Every finding on record at Runningwater Draw Care Center, Inc.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen (Kitchen #1) reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer and pantry food items were properly stored, labeled, and dated. The facility failed to ensure refrigerator and freezer temperatures were monitored and logged per their policy.These failures place residents at risk for food borne illness.Findings included:During an observation of the refrigerator on 05/05/2026 at 9:44 AM, revealed the following:Five small glasses with orange colored liquid, open to air and had no label.One plate with two pancakes, open to air; the tinfoil covering was off the plate.During an observation of the pantry area on 05/05/2026 at 9:49 AM, revealed the following:One bag of small marshmallows opened to air; several marshmallows had hardened.One bag of crisp cereal, 1/4 empty, sealed, but had no open date.One clear plastic bag of crackers not labeled or dated.Two pitcher type containers with white cream were not labeled or dated.One container of red sauce had no label or date.Observation of the walk-in freezer located outside the pantry area on 05/05/2026 at 9:50 AM, revealed the following:One clear plastic bag of pancakes, removed from the original packaging, was not labeled.One clear plastic bag of crumbled meat was not labeled.During an observation of the preparation area on 05/05/202 at 9:55 AM, revealed the following:One bag of tortilla chips, not labeled, or dated.During an observation of the temperature log binder for refrigerator and freezers on 05/05/2026 9:56 AM, revealed the May 2026 temperature documentation sheet lacked documented refrigerator and freezer temperature checks for the morning and lunch shifts on 05/04/2026. Only the dinner temperature check had been documented. During an interview on 05/06/2026 at 9:26 AM, DA A stated it was everyone's responsibility to label and date food and if it were not done, residents could get sick. DA A stated the DM was responsible for ensuring staff complied with labeling, dating, and monitoring and documenting refrigerators and freezers temperatures.During an interview on 05/06/2026 at 9:33 AM, the DM stated it was the responsibility of all dietary staff to ensure food items were labeled, dated, and stored properly. The DM stated the food could spoil and residents could become ill if spoiled food was served. The DM further stated she was responsible for ensuring refrigerator and freezer temperatures were monitored and logged daily to verify safe food storage temperatures and for ensuring staff complied with labeling and dating requirements. During an interview on 05/07/2026 at 8:37 AM, [NAME] E stated it was everyone's responsibility to ensure food items were labeled, dated, and covered. [NAME] E stated the DM was responsible for ensuring staff were labeling, dating, and documenting refrigerator and freezer temperatures. [NAME] E stated a possible negative outcome would be residents receiving spoiled food and becoming ill. Record review of facility policy, titled, Food Receiving and Storage, dated 11/2022, reflected the following: Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use .Dry food that are stored or removed from original packaging, labeled and dated ( use by date). Refrigerated/Frozen Storage.All foods stored in the refrigerator or freezer are covered, labeled and dated.Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state specific requirements.Refrigerated foods are labeled, dated and monitored so they are used by their use-by date.

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 (Resident #35 and #43) of 17 residents reviewed for advanced directives. Resident #35 had a DNR in her record that had no date of when the notary witnessed Resident #35 sign the document. Resident #43 had a DNR in her record that had no information for the physician. This failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.Findings included: Resident #35: Record review of Resident #35's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebral aneurysm (a ballooning or weakening area of an artery in the brain), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), and history of malignant neoplasm (a fast-growing cancer). Record review of Resident #35's MDS was a quarterly printed [DATE] and completed [DATE] listing her with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Record review of Resident #35's care plan printed [DATE] with admission date of [DATE] revealed the following: Focus:-Advanced Directives: DNRDate initiated [DATE]. Record review of the clinical record for Resident #35 revealed an Order Summary printed [DATE] with the following order: -DNR (Do Not Resuscitate) Active [DATE] Record review of the clinical record for Resident #35 revealed a DNR dated [DATE] (signed by Resident #35's adult child) with the following:Section - Two Witnesses: Notary in the State of Texas. -there was no date of when the notary witnessed the adult child-qualified relative sign the DNR form. Resident #43: Record review of Resident #43's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and Wegener's Granulomatosis without renal involvement (a from of autoimmune necrotizing vasculitis that affects small and medium-sized vessels, restricted primarily to the upper and lower respiratory tracts without kidney involvement). Resident #43's last MDS was an annual assessment printed [DATE] and completed [DATE] listed her with a BIMS of 05 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living. Record review of Resident #43's care plan printed [DATE] with admission date of [DATE] revealed the following: Focus:-Advanced Directives: Code Status DNR. Date Initiated: [DATE]. Record review of the clinical record for Resident #43 revealed an Order Summary printed [DATE] with the following order: -DNR (Do Not Resuscitate) Active [DATE] Record review of the clinical record for Resident #43 revealed a DNR dated [DATE] (signed by Resident #43) with the following:Section - Physician's Statement: -there was no information for the physician. No date, no signature, no printed name, and no license number. During a group interview on [DATE] at 8:59 AM LVN C (the nurse responsible for Resident #35 and Resident #43 this shift) and LVN D reported Resident #35 and Resident #43 were both currently DNR status. They reported if either resident was reported as not having a heart rate or breathing, they would verify the resident's condition, not start CPR, and notify the ADON or DON. They reviewed Resident #43's DNR in her electronic record and both verified no physician information was on the form therefore the DNR form was not valid. They reviewed Resident #35's DNR in her electronic record and it did not have a date when the notary signed the DNR form therefore it was not valid. Both reported if one of these residents coded during this shift, they would have to start CPR. LVN C and LVN D reported the facility not ensuring the DNR forms were filled out correctly could result in staff having to perform CPR on a resident who did not wish to have CPR, staff could upset family, and the staff would not be following the residents' wishes. During an interview and record review on [DATE] at 9:11 AM the BOM reported she was the notary for the facility, and she was the one who completed Resident #35's DNR form. The BOM reviewed the DNR to include the original copy and reported she missed dating her signature. When asked if the form was valid, the BOM stated, I don't know. I don't do medical. I just do the notary part. During an interview and record review on [DATE] at 9:16 AM the DON reviewed the electronic chart for Resident #35 and Resident #43 and reported both residents were currently listed as DNR's. The DON reported if either resident was found to be without a heart rate or breathing then they would let them pass. The DON reviewed Resident #43's DNR form in her electronic record and reported the physician did not sign the form, so this one was not valid. The DON review Resident #35's DNR form and reported the notary did not sign the form, and it was not valid either. The DON reported they reviewed the DNR's during each care plan meeting and recently did a full audit of all DNR's and had to correct a few. The DON reported we just missed these. The DON reported if the DNR was not correct then the staff were put in a position where they were legally supposed to code the residents, and the residents' wishes would not be fulfilled. During an interview on [DATE] at 10:26 AM the MDS/LVN reported she did assist with auditing residents DNR forms for completion and accuracy. She was made aware Resident #35 and Resident #43 had invalid DNR's and they were just missed. The MDS/LVN reported if the DNR form was not correct then it was not valid and the facility would not honor the residents wishes. Record review of the facility provided policy titled Code Status Guidelines undated, revealed no information for completing a DNR accurately. Record review of the facility provided policy titled Do Not Resuscitate Order undated, revealed the following: 2. A Do Not Resuscitate (DNR) order form must be complete and singed by the attending physician.6. The interdisciplinary care planning team will review advanced directives with the resident during quarterly care planning sessions. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following:-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional.

Based on observation, interview and record review, the facility failed to ensure that an assessment accurately reflected a resident's status for 1 (Resident #2) of 17 residents reviewed for accuracy of assessments. The facility failed to accurately assess Resident #2 for the use of a restraint. This failure could place residents at risk not receiving appropriate care and services. Findings included: Record review of Resident #2's face sheet, printed 05/06/26, revealed a [AGE] year-old female admitted [DATE], with diagnoses including, but not limited to, dislocation of left shoulder joint, chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe due to airways and air sacs in the lungs are damaged and narrowed), anxiety disorder (worry, fear, or nervousness becomes so strong it affects everyday life), and edema (swelling caused by too much fluid collecting in the body's tissues). Record review of Resident #2's most recent quarterly MDS assessment, dated 02/13/26, revealed a BIMS score of 06, indicating severe cognitive impairment. Section P0100, Physical Restraints, indicated Resident #2 used limb restraint less than daily. Record review of Resident #2's care plan dated 05/19/25 revealed the following:Resident has limited physical mobility r/t history of falls and dislocation of left shoulder joint Monitor, document, report any signs or symptoms of immobility including contractures forming or skin breakdown. Provided supportive care, assistance with mobility as needed. No documentation of restraint. Record review of Resident #2's Order Summary Report, dated 05/06/26, revealed there was no order for limb restraint. During an observation of Resident #2 on 05/05/26 at 10:19 AM revealed no restraints on her body. During an interview and observation on 05/06/26 at 11:00 AM, observation revealed no restraint on Resident #2's body. A family member of Resident #2 stated that the resident was admitted to the facility with a sling for her arm because she dislocated her shoulder. The family member stated they were not aware of any limb restraints. During an interview on 05/06/26 at 1:20 PM, the MDS LVN stated she was the MDS Coordinator for the facility and used the RAI manual policy as guidance. She stated a limb restraint should not have been coded on Resident #2's MDS assessment would be corrected. The MDS LVN further stated inaccurate MDS coding could result in incorrect care planning and impact reimbursement. During an interview on 05/07/26 at 8:47 AM, the DON stated she was not aware that a limb restraint was inaccurately coded on an MDS for Resident #2. She stated the MDS LVN was responsible for MDS assessments, but that the DON reviewed them before they were signed and submitted. The DON stated that if MDS assessments were miscoded, that resident's needs and individual care could not be met and also affect funding. During an interview on 05/07/26 at 9:02 AM, the ADM stated the MDS LVN was responsible for completing MDS assessments and the DON checked them before they were signed and submitted, but ultimately the ADM stated she was responsible for them since she was the ADM. She stated that if an MDS was miscoded, it could affect funding and care. During an interview on 05/07/26 at 10:18 AM, the ADON stated the MDS LVN was responsible for ensuring MDS assessments were accurate and submitted. She stated inaccurate MDS assessments could impact reimbursement. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025 revealed the following: SECTION P: RESTRAINTS AND ALARMSP0100. Physical RestraintsPhysical Restraints are many manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Enter Codes in BoxesUsed in Bed-A. Bed rail-B. Trunk restraint-C. Limb restraint-D. Other

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #30 and #42) of 17 residents reviewed for comprehensive care plans. -The facility failed to address the use of halo bedrails in Resident #30 and Resident #42's care plans. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.Findings included: Resident #30: Record review of Resident #30's face sheet dated 05/05/2026 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning), aortic aneurysm (a ballooning or weakening area of an artery), pain, weakness, need for assistance, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath). Record review of Resident #30's quarterly MDS printed 05/05/26 and completed 04/14/26 listed her with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring partial/moderate assistance when lying to sitting on the side of the bed. Record review of Resident #30's order summary with Active Orders as of: 05/06/26 revealed no orders to address the use of halo rails on the resident's bed. Record review of Resident #30's care plan printed 05/05/26 with date of admission [DATE] revealed no care plan for the use of halo bedrails or any bed rails. Record review of Resident #30's clinical record revealed a Halo Positioning Bar Consent listing the benefits and risk of using a bed rail signed by Resident #30 on 10/04/21. During an observation and interview on 05/05/2026 at 09:54 AM Resident #30 was in her room sitting in her recliners. Resident #30 had a halo bedrail on the right side of her bed that was up and locked in place. Resident #30 reported she uses her halo bedrail to move around in her bed, and she was trained on its use. Resident #42: Record review of Resident #42's face sheet dated 05/05/26 revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interfere with daily functioning), pain, muscle weakness (a lack of muscle strength), myocardial infarction (heart attack), and acquired absence of the left leg below the knee. Record review of Resident #42's annual MDS printed 05/05/26 and completed 02/13/26 listed him with a BIMS of 03 indicating he was severely cognitively impaired, and he had a functionality of requiring substantial/maximal assistance with lying to sitting on the side of the bed. Record review of Resident #42's order summary report with Active Orders as of: 05/06/26 revealed no orders for the use of halo rails. Record review of Resident #42's care plan printed 05/05/26 with date of admission [DATE] revealed no care plan for the use of halo rails or any bed bedrails. Record review of Resident #42's clinical record revealed a Halo Positioning Bar Consent listing the benefits and risk of using a bed rail signed by Resident #42's legal representative on 02/14/23. During an observation on 05/05/2026 at 09:41 AM Resident #42 was in his room in his recliner asleep. He did not wake to knocking or introduction. Observation revealed his bilateral halo bedrails that were up and locked in place on both sides of his bed. During a group interview on 05/07/2026 at 9:09 AM LVN C and LVN D reported a resident's halo bedrail should be care planned so they could be evaluated regularly and if they were not care planned then the halo bedrail may not be used correctly, and the resident could hurt themselves. During an interview and record revew on 05/07/2026 at 9:22 AM the DON reported all residents with a halo bedrail were required to sign a consent, have an assessment for the halo bedrail, and the halo bedrail was to be care planned for ongoing monitoring. The DON reported she signs off on all care plans to ensure they are completed. The DON reviewed the care plans for both Resident #30 and Resident #42 and reported neither of the residents had their halo bedrails included in the care plans. The DON stated, From what I'm seeing, no they are not care planned. The DON reported if the halo bedrails were not addressed in the care plans it would not affect the residents directly but the care plan would not be an accurate reflection of the residents' care. During an interview and record review on 05/07/2026 at 10:28 AM the MDS/LVN reported halo bedrails were supposed to be care planned. The MDS/LVN reviewed both Resident #30 and Resident #42 care plans and reported both care plans did not address the residents' use of halo bedrails. The MDS/LVN reported the facility uses the residents' care plans for ongoing monitoring and if the halo bedrail was not in the care plan the staff might not know if the resident had a halo bedrail. She reported she would get the halo bedrails in both Resident #30 and Resident #42 care plans right now. Record review of the facility provided policy titled Bed Rail Policy undated, revealed the following: -Be Care-Planned regarding the request for Halo Bar. Care Plan evaluations and ongoing assessment will consider the use of the Halo Bar.