, 1/20/2021, 1/21/2021, and 1/24/2021. EI #9's laboratory test results indicated the CNA was last tested by the facility for COVID-19 on 12/31/2020. According to a document provided by the facility, on 1/22/2021, EI #9 was tested for COVID-19 by her Primary Care Physician. On 1/25/2021, EI #9 was found to be positive for the COVID-19 virus. In a telephone interview on 1/28/2021 at 10:00 AM, EI #9 acknowledged that she was not tested according to the outbreak testing guidelines for the months of December 2020 and January 2021. When asked why not, EI #9 stated she would go to the Staff Development office to be tested but was asked to come back. Then on 1/22/2021, EI #9 stated she stayed late waiting on Assistant Director of Nursing (ADON) to test her but when the ADON left the facility, EI #9 left also. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #9 was not tested per outbreak testing guidelines for the month of January 2021. EI #19's December 2020 timecard revealed EI #19, a CNA, worked in the facility on 12/2/2020, 12/3/2020, 12/7/2020, 12/8/2020, 12/11/2020 - 12/13/2020, 12/16/2020, and 12/17/2020. EI #19's laboratory test results indicated the CNA was not tested for the COVID-19 virus from 12/1/2020 to 12/21/2020. EI #19's January 2021 timecard revealed the CNA worked in the facility on 1/14/2021, 1/18/2021, 1/19/2021, 1/22/2021, 1/23/2021, 1/24/2021, and 1/27/2021. EI #19's laboratory test results indicated the CNA was not tested for the COVID-19 virus from 1/14/2021 to 1/27/2021. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #19 was not tested per outbreak testing guidelines. EI #25's January 2021 timecard revealed the CNA worked in the facility on 1/7/2021, 1/11/2021, 1/12/2021, 1/15/2021 - 1/17/2021. EI #25's laboratory test results indicated the CNA was not tested for the COVID-19 virus from 1/7/2021 to 1/18/2021. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #25 was not tested per outbreak testing guidelines. EI #28's January 2021 timecard revealed the CNA worked in the facility on 1/7/2021, 1/11/2021, 1/12/2021, 1/15/2021 - 1/17/2021. EI #28's laboratory test results indicated the CNA was not tested for the COVID-19 virus from 1/7/2021 to 1/18/2021. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #28 was not tested per outbreak testing guidelines. EI #29's January 2021 timecard revealed EI #29, the Dietary Aide, worked in the facility on 1/1/2021 - 1/3/2021 and 1/5/2021 - 1/7/2021. EI #29's laboratory test results indicated the Dietary Aide was not tested for the COVID-19 virus from 12/31/2020 to 1/7/2021. EI #29 further worked in the facility on 1/16/2021, 1/17/2021, 1/19/2021, 1/19/2021, 1/22/2021, 1/24/2021 and 1/25/2021. EI #29's laboratory test results indicted the Dietary Aide was not tested for the COVID-19 virus from 1/16/2021 to 1/26/2021. EI #23's January 2021 timecard revealed EI #23, a CNA, worked in the facility on 1/1/2021, 1/2/2021, 1/3/2021, 1/6/2021, 1/7/2021, 1/11/2021, 1/12/2021, 1/15/2021 and 1/16/2021. EI #23's laboratory test results indicated the CNA was not tested for the COVID-19 virus from 12/31/2020 to 1/19/2021. In an interview on 1/28/2021 at 3:08 PM, EI #23 acknowledged she was not tested for the COVID-19 virus during the month of January 2021 until 1/20/2021. When asked why not, EI #23 stated she didn't know. EI #23 further explained the staff would tell them when to get swabbed; we are on their time. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #23 was not tested per outbreak testing guidelines. EI #24's December 2020 timecard revealed EI #24, a Registered Nurse (RN), worked in the facility on 12/4/2020, 12/5/2020 and 12/6/2020. EI #24's laboratory test results indicated the RN was not tested for the COVID-19 virus from 12/4/2020 to 12/14/2020. EI #24's January 2021 timecard revealed the RN worked in the facility on 1/1/2021, 1/2/2021, 1/3/2021 and 1/7/2021. EI #24's laboratory test results indicated the RN was not tested for the COVID-19 virus from 12/31/2020 to 1/10/2021. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #24 was not tested per outbreak testing guidelines. EI #7's December 2020 timecard revealed EI #7, a Licensed Practical Nurse (LPN), worked in the facility on 12/21/2020, 12/22/2020, 12/25/2020, 12/26/2020, 12/27/2020 and 12/30/2020. EI #7's laboratory test results indicated the LPN was not tested for the COVID-19 virus from 12/19/2020 to 12/30/2020. EI #7's January 2021 timecard revealed the RN worked in the facility on 1/8/2021, 1/9/2021, 1/10/2021, 1/13/2021, 1/14/2021, 1/18/2021 and 1/19/2021. EI #7's laboratory test results indicated the LPN was last tested for the COVID-19 virus by the facility on 1/5/2021. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #7 was not tested per outbreak testing guidelines. EI #20's December 2020 timecard revealed EI #20, a CNA worked in the facility on 12/4/2020, 12/5/2020, 12/6/2020, 12/9/2020 and 12/10/2020. EI #20's laboratory test results indicated the CNA was not tested for the COVID-19 virus from 12/4/2020 to 12/14/2020. EI #8's December 2020 timecard revealed EI #8, a RN, worked in the facility on 12/9/2020, 12/10/2020, 12/14/2020 and 12/15/2020. According to EI #8's laboratory test results, the RN was not tested for the COVID-19 virus from 12/9/2020 to 12/15/2020. EI #8's January 2021 timecard revealed EI #8 worked in the facility on 1/7/2021, 1/8/2021, 1/11/2021, 1/12/2021, 1/15/2021, 1/16/2021, 1/17/2021 and 1/20/2021. According to EI #8's laboratory test results, the RN was not tested for the COVID-19 virus from 1/7/2021 to 1/18/2021. On 1/19/2021, a specimen was collected from EI #9 to test for the COVID-19 virus. On 1/21/2021, it was reported to the facility that EI #8 tested positive for COVID-19. However, EI #8 worked in the facility from 6:20 PM on 1/20/2021 to 7:00 AM on 1/21/2021. During an interview on 1/29/2021 at 4:36 PM, EI #8 was asked about testing. EI #8, who works night shift, stated when it's time to leave from working the night shift, it's hard to slow down for a COVID test. EI #8 commented that she just missed getting tested . When asked if she had any signs and symptoms of COVID-19, EI #8 stated after she received the vaccine on 1/15/2021 she began to develop symptoms but thought they were the side effects of the vaccine. EI #8 stated she continued to have symptoms over the weekend, 1/16/2021 and 1/17/2021. Around 4:00 AM Monday, 1/18/2021 when she left work, she was tested for the COVID-19 virus. EI #8 stated she was off Monday, 1/18/2021 and Tuesday, 1/19/2021. On Wednesday, 1/20/2021, EI #8 worked in the facility but stated she still didn't feel well. Then Thursday (1/21/2021) morning before she left work, EI #8 stated she was told she would be off work for 10 days because she had tested positive for COVID-19. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #8 was not tested per outbreak testing guidelines. During an interview on 2/3/2021 at 1:00 PM, EI #2, the IP was asked what date EI #8's COVID-19 specimen was collected in the facility. EI #2 answered, it was collected on 1/18/2021. When asked why the laboratory test result indicated it was collected on 1/19/2021, EI #2 replied, she didn't know. EI #2 explained that when the staff collected the specimens, they were not documenting the collections dates anywhere; they were only labeling the specimen tube with the staff's name and date of birth. EI #26's timecard for December 2020 revealed EI #26, a LPN, worked in the facility on 12/4/2020, 12/5/2020, 12/6/2020, 12/7/2020, 12/9/2020, 12/10/2020, 12/11/2020, 12/14/2020, 12/15/2020. According to EI #26's laboratory test results EI #26 was not tested for the COVID-19 virus from 12/4/2020 to 12/15/2020. Furthermore, EI #26 worked in the facility on 12/20/2020, 12/23/2020, 12/24/2020, 12/26/2020, 12/27/2020, 12/28/2020 and 12/29/2020. EI #26's laboratory test results indicated the LPN was not tested for the COVID-19 virus from 12/19/2020 to 12/29/2020. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #26 was not tested per outbreak testing guidelines. EI #27's timecard for December 2020 revealed EI #27, a RN, worked in the facility on 12/9/2020, 12/10/2020, 12/14/2020, 12/15/2020, 12/17/2020, 12/18/2020, 12/19/2020 and 12/20/2020. According to EI #27's laboratory test results EI #27 was not tested for the COVID-19 virus from 12/9/2020 to 12/20/2020. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP acknowledged EI #27 was not tested per outbreak testing guidelines. EI #30's timecard for December 2020 revealed EI #30, a housekeeper, worked in the facility on 12/4/2020, 12/5/2020, 12/6/2020, 12/9/2020 and 12/10/2020. According to EI #30's laboratory test results, EI #30 was not tested for the COVID-19 virus from 12/4/2020 to 12/10/2020. According to EI #30's January 2021 timecard, EI #30 worked in the facility on 1/8/2021 from 6:53 AM to 2:53 PM and then again from 4:51 PM to 7:03 PM. On 1/8/2021, a specimen was collected from EI #30 to test for the COVID-19 virus. On 1/11/2021 at 8:34 AM, it was reported EI #30 was COVID-19 positive. EI #30 worked in the facility on 1/9/2021 from 6:53 AM to 2:53 PM. EI #30 left work early on 1/11/2021 due to a positive COVID-19 test result. In an interview on 1/30/2021 at 9:40 AM, EI #2, the IP stated she became aware in the middle of December 2020 that staff were not tested per outbreak testing guidelines. In a follow-up interview on 2/3/2021 at 1:00 PM, EI #2, the IP stated she was unsuccessful in identifying the staff that needed to be tested . During an interview on 2/6/2021 at 3:50 PM, EI #2, the IP stated 74 residents and 64 staff have tested positive for COVID-19 since the December 2020 outbreak. On 2/9/2021 at 1:15 PM, EI #2, the IP acknowledged that while she was aware of the lack of testing, she had not developed a concrete plan of resolution to address the lack of staff COVID-19 testing. When asked how residents could become exposed to the COVID-19 virus when they are not leaving the facility or having visitation, EI #2 replied, it would have to be the staff. When asked what the potential harm could be to residents if staff are not tested according to outbreak testing guidelines, EI #2 replied there could be an increased risk of transmission. According to EI #2, there have been four residents, Resident Identifier (RI) #12, RI #19, RI #20 and RI #21, to expire after testing positive for COVID-19. ************************* On 2/8/2021, the facility submitted an acceptable Removal Plan which documented . The facility failed to ensure that outbreak testing, in accordance with CMS rules and the facility's policy, for 16 of 17 staff since December 4, 2021 was performed consistently. As of February 7, 2021, utilizing a 7-day lookback period, the facility performed outbreak testing for all staff as required by CMS and the facility policy. As of February 1, 2021, the facility has ensured there is a testing schedule in place to test all staff according to the required frequency. All eligible staff were tested as of February 7, 2021 except employees who are in the 90-day timeframe due to previously testing positive. Seven employees were removed from the schedule due to failure to test. Employees who do not test as required will not be allowed to work until they have tested according to the required frequency. All non-administrative employees will use the Rehab Unit entrance for testing when applicable. If the employee is already onsite at the facility they will report to the designated testing area for testing. The Director of Nursing (DON) will oversee the testing process. Testing will be performed by the Director of Nursing, Assistant Director of Nursing (ADON) and Staff Development Coordinator (SDC). Any individuals designated to assist with testing will be educated by the DON, ADON or SDC to ensure proper procedures are followed. When testing is required twice weekly, nursing department employees who work twelve hour shifts on Wednesday and Thursdays will be tested on Sunday and Wednesdays of each week and nursing department employees that work twelve hour shifts on Monday, Tuesday and Friday will be tested on Monday and Friday of each week. When weekly testing is required, nursing department employees will be tested on Mondays and Wednesdays. Other department employees will be tested Mondays and Wednesdays of each week depending on the required testing frequency. Each week on Friday, the upcoming week testing frequency and testing schedule will be posted at the time clock. All staff will be educated on the testing requirements by February 8, 2021. The education will be provided by the Administrator/ designee. Any employees that have not completed the education by February 8, 2021 will not be allowed to work until the education is completed. On February 1, 2021, the Administrator and Director of Nursing were provided education regarding testing requirements and monitoring of testing. The education was provided by the Director of Clinical Services and Quality Assurance. The facility request that the IJ be removed effective February 8, 2021. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F886 was lowered to a F level on 2/8/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 036.

Based on interview and review of the facility's RECORD OF MEDICATION DISPOSAL forms, the facility failed to ensure the controlled drug destruction records had three required signatures. This was noted in 10/2018 and 5/2019, two of the six months of controlled drug destruction records reviewed. Findings Included: Review of the RECORD OF MEDICATION DISPOSAL forms, dated 10/16/18, revealed there were only two signatures present for the disposal of controlled medications. The section of the form for Signature of Witness (Only required for Controlled Drugs) was blank. Review of the RECORD OF MEDICATION DISPOSAL forms, dated 5/10/19, revealed there were only two signatures present for the disposal of controlled medications. The section of the form for Signature of Witness (Only required for Controlled Drugs) was blank. On 6/06/19 04:30 PM, the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse/Director of Nursing (DON). EI #1 was asked who was responsible for signing the controlled drug destruction sheets. EI #1 said the pharmacist, herself and the nurse assisting with destruction. EI #1 was asked when the sheets are signed, how many signatures should there be on the controlled drug destruction sheets, including witnesses. EI #1 said three. EI #1 reviewed the destruction records for 10/16/18 and 5/10/19, and said there were not three signatures present.

Based on interviews, medical record review and review of Potter and Perry Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, the facility failed to ensure a physician's orders [REDACTED].#175's bilateral lower extremity Doppler study. This affected RI #175, one of 27 sampled residents for whom medical records were reviewed. Findings Include: Review of Potter and Perry Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, copyright (YEAR), page 311, revealed the following: . Health Care Providers' Orders . Make sure that all health care provider orders are in writing . and transcribed correctly . RI #175 was re-admitted to the facility on [DATE]. RI #175 had [DIAGNOSES REDACTED]. Review of Consultation Notes revealed RI #175 saw his/her oncologist on 4/3/19. This report documented the following: . PLAN . Biggest complaint today is . lower extremity [MEDICAL CONDITION]. I suggest a great lower extremity Dopplers to rule out blood clot . an order for [REDACTED]. . LE (lower extremity) [MEDICAL CONDITION]- (check) LE Doppler . However, when RI #175's order for the Dopplers was transcribed onto the facility's written physician order [REDACTED].> . 4-3-19 Stat venous doppler LLE (Left Lower Extremity) ([MEDICAL CONDITION]) . A DOPPLER REPORT, for date of service 4/04/19, indicated RI #175 only received a Doppler of the left lower extremity on this date. On 6/06/19 at 11:25 AM an interview was conducted with Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN). EI #6 was asked what type of tests were ordered for RI #175 on 4/3/19 by the Oncologist. EI #6 answered lower extremity Doppler. EI #6 was asked what was transcribed from that order. EI #6 answered stat venous Doppler left lower extremity, EI #6 was asked if that was accurate. EI #6 answered no, the resident needed both lower extremities done. EI #6 was asked what was the facility policy regarding accuracy of the transcription of physician's orders [REDACTED]. EI #6 was asked what was the concern of inaccurate transcription of physician's orders [REDACTED].#6 answered we might not get both of them and the other one could have had a [MEDICAL CONDITIONS]. On 6/06/19 at 12:07 PM an interview was conducted with EI #5, an LPN. EI #5 was asked what type of tests were ordered for RI #175 on 4/3/19 by the Oncologist. EI #5 answered lower extremity Dopplers. EI #5 was asked what was transcribed from that order. EI #5 answered stat venous Doppler of left lower extremity. EI #5 was asked if that was accurate. EI #5 answered no, that was not what the doctor had written. EI #5 was asked what was the facility policy regarding accuracy of transcription of physician's orders [REDACTED].#5 answered to make sure it is transcribed accurately. EI #5 was asked what was the concern of inaccurate transcription of physician's orders [REDACTED].#5 answered the test may not be done. On 6/06/19 at 4:34 PM an interview was conducted with EI #1, the Director of Nursing, (DON). EI #1 was asked what type of tests were ordered for RI #175 on 4/3/19 by the Oncologist. EI #1 answered a lower extremity venous Doppler study. EI #1 was asked what was transcribed from that order. EI #1 answered left lower extremity Doppler. EI #1 was asked if that was accurate and she answered no. EI #1 was asked what was the facility policy regarding accuracy of the transcription of physician's orders [REDACTED].#1 answered it should be correct as it is written. EI #1 was asked what was the concern of inaccurate transcription of physician's orders [REDACTED].#1 answered the Dr's orders were not followed.

Based on interviews, review of Resident Identifier (RI) #25's medical record, the facility's investigation file and Employee Identifier (EI) #5's personnel file, EI #5, a CNA neglected to transfer RI #25 with a Hoyer lift and the assistance of another staff member on 5/17/2018. During the 3:00 PM to 11:00 PM shift on 5/17/2018, EI #5 failed to follow RI #25's plan of care when she transferred the resident by herself by picking the resident up and pivoting the resident to the bed. No Hoyer lift was used and no assistance was provided by another staff member. During the transfer the resident's right knee was twisted and the resident began to complain of pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. RI #25 was transferred to the local hospital for further evaluation. An X-ray showed a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. This deficient practice affected RI #25, one of four sampled residents reviewed for neglect. Findings include: RI #25 was admitted to the facility on [DATE]. RI #25 has a medical history to include [DIAGNOSES REDACTED]. RI #25's Quarterly Minimum Data Set with an assessment reference date of 3/5/2018, indicated RI #25 was moderately impaired in cognitive skills with a Brief Interview for Mental Status (BIMS) score of 12. RI #25 was assessed as requiring extensive assistance of two plus persons for transfers. RI #25's care plan titled Potential for fall . with a problem onset date of 10/8/2014, had an approach of . 3-5-18 . Two person assist with transfers per hoyer lift . RI #25's Departmental Notes dated 5/18/2018 at 11:27 PM, documented Resident c/o (complained of) leg pain on last rounds tonight about 10:45 pm . called MD (Medical Doctor) (name of medical doctor) for order to transfer to (local hospital) - (RI #25's) R (right) leg between knee and ankle is red, warm, swollen and painful - called 911 for ambulance transfer at 11:15 (PM)- ambulance arrived at 11:23 (PM). RI #25's physician orders [REDACTED]. The local hospital documentation indicated RI #25 was admitted to the hospital on [DATE] at 12:13 AM with an admit [DIAGNOSES REDACTED]. The History of Present Illness indicated . [AGE] year-old with multiple chronic medical conditions here for evaluation of right knee pain. Patient states that (his/her) (aide was) transferring (him/her) in the bed and (he/she) twisted (his/her) right knee is having pain ever since that time . X-ray shows a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. Patient is nonweightbearing at baseline. I do not think patient is a surgical candidate. I will place (him/her) in a knee immobilizer on that right leg give [MEDICATION NAME] for pain control . and have (him/her) follow-up with orthopedics as well as primary care provider . According to the hospital records, RI #25 was discharged back to the nursing facility on 5/19/2018 at 6:09 AM. The ROBERTSDALE REHABILITATION AND HEALTHCARE CENTER Summary of Investigation: Injury of Unknown Origin dated 5/24/2018, documented . (RI #25), is a long term resident of this facility since 10/8/2014 ) . On (MONTH) 17, (YEAR), (RI #25) was out of bed due to a dental appointment to which the facility transported (him/her). At 4:04pm on the 17th, (RI #25) used (his/her) nurse call (system) which was responded to at 4:06 pm by (EI #5) CNA. (EI #5) was in the room for approximately 4 minutes. At 4:25pm (EI #5) again responded to the nurse call system and was in the room until 4:38pm. Per camera it shows that (EI #5) entered the room without assistive lifts and left at 4:38pm with soiled linens. (RI #25) is care planned and had on (his/her) profile sheet, used to communicate resident needs to the CNAs, to use a Hoyer lift and assistance of two. Later in the evening, a Nursing Assistant, (EI #15) went in to assist (RI #25) . (RI #25) reported to (EI #15) that (EI #5) had moved (him/her) from the wheelchair to the bed earlier in the evening, twisted (his/her) leg and it was now hurting . The following day, (RI #25) did not get out of bed during the day shift. On the 3-11p shift, (RI #25) complained of pain . The physician was contacted and orders were received to transfer to the hospital emergency room . At 4:20am the emergency room called the facility with a report of a fracture . It was determined during the investigation that (EI #5), on two separate interviews, was not forthright in reporting the type of transfer she provided (RI #25). There was no mechanical lift brought into (RI #25's) room per the security camera that visualizes the room entrance well. There was no one in the room with (EI #5) and (RI #25). (RI #25) has consistently reported that (he/she) was lifted by (EI #5) and transferred into the bed. This caused injury to (RI #25's) leg . The origin of injury is now known and it is due to neglect by (EI #5) CNA not following direction on the profile sheet for transfers . Based on performance and resident safety, . (EI #5) will be terminated . Contained within the facility's investigation file was RI #25's written statement dated 5/19/2018 at 7:45 AM, which documented . How did you become aware of the alleged incident? The CNA was putting me to bed . What did you observe concerning the alleged incident? I was in my chair and the CNA leaned down over me and picked me up. She hit my leg on the side of the bed. I told her not to do it by herself . In an interview with RI #25 on 8/9/2018 at 8:22 AM, the resident was asked what happened to his/her right leg. RI #25 said a girl put (him/her) to bed by herself. RI #25 explained that he/she told the girl that there was supposed to be two people. According to RI #25, the aide (EI #5) reached down and picked (him/her) up. RI #25 stated his/her foot got caught on the bed. RI #25 said it was not a smooth transfer. When asked why EI #5 transferred the resident by herself, RI #25 said EI #5 was in a hurry and thought she could do it by herself. When asked when did this happen, RI #25 stated it was back in (MONTH) (YEAR). When asked how many times he/she had been transferred in that manner, RI #25 said that was the first time. RI #25 explained that he/she is usually transferred by two staff members. A telephone interview was conducted on 8/9/2018 at 10:31 AM, with EI #5, the CNA assigned to care for RI #25 during the 3:00 PM to 11:00 PM shift on 5/17/2018. EI #5 acknowledged that she had been terminated from the facility. When asked why, EI #5 stated because a resident (RI #25) was a two person assist and she transferred the resident by herself. When asked if she assisted RI #25 to bed on 5/17/2018, EI #5 said yes. EI #5 was asked, how she assisted the resident. EI #5 explained that RI #25 was sitting in the chair and she picked RI #25 up by herself and pivoted the resident to the bed. According to EI #5, when she pivoted RI #25, the resident told her to be careful as he/she had a [DIAGNOSES REDACTED].#5 said two persons. When asked why she transferred the resident by herself, EI #5 said she just decided to do it herself. EI #5 stated she didn't look at the resident profile sheet. When asked if she attempted to get someone else to assist in the transfer, EI #5 said no. EI #5 was asked if RI #25 was injured as the result of the transfer. EI #5 replied, the resident sustained [REDACTED]. On 8/9/2018 at 6:53 PM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked when she was made aware RI #25 had sustained a fracture to his/her right leg. EI #2 said she was notified on 5/19/2018 at 5:00 AM. EI #2 explained that after the facility received noticed that RI #25 had a fracture, they started an investigation to determine how it could have happened. EI #2 said the facility's investigation concluded RI #25 sustained a fracture as the result of the transfer that occurred on 5/17/2018, when EI #5, a CNA, transferred the resident by herself, without the assistance of two people and the Hoyer lift. EI #2 said the CNA, EI #5, admitted to transferring RI #25 by herself because she thought she could do it. EI #2 was asked what has been done to ensure an incident such as this would not recur. EI #2 stated we (administrative staff) began educating/re-educating all the staff on reviewing and following the residents' profile sheets. A 100% staff education/re-education would be completed by the end of (MONTH) (YEAR). All the residents had been identified who was assessed as requiring the use of an assistive device for transfers. Beginning next week on 8/24/2018, the facility would begin to randomly monitor in-room transfers.

Based on interviews, review of Resident Identifier (RI) #25's medical record and the facility's investigation file, Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) failed to follow RI #25's plan of care when she transferred the resident by herself by picking the resident up and pivoting the resident to the bed. RI #25 is care planned for two person assist with transfers with the Hoyer lift. During the transfer the resident's right knee was twisted and the resident began to complain of pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. RI #25 was transferred to the local hospital for further evaluation. An X-ray showed a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. This deficient practice affected RI #25, one of 39 sampled residents. Findings include: The facility's policy titled Care Plans with a revised date of (MONTH) 2009, documented PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident . RI #25 was admitted to the facility on [DATE]. RI #25 has a medical history to include [DIAGNOSES REDACTED]. RI #25's Quarterly Minimum Data Set with an assessment reference date of 3/5/2018, indicated RI #25 was moderately impaired in cognitive skills with a Brief Interview for Mental Status (BIMS) score of 12. RI #25 was assessed as requiring extensive assistance of two plus persons for transfers. RI #25's care plan titled Potential for fall . with a problem onset date of 10/8/2014, had an approach of . 3-5-18 . Two person assist with transfers per hoyer lift . RI #25's Departmental Notes dated 5/18/2018 at 11:27 PM, documented Resident c/o (complained of) leg pain on last rounds tonight about 10:45 pm . called MD (Medical Doctor) (name of medical doctor) for order to transfer to (local hospital) - (RI #25's) R (right) leg between knee and ankle is red, warm, swollen and painful - called 911 for ambulance transfer at 11:15 (PM)- ambulance arrived at 11:23 (PM). RI #25's physician orders [REDACTED]. The local hospital documentation indicated RI #25 was admitted to the hospital on [DATE] at 12:13 AM with an admit [DIAGNOSES REDACTED]. The History of Present Illness indicated . [AGE] year-old with multiple chronic medical conditions here for evaluation of right knee pain. Patient states that (his/her) (aide was) transferring (him/her) in the bed and (he/she) twisted (his/her) right knee is having pain ever since that time . X-ray shows a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. Patient is nonweightbearing at baseline. I do not think patient is a surgical candidate. I will place (him/her) in a knee immobilizer on that right leg give [MEDICATION NAME] for pain control . and have (him/her) follow-up with orthopedics as well as primary care provider . According to the hospital records, RI #25 was discharged back to the nursing facility on 5/19/2018 at 6:09 AM. The ROBERTSDALE REHABILITATION AND HEALTHCARE CENTER Summary of Investigation: Injury of Unknown Origin dated 5/24/2018, documented . (RI #25), is a long term resident of this facility since 10/8/2014 ) . On (MONTH) 17, (YEAR), (RI #25) was out of bed due to a dental appointment to which the facility transported (him/her). At 4:04pm on the 17th, (RI #25) used (his/her) nurse call (system) which was responded to at 4:06 pm by (EI #5) CNA. (EI #5) was in the room for approximately 4 minutes. At 4:25pm (EI #5) again responded to the nurse call system and was in the room until 4:38pm. Per camera it shows that (EI #5) entered the room without assistive lifts and left at 4:38pm with soiled linens. (RI #25) is care planned and had on (his/her) profile sheet, used to communicate resident needs to the CNAs, to use a Hoyer lift and assistance of