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #16) of 4 residents observed for infection control. -Resident #16 had her catheter bag on the floor for 3 hours. This failure could place residents at risk for the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.Findings included: Record review of Resident #16's face sheet printed 05/06/2026 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions) and calculus of kidney with calculus of ureter (the presence of solid, crystal-like deposits within the kidney that have moved into and become lodged in the ureter). Record review of Resident #16's MDS printed 05/06/2026 was a quarterly completed 04/15/2026 with a BIMS that was not completed because of memory issues, and she had a functional status of being dependent on staff for all her activities of daily living. Resident #16 was not listed as having an indwelling catheter. Record review of Resident #16's care plan printed 05/06/2026 with admission date of 02/06/2027 revealed the following: Focus:Resident has an foley catheter d/t renal calculi w/ stents. Dated initiated: 05/01/2026.Interventions:-Enhanced Barrier Precautions due to indwelling foley catheter, bilateral urethral stents. Date initiated: 05/01/2026. Record review of Resident #16 Order Summary Report printed 05/06/2026 with Active Orders as of: 05/06/2026 revealed the following order:- Enhanced Barrier Precautions due to indwelling foley catheter, bilateral ureteral stents. Active 05/01/2026. During an observation on 05/05/2026 at 10:09 AM Resident #16 was lying in bed with the bed in the lowest position and appeared to be sleeping. Resident #16's catheter bag was observed on the right side of the bed and attached to the lower portion of the bed frame; however, due to the bed being in the lowest position, the catheter bag was resting on the floor. No privacy bag was in place over the catheter bag. The catheter bag was observed to be approximately one quarter full of urine. During an observation on 05/05/2026 at 10:36 AM Resident #16 was observed in her bed with her catheter bag hanging from the foot of her bed with the bottom half of the catheter bag in contact with the floor. Noted the drain mechanism of the catheter bag was in direct contact with the floor. During an observation on 05/05/2026 at 11:06 AM Resident #16 catheter bag was still hanging from the foot of her bed with the bottom half to include the drain mechanism on the floor. There was no barrier between the catheter bag and the floor. During an observation on 05/05/2026 at 11:11 AM CNA B was observed taking Resident #16's catheter bag off the floor, putting it in a privacy bag, then securing the catheter bag to the right side of Resident #16's bed. During an interview on 05/05/2026 at 11:24 AM CNA B reported he was told that Resident #16's catheter was on the floor, so he went to correct the issue. CNA B reported he and another staff member put Resident #16 to bed shortly after breakfast approximately after 8 AM with the use of a Hoyler lift and that was when the catheter bag was in contact with the floor. CNA B reported the catheter bag on the floor was an issue for infection control. CNA B when in CNA training he was taught to always have a barrier between the catheter bag and the floor to prevent bodily fluids from contacting the floor surface. During a group interview on 05/07/2026 at 9:08 AM LVN C and LVN D reported that a catheter bag should not touch the facility floor. That if the catheter bag touches the floor, it can be a dignity issue and an infection control issue. They both reported that a catheter bag should always have a barrier between the bag and any surface. During an interview on 05/07/2026 at 9:14 AM the DON reported a catheter bag should be stored off the floor and in a privacy bag. The DON reported if a residents' catheter bag was allowed to touch the floor then there was a risk of dislodging the catheter, infection control, and dignity through exposure. Record review of the facility provided policy titled Urinary Catheter Bag Storage undated, revealed the following: Purpose:To ensure proper stoae and handling of urinary catheter drainage bags to reduce the risk of infection, maintain residents' dignity, and comply with Texas LTC regulation and infection control standards.Policy Statement:The facility will ensure that all urinary catheter bags are stored in a manner that:-Prevents contamination.Policy Guidelines:General Storage Requirements-Bags must never touch the floor.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure foods were properly stored, labeled, and dated. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the walk-in refrigerator on 02/25/2025 at 9:50 AM revealed the following: 1. 1 ziplock bag with a square yellow substance no label, no date. 2. 1 open bag of turkey breast lunch meat in a ziplock bag, no open date, no received date. 3. 1 bag of turkey breast lunch meat no received date. 4. 1 ziplock bag of small round meat no label, no date. Observation of the walk-in pantry on 02/25/2025 at 10:00 AM revealed the following: 5. 2 lb. bag of opened toasted oats cereal in a white basket, no open date, no received date on packaging. Observation of walk-in freezer on 02/25/2025 at 10:13 AM revealed the following: 6. 1 box of biscuits, opened to air, no date. 7. 1 basket of individual containers of blue-ribbon ice cream, no date. Observation of refrigerator on 02/25/2025 at 10:32 AM revealed the following: 8. 1 container of Southern Butter Pecan Coffee Creamer approximately 1/8 full no open date. 9. 5 Styrofoam cups with liquid in the cups, no label, no date. 10. 9 individual containers of white creamy substance with no label, no date. In an observation and interview on 02/26/2025 at 8:54 AM, the DM threw the coffee creamer in the trash and stated the creamer was hers and it was her fault it was in the refrigerator. The DM was observed with the yellow substance in the ziplock bag and the opened turkey meat and stated she did not know how it got missed and threw the items in the trash. The DM said all kitchen employees were responsible for ensuring items in the kitchen were labeled, dated, and covered. The DM stated a possible negative outcome for not having items labeled, dated, or stored properly would be the food would go bad. In an interview on 02/26/2025 at 2:06 PM, the DA stated that all staff were responsible for ensuring items in the kitchen were covered, labeled, and dated and a possible negative outcome would be residents could receive bad food. Record review of Food Receiving and Storage Policy dated November 2022 revealed the following: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: Dry foods that are stored in bins are removed from original packaging, labeled, and dated. Refrigerator/Frozen Storage: All foods stored in the refrigerator or freezer are covered, labeled, and dated.

Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored under proper temperature, and the expiration date when applicable on 2 of 2 medication carts and 1 of 1 medication rooms reviewed for medication storage. - Medication cart for Side B revealed a Breo Ellipta inhaler for Resident #8 with no open date on inhaler. - Medication cart for Side A revealed a Novolin R insulin bottle for Resident #10 with no open date on bottle. - Refrigerator in medication room was below 36 degrees for 2 days. Refrigerator contained insulins for the following residents: *Resident #2 had 1 unopened box for Tesiba flex touch *Resident #2 had 2 bottles Novolin R *Resident #5 had 2 flex pen boxes Novolin ,d+[DATE] *Resident #5 had 1 bottle Novolin R *Resident #10 had 3 KwikPen boxes for Basaglar *Resident #10 had 2 bottles of Humulin R *Resident #10 had 4 bottles of Novolin R *Resident #15 had 3 bottles of Novolin R *Resident #15 had 2 bottles of Humulin ,d+[DATE] *Resident #27 had 1 KwikPen Basaglar *Resident #29 had 4 bottles of Lantus *Resident #29 had 1 bottle of Humulin R *Resident #35 had 2 bottles of Lantus *Resident #38 had 1 pen box for Lantus Solostar *Resident #48 had 1 bottle of Novolin R *Resident #48 had 1 bottle of Humulin R ,d+[DATE] The facility's failures could place residents receiving medication at risk for lack of drug efficacy, and adverse reactions. Findings included: During an observation on [DATE] at 10:30 AM of Medication cart for side B contained a Breo Ellipta inhaler for Resident #8 with an open date of [DATE], but on the actual inhaler there was no open dated noted. During an interview on [DATE] at 10:35 AM Interview with LVN A stated that a negative outcome for not writing an open date on the medication would be that the medication could be expired and not be effective. During an observation on [DATE] at 10:40 AM of Medication cart for side A revealed that Resident #10's Novolin R had no open date written on it. During an interview on [DATE] at 10:46 AM LVN B stated that a negative outcome for not writing the open date on a medication would lead to a waste of medication and could lead to harm if the medication is expired. During an observation on [DATE] at 10:48 AM of the medication room with LVN A revealed that the refrigerator temperature log for the medications was out of range on [DATE] at 35 degrees and [DATE] at 35 degrees. Temperature was observed in fridge at 39 degrees when visually checked. Medications for the following residents were revealed to have been below recommended temperatures for 2 days: *Resident #2 had 1 unopened box for Tesiba flex touch *Resident #2 had 2 bottles Novolin R *Resident #5 had 2 flex pen boxes Novolin ,d+[DATE] *Resident #5 had 1 bottle Novolin R *Resident #10 had 3 KwikPen boxes for Basaglar *Resident #10 had 2 bottles of Humulin R *Resident #10 had 4 bottles of Novolin R *Resident #15 had 3 bottles of Novolin R *Resident #15 had 2 bottles of Humulin ,d+[DATE] *Resident #27 had 1 KwikPen Basaglar *Resident #29 had 4 bottles of Lantus *Resident #29 had 1 bottle of Humulin R *Resident #35 had 2 bottles of Lantus *Resident #38 had 1 pen box for Lantus Solostar *Resident #48 had 1 bottle of Novolin R *Resident #48 had 1 bottle of Humulin R ,d+[DATE] During an interview on [DATE] at 10:56 AM LVN A stated that the negative outcome for having medication at a temperature below the recommended level could lead to the medications losing their efficacy and not perform like they should for the resident. During an interview on [DATE] at 11:06 AM DON stated that it was the night nurse's responsibility to check the carts and the temperatures of the medication refrigerator. DON stated that the Nurse that performs the nightly duties is supposed to report abnormalities to the DON, however DON was not made aware of this discrepancy. DON stated that the negative outcome for the medications not having open dates on the medication could lead to the medication being expired and losing its effectiveness. DON stated that the negative outcome for having medications stored below their recommended storage temps could lead to the medications being compromised and losing their efficacy. Record review of the facility provided policy titled, Medication Labeling and Storage, undated, revealed the following: Policy Statement The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls . .Medication Storage . .3. If the facility has discontinued, outdated or deteriorated medications or biologicals .6.Refrigeration temperature settings should e maintained between ,d+[DATE] degrees Fahrenheit. .Medication Labeling . .2 .d .expiration date, when applicable; . .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #45) of 15 residents reviewed for resident rights. The facility failed to prevent LVN B from referring to Resident #45's table in the dining room as the feeder table. The facility failed to prevent labelling 10-12 residents at the center table in the dining room as Feed/Assist on a large whiteboard diagram on the wall of the dining room. These failures could negatively impact the self-esteem, self-worth, and identity of residents who need assistance with eating. Findings Included: Record review of Resident #45's admission record dated 02/25/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinsonism (conditions that affect the ability to move and live independently), absolute glaucoma right eye (severe form of disease where eye has lost all vision and has uncontrolled pressure), and weakness. Record review of Resident #45's quarterly MDS completed on 01/19/25 revealed the following: Section B Hearing, Speech, and Vision: Resident #45's vision was impaired. Section C Cognitive Patterns: Resident #45 had a BIMS of 9 which indicated moderately impaired cognition. Section GG Functional Abilities: Resident #45 had impairment on both sides of his upper and lower extremities and utilized a wheelchair. He was dependent across all ADLs except for eating, upper body dressing, and rolling from side to side where he required substantial/maximal assistance. Section I Swallowing/Nutritional Status: Resident #45 coughed and choked during meals or when swallowing medications and required a mechanically altered diet while he was a resident. Record review of Resident #45's care plan completed on 01/24/25 revealed he had a puree textured diet and nectar thickened liquids. The care plan noted, Resident may sit at the Feeding/Assist table. The resident sits at feeding table and is dependent x1 staff for eating pureed diet on divided plate with nectar thick liquids. Record review of Resident #45's active orders report as of 02/25/25 revealed the following orders: Regular diet Pureed texture, Nectar/Mildly Thick consistency . with a start date of 10/03/24. May have a divided plate and right handed [sic] curved spoon for ease of loading utensils and promoting independence. with meals with a start date of 10/27/24. During an observation and interview on 02/25/25 at 12:00 PM in the dining room LVN B was standing approximately 3 feet from residents seated at a large oval table made up of several skinny tables end to end with the middle left open for staff to sit and assist residents with eating. This table was located in the center of the dining room on the end closest to the kitchen. When LVN B was asked to point out Resident #45 she gestured to opposite side of the large oval table in the center of the dining room and stated, He's in the red sweater at the feeder table. During an observation on 02/25/25 at 12:02 PM in the dining room a dry erase white board approximately 2 feet by 3 feet was hanging on the wall. It had diagrams of each table in the dining room with round magnets with numbers placed around the tables. The large oval table in the center of the dining room was labelled Feed/Assist. Two small tables on the same wall as the white board were labelled Assist and the remaining tables in the dining room were labelled Table 1- Table 6. During an observation and interview on 02/25/25 at 12:14 PM in the dining room LVN B was again standing approximately 3 feet from residents seated the large oval table. When LVN B was asked to point out another resident she gestured to end of the large oval table and stated, He is at the feeder table in the green sweater. During an interview on 02/26/25 at 02:08 PM CNA C stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, It is a dignity issue with them. Or if other residents hear that we are saying that to them. CNA C stated the whiteboard in the dining room was used by staff to know where residents sat in the dining room. She stated the magnets arranged around the diagrams of the tables had the room numbers of the residents. CNA C stated the white board might have a negative outcome for residents if they saw their room numbers on the table labelled Feed/Assist. She stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders. During an interview on 02/26/25 at 02:13 PM LVN A stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated doing so could negatively affect their morale and self-esteem. LVN A stated of the residents who needed assistance eating, A lot of them still understand and can't help not being able to feed themselves. LVN A stated she had not noticed the whiteboard in the dining room with the large oval table labelled Feed/Assist. She stated she could see how the whiteboard might have a negative impact on residents' dignity. LVN A stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders. During an interview on 02/26/25 at 02:28 PM ADON stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, It is degrading. It is a dignity issue. It doesn't present a homelike experience. She stated a possible negative outcome of the whiteboard in the dining room with the large oval table labelled as Feed/Assist was, Again, it is not a homelike experience which we try to create here, and it is embarrassing and does not maintain dignity and integrity of our residents as humans. ADON stated staff had been trained not to refer to residents who needed assistance eating as feeders. During an interview on 02/26/25 at 02:34 PM DON stated referring to residents as feeders could be a dignity issue if outside people heard. She stated she did not think the whiteboard with the large oval table labelled as Feed/Assist was a dignity issue unless outside people saw it, but we don't really have outside people go into our dining room. I think it just depends on who sees it (the whiteboard). During an interview on 02/26/25 at 02:53 PM ADM stated it was not okay for staff to refer to residents who needed assistance eating as feeders. She stated, It is a dignity issue. Record review of facility policy titled Dignity and dated 2021 revealed the following: . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: . e. provided with a dignified dining experience. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labelling' or referring to the resident by his or her room number, diagnosis, or care needs. Staff protect confidential clinical information. Examples include the following: . b. Signs indicating the resident's clinical status or care needs are not openly posted . 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity . Record review of facility policy titled Resident Rights and dated 2021 revealed the following: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .

Based on interview, and record review the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 (Resident #214) of 15 residents reviewed for comprehensive assessments. The facility failed to complete an Admission MDS on Resident #214 within 14 calendar days after admitted [DATE]. This failure could place residents at risk of not having their needs met due to lack of information. Findings Included: Record review of Resident #214's admission record dated 02/25/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body) and melena (dark, tarry stool). Record review of Resident #214's EHR revealed an Admission MDS with ARD of 02/19/25 which was not competed. It was noted to be in progress. Record review of Resident #214's care plan revealed it was initiated on 02/19/25. During an interview on 02/26/25 at 02:17 PM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when completing MDS assessments. MDS LVN stated an Admission MDS was to be completed within 14 days of a resident's admission to the facility. MDS LVN stated she thought she had completed Resident #214's Admission MDS timely. She looked at her computer screen and said, Oh, it is still in progress, and I need to sign it. MDS LVN stated a possible negative outcome of not completing an Admission MDS timely was, We might not get paid as well and it could lead to care plan not being updated as quickly. During an interview on 02/26/25 at 02:28 PM ADON stated an Admission MDS not being completed timely could lead to we cannot completely take care of the residents due to not having a complete assessment of care areas. During an interview on 02/26/25 at 02:34 PM DON stated having an Admission MDS completely timely was important to the care of a resident so everyone can be on the same page. During an interview on 02/26/25 at 02:53 PM ADM stated MDS LVN was responsible for completing MDS assessments. She stated an Admission MDS not being completed timely could negatively impact resident care. ADM stated, You need to know everything you can about a resident as soon as they show up. Find out as much as you can as soon as you can. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed a chart on page 38 with the following: Assessment Type .Admission .MDS Completion Date .no later than 14th calendar day of the resident's admission (admitted + 13 calendar days) .

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #11 and Resident #36) of 15 residents reviewed for accuracy of assessments. The facility failed to remove diagnoses of Wound Infection (other than foot) from Resident #11 and Resident #36's MDS' when said diagnoses were inactive. This failure could lead to residents receiving unnecessary care or not receiving necessary care. Findings Included: 1. Record review of Resident #11's admission record dated 02/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, local infection of the skin and subcutaneous tissue (a bacterial or fungal infection confined to a specific are of the skin and the layer of tissue directly beneath it resulting in inflammation, redness, warmth, swelling, pain), psoriasis (chronic skin condition characterized by raised, red, scaly patches of skin called plaques), pruritus (an unpleasant sensation that triggers the urge to scratch), and seborrheic dermatitis (common chronic skin condition that causes flaky greasy scales and redness). The onset date of the local infection of the skin and subcutaneous tissue diagnosis was 05/17/17. The onset dates of the psoriasis and seborrheic dermatitis diagnoses were 02/25/15. The onset date of the pruritus diagnosis was 01/11/21. Record review of Resident #11's annual MDS completed on 11/22/24 by the previous DON revealed the following: Section I-Active Diagnoses: Active Diagnoses in the last 7 days - Check all that apply The box next to Question I2500 Wound Infection (other than foot) was marked indicating Resident #11 had a wound or infection of this kind. Question I8000 Additional active diagnoses listed pruritus and disorder of the skin and subcutaneous tissue. Record review of Resident #11's care plan completed on 01/24/25 revealed no mention of a wound. Record review of Resident #11's active orders report as of 02/26/25 revealed no order for the treatment of a wound. 2. Record review of Resident #36's admission record dated 02/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, local infection of the skin and subcutaneous tissue (a bacterial or fungal infection confined to a specific are of the skin and the layer of tissue directly beneath it resulting in inflammation, redness, warmth, swelling, pain), cellulitis of other sites (common bacterial skin infection that causes redness, swelling, and pain), and seborrheic dermatitis (common chronic skin condition that causes flaky greasy scales and redness). The onset date of the local infection of the skin and subcutaneous tissue diagnosis was 08/26/23. The onset date of the cellulitis of other sites diagnosis was 05/14/22. The onset date of the seborrheic dermatitis was 01/09/20. Record review of Resident #36's quarterly MDS completed on 01/20/25 by DON revealed the following: Section I-Active Diagnoses: Active Diagnoses in the last 7 days - Check all that apply The box next to Question I2500 Wound Infection (other than foot) was marked indicating Resident #36 had a wound or infection of this kind. Question I8000 Additional active diagnoses listed cellulitis and seborrheic dermatitis. Record review of Resident #36's care plan completed on 01/24/25 revealed no mention of a wound. Record review of Resident #36's active orders report as of 02/26/25 revealed no order for treatment of a wound. During an interview on 02/26/25 at 02:17 PM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when completing MDS assessments. MDS LVN stated she and the previous DON disagreed on which diagnoses should remain active on an MDS assessment. MDS LVN stated she believed if a diagnosis has been cleared and was no longer affecting the resident it should no longer be active on the MDS in Section I. She stated the previous DON thought all diagnoses should remain active on the MDS in Section I whether they had cleared up or not. She stated that was the reason Resident #11 and Resident #36 were coded as having wound infections. MDS LVN stated an inaccurate MDS would not affect residents' care. During an interview on 02/26/25 at 02:28 PM ADON stated an inaccurate MDS could lead to inaccurate care of a resident. She stated, And we want accurate care here from every level. During an interview on 02/26/25 at 02:34 PM DON stated having an inaccurate MDS could lead to the facility not providing the care they (residents) need. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: .: Active Diagnoses in the Last 7 Days . Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. Examples of Inactive Diagnoses (do not code) 1. The admission history states that the resident had pneumonia 2 months prior to this admission. The resident has recovered completely, with no residual effects and no continued treatment during the 7-day look back period. Coding: Pneumonia item (I2000), would not be checked. Rationale: The pneumonia diagnosis would not be considered active because of the resident's complete recovery and the discontinuation of any treatment during the lookback period. 47854

Based on interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #214) of 15 residents reviewed for preadmission screening. The facility failed to perform a preadmission screening for Resident #214 prior to or at admission of 02/11/25. This failure could place residents at risk of not receiving needed services. Findings Included: Record review of Resident #214's admission record dated 02/25/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body) and melena (dark, tarry stool). Record review of Resident #214's EHR revealed no completed MDS assessment. Record review of Resident #214's care plan revealed it was initiated on 02/19/25 and did not address any mental health issues or intellectual disabilities. Record review of Resident #214's PASRR Level 1 revealed an assessment date of 02/19/25. During an interview on 02/26/25 at 02:17 PM MDS LVN stated she and the previous DON shared the responsibility of completing PASRRs. She stated, But it is mostly me lately. MDS LVN stated a possible negative outcome of not completing Resident #214's PASRR prior to or at admission was, If she (Resident #214) was positive (from mental disorder or intellectual disability), which she was not, she could have lacked or delayed services. During an interview on 02/26/25 at 02:28 PM ADON stated MDS LVN and DON have historically been responsible for completing PASRRs prior to or at admission. She stated a possible negative outcome of not completing the PASRR prior to or at admission was, Accuracy of care. Making sure we are offering them the services they need. During an interview on 02/26/25 at 02:34 PM DON stated MDS LVN was responsible for completing PASRRs. DON stated when she was employed in the facility previously (as DON) she was responsible for completing PASRRs. She stated she was not sure why the responsibility had shifted to MDS LVN. DON stated she did not believe there would be a negative outcome to the resident if a PASRR was not completed at or prior to admission. During an interview on 02/27/25 at 09:14 AM ADM stated a resident might not get the services they need if a PASRR was not completed at or prior to admission. Record review of facility policy titled Admission Criteria and dated 2019 revealed the following: . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) process. a. The facility conducts a Level I PASARR [sic] screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD.