two. Later in the evening, a Nursing Assistant, (EI #15) went in to assist (RI #25) . (RI #25) reported to (EI #15) that (EI #5) had moved (him/her) from the wheelchair to the bed earlier in the evening, twisted (his/her) leg and it was now hurting . The following day, (RI #25) did not get out of bed during the day shift. On the 3-11p shift, (RI #25) complained of pain . The physician was contacted and orders were received to transfer to the hospital emergency room . At 4:20am the emergency room called the facility with a report of a fracture . It was determined during the investigation that (EI #5), on two separate interviews, was not forthright in reporting the type of transfer she provided (RI #25). There was no mechanical lift brought into (RI #25's) room per the security camera that visualizes the room entrance well. There was no one in the room with (EI #5) and (RI #25). (RI #25) has consistently reported that (he/she) was lifted by (EI #5) and transferred into the bed. This caused injury to (RI #25) leg . The origin of injury is now known and it is due to . (EI #5) not following direction on the profile sheet for transfers . RI #25's undated RESIDENT PROFILE indicated for mobility/transfer RI #25 required a Hoyer lift and two person assist. Contained within the facility's investigation file was RI #25's written statement dated 5/19/2018 at 7:45 AM, which documented . How did you become aware of the alleged incident? The CNA was putting me to bed . What did you observe concerning the alleged incident? I was in my chair and the CNA leaned down over me and picked me up. She hit my leg on the side of the bed. I told her not to do it by herself . In an interview with RI #25 on 8/9/2018 at 8:22 AM, the resident was asked what happened to his/her right leg. RI #25 said a girl put (him/her) to bed by herself. RI #25 explained that he/she told the girl that there was supposed to be two people. According to RI #25, the aide (EI #5) reached down and picked (him/her) up. RI #25 stated his/her foot got caught on the bed. RI #25 said it was not a smooth transfer. When asked why EI #5 transferred the resident by herself, RI #25 said EI #5 was in a hurry and thought she could do it by herself. When asked when did this happen, RI #25 stated it was back in (MONTH) (YEAR). When asked how many times he/she had been transferred in that manner, RI #25 said that was the first time. RI #25 explained that he/she is usually transferred by two staff members. A telephone interview was conducted on 8/9/2018 at 10:31 AM, with EI #5, the CNA assigned to care for RI #25 during the 3:00 PM to 11:00 PM shift on 5/17/2018. EI #5 acknowledged that she had been terminated from the facility. When asked why, EI #5 stated because a resident (RI #25) was a two person assist and she transferred the resident by herself. When asked if she assisted RI #25 to bed on 5/17/2018, EI #5 said yes. EI #5 was asked, how she assisted the resident. EI #5 explained that RI #25 was sitting in the chair and she picked RI #25 up by herself and pivoted the resident to the bed. According to EI #5, when she pivoted RI #25, the resident told her to be careful as he/she had a [DIAGNOSES REDACTED].#5 said two persons. When asked why she transferred the resident by herself, EI #5 said she just decided to do it herself. When asked if she attempted to get someone else to assist in the transfer, EI #5 said no. EI #5 was asked if RI #25 was injured as the result of the transfer. EI #5 replied, the resident sustained [REDACTED]. On 8/9/2018 at 6:53 PM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked when she was made aware RI #25 had sustained a fracture to his/her right leg. EI #2 said she was notified on 5/19/2018 at 5:00 AM. EI #2 explained that after the facility received noticed that RI #25 had a fracture, they started an investigation to determine how it could have happened. EI #2 said the facility's investigation concluded RI #25 sustained a fracture as the result of the transfer that occurred on 5/17/2018, when EI #5, a CNA, transferred the resident by herself, without the assistance of two people and the Hoyer lift. EI #2 said the CNA, EI #5, admitted to transferring RI #25 by herself because she thought she could do it. When asked how RI #25 was care planned to be transferred, EI #2 said two person Hoyer lift. EI #2 was asked when EI #5 transferred RI #25 by herself on 5/17/2018, was the CNA (EI #5) following the resident's care plan. EI #2 replied, no she was not. When asked what procedure the facility had in place to ensure staff knew the type of care a resident would require, EI #2 explained residents have a profile sheet inside their closet door and the staff was educated upon hire to follow the profile sheet. A review of EI #5's personnel file indicated the CNA began her employment with the facility on 4/23/2018. On 4/23/2018, EI #5 received training on Safe Patient Handling.

Based on interviews, review of Resident Identifier (RI) #25's medical record and the facility's investigation file, Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN) failed to assess RI #25 for a complaint of leg pain during the 3:00 PM to 11:00 PM shift on 5/17/2018. During the 3:00 PM to 11:00 PM shift on 5/17/2018, EI #5, a Certified Nursing Assistant (CNA) failed to follow the resident's plan of care, when she transferred the resident to the bed. During the transfer the resident's right knee was twisted and the resident began to complain of pain. EI #6 administered an over-the-counter headache pain reliever, [MEDICATION NAME], to the resident for the resident's complaint of pain; however, failed to assess the resident's complaint of leg pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. RI #25 was transferred to the local hospital for further evaluation. An X-ray showed a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. This deficient practice affected RI #25, one of three sampled residents reviewed for pain. Findings include: Chapter 44 titled Pain Management page 1022 of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of (YEAR), documented . Assessment During the assessment process thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. A comprehensive assessment of pain aims to gather information about the cause of a person's pain and determine its effect on his or her ability to function . Patients expect nurses to accept their reports of pain and be prompt in meeting their pain needs. When assessing pain, be sensitive to the level of discomfort and determine which level will allow your patient to function . If pain is acute or severe, it is unlikely that a patient is able to provide a detailed description of the entire experience. During an episode of acute pain, streamline your assessment and assess its location, severity, and quality. Collect a more detailed acute pain assessment when the patient is more comfortable . RI #25 was admitted to the facility on [DATE]. RI #25 has a medical history to include [DIAGNOSES REDACTED]. RI #25's Departmental Notes dated 5/18/2018 at 11:27 PM, documented Resident c/o (complained of) leg pain on last rounds tonight about 10:45 pm . called MD (Medical Doctor) (name of medical doctor) for order to transfer to (local hospital) - (RI #25's) R (right) leg between knee and ankle is red, warm, swollen and painful - called 911 for ambulance transfer at 11:15 (PM)- ambulance arrived at 11:23 (PM). RI #25's physician orders [REDACTED]. The local hospital documentation indicated RI #25 was admitted to the hospital on [DATE] at 12:13 AM with an admit [DIAGNOSES REDACTED]. The History of Present Illness indicated . [AGE] year-old with multiple chronic medical conditions here for evaluation of right knee pain. Patient states that (his/her) (aide was) transferring (him/her) in the bed and (he/she) twisted (his/her) right knee is having pain ever since that time . X-ray shows a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. Patient is nonweightbearing at baseline. I do not think patient is a surgical candidate. I will place (him/her) in a knee immobilizer on that right leg give [MEDICATION NAME] for pain control . and have (him/her) follow-up with orthopedics as well as primary care provider . According to the hospital records, RI #25 was discharged back to the nursing facility on 5/19/2018 at 6:09 AM. The ROBERTSDALE REHABILITATION AND HEALTHCARE CENTER Summary of Investigation: Injury of Unknown Origin dated 5/24/2018, documented . (RI #25), is a long term resident of this facility since 10/8/2014 ) . On (MONTH) 17, (YEAR), (RI #25) was out of bed due to a dental appointment to which the facility transported (him/her). At 4:04pm on the 17th, (RI #25) used (his/her) nurse call (system) which was responded to at 4:06 pm by (EI #5) CNA. (EI #5) was in the room for approximately 4 minutes. At 4:25pm (EI #5) again responded to the nurse call system and was in the room until 4:38pm. Per camera it shows that (EI #5) entered the room without assistive lifts and left at 4:38pm with soiled linens. (RI #25) is care planned and had on (his/her) profile sheet, used to communicate resident needs to the CNAs, to use a Hoyer lift and assistance of two. Later in the evening, a Nursing Assistant, (EI #15) went in to assist (RI #25) . (RI #25) reported to (EI #15) that (EI #5) had moved (him/her) from the wheelchair to the bed earlier in the evening, twisted (his/her) leg and it was now hurting. (EI #15) then reported this to the nurse, (EI #6) LPN . Upon questioning, (RI #25) reports that (EI #6) did not look at (his/her) leg. The following day, (RI #25) did not get out of bed during the day shift. On the 3-11p shift, (RI #25) complained of pain . The physician was contacted and orders were received to transfer to the hospital emergency room . At 4:20am the emergency room called the facility with a report of a fracture . Both (EI #5) and (EI #6) were placed on Administrative Leave during the investigation. It was determined during the investigation that . (EI #6) failed to assess the resident despite being told of the leg pain by both (EI #15) and (RI #25). (EI #6) stated she did not recall hearing either of the people tell her this and that (RI #25) has numerous complaints so she did not pay attention . This lack of assessment delayed the care that this resident needed and the lack of documentation prevented continuity of care . Contained within the facility's investigation file was RI #25's written statement dated 5/19/2018 at 7:45 AM, which documented . How did you become aware of the alleged incident? The CNA was putting me to bed . What did you observe concerning the alleged incident? I was in my chair and the CNA leaned down over me and picked me up. She hit my leg on the side of the bed. I told her not to do it by herself . What immediate action did you take: I told (EI #6) the nurse about it and that my leg hurt and she gave me something for pain. She (EI #6) did not look at my leg . In an interview with RI #25 on 8/9/2018 at 8:22 AM, the resident was asked what happened to his/her right leg. RI #25 said a girl put (him/her) to bed by herself. When asked when did this happen, RI #25 stated it was back in (MONTH) (YEAR). When asked who she told, RI #25 said she told the nurse, EI #6. RI #25 explained that other than giving him/her something for pain, the nurse didn't do anything. RI #25 stated that is the reason the nurse did not work at the facility anymore. In an interview on 8/22/2018 at 6:47 PM, EI #15, a Nurse Aide (NA) acknowledged that she had reported RI #25's complaints of pain to the nurse, EI #6. According to EI #15, EI #6 told her that she had already given RI #25 something for pain. In a telephone interview on 8/22/2018 at 10:01 PM, EI #6, the LPN assigned to care for RI #25 during the 3:00 PM to 11:00 PM shift on 5/17/2018 was asked why she was no longer employed by the facility. EI #6 stated she was let go because of poor work performance. When asked if she was familiar with RI #25, EI #6 said yes. EI #6 was asked if the resident or anyone reported to her RI #25's complaint of pain. EI #6 said the resident told her his/her legs were hurting when she responded to the resident's call