Based on interview and record review the facility failed to ensure each resident was free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to ensure Resident #1 was free from neglect. On 5/15/24 after lunch, CNA B performed a 1-person transfer of Resident #1, who was a 2-person transfer. The transfer resulted in CNA B and Resident #1 falling to the floor, causing the fracture of Resident #1's right femur. CNA B did not report the fall. CNA C, who was in the room with CNA B at the time of the incident, did not report the fall until approximately 7 hours after the inappropriate transfer and fall occurred. This failure could place residents at risk of major injury due to neglect in their care. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began. Findings included: Record review of Admission Notes revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment and a diagnoses of complete transverse atypical (abnormal) femoral (femur) fracture, right leg, sequela (consequence of previous disease), unspecified osteoarthritis (degenerative joint disease, in which the joint breaks down over time), unspecified site, pain in unspecified knee, other abnormalities of gait and mobility, repeated falls, presence of right artificial knee joint, and non-displaced fracture of greater trochanter (outside hip joint) of right femur. Resident #1's Quarterly Care Plan dated 4/20/24 revealed an ADL self-care performance deficit related to Osteoarthritis, Abnormalities of Gait, Weakness and Right Femur Fracture. She had bilateral lower extremity contractures at the knee, which required the use of Podus Boots (lightweight, quality plastic shell brace with poly/pile liner) to both feet to prevent skin breakdown. Resident #1 required total assistance x 2 staff for all transfers and movement between surfaces. Resident #1 required the use of a Geri chair (a wheelchair designed for resident who may need a more substantial, and many times less restrictive, seating platform.) for mobility and postural support related to hip fracture. Resident #1 was at moderate risk for falls related to Alzheimer's Disease, along with weakness and contracture to her legs. A chair alarm was required while Resident #1 was seated, and a bed alarm was required while Resident #1 was in bed. Both were used to encourage safety awareness. Resident #1 required a fall mat at her bedside, while in bed, to decrease the risk of injury from falls. The resident's call light was to be in place and working at all times. Resident #1 had chronic pain related right knee and hip and was prescribed pain medications, including Tramadol, an opioid, to relieve discomfort. Review of Vista Teleradiology notes dated 5/15/24 revealed an x-ray was taken of Resident #1's right leg at 10:16PM. Findings were as follows: Bones: There is a mildly displaced metaphyseal fracture along the distal femoral bone, at the edge of the femoral prosthesis cap. Total left hip prosthesis changes. No sclerotic or destructive changes observed. Soft tissues: Joint effusion. Impression: Mild displaced metaphyseal fracture at the distal femoral bone, at the edge of the femoral prosthesis cap. Record Review of facility Progress Notes dated 5/15/24 revealed Resident #1 sustained a complete transverse atypical femoral fracture to her right leg when CNA B attempted a 1-person transfer of Resident #1 (who was a 2-person assist for all ADL s according to the MDS and Care Plan dated 4/20/24), which resulted in both falling to the floor. CNA C was also in the resident's room at the time of the incident, caring for Resident #2, and did not witness what took place. Record Review of facility in-services for the last 90 days revealed training on Abuse/Neglect, and Transfer of Residents had taken place for all staff on 5/14/24, the day prior to the incident. CNA B and CNA C attended this in-service. On 5/30/24 at 9:38AM an interview with the Administrator revealed on 5/14/24 staff had been in-serviced on resident abuse and neglect, and transfer of residents. She stated on 5/15/24 at approximately 1:30PM, CNA B attempted a 1-person transfer of Resident #1, which resulted in both falling to the floor. CNA B, along with CNA C, who was in the resident's room at the time of the incident, failed to report the fall to facility staff, resulting in Resident #1 not being assessed by nursing staff. Sometime between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A to report the incident, after her shift had ended. LVN A immediately called the DON and the DON arrived at the facility at approximately 9:15PM to assess Resident #1. It was determined that an x-ray was required, and the mobile x-ray service arrived at the facility at approximately 10:15PM. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. A phone interview with Resident #1's Representatives on 5/30/24 at 11:52AM revealed the facility had informed them of Resident #1's fall late in the evening of 5/15/24, and due to the late hour of the incident, requested that their resident not be transferred to the hospital, until morning. RR stated approximately 9:40AM on 5/16/24, Resident #1 was transported to the hospital via ambulance, where the fracture to the right femur was again confirmed, through x-ray. It was determined that the fracture was inoperable due to a prior knee replacement which took place in October of 2022, along with a previous fracture of the right hip, which took place in November of 2022. A leg immobilizer and additional pain medication were ordered, and the resident was returned to the facility. Record review revealed Resident #1's Care Plan was updated on 5/16/24 to include the use of the leg immobilizer to her right leg and palliative care, including Morphine Sulfate, after the fall on 5/15/24. These measures were put into place to prevent any further contracture to the right leg and relieve residual pain. Multiple observations throughout the investigation on 5/30/24 and 5/31/24 revealed that above each occupied resident bed was a sign indicating what type of transfer each resident required. Multiple staff interviews throughout the investigation on 5/30/24 and 5/31/24 revealed that staff had received extensive training on 5/14/24 and 5/16/24 on abuse and neglect, reporting requirements, appropriate transfers and procedures to follow if a resident falls during a transfer. These interviews revealed that as a result of the incident, competency checks on transfers were initiated and completed for all staff on 5/16/24. Record review of CNA B's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, the resulting fall and failure to report The Employee Warning Notice indicated that CNA B declined to write a statement. In the action to be taken section of the Employee Warning Notice, dismissal was checked. CNA B's employment with the facility was terminated on 5/16/24. Record review of CNA C's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, CNA C's initial failure to report the subsequent fall. The Employee Warning Notice indicated that CNA C declined to write a statement. In the action to be take section of the Employee Warning Notice, other was checked and the following statement was written: Suspension x 2 weeks. Consequence should incident occur again - additional disciplinary action up to termination. CNA C was immediately suspended for 2 weeks. Record Review of in-services for the last 90 days revealed staff were again in-serviced on Abuse/Neglect and Transfer of Residents on 5/16/24. The subject matter of these inservices included requirements for reporting any suspected abuse or neglect, responsibilities for reporting, what to report and who to report to, appropriate transfer of residents using the required number of staff and what to do in the event that a resident falls during a transfer. An interview with the CNA Supervisor on 5/30/24 at 3:10PM revealed CNA B was not in attendance for these additional in-services due to being terminated from her position the morning of 5/16/24 and CNA C was not in attendance due to being placed on two-weeks leave without pay. The CNA Supervisor stated she had no prior issues with CNAs and suspected neglect of residents. She stated at the Stand Up meeting on the morning of 5/16/24 she was informed by an unnamed CNA, that Resident #1 had been dropped by CNA B, the previous day. CNA Supervisor then spoke with other facility staff to gain insight into what had happened to Resident #1. When CNA Supervisor spoke with CNA B, she could not explain what had happened to Resident #1 other than she had tried to transfer Resident #1 by herself, and both had fallen to the floor. CNA B stated she had panicked and didn't know what to do. She was aware she had done something bad but had not reported it and had asked CNA C to not report the incident, as well. CNA B was immediately terminated, and CNA C was placed on leave without pay, pending the internal investigation. An interview with CNA C on 5/30/24 at 3:22PM revealed CNA C had been present in the room at the time of the incident, but had not seen what had taken place, due to providing care to Resident #1's roommate. CNA C stated both she and CNA B had worked the 5AM-5PM shift and had left the faciity on the day of the incident at their usual departure time of 5PM. Between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A and confessed to the fall taking place earlier that day, during her shift. She stated she had attended the in-service on Abuse/Neglect and Transfer of Residents on 5/14/24. Multiple attempts were made to speak with CNA B. These calls were not returned. Record Review of facility policy for Resident Neglect, dated July 10,2019 defined neglect as: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Furthermore, it is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional anguish. To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain or death of a resident was due to the NF's failure to provide goods or services to a resident. Example of neglect: A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.

Based on interview and record review the facility failed to ensure that all allegations involving neglect are reported immediately, but no later than 2 hours after the event, if the resident sustains serious bodily injury, to the Administrator of the facility and the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to report an allegation of neglect for Resident #1 within 2 hours of the event. CNA C did not report a fall with potential injury until approximately 7 hours after the inappropriate transfer and fall occured. CNA B did not report the fall. This failure could place residents at risk of not having incidents of neglect reported and investigated in a timely manner and delay in proper treatment of injury. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began. Findings included: Record review of Admission Notes revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment and a diagnoses of complete transverse atypical (abnormal) femoral (femur) fracture, right leg, sequela (consequence of previous disease), unspecified osteoarthritis (degenerative joint disease, in which the joint breaks down over time), unspecified site, pain in unspecified knee, other abnormalities of gait and mobility, repeated falls, presence of right artificial knee joint, and non-displaced fracture of greater trochanter (outside hip joint) of right femur. Resident #1's Quarterly Care Plan dated 4/20/24 revealed an ADL self-care performance deficit related to Osteoarthritis, Abnormalities of Gait, Weakness and Right Femur Fracture. She had bilateral lower extremity contractures at the knee, which required the use of Podus Boots (lightweight, quality plastic shell brace with poly/pile liner) to both feet to prevent skin breakdown. Resident #1 required total assistance x 2 staff for all transfers and movement between surfaces. Resident #1 required the use of a Geri chair (a wheelchair designed for resident who may need a more substantial, and many times less restrictive, seating platform.) for mobility and postural support related to hip fracture. Resident #1 was at moderate risk for falls related to Alzheimer's Disease, along with weakness and contracture to her legs. A chair alarm was required while Resident #1 was seated, and a bed alarm was required while Resident #1 was in bed. Both were used to encourage safety awareness. Resident #1 required a fall mat at her bedside, while in bed, to decrease the risk of injury from falls. The resident's call light was to be in place and working at all times. Resident #1 had chronic pain related right knee and hip and was prescribed pain medications, including Tramadol, an opioid, to relieve discomfort. Record Review of x-ray notes dated 5/15/24 revealed an x-ray was taken of Resident #1's right leg at 10:16PM. Findings were as follows: Bones: There is a mildly displaced metaphyseal fracture along the distal femoral bone, at the edge of the femoral prosthesis cap. Total left hip prosthesis changes. No sclerotic or destructive changes observed. Soft tissues: Joint effusion. Impression: Mild displaced metaphyseal fracture at the distal femoral bone, at the edge of the femoral prosthesis cap. Record Review of facility Progress Notes dated 5/15/24 revealed Resident #1 sustained a complete transverse atypical femoral fracture to her right leg when CNA B attempted a 1-person transfer of Resident #1 (who was a 2-person assist for all ADL s according to the MDS and Care Plan dated 4/20/24), which resulted in both falling to the floor. CNA C was also in the resident's room at the time of the incident, caring for Resident #2, and did not witness what took place. Record Review of facility in-services for the last 90 days revealed training on Abuse/Neglect, and Transfer of Residents had taken place for all staff on 5/14/24, the day prior to the incident. CNA B and CNA C attended this in-service. Record Review of in-services for the last 90 days revealed staff were again in-serviced on Abuse/Neglect and Transfer of Residents on 5/16/24. The subject matter of these inservices included requirements for reporting any suspected abuse or neglect, responsibilities for reporting, what to report and who to report to, appropriate transfer of residents using the required number of staff and what to do in the event that a resident falls during a transfer. On 5/30/24 at 9:38AM an interview with the Administrator revealed on 5/14/24 staff had been in-serviced on resident abuse and neglect, and transfer of residents. She stated on 5/15/24 at approximately 1:30PM, CNA B attempted a 1-person transfer of Resident #1, which resulted in both falling to the floor. CNA B, along with CNA C, who was in the resident's room at the time of the incident, failed to report the fall to facility staff, resulting in Resident #1 not being assessed by nursing staff. Sometime between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A to report the incident, after her shift had ended. LVN A immediately called the DON and the DON arrived at the facility at approximately 9:15PM to assess Resident #1. It was determined that an x-ray was required, and the mobile x-ray service arrived at the facility at approximately 10:15PM. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. A phone interview with Resident #1's Representatives on 5/30/24 at 11:52AM revealed the facility had informed them of Resident #1's fall late in the evening of 5/15/24, and due to the late hour of the incident, requested that their resident not be transferred to the hospital, until morning. RR stated approximately 9:40AM on 5/16/24, Resident #1 was transported to the hospital via ambulance, where the fracture to the right femur was again confirmed, through x-ray. It was determined that the fracture was inoperable due to a prior knee replacement which took place in October of 2022, along with a previous fracture of the right hip, which took place in November of 2022. A leg immobilizer and additional pain medication were ordered, and the resident was returned to the facility. Record review revealed Resident #1's Care Plan was updated on 5/16/24 to include the use of the leg immobilizer to her right leg and palliative care, including Morphine Sulfate, after the fall on 5/15/24. These measures were put into place to prevent any further contracture to the right leg and relieve residual pain. An interview with the CNA Supervisor on 5/30/24 at 3:10PM revealed CNA B was not in attendance for these additional in-services due to being terminated from her position the morning of 5/16/24 and CNA C was not in attendance due to being placed on two-weeks leave without pay. The CNA Supervisor stated she had no prior issues with CNAs and suspected neglect of residents. She stated at the Stand Up meeting on the morning of 5/16/24 she was informed by an unnamed CNA, that Resident #1 had been dropped by CNA B, the previous day. CNA Supervisor then spoke with other facility staff to gain insight into what had happened to Resident #1. When CNA Supervisor spoke with CNA B, she could not explain what had happened to Resident #1 other than she had tried to transfer Resident #1 by herself, and both had fallen to the floor. CNA B stated she had panicked and did not know what to do. She was aware she had done something bad but had not reported it and had asked CNA C to not report the incident, as well. CNA B was immediately terminated, and CNA C was placed on leave without pay, pending the internal investigation. An interview with CNA C on 5/30/24 at 3:22PM revealed CNA B had asked her to not report the incident to facility staff. CNA C stated both she and CNA B had worked the 5AM-5PM shift and had left the faciity on the day of the incident at their usual departure time of 5PM, without notifying staff of the fall. Between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A and confessed to the fall taking place earlier that day, during her shift. CNA B had not reported the incident to facility staff. CNA B was immediately terminated, and CNA C was placed on leave without pay, pending the internal investigation. Multiple attempts were made to speak with CNA B. These calls were not returned. Multiple observations throughout the investigation on 5/30/24 and 5/31/24 revealed that above each occupied resident bed was a sign indicating what type of transfer each resident required. Record review of CNA B's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1. The Employee Warning Notice indicated that CNA B declined to write a statement. In the action to be taken section of the Employee Warning Notice, dismissal was checked. CNA B's employment with the facility was terminated on 5/16/24. Record review of CNA C's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, CNA C's initial failure to report the subsequent fall. The Employee Warning Notice indicated that CNA C declined to write a statement. In the action to be take section of the Employee Warning Notice, other was checked and the following statement was written: Suspension x 2 weeks. Consequence should incident occur again - additional disciplinary action up to termination. CNA C was immediately suspended for 2 weeks. Multiple staff interviews throughout the investigation on 5/30/24 and 5/31/24 revealed that staff had received extensive training on 5/14/24 and 5/16/24 on abuse and neglect, reporting requirements, appropriate transfers and procedures to follow if a resident falls during a transfer. These interviews revealed that as a result of the incident, competency checks on transfers were initiated and completed for all staff on 5/16/24. Record Review of facility policy for Resident Neglect, dated July 10,2019 defined neglect as: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Furthermore, it is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional anguish. To determine whether neglect may have occurred, a NF must decide if an injury, emotional harm, pain or death of a resident was due to the NF's failure to provide goods or services to a resident. Example of neglect: A resident, per his care plan, requires a two-person transfer from his bed to a chair. Only one staff member assists the resident in transferring him from his bed to a chair and the resident falls, resulting in extensive bruising to his thigh that was determined to be a serious injury. Record Review of facility policy for Abuse, Neglect and Reporting/Investigation of Incidents, dated September 2022, revealed the following: Reporting Allegations to the Administrator and Authorities 1. If resident neglect is suspected, the suspicion must be reported immediately to the Administrator and other officials, according to state law. Immediately is defined as within two hours of an allegation involving serious bodily injury or within 24 hours if the allegation does not result in serious bodily injury. 6. Upon receiving any allegation of neglect, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The Administrator initiates investigations. 4. The Administrator is responsible for keeping the resident and his/her representative(s) informed of the progress of the investigation. 6. Any employee who has been accused of resident neglect is place on leave with no further contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interview any witnesses to the incident; f. interviews the resident (as medically appropriate) or resident's representative; g. interviews resident's attending physician to determine resident's condition; h. interviews staff members on all shifts who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. Corrective Actions 1. All relevant professional and licensing boards are notified when an employee is found to have committed abuse/neglect. 2. If the investigation reveals that the allegation(s) are founded, the employee is terminated. 3. Any allegations of abuse/neglect are filed in the accused employee's personnel record along with any statement by the employee disputing the allegation if the employee chooses to make one. 4. Of the investigation reveals that the allegations of abuse/neglect are unfounded, the employee may be reinstated to his/her former position with back pay. 5. Records concerning allegations that are determined to be unfounded are destroyed or archived per human resources policy. 6. Corrective action may include a full review of the incident by the QAPI committee. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/30/24 at 4:40PM and ended on 5/31/24 at 8:30AM. The facility had corrected the non-compliance before the survey began.

Based on interview and record review the facility failed to ensure that the resident environment remains free of accidents and hazards, as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for adequate supervision to prevent accidents and hazards. The facility failed to ensure that Resident #1 was assisted x 2 staff for all transfers and movement between surfaces. CNA B transferred Resident #1 independently which resulted in CNA B and Resident #1 falling to the floor. As a result of the fall, Resident #1 suffered a fractured right leg. This failure could place residents at risk for falls with serious injuries. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began. Findings included: Record review of Admission Notes revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment and a diagnoses of complete transverse atypical (abnormal) femoral (femur) fracture, right leg, sequela (consequence of previous disease), unspecified osteoarthritis (degenerative joint disease, in which the joint breaks down over time), unspecified site, pain in unspecified knee, other abnormalities of gait and mobility, repeated falls, presence of right artificial knee joint, and non-displaced fracture of greater trochanter (outside hip joint) of right femur. Resident #1's Quarterly Care Plan dated 4/20/24 revealed an ADL self-care performance deficit related to Osteoarthritis, Abnormalities of Gait, Weakness and Right Femur Fracture. She had bilateral lower extremity contractures at the knee, which required the use of Podus Boots (lightweight, quality plastic shell brace with poly/pile liner) to both feet to prevent skin breakdown. Resident #1 required total assistance x 2 staff for all transfers and movement between surfaces. Resident #1 required the use of a Geri chair (a wheelchair designed for resident who may need a more substantial, and many times less restrictive, seating platform.) for mobility and postural support related to hip fracture. Resident #1 was at moderate risk for falls related to Alzheimer's Disease, along with weakness and contracture to her legs. A chair alarm was required while Resident #1 was seated, and a bed alarm was required while Resident #1 was in bed. Both were used to encourage safety awareness. Resident #1 required a fall mat at her bedside, while in bed, to decrease the risk of injury from falls. The resident's call light was to be in place and working at all times. Resident #1 had chronic pain related right knee and hip and was prescribed pain medications, including Tramadol, an opioid, to relieve discomfort. Record review revealed Resident #1's Care Plan was updated on 5/16/24 to include the use of the leg immobilizer to her right leg and palliative care, including Morphine Sulfate, after the fall on 5/15/24. These measures were put into place to prevent any further contracture to the right leg and relieve residual pain after the fall which resulted in fracture. Record review of Resident #1's fall assessment dated [DATE] revealed Resident #1 had intermittent confusion related to Alzheimer's Disease. She had a history of 1-2 falls in the past 3 months. She was chair-bound and required assistance with bowel and bladder voiding. Her vision was adequate without the use of glasses, and she required the use of assistive devices related to gait and balance. Her fall assessment score was 13, indicating she was at high risk for falls and accidents. An interview with the Administrator on 5/30/24 at 9:38AM revealed all staff had been in-serviced on 5/14/24, one day prior to the incident, regarding resident abuse and neglect, reporting of incidents and transfer of residents. She stated on 5/15/24 at approximately 1:30PM, CNA B attempted a 1-person transfer of Resident #1, which resulted in both falling to the floor. CNA B, along with CNA C, who was in the resident's room at the time of the incident, failed to report the fall to facility staff, resulting in Resident #1 not being assessed by nursing staff. Sometime between the hours of 8:00PM and 8:30PM on 5/15/24, CNA C called LVN A to report the incident, after her shift had ended. LVN A immediately called the DON and the DON arrived at the facility at approximately 9:15PM to assess Resident #1. It was determined that an x-ray was required, and the mobile x-ray service arrived at the facility at approximately 10:15PM. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. At approximately 1:30AM, the facility received the results of the x-ray and a fracture to the right femur was confirmed. The facility informed Resident #1's representative and due to the late hour, they requested that their resident not be transferred to the hospital, until morning. At approximately 9:40AM on 5/15/24, Resident #1 was transported to the hospital via ambulance, where the fracture to the right femur was again confirmed, through x-ray. It was determined that the fracture was inoperable due to a prior knee replacement which took place in October of 2022, along with a previous fracture of the right hip, which took place in November of 2022. Multiple observations throughout the investigation on 5/30/24 and 5/31/24 revealed that above each occupied resident bed was a sign indicating what type of transfer each resident required. Record review of CNA B's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1. The Employee Warning Notice indicated that CNA B declined to write a statement. In the action to be taken section of the Employee Warning Notice, dismissal was checked. CNA B's employment with the facility was terminated on 5/16/24. Record review of CNA C's personnel file revealed an Employee Warning Notice dated 5/16/24. The Employee Warning Notice contained a summary of the inappropriate transfer of Resident #1, CNA C's initial failure to report the subsequent fall. The Employee Warning Notice indicated that CNA C declined to write a statement. In the action to be take section of the Employee Warning Notice, other was checked and the following statement was written: Suspension x 2 weeks. Consequence should incident occur again - additional disciplinary action up to termination. CNA C was immediately suspended for 2 weeks. Multiple staff interviews throughout the investigation on 5/30/24 and 5/31/24 revealed that staff had received extensive training on 5/14/24 and 5/16/24 on abuse and neglect, reporting requirements, appropriate transfers and procedures to follow if a resident falls during a transfer. These interviews revealed that as a result of the incident, competency checks on transfers were initiated and completed for all staff on 5/16/24. Record review of the facility's Safety Precautions, Nursing Services Policy dated December 2009 revealed in part: o Report all unsafe acts or condition to your supervisor as soon as possible. o Pick up debris from the floor. Clean up spills immediately. o Report all injuries, no matter how small. o Follow proper lifting procedures when lifting residents or heavy objects. Record review of the facility's undated Fall Assessment and Management Policy and Procedure, revealed the following: Purpose To ensure fall assessment and management is carried out in a prompt and consistent manner utilizing validated best practice assessment tools. To identify resident fall risk factors. To provide direction for the interdisciplinary team to incorporate and develop best practice fall prevention. To decrease the incidence of falls and fall injuries. Policy All resident's will be assessed for fall risk upon admission. The resident's care plan shall be developed and updated to include individualized and appropriate interventions to prevent falls and reduce the risk of injury based on risk. If a resident has a fall, an assessment shall be undertaken to assess the risk for further falls and determine additional strategies to reduce fall and injury risk. Regardless of risk, fall risk factor and interventions shall be reviewed by the interdisciplinary team at least quarterly. Documentation in resident's health record shall be completed by the care plan manager. All unusual observations and resident's responses will be documented. Procedure If the resident is considered a HIGH RISK, the falls assessment form does not need to be repeated with each fall but does need to be reviewed for possible risk factor changes. A care plan shall be formulated by the interdisciplinary team which includes individualized multi-factorial fall and injury prevention strategies to address risk factors identified from the fall risk form, regardless of the resident's level of risk. Interventions reviewed and updated based on the findings of the reassessments and/or post-fall investigations, including individualized interventions which are re-evaluated and updated to prevent or minimize the risk of falls. Individualized interventions based on causal factors and/or identified risk factors. Date of falls and causal factors identified. Outcomes Individualized interventions identified in the care plan are implemented. Effectiveness of the individualized interventions are monitored and evaluated. Post-fall Assessment, Clinical Review Assess immediate danger to all involved. Call for assistance. Do not move the resident until he/she has been assessed for safety to be moved. Identify all visible injuries and initiate first aid; for example, cover wounds. Assist resident to move using safe handling practices. Notify the physician. Notify family of incident, any new orders, or possible transfer Initiate risk management and follow prompts in Point Click Care for fall prevention. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. The facility had corrected the non-compliance before the survey began.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. The facility failed to store food at least 6 inches above the floor. This failure could place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 1/16/2024 beginning at 10:03 am revealed the following: Observation of pantry on 1/16/24 at 10:06 am revealed 1 container of Jif peanut butter individual packs with no label or date. Observation of pantry on 1/16/ 24 at 10:11 am revealed 1 container of individual jelly packets with no label or date. Observation of pantry room on 1/16/24 at 10:26 am revealed 1 container of croutons with no label or date. Observation of refrigerator 1 on 1/16/24 at 10:43 am revealed 1 box of cabbage with no date. Observation of refrigerator 1 on 1/16 at 10:43 am revealed 1 box of tomatoes on shelf with no date. Observation of serving cart on 1/16/2 at 10:43 am revealed jelly packets in a bin with no label or date. Observation of serving cart on 1/16/24 at 1043 am revealed butter packets with no label or date. Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed I tray of honey mustard in individual cups with no date. Observation of refrigerator 2 on 1/16/24 at 10: 48 am revealed unidentified I tray of salsa in fridge with no label or date. Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed 1 bottle of ketchup with no date. Observation of freezer 1 on 1/16/24 at 11:02 am revealed 6 boxes of frozen meat on the floor not 6 inches off the floor. During an interview on 1/16/2024 at 11:20 pm, the cook stated that all kitchen staff are responsible for safe food storage per their policy. The cook said that she would go to the policy to see what the policy stated concerning food storage. The cook stated that the negative outcome for not practicing food storage would be contamination. During an interview on 1/16/24 at 1:27 pm, Dietary Manager stated that she is responsible for training kitchen staff. The Dietary Manager said kitchen staff are to follow facility policy for proper food storage. The Dietary Manager said that a negative outcome for Residents would be contamination. She said that a former DM told her that they could store items in the freezer on the floor. During an interview with the FSA on 1/17/24 at 10:33 am, FSA said she would go to the DM with any questions concerning food storage. She said a negative outcome would be a resident could get sick from bad food. FSA has not had any training on labeling and food storage. Record review of Food Receiving and Storage Policy dated /11/22 at 2:30 PM revealed the following: Dry foods that are stored in bins are removed from the original packaging, label and dated (use by date). Such foods are rated using a fist in-first out system. Food in designated dry storage areas is kept at least six inches off the floor. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Record review of Dietary Services Policy & Procedure Manual dated 11- 2022, for storage area stated all stored items must be 6 inches above the floor. Record review of Food and Drug Administration on, dated 1/18/23, stated in section 5-305.11 food storage should be at least 15cm (6 inches) above the floor.

Based on observation, interview, and record review the facility failed to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for one (Resident #54) of 18 residents reviewed for significant change. The facility failed to update Resident #54's MDS assessment within 14 days of Resident #54 being admitted to hospice. This failure could result in residents not receiving the care and coordination of services necessary to meet their needs and/or desires. Findings Included: Record review of Resident #54's admission record, dated 01/18/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia severe with agitation (a group of thinking and social symptoms that interferes with daily functioning), nausea, dizziness and giddiness, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). The admission record made no mention of Resident #54 receiving hospice care. Record review of Resident #54's EHR MDS front sheet revealed a significant change MDS that was export ready with an ARD of 01/17/24. Record review of Resident #54's quarterly MDS completed on 11/25/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS indicated Resident #54 was not receiving hospice care While a Resident. Record review of Resident #54's care plan revealed the following focus area dated 12/14/23: The resident has a terminal prognosis r/t Severe Dementia. One of the interventions listed for this focus area was: Resident with [Name of Hospice]. This intervention was initiated on 12/14/23. Another intervention listed for this focus area was initiated on 01/16/24 and stated, Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #54's active orders, dated 01/18/24 revealed an order of Admit to [Name of Hospice] dated 12/14/23. During an observation on 01/16/24 at 10:40 AM Resident #54 was being pushed in her wheelchair down the hallway of the locked unit. She was neatly dressed, and her hair was neatly combed. Resident #54 was able to say hello and shake hands. When asked what her name was, Resident #54 was unable or unwilling to answer and looked down and to the left. During an observation on 01/16/24 at 12:06 PM Resident #54 was seated in her wheelchair at a table in the dining room. She had her eyes closed and staff were attempting to feed her bites from a plate of pureed food. Staff called her name repeatedly until she would open her eyes and take a bite. This pattern was repeated for each bite. During an interview on 01/16/24 at 06:51 PM Resident #54's family member stated he was pleased with the care she was receiving in the facility. He stated he chose to place Resident #54 in hospice care due to her condition and conversations he had with facility staff. During an interview on 01/18/24 at 11:09 AM when asked what policy she used for determining MDS assessment timing, MDS LVN stated, I follow the RAI manual. She said when a resident had a significant change the MDS assessment was to be completed within 14 days. When asked why this timing was not followed for Resident #54's significant change due to being admitted to hospice, MDS LVN stated, She was an interesting case. We had a care plan meeting with [Resident #54's family member] and we discussed steady decline. We discussed palliative care etcetera. A few days later he [Resident #54's family member] contacted hospice himself and I put it in the care plan and everywhere else but did do the dadgum MDS. I missed it. She said a possible negative outcome of not following the assessment timing as laid out in the RAI was, You know, state was not notified when they needed to be. During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not having a significant change MDS in the allotted 14 days was, What is the payer source? Because I can see that being an issue. Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following: .For the other comprehensive MDS assessments, Significant Change in Status Assessment the . Completion Date must be no later than . 14 days from the determination date of the significant change in status . An SCSA [Significant Change in Status Assessment] is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD must be within 14 days from the effective date of the hospice election . Record review of facility policy titled, Hospice Program and dated 08/09/23 revealed the following: Palliative/End-of-Life Care-Clinical Protocol Assessment and Recognition . 5. The comprehensive assessment will recur on a regular basis and in response to significant changes of condition .