light. When asked if the resident said which leg was hurting, EI #6 said no. When asked if she assessed the resident for his/her complaint of pain, EI #6 said no. When asked why not, EI #6 said she knew the resident had been up all day, so she figured that what the resident was complaining of. EI #6 was asked if she physically looked at RI #25's leg. EI #6 said no. EI #6 was asked how the facility's policy directed the staff to assess a resident after a complaint of pain. EI #6 explained, the staff was to assess the location of pain; have the resident, if applicable, rate the pain; description; and notify the physician if it is a new complaint of pain or unrelieved pain. When asked if she did this, EI #6 said no. In an interview on 8/23/2018 at 10:50 AM, EI #16, the LPN assigned to care for RI #25 during the 11:00 PM to 7:00 AM shift on 5/17/2018 acknowledged that no one reported to her RI #25 complained of pain. When asked if RI #25 complained of pain during the 11:00 PM to 7:00 AM shift on 5/17/2018, EI #16 said no. In an interview on 8/22/2018 at 3:32 PM, EI #17, the LPN assigned to care for RI #25 during the 7:00 AM to 3:00 PM shift on 5/18/2018 acknowledged that no one reported to her RI #25 complained of pain. When asked if RI #25 complained of pain during the 7:00 AM to 3:00 PM shift on 5/18/2018, EI #17 said no. During an interview on 8/23/2018 at 10:11 AM, EI #18, the Registered Nurse (RN) assigned to care for RI #25 during the 3:00 PM to 11:00 PM shift on 5/18/2018, acknowledged she was informed by a CNA that RI #25 was complaining pain. According to EI #18, the CNA had gone into RI #25's room to change the resident's incontinence brief. When the CNA flipped the covers back, RI #25 complained that his/her leg was hurting. EI #18 stated she immediately went to RI #25's room and assessed the resident's complaint of pain. EI #18 said RI #25's right leg was swollen, red, warm and painful to touch. The redness was under the knee but the entire leg was a little swollen. When asked what time was this, EI #18 said this was around 10:00 PM. EI #18 stated she asked the CNA to stay with the resident, while she reported to the house supervisor, EI #19, and get the vital sign machine. After assessing RI #25's vital signs, the physician was called and the resident was prepped for transport to the local hospital for further evaluation. According to EI #18, prior to the CNA reporting to her around 10:00 PM, RI #25's complaint of pain, the resident had not voiced any complaints of pain during the shift. On 8/9/2018 at 6:53 PM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked did RI #25 normally complain of pain. EI #2 said RI #25 normally complains of leg and headache pain. When asked if RI #25 complained of pain on 5/17/2018, EI #2 said yes. When asked if there was any documentation of the resident's complaint of pain, EI #2 said no. The only documentation was that an [MEDICATION NAME] (an over-the-counter headache pain reliever) was administered that evening. EI #2 acknowledged the nurse, EI #6, failed to assess the resident despite being informed of the complaint of pain. When asked why EI #6's employment with the facility was terminated, EI #6 said EI #6 neglected to assess RI #25 for an acute complaint of pain; ignored the report of the nursing assistant (EI #15) who reported RI #25 was injured; failed to fill out an incident report; failed to document the injury in RI #25's medical record; and failed to communicate the complaint of pain on the shift to shift communication report.

Based on interviews, review of Resident Identifier (RI) #25's medical record and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) used a Hoyer lift and the assistance of another staff person, as determined by RI #25's assessment and plan of care, during a transfer on 5/17/2018. During the 3:00 PM to 11:00 PM shift on 5/17/2018, EI #5 failed to follow RI #25's plan of care when she transferred the resident by herself by picking the resident up and pivoting the resident to the bed. No Hoyer lift was used and no assistance was provided by another staff member. During the transfer the resident's right knee was twisted and the resident began to complain of pain. One day later, on 5/18/2018, RI #25's right leg between the knee and ankle was noted to be red, warm, swollen and painful. RI #25 was transferred to the local hospital for further evaluation. An X-ray showed a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. The facility concluded in their investigation, RI #25's injury was caused by the transfer that occurred on 5/17/2018. This deficient practice affected RI #25, one of four sampled residents reviewed for accident hazards. Findings include: The facility's policy titled Lifting and Transferring Residents dated (MONTH) 2013, documented PURPOSE: The purpose of this policy is to provide guidance regarding transferring residents in the safest manner and to minimize the risk of staff and resident injury. STANDARD: Resident transfers should be performed based on the resident's functional status as determined by the Resident Assessment Process . Extensive Assistance Residents All residents classified as extensive assistance should be lifted and transferred between beds, chairs, toilets, bathing and weighing equipment with the aid of a mechanical lift device . RI #25 was admitted to the facility on [DATE]. RI #25 has a medical history to include [DIAGNOSES REDACTED]. RI #25's Quarterly Minimum Data Set with an assessment reference date of 3/5/2018, indicated RI #25 was moderately impaired in cognitive skills with a Brief Interview for Mental Status (BIMS) score of 12. RI #25 was assessed as requiring extensive assistance of two plus persons for transfers. RI #25's care plan titled Potential for fall . with a problem onset date of 10/8/2014, had an approach of . 3-5-18 . Two person assist with transfers per hoyer lift . RI #25's Departmental Notes dated 5/18/2018 at 11:27 PM, documented Resident c/o (complained of) leg pain on last rounds tonight about 10:45 pm . called MD (Medical Doctor) (name of medical doctor) for order to transfer to (local hospital) - (RI #25's) R (right) leg between knee and ankle is red, warm, swollen and painful - called 911 for ambulance transfer at 11:15 (PM)- ambulance arrived at 11:23 (PM). RI #25's physician orders [REDACTED]. The local hospital documentation indicated RI #25 was admitted to the hospital on [DATE] at 12:13 AM with an admit [DIAGNOSES REDACTED]. The History of Present Illness indicated . [AGE] year-old with multiple chronic medical conditions here for evaluation of right knee pain. Patient states that (his/her) (aide was) transferring (him/her) in the bed and (he/she) twisted (his/her) right knee is having pain ever since that time . X-ray shows a comminuted mildly displaced proximal tibia fracture as well as a proximal fibular fracture. Patient is nonweightbearing at baseline. I do not think patient is a surgical candidate. I will place (him/her) in a knee immobilizer on that right leg give [MEDICATION NAME] for pain control . and have (him/her) follow-up with orthopedics as well as primary care provider . According to the hospital records, RI #25 was discharged back to the nursing facility on 5/19/2018 at 6:09 AM. The ROBERTSDALE REHABILITATION AND HEALTHCARE CENTER Summary of Investigation: Injury of Unknown Origin dated 5/24/2018, documented . (RI #25), is a long term resident of this facility since 10/8/2014 ) . On (MONTH) 17, (YEAR), (RI #25) was out of bed due to a dental appointment to which the facility transported (him/her). At 4:04pm on the 17th, (RI #25) used (his/her) nurse call (system) which was responded to at 4:06 pm by (EI #5) CNA. (EI #5) was in the room for approximately 4 minutes. At 4:25pm (EI #5) again responded to the nurse call system and was in the room until 4:38pm. Per camera it shows that (EI #5) entered the room without assistive lifts and left at 4:38pm with soiled linens. (RI #25) is care planned and had on (his/her) profile sheet, used to communicate resident needs to the CNAs, to use a Hoyer lift and assistance of two. Later in the evening, a Nursing Assistant, (EI #15) went in to assist (RI #25) . (RI #25) reported to (EI #15) that (EI #5) had moved (him/her) from the wheelchair to the bed earlier in the evening, twisted (his/her) leg and it was now hurting . The following day, (RI #25) did not get out of bed during the day shift. On the 3-11p shift, (RI #25) complained of pain . The physician was contacted and orders were received to transfer to the hospital emergency room . At 4:20am the emergency room called the facility with a report of a fracture . It was determined during the investigation that (EI #5), on two separate interviews, was not forthright in reporting the type of transfer she provided (RI #25). There was no mechanical lift brought into (RI #25's) room per the security camera that visualizes the room entrance well. There was no one in the room with (EI #5) and (RI #25). (RI #25) has consistently reported that (he/she) was lifted by (EI #5) and transferred into the bed. This caused injury to (RI #25) leg . Contained within the facility's investigation file was RI #25's written statement dated 5/19/2018 at 7:45 AM, which documented . How did you become aware of the alleged incident? The CNA was putting me to bed . What did you observe concerning the alleged incident? I was in my chair and the CNA leaned down over me and picked me up. She hit my leg on the side of the bed. I told her not to do it by herself . In an interview with RI #25 on 8/9/2018 at 8:22 AM, the resident was asked what happened to his/her right leg. RI #25 said a girl put (him/her) to bed by herself. RI #25 explained that he/she told the girl that there was supposed to be two people. According to RI #25, the aide (EI #5) reached down and picked (him/her) up. RI #25 stated his/her foot got caught on the bed. RI #25 said it was not a smooth transfer. When asked why EI #5 transferred the resident by herself, RI #25 said EI #5 was in a hurry and thought she could do it by herself. When asked when did this happen, RI #25 stated it was back in (MONTH) (YEAR). When asked how many times he/she had been transferred in that manner, RI #25 said that was the first time. RI #25 explained that he/she is usually transferred by two staff members. A telephone interview was conducted on 8/9/2018 at 10:31 AM, with EI #5, the CNA assigned to care for RI #25 during the 3:00 PM to 11:00 PM shift on 5/17/2018. EI #5 acknowledged that she had been terminated from the facility. When asked why, EI #5 stated because a resident (RI #25) was a two person assist and she transferred the resident by herself. When asked if she assisted RI #25 to bed on 5/17/2018, EI #5 said yes. EI #5 was asked, how she assisted the resident. EI #5 explained that RI #25 was sitting in the chair and she picked RI #25 up by herself and pivoted the resident to the bed. According to EI #5, when she pivoted RI #25, the resident told her to be careful as he/she had a [DIAGNOSES REDACTED].#5 said two persons. When asked why she transferred the resident by herself, EI #5 said she just decided to do it herself. When asked if she attempted to get someone else to assist in the transfer, EI #5 said no. EI #5 was asked if RI #25 was injured as the result of the transfer. EI #5 replied, the resident sustained [REDACTED]. On 8/9/2018 at 6:53 PM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked when she was made aware RI #25 had sustained a fracture to his/her right leg. EI #2 said she was notified on 5/19/2018 at 5:00 AM. EI #2 explained that after the facility received noticed that RI #25 had a fracture, they started an investigation to determine how it could have happened. EI #2 said the facility's investigation concluded RI #25 sustained a fracture as the result of the transfer that occurred on 5/17/2018, when EI #5, a CNA, transferred the resident by herself, without the assistance of two people and the Hoyer lift. EI #2 said the CNA, EI #5, admitted to transferring RI #25 by herself because she thought she could do it. When asked if this was an avoidable accident, EI #2 replied, yes.