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (Resident #26) of 18 residents reviewed for accuracy of assessments. Resident #26 had an order for continuous oxygen dated 08/29/23 and her MDS with a completion date of 11/10/23 did not indicate she received oxygen while a resident. This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care. Findings Included: Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats>90%. This intervention was initiated on 06/22/23 and revised on 09/18/23. Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat>90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date. Record review of Resident #26's O2 Sats Summary revealed 25 entries for the 14 days prior to completion of Resident #26's most recent MDS. Of those 25 entries, Resident #26 was receiving O2 17 times and was on room air 8 times. During an interview on 01/18/24 at 11:09 AM MDS LVN stated she followed the RAI as her policy for completing MDS Assessments. Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following: . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days.

Based on observation, interview, and record review, the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 18 residents (Resident #41) reviewed for PASRR requirements. The facility failed to ensure Resident #41 had an initial PASRR Level 1 before admission on 08/08/2023. This failure could place residents with an MI (Mental Illness), ID (Intellectual Disability) or DD (Developmental Disability) at risk for not receiving PASRR related services, if qualified. The findings include: Record review of Resident #41's face sheet, dated 01/16/2024, revealed a [AGE] year-old male admitted to the facility initially on 08/08/2023 with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease with (acute) lower respiratory infection, major depressive disorder, recurrent, unspecified, atherosclerosis (plaque build up) of native coronary artery of transplanted heart without angina pectoris (chest pain), muscle weakness, epitaxis (bleeding from the nose), essential primary hypertension. Record review of Resident #41's quarterly MDS assessment, dated 11/24/2023, revealed a BIMS score of 11 out 15 which indicated his cognition was moderately impaired. He functional ability with eating, oral hygiene, toileting, and personal hygiene is classified as independent, with supervision or touching assistance with showering/bathing. Resident #41 is partial/moderate assistance with upper and lower body dressing and putting on/taking off footwear. Record review of Resident #41's care plan, revised 11/27/2023, revealed no documentation regarding PASRR status. Record review of Resident #41's PASRR Level 1 Screening, dated 01/22/2021, revealed, that in Section C, subsection C0100, C0200, and C0300 all sections are marked no. There was no new updated PASRR in Resident #41's chart. Resident #41 had no new PASRR performed with new admission on 08/08/2023. During an observation and interview on 01/16/2024 at 09:34 AM, Resident #41 was in his room, Resident #41 was standing next to his dresser putting his laundry away. Resident #41 had a NC hooked to portable oxygen; he had a rolling walker close by to assist him to ambulate. Resident stated that everyone treated him fine and did not voice any concerns with his care. During an interview on 01/18/2024 at 09:01 AM MDS LVN was asked about Resident #41's most recent PASRR. MDS LVN stated Yes, we saw that. I just didn't understand that a new one needed to be done. The new PASRR has been completed, but I can't submit it due to the admitted being more than 90 days out. MDS LVN was asked what a negative outcome would be for a resident not having and updated PASRR. MDS LVN stated since he is a resident that does not receive services there would be no negative outcome. MDS LVN stated that she had the email from the PASRR office and the email that she submitted to the PASRR office. Copies of this documentation was requested. During an interview on 01/18/2024 at 09:13 AM with DON revealed that a negative outcome for not having an updated PASRR upon admission could lead to the resident would have no help from services if needed. During an observation and interview on 01/18/2024 at 09:29 AM revealed paperwork provided by the MDS LVN that showed emails dated 01/17/2024 at 2:48pm, that she sent to PASRR support, it stated the following, Hi, I have missed completing a PASRR for a resident that was admitted on 08.08.2023. I have attempted to complete it for today's date and when it comes to adding in the NF admitted it says that it is an error. How can I correct this issue. The response email from PASRR support stated, Thank you for contacting the PASRR mailbox. Depending on the volume of emails received, it may take up to 3 business days to receive a response. We appreciate your patience. Record review of facility policy, titled Admission-From Other Healthcare Facilities dated revised March 2017 states the following: 2. The following information will be provided to the facility prior to or upon the resident's admission: .I. PASARR (as appropriate);

Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for one (Resident #26) of 18 residents reviewed for medical records. The facility failed to ensure Resident #26 had the most current physician's order in her chart for oxygen. The order in Resident #26's chart was for continuous oxygen but the most recent verbal order from the physician was to begin weaning Resident #26 off continuous oxygen. This failure could place residents at risk of having records that do not reflect their current status or needs. Findings Included: Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats>90%. This intervention was initiated on 06/22/23 and revised on 09/18/23. Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat>90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date. Record review of Resident #26's progress notes revealed a note by LVN A dated 01/07/24 at 02:34 PM. This note stated, This nurse monitoring resident without O2. O2 reading of 92% RA [Room Air]. No s/s of distress noted. During an observation on 01/16/24 at 10:23 AM Resident #26 was lying in her bed on her right side in the fetal position under a blanket. She was not receiving O2. Her O2 concentrator machine was next to the bed with the tubing gathered together into a zipped plastic bag taped to the top of the machine. During an observation on 01/16/24 at 12:05 PM Resident #26 was sitting in her w/c with her eyes closed at a dining room table. She was not receiving O2. During an observation on 01/17/24 at 07:36 AM Resident #26 was sitting in her w/c at the dining room table eating her breakfast. She was not receiving O2. She did not respond when spoken to. During an observation on 01/17/24 at 08:19 AM Resident #26 was sitting in her w/c in the common room with several other residents. She was not receiving O2. During an observation on 01/17/24 at 11:25 AM Resident #26 was sitting in the common room in her w/c. She was not receiving O2. During an observation on 01/18/24 at 08:44 AM Resident #26 was sitting in her w/c in the common area having her hair curled by a staff member. She was not receiving O2. During an observation and interview on 01/18/24 beginning at 10:41 AM LVN A stated she had worked for the facility for 5 years. She said if a resident had orders for continuous O2 to keep O2 saturation above 90% the resident was supposed to have it [O2] on all the time. She stated nurses checked the residents' O2 sats in the morning. She stated nurses, Special Care staff, and CNAs were responsible for to make sure O2 orders were followed. She clarified that the nurse was responsible for setting levels and ensuring the order was followed and CNAs and Special Staff could adjust or apply the nasal cannulas. When asked why Resident #26 had an active order for continuous O2 and was not receiving O2, LVN A stated, We were gonna try to wean her and I think I have a note in there. At this point LVN A began to search her computer screen and printed off a note dated 01/07/24 at 02:34 PM. When asked if the physician said to wean Resident #26 off oxygen, LVN A looked at her computer screen and stated, Yes, but I didn't write it down. It is not in there. She stated a possible negative outcome of having the wrong orders in the chart was a resident could become disoriented, agitated, combative or restless. During an interview on 01/18/24 at 10:47 AM ADON stated if a resident had orders for continuous oxygen that resident should always be receiving oxygen. She stated she, the DON, and the nurses were responsible to ensure orders were followed. When asked about Resident #26 having orders for continuous oxygen and LVN A saying Resident #26 was being weaned from oxygen, ADON stated, Nurse would be responsible for noting that in the chart and would contact the doctor and get doctor orders and the nurse would be responsible to put those orders in the chart too. She stated a possible negative outcome of having the wrong orders in the chart was, Shortness of breath, they [residents] can't breathe. During an interview on 01/18/24 at 10:55 AM SC B said she knew which residents to put oxygen on because the nurse tells us. When asked how she knew which residents needed oxygen sometimes or all the time she stated, I ask the nurse. Has to be passed down through communication. They tell us who needs it all day. When asked why Resident #26 was not receiving oxygen she said, They [nurses] told us awhile back that she did not need it anymore. So, they leave her on it for a little bit and they take it off of her. During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not following the orders in the EHR was, You could have someone go hypoxic (low levels of O2 in the blood). When asked about Resident #26 having orders in her EHR for continuous oxygen and LVN A stating they were weaning her off oxygen, DON stated, Nurse should have changed the order from continuous to PRN on the day that she spoke to the doctor. Record review of facility policy titled Oxygen Administration and dated 08/09/23 revealed the following: . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Record review of facility policy titled Medication and Treatment Orders and dated July 2016 revealed the following: . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Record review of facility policy titled Telephone Orders and dated February 2014 revealed the following: . 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Record review of facility policy titled Verbal Orders and dated February 2014 revealed the following: . Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. 1. Only authorized, licensed practitioners or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 2. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone. 4. The individual receiving the verbal order must write it on the physician's order sheet as 'v.o.' (verbal order) or 't.o.' (telephone order). 5. The individual receiving the verbal order will: . b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 10 residents (#1,#2,#3, #4,#5,#6,#7,#8,#9,#10) residents reviewed for infection control. 1. The facility failed to ensure staff (HK A, Unit Clerk, HK B, CNA C, CNA D, CNA E, HK F) utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents' positive with COVID-19 and residents who were not positive for the virus. 2. The facility failed to ensure staff (CNA D and CNA E) practiced hand hygiene by using hand sanitizer or washing their hands after exiting positive COVID-19 resident rooms or touching COVID negative resident food trays. These failures could affect residents and staff members by placing them at risk for the transmission of communicable diseases, infections, including COVID-19, which could result in fatigue, cough, pneumonia, sepsis and death. Findings included: Record Review of the facility provided resident roster, identified 9 residents (Resident #1, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 Resident #9, and Resident #10,) currently positive and quarantined for COVID, 1 resident (Resident #2) who had been positive for COVID-19 and was deceased . Record Review of the facility provided Staff with COVID sheet revealed 9 staff members tested positive during the time period from [DATE]-[DATE]. Record Review of the facility provided Residents with COVID Sheet with symptoms listed revealed the following COVID positive residents and date of positive test for: Resident #1, COVID positive on [DATE]; Fatigue, body aches, congestion, sore throat Resident #2, COVID positive on [DATE]; Diarrhea, loss of appetite, short of breath, Confusion, weakness, body aches Resident #3, COVID positive on [DATE]; sore throat, hoarse, congestion, runny nose Resident #4, COVID positive on [DATE]; sore throat, congestion, fatigue Resident #5, COVID positive on [DATE]; congestion, nasal drainage, watery eyes, hoarse, sore throat, body aches, restlessness, anxiety Resident #6, COVID positive on [DATE]; headache, sore throat, loss of appetite, shortness of breath, decrease O2, congestion, hoarse. Resident #7, COVID positive on [DATE]; decrease O2, cough, chills, headache, vomiting, muscle aches, sore throat, loss of appetite, congestion, signs/symptoms of cold. Resident #8, COVID positive on [DATE]; afebrile, decrease O2, cough, fatigue, sore throat, weakness, signs/symptoms common cold. Resident #9, COVID positive on [DATE]; cough Resident #10, COVID positive on [DATE]; fatigue, signs/symptoms cold, afebrile, hoarseness. Record Review of an undated face sheet for Resident #1 revealed: admitted to the facility on [DATE] with the following diagnoses : Multiple Sclerosis- (potentially disabling disease of the brain and spinal cord (central nervous system) Anemia(Low healthy red blood cells), Weakness, Reduced Mobility, Postural Kyphosis-Thoracolumbar Region(spinal disorder resulting in rounding of upper back), Primary Hypertension. Record Review of an undated face sheet for Resident #2 revealed: admitted to the facility on [DATE], discharge (deceased ) on [DATE] at 3:00 am with the following diagnoses : unspecified protein-calorie malnutrition, acute respiratory distress syndrome, pressure ulcer/skin tears, hypothyroidism(low thyroid hormone), major depressive disorder, acute cystitis with hematuria(blood in urine), dysphagia(difficulty in swallowing), weakness. Record Review of an undated face sheet for Resident #3 revealed: admitted to the facility on [DATE] with the following diagnoses : major depressive disorder(Persistent depressed mood), unspecified dementia, acute pain. Record Review of an undated face sheet for Resident #4 revealed: admitted to the facility on [DATE] with the following diagnoses : Dementia, COVID-19, Hypothyroidism (low thyroid hormone), Type 2 Diabetes, Shortness of Breath. Record Review of an undated face sheet for Resident #5 revealed: admitted to the facility on [DATE] with the following diagnoses : Dementia, Anxiety Disorder, Hypertension, Anorexia, COVID -19, Urinary Tract Infection. Record Review of an undated face sheet for Resident #6 revealed: admitted to the facility on [DATE] with the following diagnoses : Dementia, COVID-19, Essential hypertension; Anxiety. Record Review of an updated Resident #7's face sheet for Resident #7 revealed: admitted to the facility on [DATE] with the following diagnoses : Anemia, Shortness of Breath, COVID-19, Repeated Falls. Record Review of an undated face sheet for Resident #8 revealed: admitted to the facility on [DATE] with the following diagnoses : Transient Cerebral Ischemic Attack(stroke), COVID-19, Cough, Dementia, Hypertension. Record