Based on observation, interview, review of facility's policy titled, FOOD STORAGE LABELING and the (YEAR) Food Code, the staff failed to ensure food was consistently covered and stored with labels to identify contents, date of preparation and use-by date. This had the potential to affect all residents for whom meals were prepared and served at the time of the survey. Findings include: The facility's FOOD STORAGE LABELING policy, revised (MONTH) (YEAR), documented POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PR[NAME]EDURE: 1. All food items must be labeled with the date they are received. 2. All food items that are not in their original containers must be labeled with the common name of the food and the date they are received. TCS (Time/Temperature Control for Safety) food held for longer than 24 hours must be labeled and date marked to indicate the use by date . 2. Suggested labeling includes: a. Common Name b. Date of preparation or Use By Date . The (YEAR) Food Code, documented . 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants . During the initial kitchen tour on 8/7/2018 at 7:35 AM, the following items were stored in the reach-in refrigerator with no label as to contents and/or no date to indicate the use-by date: a) one gallon pitcher of light beige-colored thick liquid; b) a 1/3-size steam table pan with prepared egg salad, loosely covered by plastic wrap and partially open exposing the contents; and c) a container of undated, chopped fresh tomatoes without a date or label. On 8/8/2018 at 11:25 AM, the surveyor conducted an interview with EI #7, the Dietary Manager and EI #8, the Corporate Dietary Consultant. EI #7 explained the facility's policy was to store left-over foods for two to three days. EI #7 explained the pitcher most likely had contained soup or chicken gravy; each item should have had a dated label attached. EI #7 explained the potential hazard of no label could be contamination. EI #7 stated it was the responsibility of whomever placed the item in the refrigerator. EI #7 stated the lack of a complete covering over the food item could result in food spoilage.

Based on observations, interviews, and record reviews of Job Description, MEAL SERVICE TIMES, and a facility policy titled, Frequency of Meals, the facility failed to ensure the breakfast and lunch meals were served at the appropriate time on 6/14/17. This was observed on one of three survey days and affected 120 residents that received a meal from the kitchen. Findings Include: A review of a facility policy titled, ADMINISTRATIVE POLICY SUBJECT: Frequency of Meals, with a revised date of 7/06, revealed: POLICY: Three meals are served daily at regular times comparable to normal meal time in the community . PROCEDURE: 1. Meal service times for the residents are as follows: (Subject to adjustments per facility) a. Breakfast 7:30 AM b. Lunch 11:30 AM c. Dinner 5:30 PM . A review of the Meal Service Times revealed Breakfast 7-8 a.m. Lunch 11:30 a.m.- 1 p.m. Dinner 5-6 p.m. The MEAL SERVICE TIME schedule was reviewed for breakfast and indicated the times meals were started in the kitchen and what time they were to be delivered to the units. The following was the meal times for breakfast: START MAIN 7:00 UNIT 7:15 HALL 2 7:15 UNIT 7:20 REHAB 7:20 7:30 MSU (Medical/Surgical Unit)/LUDKE (Dementia Unit) 7:30 UNIT 7:45 MAIN DINING 7:45 UNIT 8:15. The MEAL SERVICE TIME schedule was reviewed for lunch. The following was the meal times for lunch: START MAIN 11:15 UNIT 11:30 HALL 2 11:30 UNIT 11:40 REHAB 11:40 UNIT 11:50 MSU/LUDKE 11:50 UNIT 12:00 MAIN DINING 12:00 UNIT 12:30. A review of COOK JOB DESCRIPTION, modified 5/2003, revealed: General Purpose: To prepare food in accordance with current federal, state, and local standards, the facility's established policies and procedures, and as may be directed by the Head Cook and/or Director of Food Services, to ensure that quality food service is provided at all times.Other Job Functions: .B. Administrative Functions Duties: .assist in standardizing work methods and establishing food service production lines to ensure meals are timely prepared . On 6/13/17 at 3:30 p.m., a Resident Council Meeting was conducted. Thirteen residents attended the meeting. When asked if the meals were generally on time or late, all 13 residents stated the meals were late. The residents were asked if they told staff about their concern and they stated yes and were told they would try harder to correct the concern. On 6/14/17 at 8:27 a.m., a surveyor observed a breakfast meal cart that arrived to the LUDKE Unit. The cart was due on the unit at 7:45 a.m The meal was 43 minutes late. On 6/14/17 at 10:55 a.m., an observation was made of the lunch meal in the kitchen. While observing EI (Employee Identifier) #1, Dietary Manager, calibrating a thermometer, EI #1 stated they only had three staff members in the kitchen and they were trying something new. EI #1 stated they usually had four staff members at each meal but, they were going to see if the kitchen could be ran with three staff members. EI #1 stated only the cook could serve the food and that she was the cook today so she would be working the trayline. EI #1 indicated she had only been employed at the facility since May and this was her first time working the trayline in the facility. The menu for 6/14/17 included a hamburger on a bun, relish plate, baked beans, strawberry delight, and beverages. At 11:55 a.m. on 6/14/17, EI #1 began plating the lunch meal. According to the MEAL SERVICE TIME schedule, the lunch meal should have been started at 11:15 a.m. and out to the Main hall unit at 11:30 a.m The first cart out of the kitchen to the Main Hall was at 12:20 p.m.- due on the unit at 11:30 a.m The meal was delivered 50 minutes late. Cups with lids were observed on trays on a cart with ice and tea. The ice was melted in both the water and tea. The water and tea were placed on the trays that were placed on the cart and delivered to the residents on the hall. At 12:33 p.m., cart 2 was sent out of the kitchen to Hall 2, due on the unit at 11:40 a.m The meal was 53 minutes late. Again, cups with water and tea had melted ice that were placed on the trays and onto the cart. At 12:45 p.m., cart 3 left the kitchen to the Rehab unit, due out on the unit at 11:50 a.m The meal was 55 minutes late. Cups with ice and tea were observed with melted ice. At 12:52 p.m., the surveyor was informed by another surveyor that RI (Resident Identifier) #12 left the dining room because the resident was furious with the late meal. The resident stated he/she could not wait anymore and he/she was hungry. RI #12 indicated he/she had crackers in the room he/she would eat but was not waiting in the dining room any longer. The service time for the dining room was 12:30 p.m At 1:05 p.m., residents were still observed sitting in the dining room and had not been served yet. At 1:06 p.m., cart 4 left the kitchen to MSU/LUDKE, due out on unit at 12:00 p.m The meal was one hour and six minutes late. At 1:08 p.m., the plating for the dining room was started. At 1:28 p.m., some residents in the dining room were observed without lunch meal served yet. At 1:32 p.m., some residents in the dining room had not received lunch meal. At 1:38 p.m., the last plate was served to residents in the dining room. The meal service schedule indicated the lunch should be out to the dining room at 12:30 p.m The meal was one hour and eight minutes late. On 6/14/17 at 1:07 p.m., a surveyor observed a lunch meal cart arrived to the LUDKE Unit. The cart was due on the unit at 12:00 p.m. The meal cart was 1 hour and 7 minutes late being delivered to the unit. On 6/14/17 at 5:41 p.m., RI (Resident Identifier) #9 was interviewed. RI #9, a cognitively intact resident, stated he/she did not get a lunch meal until 1:10 p.m. today (6/14/17). When asked how did it make him/her feel when the food was late, RI #9 stated, Like they don't care and I don't matter. Disrespected. On 6/15/17 at 8:37 a.m., RI #12 was interviewed. RI #12, a resident with moderate cognitive impairment, was asked if meals were delivered on time. RI #12 stated the lunch and dinner were usually late. RI #12 indicated for the 6/14/17 lunch meal, he/she got tired of sitting in the dining room for so long. RI #12 indicated he/she was bored and had other things he/she could be doing. On 6/15/17 at 10:04 a.m., EI #1, Dietary Manager, was interviewed. EI #1 was asked how late was the lunch meal served on 6/14/17 and EI #1 stated she believed it was about an hour late. EI #1 was asked why was the lunch meal late. EI #1 stated it was her first day on the trayline and she was the cook. EI #1 explained that she had to get the hamburger patties up higher in temperature and she fell behind trying to get chopped and pureed done and it pushed everything back. EI #1 stated they had been doing four staff in the morning and four in the evening and would use a floater to help move things to get the the carts out. EI #1 stated they started using three dietary staff members instead of four to see if they could run the kitchen with three instead of four staff members. EI #1 was asked how does the meal being late affect residents and she stated it delays them getting their food. EI #1 said CNAs (Certified Nursing Assistants) came up to the window to get trays for resident to take to their room. It puts lunch and dinner too close together and gets the residents off their schedule. EI #1 was asked if anyone explained to the residents why the lunch meal was late on 6/14/17. EI #1 stated the Dietician tried to speak to them, but the staff serving in the dining room did not explain why it was late or tell them it was coming. When asked if they should have, EI #1 stated yes, staff should refill their water and tea and keep in touch with the residents to let them know it's coming. On 6/15/17 at 2:25 p.m., RI #16, a cognitively intact resident, was interviewed. RI #16 was asked if meals were served on time and the resident responded not always. When asked what meals were served late, RI #16 stated lunch. RI #16 was asked how often were they late and RI #16 stated about a third of the time. RI #16 asked how did it make him/her feel with the lunch being served late on 6/14/17. RI #16 stated it made them feel aggravated and lose patience. When asked if anyone explained to him/her why the lunch meal was late on 6/14/17, RI #16 stated no, the left hand did not know what the right was doing. On 6/15/17 at 4:35 p.m., RI #15, a cognitively intact resident, was interviewed. RI #15 was asked if meals were served on time. The resident stated no, it happens more than it should, it happens once or twice a week. RI #15 was asked which meals were late and the resident stated all 3 meals. When asked how did it make him/her feel about the lunch meal being late on 6/14/17, RI #15 stated it did not make him/her feel good. RI #15 stated they (residents) turn around and look and no one tells them anything about why it's late.

Based on observations, record reviews, a review of an ADMINISTRATIVE POLICY SUBJECT: Physical Restraints, a review of a facility document titled, RESTRAINT ASSESSMENT, and interviews, the facility failed to ensure the least restrictive restraint was used and a medical [DIAGNOSES REDACTED]. This was observed on two of three survey days. This affected Resident Identifier (RI) #1, one of two residents sampled for restraints. Findings Include: A review of the facility policy titled, ADMINISTRATIVE POLICY with a revision date of 02/13 revealed, . SUBJECT: Physical Restraints PURPOSE: . limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints . PROCESS: . c) A restraint assessment, form NM.I-26a, should be completed prior to restraint use. A review of the facility document titled, RESTRAINT ASSESSMENT (NM.I-26 (a)) with an effective date of 8/07, revealed, . THIS FORM MUST BE COMPLETED PRIOR TO THE USE OF ANY PHYSICAL RESTRAINT. Resident Room No. (number) Assessment Date admitted [DIAGNOSES REDACTED]. RESTRAINT RE-ASSESSMENT Date Is restraint still needed? ___Yes ___No Change in restraint type? Explain Reason restraint is or is not needed Have there been any negative effects due to physical restraint, (i.e., (in example) decrease in muscle strength, independence, incontinence, pressure sore, contractures, dignity) Assessed by Title . (NOTE: This form was not completed for RI #1) A review of the medical record for RI #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15. This score indicated RI #1 was moderately impaired for daily decision making skills. This assessment indicated RI #1 had a limb restraint used daily in bed and out of bed or in chair. An observation was made on 6/13/17 at 10:11 a.m. of RI #1 in bed with two wrist restraints in use. An observation was made on 6/13/17 at 3:59 p.m. of RI #1 in bed with two wrist restraints in use. An observation was made on 6/14/17 at 7:33 a.m. of RI #1 in bed with two wrist restraints in use as a Respiratory Therapist was caring for the resident. An observation was made on 6/14/17 at 8:58 a.m. of RI #1, during a medication pass observation, with two wrist restraints in use. An observation was made on 6/14/17 at 11:04 a.m. of RI #1 with two wrist restraints in use as he/she touched his/her face with his/her left hand while restrained. An interview was conducted with Employee Identifier (EI) #5, Registered Nurse (RN), on 6/15/17 at 2:52 p.m EI #5 was asked if RI #1 had pulled out their [MEDICAL CONDITION] at the facility. EI #5 answered no. EI #5 added the resident was admitted with a restraint and was agitated. EI #5 was asked if there was any reason other than the admission report and agitation for use of the restraints. EI #5 answered RI #1 was pulling at things. EI #5 was asked where that was documented. EI #5 reviewed the Nurse's notes and responded, It doesn't say anything. EI #5 was asked if the fact that the resident presented to the facility with a restraint constituted a medical [DIAGNOSES REDACTED].#5 answered no. EI #5 was asked what was indicated as the reason for the signed verbal order for restraints for RI #1. EI #5 answered it said the resident was pulling their [MEDICAL CONDITION] out. EI #5 was asked if that was accurate and she answered not here (not at this facility). EI #5 was asked where was the documentation that RI #1 had pulled out their [MEDICAL CONDITION] at the facility. EI #5 answered, I don't see it documented at all. EI #5 was asked what did the Psychiatric consult note from 3/21/17 indicate. EI #5 answered, No [MEDICAL CONDITION] since dc (discontinue) of [MEDICATION NAME] (antipsychotic medication). EI #5 was asked what was the facility's response and she answered RI #1 had ESBL (Extended Spectrum Beta-Lactamases) and was yelling out. EI #5 was asked if that was a medical [DIAGNOSES REDACTED]. EI #5 was asked who was responsible for ensuring follow up and/or changes related to consults and she answered the nurses. EI #5 was asked if she could show the surveyor any changes nurses put in place after the 3/21/17 visit by the Physician. EI #5 answered, Nothing noted. EI #5 was asked how the facility should have responded after another Psychiatric consult note on 5/2/17 indicated no reports of any repeat agitation. EI #5 answered trial of releasing the restraint. EI #5 was asked if there was any documentation of that attempt being done and she answered no. EI #5 was asked where was the documentation to support the resident pulled out lines as the basis for use of the wrist restraints. EI #5 answered it was reported when RI #1 was admitted (from another facility). EI #5 was asked what documentation could she provide of any attempt of progress toward discontinuance of the restraints. EI #5 answered, Don't have any. EI #5 was asked what was the facility policy regarding restraints. EI #5 answered it has to be documented, everything prior to using restraints. EI #5 was asked if that was done. EI #5 answered, I didn't know to do this at that time. EI #5 was asked if the wrist restraints were the least restrictive option for RI #1 and she answered, No. EI #5 was asked what documentation she had of a Physician's acknowledgement of continued use of the wrist restraints. EI #5 answered, I don't have any documentation. EI #5 was asked when RI #1 was put in restraints and she answered on admission. EI #5 was asked what was the current medical necessity [DIAGNOSES REDACTED]. EI #5 was asked what the initial assessment for restraints for RI #1 revealed. EI #5 answered, It was not done. I did not know. It was the first time I had done one. EI #5 was asked where was documentation of MD notification of the evaluation by the Unit Manager/Charge Nurse. EI #5 answered they had no documentation. EI #5 was asked when RI #1 touched his/her face while the restraint was applied, was RI #1 in reach of their [MEDICAL CONDITION], Catheter tube, and Gastrostomy tube. EI #5 answered yes. EI #5 was asked if RI #1 could have pulled out the lines if they were able to reach them and she answered, Yes. EI #5 was asked what had been done since 5/10/17, the last documented behavior, to use a less restrictive method of restraint. EI #5 answered, Nothing. EI #5 was asked what active plan was in place to decrease usage or eventual removal of the restraint. EI #5 answered, Don't have one. An interview was conducted with EI #3, the Social Worker on 6/15/17 at 4:06 p.m EI #3 was asked what was her responsibilities as Social Worker regarding MDS assessments. EI #3 answered the BIMS assessment, mood/behavior, and discharge planning. EI #3 was asked if she had received information regarding RI #1's behaviors by staff. EI #3 answered, Yes, in 24 hour report and leadership meetings. EI #3 was asked what she was told and where was it documented. EI #3 answered it was not documented. EI #3 was asked what she discussed with the doctors regarding RI #1's behaviors and need for restraints and where was it documented. EI #3 answered she had not documented these discussions. EI #3 was asked what was the first documentation regarding RI #1's behaviors and when was it documented. EI #3 answered yelling and disrobing on 4/10/17. EI #3 was asked what intervention was put in place and she answered, Nothing. EI #3 was asked what efforts had been made towards the least restrictive possible means of restraining RI #1. EI #3 answered we and activities interacted with him to lessen his/her behaviors. EI #3 was asked if that was a less restrictive restraint. EI #3 answered, No. EI #3 was asked what notification EI #4, the Medical Doctor, received regarding RI #1's behaviors and restraints. EI #3 answered, None. EI #3 was asked to describe her evaluation and visits with RI #1. EI #3 responded RI #1 was very anxious and frustrated with his/her spouse, wanted to go home, and very angry. EI #3 was asked if that was a medical [DIAGNOSES REDACTED].#3 answered, No. EI #3 was asked how often she visited with RI #1 and what was done. EI #3 answered three to four times and that she just provided encouragement. EI #3 was asked were those visits documented and she answered no. An interview was conducted with EI #4, the Medical Doctor for RI #1, on 6/15/17 at 4:53 p.m EI #4 was asked if he was aware that RI #1 had not pulled out the [MEDICAL CONDITION] at the facility and he answered no. EI #4 was asked if the order indicated to leave until safe to discontinue, after Psychiatry notes of no episodes, would he have expected attempts to discontinue the restraints. EI #4 answered, Yes, I would. EI #4 was asked if he would have expected to be notified if restraints remained in use after medications were changed and no more episodes of trying to pull out lines was documented. EI #4 answered, I would. EI #4 was asked what changes he was made aware of to order the restraints discontinued on 6/14/17 and he answered none. EI #4 was asked what was the concern of restraints left in place when the only behavior documented was yelling. EI #4 answered, That's not a medical [DIAGNOSES REDACTED]. An interview was conducted with EI #2, the Director of Nursing (DON), on 6/15/17 at 4:53 p.m. EI #2 was asked if RI #1 had pulled out their [MEDICAL CONDITION] at the facility. EI #2 answered she did not see that RI #1 had pulled it out. EI #2 was asked what was indicated as the reason for the signed verbal order for restraints for RI #1. EI #2 answered RI #1 pulling their [MEDICAL CONDITION] out. EI #2 was asked if that was accurate. EI #2 answered no, but RI #1 had attempted to pull it out. EI #2 was asked where was documentation to support the resident pulled out lines as the basis for use of the wrist restraints. EI #2 answered, There is none. EI #2 was asked what documentation could she provide of any attempt of progress toward discontinuance of the restraints. EI #2 answered, I can't provide any. EI #2 was asked what was the facility policy regarding restraints. EI #2 answered, Evaluate for need, attempt other interventions before restraints. If other interventions are unsuccessful, notify M.D. to report what was deemed necessary. EI #2 was asked if the wrist restraints were the least restrictive option for the patient and she answered, Not sure (he/she) needed the restraints during the day. EI #2 was asked what documentation she had of a Physician's acknowledgement of continued use of the wrist restraints. EI #2 answered, None. EI #2 was asked why RI #1 had been restrained and when. EI #2 answered, January 4th, the Unit Manager felt it was necessary. (He/She) was anxious. EI #2 was asked if that was a medical [DIAGNOSES REDACTED]. EI #2 was asked what active plan was in place to decrease usage or eventual removal of the restraint. EI #2 answered there was not one. EI #2 was asked when was the restraint assessment first done for RI #1. EI #2 answered 4/6/17. EI #2 was asked when should it have been done. EI #2 answered before the restraints were put on. EI #2 was asked what was the concern of restraints used without an assessment. EI #2 answered without a thorough assessment, staff does not know if other interventions would have been successful.