Review of an undated face sheet for Resident #9 revealed: admitted to the facility on [DATE] with the following diagnoses : Fracture of First Lumbar Vertebra(compression fracture of the spine), COVID-19, Nausea, Hyperlipemia(high fat/lipids in blood), Depression, Hypertension, Chronic Obstructive Pulmonary Disease (COPD). Record Review of an undated face sheet for Resident #10 revealed: admitted to the facility on [DATE] with the following diagnoses : Metabolic Encephalopathy(brain disease/alteration in consciousness), Squamous Cell Carcinoma of Skin of nose(cancer of skin), Dehydration, Hypertension, Osteoarthritis(degeneration of joint cartilage), Repeated falls. During an observation on [DATE] at 10:40 a.m. upon entrance to facility, posting on door instructed masks required, list of COVID symptoms. A desk was observed inside the door with N-95 and surgical masks and a hand sanitizer station. During observations on [DATE] between 12:00 p.m. and 1:00 p.m. of the 4 resident hallways revealed no hand sanitizer on PPE carts outside of COVID positive resident rooms or within reach to DON or DOFF (putting on and taking off) PPE. During an interview and observation on [DATE] at 12:06 p.m., HK A was observed in the hallway with her mask pulled down below her nose. HK A was observed pinching her nose and wiping her nose with her bare hands and then touching the housekeeping cart. HK A stated she only spoke Spanish and a Therapy staff member translated the interview. HK A stated that she was sweaty from wearing the mask and wiped her nose several times to wipe the sweat away. HK A stated she was aware of the COVID outbreak and was trained to disinfect her hands with hand sanitizer or soap and water. HK A stated she planned on washing her hands after she took the trash outside. During an interview and observation on [DATE] at 12:19 p.m., Unit Clerk was observed behind the nurses station wearing a N95 mask over a surgical mask. The Unit Clerk stated she believed that wearing a N95 over a surgical mask would offer more protection against N-95. The Unit Clerk stated she had been trained on Infection Control, COVID and how to properly wear a N-95 mask and had not been trained to wear a N95 over a surgical mask. During an observation and attempted interview on [DATE] at 12:22 p.m. of HK B revealed Resident #5's room door was left open to the hallway, HK B exited Resident #5's room with a N95 mask on and carried a trash bag out of the resident room. HK B grabbed disinfectant off the PPE cart outside the door and sprayed aerosol disinfectant on her body and walked off. HK B stated she did not speak English and left the hallway. During an interview on [DATE] at 12:26 p.m. the ADM, stated that staff should remove the N95 after they exit a positive COVID room. The ADM stated that staff should disinfect their hands after they exit the positive COVID room at one of the dispensers. The ADM stated that Spanish speaking staff are in-serviced and trained on COVID precautions by their supervisor who understands English but barely speaks it. The ADM stated that the HKS is provided the written infection control policies in English and the HKS then verbally provides the in-service or trainings in Spanish. The ADM stated that the DON is in charge of Infection Control. During an observation and interview on [DATE] at 12:39 p.m. CNA C exited Resident #2's room with a N95 mask on, opened the PPE cart outside the door, grabbed a trash bag and placed trash bag on top of the PPE cart. The PPE cart had no hand sanitizer. CNA C removed her contaminated N95 mask with her bare hands, opened a closed PPE cart drawer and reached into a box and pulled out a new N95 mask. CNA C then donned the new N95 mask, grabbed the trash bag and walked down the hall. CNA C walked down the hall, opened, and closed a utility room door and then opened and entered the next utility room door. CNA C tossed the trash bag, washed her hands with soap and water and exited the utility room wearing the N95 mask. CNA C stated that she could not disinfect her hands before removing her contaminated N95 mask or before she donned a new N95 mask because there was no hand sanitizer outside of the room. CNA C stated she should have disinfected her hands after she removed her N95 mask. CNA C stated that she should not have grabbed a new N95 mask or put it on because she did not disinfect her hands. CNA C stated that COVID is spread by droplets and droplets could be on her N95 mask from Resident #2. CNA C stated when she touched the contaminated N95 mask and then touched the PPE cart and door handles, she spread COVID because her hands were not disinfected. During an observation of meal service on [DATE] at 12:52 p.m., CNA E exited Resident # 5's room wearing a N95 mask. CNA E did not remove the N95 mask and did not disinfect her hands before or after CNA E touched her N95 mask several times with her bare hands. CNA E then touched the meal tray cart and moved the cart forward. CNA E then touched a resident meal tray with her bare hands. The DON approached and was made aware of the situation and informed CNA E to disinfect her hands, remove the N95 mask, wash her hands and to put on a new mask. During an interview and observation of meal service on [DATE] at 12:55 p.m., CNA D was outside Resident #2's room and was observed placing a surgical mask on and then placing a N95 mask over it. CNA D then reached and touched an unknown resident meal tray that CNA D previously touched. The DON was in the hallway and stated that CNA D should not wear a surgical mask under the N95 mask. The DON was made aware that CNA D touched the meal tray, and the DON stated the tray was contaminated and removed the tray from meal service. During an observation and interview on [DATE] at 12:58 p.m. with CNA E and DON, CNA E was observed entering Resident #5's room wearing full PPE. CNA E exited the room with no N95 mask on. The DON stated that the sign on the door printed from the CDC provided instructions on how to DOF PPE and the DON confirmed that CNA E should have waited to remove the N95 mask until she exited the room. During an interview on [DATE] at 3:02 p.m. CNA E stated that prior to today, she had been taking off the N95 mask in the COVID positive resident rooms. CNA E stated that the DON had instructed them in the past to remove the N95 mask before they would exit the resident room but today, she was instructed to remove the N95 after exiting the positive resident room. CNA E stated that although she would disinfect her hands before she exited the resident room, she would still pull the door handle to shut the resident room and would not disinfect her hands again. CNA E stated that there is not hand sanitizer on the PPE carts and they would have to use a hand sanitizer station on the wall down the hall. CNA E stated that the posting on the resident room door instructed staff to remove the N95 after they exit the resident room. CNA E stated that COVID is airborne and is spread via droplets. CNA E stated COVID had spread in the facility with residents and staff, and she believed there were several factors contributing to the rise in facility cases. CNA E stated that staff had not followed the CDC postings on proper hand washing or wearing or taking off PPE and residents also roam the building. During an interview on [DATE] at 3:16 p.m. CNA E stated that prior to this outbreak the facility had a special unit for COVID positive residents but now residents were in several hallways. CNA E stated that she believed she wore the N-95 mask over the surgical mask so she would not have to change out the surgical mask after she exited the resident room. CNA E stated that prior to today, she would remove her mask inside of the positive covid resident room because she had been instructed to by the DON. CNA E stated that after she exited the resident room, she would have to walk down the hall to get to a hand sanitizer pump on the wall. CNA E stated that she had COVID during this outbreak. Stated that Resident #1 tested positive before she did, but she had not worked in her hall prior to when Resident #1 tested positive. CNA E stated she had been trained several times on how to correctly use PPE, DON/DOFF PPE, hand sanitizing and COVID/Infection Control. CNA E stated the risk of staff not following COVID precautions is that it could spread to other residents or other staff in the facility. During an interview on [DATE] at 4:35 p.m. the DON stated that the previous administrative staff instructed staff to spray themselves with and she stated she would personally not do it or instruct staff to do it. The DON stated that a nurse who was working the floor today tested positive for COVID and was sent home. The DON stated that the RN had worked with approximately half of the residents today. The DON stated that she never instructed staff to remove the N95 in the positive resident room and that I literally told them this morning not to not be taking them off in the room. The DON stated today there was an in-service that went over Don/doffing, handwashing, infection control. The DON stated that the HKS received the in-service in English. The DON stated I'm not saying she understands everything. She can read English. She gives the in-services to her staff in Spanish. No one is with her when she gives the in-services unless she has questions. No one oversees her giving the in-services but if you think it's something we should do then let us know. The DON stated that there is a risk of staff spreading COVID by not wearing masks properly or not sanitizing their hands. The DON stated that the infection control policies and procedures instruct staff to wear full PPE into the COVID resident room, to remove all PPE except the N95 mask before exiting the room and to disinfect hands before and after exiting the resident room and before and after replacing the N-95 mask once outside the resident room. The DON stated that by wearing and removing PPE properly and disinfecting hands it would prevent the spread of COVID-19. During an interview on [DATE] at approximately 9:40 a.m. the ADM stated that there were additional residents who tested positive since [DATE] and she would have to get the list from the DON. During an interview on [DATE] at 9:47 a.m., conducted in person and on speaker phone with an interpreter with HK B, who stated that the housekeeping supervisor (HKS) trains her on Don/Dof PPE, COVID and Infection control. HK B stated that the in-services and trainings are written in English and the HKS gives them the in-services orally in Spanish. HK B stated that on [DATE] when she exited Resident #5's room, she forgot to remove her N95 mask, and she did not remove it until after she took the trash outside. HK B stated that she did not disinfect her hands until after she came back inside from taking the trash out and removing the N95. HK B stated that she has never signed an in-service. HK B stated that she speaks, reads, and writes Spanish and cannot read English. HK B stated that if she received trainings and in-services in Spanish, it would be beneficial so she could fully understand the material. During an interview on [DATE] at 10:14 a.m. conducted in person and by speaker phone with an interpreter with HKS, who stated that the in-services are presented to her in English, and she presents them to the housekeeping staff in Spanish. HKS stated that she can read English and when there are parts of the training or in-services she does not understand, she will either ask the DON or use the computer to look up the words she does not understand. HKS stated that today the facility posted the CDC postings on DON/Doffing in both English and Spanish on the resident doors. HKS stated that it would be helpful to have in-services and trainings written in Spanish because her staff all speak Spanish and cannot read English. HKS stated that HK A should not have pulled her mask down and wiped her nose without disinfecting her hands after. HKS stated that she spoke with HK A about it and instructed her to disinfect or wash her hands. HKS stated that housekeeping has meetings every 2 weeks and staff sign the trainings during those meetings. HKS stated that if the facility puts out an in-service on a day that does not fall on her staff meeting days, she does not have staff sign the roster. HKS stated that HK B should not have left the N95 mask on when she exited Resident #5's room and she had been trained to disinfect her hands, remove the N95 mask, disinfect her hands and then put on a new clean mask. Record Review of Resident #2's nurse's note revealed Resident #2's tested positive for COVID on [DATE], and on [DATE] Resident #2 was found unresponsive with no pulse in her bed. The facility performed CPR and emergency services contacted, resident was transferred to the hospital and declared deceased . During an interview on [DATE] at 11:40 a.m. the DON stated that Resident #2 passed away at the hospital this morning. The DON stated that staff went into Resident #2's room at approximately 1:45 a.m. to complete the second round of checks for the night. The DON stated that the staff found Resident #2 unresponsive, warm and no pulse. The DON stated that staff immediately began CPR and continued until the ambulance arrived. The DON stated that Resident #2 passed away at the hospital. The DON stated that the resident had COVID and the previous weekend her oxygen levels had dropped, and she was ordered oxygen. The DON stated that the resident had been restless the previous day. The DON stated that there is another resident who is positive, Resident #10. The DON stated that there are currently 9 positive residents and 1 deceased resident. During an observation on [DATE] at 11:46 a.m. of HK F in Resident #10's room revealed HK F entered room wearing N95 mask, gown and face shield and left the resident door fully opened to the hallway. HK F was observed wiping down a table and moving items around the room with bare hands. HK F reached into her pocket and pulled out a pair of surgical gloves. HK F put on the surgical gloves and continued to clean the room with the door opened. During an interview on [DATE] at 11:00 a.m. with HK B, translated by facility staff member LVN G. LVN G stated she is fluent in English and Spanish is able to translate the interview and HK B consented to the translation by LVN G. HK B stated she was in-serviced and received hands on training on DON/DOF PPE, hand sanitizing, face masks and to keep resident doors closed. HK B stated that she is more cautious about the methods of infection control, and she stated she felt the training was beneficial because it was presented in Spanish. HK B stated that the staff had also been provided written training in Spanish. During an interview and observation on [DATE] at 11:30 a.m. with Resident #10; stated that she had been in isolation in her room for the last 3 days. Stated that her throat is raspy and sore. During an interview and observation on [DATE] at 12:14 p.m. of Resident #1 in the dining room, Resident stated that she had COVID and was on isolation for approximately ,d+[DATE] days. Resident #1 stated that she did not know where or how she contracted COVID. Record review of the facility provided policies for infection control: Handwashing/Hand Hygiene dated 2001 Medpass/Revised [DATE]: Hand hygiene is the final step after removing and disposing of PPE. Centers for Disease Control (CDC) Respirator On/Respirator Off: Remove by pulling the bottom strap over back of head, followed by the top of strap without touching the respirator. Discard in waste container. Clean your hands with alcohol-based hand sanitizer or soap and water. Centers for Disease Control (CDC) Airborne precautions: everyone must: Clean hands before entering and leaving the room. Remove respirator after exiting the room and closing the door.