Based on observation, interview, and record review of facility policies titled RESIDENT TRAY SERVICE AND DELIVERY and RESIDENT'S RIGHTS, the facility failed to ensure residents seated at the same table in the dining room were served the lunch meal at the same time on 6/14/17. Residents were observed being served randomly at various tables during the lunch meal. This was observed on one of three survey days and the potential to affect 11 residents who eat in the private dining room. Findings Include: A review of the facility's policy titled, RESIDENT TRAY SERVICE AND DELIVERY, with a revision date of 6/14, revealed: PROCEDURE: . 6. Meal tray delivery-dining room .j. Trays are served concurrently to all residents seated at the same table. A review of an undated facility policy titled, RESIDENT'S RIGHTS, revealed: The Resident has the right to be treated with dignity, . respect and to live in a . homelike environment. On 6/14/17 at 1:38 p.m., an observation was made of the lunch meal being served in the private dining room. Residents were observed sitting in the dining room waiting for the lunch meal to be served. Two plates were placed on a tray by the dietary staff in the kitchen and the tray would be passed through the kitchen window. The dining room staff would then pass the lunch plates out to random residents at random tables. Residents sitting at the same table were not served at the same time. Instead, residents were being randomly served the lunch meal at various tables in the dining room. The plates being placed on the trays occurred during the entire lunch meal being served in the dining room on 6/14/17. On 6/15/17 at 10:04 a.m., EI (Employee Identifier) #1, Dietary Manager, was interviewed. EI #1 was asked how were plates to be served in the dining room during the lunch meal. EI #1 stated everything went on a tray. EI #1 indicated on 6/14/17, the big trays were used instead of the individual trays that had silverware on them and with using the big trays, staff had to take off everything rather than serving individual trays with everything already on them. EI #1 further stated that Restorative told them how to set up tray cards and residents were moved around on 6/14/17 so the tray cards were not in order. EI #1 stated the tray cards were in order as usual but, the residents were moved around to other tables. EI #1 was asked why were residents served randomly at tables. EI #1 stated the table arrangements were changed and Restorative had not updated dietary of the change in the seating arrangements. When asked what was the concern with residents not being served at the same table at the same time, EI #1 stated everyone should be served at the table at the same time. EI #1 stated that was table etiquette. On 6/15/17 at 2:25 p.m., RI (Resident Identifier) #16, a cognitively intact resident, was interviewed and asked if everyone at the table he/she sat at received the lunch meal at the same time as the others at the same table. RI #16 stated no one ever got served at the same time. RI #16 was asked how it made him/her feel. RI #16 stated he/she tried to not be out of patience, but it was hard not to. RI #16 stated he/she was always served last. On 6/15/17 at 4:35 p.m., RI #15, a cognitively intact resident, was interviewed and asked if everyone at the table he/she sat at received the lunch meal at the same time as the others at the same table. RI #15 stated no, it was that way all the time. When asked how it made them feel, RI #15 stated he/she had gotten used to it. RI #15 said sometimes they serve people up front then go here and there. RI #15 stated they do not have a system.

Based on record review, interviews, a review of the job description for the Social Worker, and review of a facility policy titled ADMINISTRATIVE POLICY SUBJECT: Behavior Management Program, the facility failed to ensure medically related Social Services were provided to Resident Identifier (RI) #1, regarding behaviors, behavior monitoring, and use of restraints. This affected RI #1, one of two residents sampled for restraints and behaviors. Findings Include: A review of a facility policy titled, ADMINISTRATIVE POLICY SUBJECT: Behavior Management Program with an effective date of 02/13 revealed, . STANDARD: Residents who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem . PURPOSE: . II. Behavior Management Programs .The unit manager/charge nurse will evaluate the resident for possible causes or precipitating factors. The occurrence will be reported to the physician, if indicated and recorded in the clinical record. The Social Service department, Director of Nursing and Administrator will be notified by the documentation on a facility communication tool. A summary of the resident's behavior during the 7 day monitoring period should be recorded in the Social Services progress notes. A review of the SOCIAL SERVICES WORKER JOB DESCRIPTION with an effective date of 05/99, revealed: . General Purpose: To assist the Director of Social Services in acting as a liaison and representative of the residents' social interests and to assist in planning, organizing, implementing, evaluating and directing the overall orientation of the Social Services Department in accordance with current federal, state and local standards governing the facility, and as may be directed by the Administrator, to ensure that the medically-related emotional and social needs of the residents are met and maintained on an individual basis. A review of the medical record for RI #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15. This score indicated RI #1 was moderately impaired for daily decision making skills. This assessment indicated RI #1 had a limb restraint used daily in bed and out of bed or in chair. A review of the medical record for RI #1 revealed no social service oversight for the use of restraints, to plan for decrease in usage, the eventual removal of the restraints, or behavior monitoring . An interview was conducted with Employee Identifier (EI) #5, a Registered Nurse (RN), on 6/15/17 at 2:52 p.m EI #5 was asked what had been done since 5/10/17, the last documented behavior, to use a less restrictive method of restraint. EI #5 answered, Nothing. EI #5 was asked what active plan was in place to decrease usage or eventual removal of the restraint. EI #5 answered, Don't have one. An interview was conducted with EI #3, the Social Worker, on 6/15/17 at 4:06 p.m EI #3 was asked what was her responsibilities as Social Worker regarding MDS assessments. EI #3 answered the BIMS assessment, mood/behavior, and discharge planning. EI #3 was asked if there was a behavior monitoring program at the facility. EI #3 answered there was, but she did not do one on RI #1. EI #3 was asked why and she answered, I don't know. EI #3 was asked what her role was in care plan meetings. EI #3 answered, I am the transcriptionist, get mental history of mental health from family, updating any information regarding the patient problems and ask family for interventions. EI #3 was asked if she had received information regarding RI #1's behaviors by staff. EI #3 answered, Yes, in 24 hour report and leadership meetings. EI #3 was asked what she was told and where was it documented. EI #3 answered it was not documented. EI #3 was asked what she discussed with the doctors regarding RI #1's behaviors and need for restraints and where was it documented. EI #3 answered she had not documented those discussions. EI #3 was asked what was the first documentation regarding RI #1's behaviors and when was it documented. EI #3 answered yelling and disrobing on 4/10/17. EI #3 was asked what intervention was put in place and she answered, Nothing. EI #3 was asked what efforts have been made towards the least restrictive possible means of restraining RI #1. EI #3 answered Social Services and Activities interacted with him/her to lessen his/her behaviors. EI #3 was asked if that was a less restrictive restraint. EI #3 answered, No. EI #3 was asked what notification EI #4, the Medical Doctor, received regarding RI #1's behaviors and restraints. EI #3 answered, None. EI #3 was asked to describe her evaluation and visits with RI #1. EI #3 responded RI #1 was very anxious, frustrated with his/her spouse, wanted to go home, and very angry. EI #3 was asked if that was a medical [DIAGNOSES REDACTED].#3 answered, No. EI #3 was asked how often she visited with RI #1 and what was done. EI #3 answered three to four times and that she just provided encouragement. EI #3 was asked were those visits documented and she answered no. EI #3 was asked what the care plan indicated regarding behavior monitoring and she answered to monitor and document resident behavior. EI #3 asked if that had been done and she answered, No. EI #3 was asked how the effectiveness was monitored for identified behaviors or changes to medications and the plan of care. EI #3 answered there was one (a tool that was not used). EI #3 was asked should the effectiveness be monitored and she answered, Yes. EI #3 was asked why and she answered, We want to make sure the residents are comfortable.