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property and exploitation for 1 of 5 residents (Resident #5) reviewed for neglect in that: A. The facility failed to ensure the stand-up lifts were in working order in which a resident (#5) died ; B. The facility failed to properly secure the harness straps for Resident #5 into a stand-up lift causing the resident to fall out resulting in death. On [DATE] at 9:25pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on ([DATE]) the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility's plan to monitor the plan of removal for effectiveness and train staff. This failure had the potential to affect the other 3 residents (#1, 2, and 4) who utilize a stand-up lift for transfers that reside in the facility. This failure could result in harm, injury, or death to these residents. The findings include: [DATE] Record review of R#5's current physician's orders [REDACTED]. R#5's [DIAGNOSES REDACTED]. Review of R#5's Annual Minimum Data Set ((MDS) dated [DATE] and MDS (quarterly) dated [DATE]. These reports indicated R#5, under Activities of Daily Living Assistance, required extensive assistance for transfers with a 2+ person physical assist. In addition these reports indicated R#5 utilized a wheelchair for mobility. Review of R#5's Comprehensive Plan of Care reflected the ADL Functional / Rehabilitation Potential listed a 'problem' on [DATE] with an Approach start date: [DATE] which documented Follow PT/OT recommendations: Recommend standing chair lift (2 CNA's) for all transfers following OT screen. There was another Approach for this same 'problem' dated [DATE] which reflected Provide total X two persons assistance for transferring. Record review of the Occupational Therapist's progress note dated [DATE] reflected Recommend use of standing lift (2 CNA's) for all transfers following OT Screen. Record review of incident report dated [DATE] at 8:25 AM in room [ROOM NUMBER]A states: R#5's condition before incident: normal; Does R#5 have body alarms ordered? No; If body alarms are not ordered, would this incident initiate consideration for their use? No; Were bed rails ordered? N/A; Hospice resident? No; Describe what wound/injury is and how it occurred: CNA was transferring resident on standing lift. Once he was up on lift, she rolled lift toward bathroom. Resident fell backward, hitting head on inside edge of bathroom door. 2 nurses responded immediately. Resident's eye were open. Within a couple of minutes, resident grimaced and went unconscious. RN was not able to get a pulse. EMS arrived. Resident is a DNR. Resident was pronounced deceased at facility. Physician notified at 8:35 AM; R#5 was not seen by physician and was not taken to the hospital; Family (daughter) notified at 8:45 AM and had personal conversation; EMS was called; Temp ----, Pulse 62, Resp. 10, B/P ,[DATE], O2 Stat ----; Fall; CNA #1 witness of incident and reporting incident. In an interview on [DATE] at 5:15pm CNA #1 stated that she helped R#5 to the bathroom using the stand-up lift. CNA #1 stated that she had put the harness on the back torso wrapping around to the front of the torso of R#5 putting the harness straps into the pigtail harness hooks which holds the straps and she clicked the seat belt secure. Upon raising the chair, she and R#5 heard the chair pop. CNA #1 then went to adjust the right harness strap which snapped off the hook causing R#5 to Swing outward hitting the back of his head on the edge of the door. CNA #1 stated that R#5 slumped over with the seatbelt still attached so she unlatched the belt and lowered him to the floor. CNA #1 indicated the accident occurred because the strap was not properly attached to the lift. CNA #1 stated she was the only person assisting R#5 to the restroom. CNA #1 was asked if she had been trained on using the stand-up lifts; she said yes a couple of months ago. CNA #1 stated she always transfer R#5 by herself. She continued to state the strap had slipped a couple of times before but she was always able to slip the strap down onto the pigtail hook. She stated she had never told anyone about the strap slipping. Observation of CNA#1 demonstrating step by step of how she transferred R#5 in room [ROOM NUMBER]A on [DATE] at 3:15 PM. CNA #1 demonstrated with Administrator as the resident and stated: R#5 was in the wheelchair between the bed (left side of resident) and the dresser (right side of resident) and resident was facing towards the door and bathroom. CNA #1 pushed the stand-up lift to the front of the resident's wheelchair put his feet on the foot platform and the knees against the pads for the knees and shin. She stated she put the harness behind resident, put the straps in the pigtail hooks; she buckled the torso belt around his mid-section then with the remote, she pressed the button to lift the resident. CNA #1 backed the stand-up lift towards the door and swung the stand-up lift to the right towards the bathroom. The bathroom door was open half way, CNA #1 stated the stand -up lift got here (left side of resident was facing bathroom door way and door) when she heard a pop and R#5 had look on his face of startled when he heard the pop. CNA #1 stated she looked at the right side of the lift & when she tried to move the strap down it slipped up and off hook (observed the strap was on the tip of the pigtail hook). She stated the strap came off the hook harness swung resident's right side toward the bathroom entry way and the door. When R#5 swung out, his head hit the edge of the door that houses the knob. CNA#1 stated she was holding the stand-up lift to keep the lift from turning over; she then reached over to release the seat belt on the torso and guided the resident to the floor. CNA#1 stated she called for help on the radio and then stepped into the hall looking for help. CNA #1 was questioned about the leg belt, she stated she didn't use the leg belt because R#5's left leg was contracted @ the knee from a stroke and he couldn't straighten it out and they tried to straighten he would wince; and she would not belt the right leg because the resident liked to spread his legs out once he was sitting on the toilet so could push his private part towards the toilet bowl. CNA#1 continued state the stand-up lift would stay in the bathroom with R#5 still connected to stand-up lift with harness because he was unstable to sit on toilet. Record review of CNA #1's written statement reflected that she was helping R#5 to the restroom from his wheelchair. As I (CNA #1) lifted R#5 to standing position on stand lift, the stand jerked. I immediately stopped to adjust the canvas hook. As soon as I moved the hook to adjust it came loose off metal hook. The resident's right side of body swung left causing him to hit his back of head on the inside edge of door. Record review of the resident progress note for R#5 that was entered by LVN #2 dated [DATE] at 11:55am reflected the following: This nurse to room (LVN #2). CNA #1 standing outside of room stating that resident fell out of standing lift. This nurse (LVN #2) into room. This nurse (LVN #2) to begin VS. BP ,[DATE] P62. Resident making eye contact with me when I called his name. Resident then squeezed eyes shut, opened them, and then began to slowly close them. This nurse (LVN #2) unable to palpate pulse. 0900 Resident noted with 0 breath sounds, 0 cardiac output, mottling to upper extremities. RN #1 pronounced resident (R#5) deceased . Record review of the resident progress note for R#5 that was entered by RN #1 dated [DATE] at 11:51am reflected the following: Resident had a pulse, was breathing, and would look at the person speaking to him. Charge nurse (LVN #2) had been maintaining palpable pulse and stated she couldn't feel it; Writer (RN #1) was assessing for carotid pulse and could not feel it. No heartbeat or breath sounds heard, no visible chest rise or expansion noted. Resident's hands were purple. Resident was not responsive at this point even with sternal rub. Observation on [DATE] at 5:15pm revealed the chair lift had only 1 safety catch clip attached to the pigtail harness hooks on the right side of chair, it was silver in color. The left side had the pigtail harness hook only. The stand-up lift manual was attached to the right side handle of the lift itself. In an interview on [DATE] at 8:45pm the Administrator was asked for documentation of training on stand-up lifts for the past year and she stated there wouldn't be any other in-services before [DATE] because the facility just decided this year to train on lifts annually. Record review of the facilities policy and procedure dated [DATE] and titled Runningwater Draw Care Center, Inc. Abuse Prevention Policy reflected: The Facility prohibits abuse, neglect, involuntary seclusion and misappropriation of property for all residents by training and providing ongoing supervision for employees and volunteers who provide services, whether direct caregivers or in ancillary departments. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional stress. Record review of the facilities undated policy and procedure titled Runningwater Draw Care Center, Inc. Safe Lifting and Movement of residents reflected: Policy Interpretation and Implementation: 6. Staff will be observed for competency in using stand-up lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 11. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury- prevention strategies. Record review of the facilities undated policy and procedure titled Runningwater Draw Care Center, Inc. Safety and Supervision of residents reflected: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation an Implementation: Facility-Oriented Approach to Safety: 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring . 4. Employees shall be trained and in-serviced on potential accidents and how to identify and report accident hazards, and try to prevent avoidable accidents. Systems Approach to Safety: The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. Record review of the Lift Policy reflected there were 3 versions: Record review of the facilities undated policy and procedure titled Lift Policy reflected: (Version 1 of the Lift Policy) Proper number of staff assisting specified residents during lift transfers is determined by Manufacturer specifications; Pocket Worksheet notations; and/or Care Plan. Transfer procedures are to adhere to Manufacturer's specifications. (Version 2 of the Lift Policy dated [DATE]) Due to the small stature or weakness of certain nurse aides, their use of a Standing Lift with Therapy's approval - as an exception - on specifically identified residents may be approved. Minimum number of staff required in Lift transfers are: 2 for Standing Lift 3 for Total Lift (Version 3 of the Lift Policy dated [DATE]) Minimum number of staff required in Lift transfers are: ,[DATE] for Standing Lift 3 for Total Lift Record review of the lift manufacturer's manual dated [DATE] and titled EZ Way Smart Stand 400, 500, & 800 lb. Capacities. Operator's Manual reflected: Safety Notes: All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. Raise the patient: 2. With hand control in-hand stand beside the patient. Verify the loops are properly hooked inside the pigtail at the end of the EZ WAY Smart Stand arms and Safety Catch is in place, blocking the strap from exiting through the pigtail. EZ WAY Smart Stand Safety & Maintenance Checklist: 5) Safety tabs need to be checked to make sure they are in place. 12) Do a visual check for any damaged, missing, or loose parts. Repair as necessary. Record review of the facilities Job Description For Nurse Aide reflected: Qualifications: 4. Demonstrates competency in skills and techniques necessary to care for residents' needs . Responsibilities: 2. Handling and serving residents to assure safety and comfort. Work Performed: 4. Detecting and correcting situations that have a high probability of causing accidents or injuries to resident. Job Knowledge: 5. Care of equipment and supplies. SPECIAL DEMANDS: 1. Work under close supervision with awareness that error may have serious consequences. In an interview on [DATE] at 8:45pm the Administrator stated the facility had a Lift Policy they used for a long time but decided they needed to re-vise the policy ([DATE]) identifying how many staff is required to use the Standing lift and the Total lift because some CNAs are small statured and need help with transfers but other CNAs are larger and can do it by themselves. We changed the policy again on [DATE] after deciding to change the number of staff required for the Standing lift and the Total lift. An IJ was identified on [DATE] at 9:25pm; the Administrator and DON were informed at that time. [DATE] Record reviewed on [DATE] at 12:00 PM the in-services the Administrator provided that the facility had done earlier in the day on stand-up lift and Hoyer lift transfers. Observation on [DATE] at 1:20pm revealed both of the pigtail harness hooks had safety catch clips on it. The right side had the silver colored metal rectangular shape clip and the left side had a yellow-mustard colored metal rectangular shape clip. The facility's made yellow-mustard colored metal rectangular shape clip did not appear to be the same strength as the manufacture silver colored metal rectangular shape clip. In an interview on [DATE] at 1:28pm the DON stated that the Administrator told the Maintenance Director to put clips on the stand-up lift pigtail hooks that were missing (clips). In an interview on [DATE] at 1:35pm the Administrator was asked if the facility put new clips on the stand-up lift pigtail hooks and she stated yes this morning, the Maintenance Director made them. The administrator was then asked about the stand-up lift's manufacturers recommendations (would they allow 'home-made' safety catch clips to be used in place of the original clips) she responded saying they made them because you can't buy the clips by themselves, you have to buy the whole arm which is $100. In an interview on [DATE] at 1:45pm the DON was asked if there was any other documentation on lift training other than the [DATE], [DATE], and [DATE] in-services and she replied no. The DON was asked if the facility provided training on other equipment such as wheelchairs, shower chairs, she stated if an incident occurs, we probably would. (The [DATE] & [DATE] in-services on performing lift transfers were done in response to the incident/accident that occurred with R#5 on [DATE]). In an interview on [DATE] at 1:35pm the Administrator was asked if the facility did competency checks for the stand-up lifts; she said she didn't think so then looks at the DON across the table. DON stated that the CNA Supervisor is supposed to do the competency checks. In an interview on [DATE] at 2pm the DON was asked if she had the requested documentation of the CNA competency checks and she stated there's not any, nobody here does these. In an interview on [DATE] at 2:45pm the Maintenance Director was asked if he performed maintenance checkups on the stand-up lifts, he said yes every 6 months but that he did not have documentation of these checks. The Maintenance Director said he didn't know the clips (Safety Catch) were missing, no one had told him. He was asked if he serviced the stand-up lifts today and he stated that he did (2 of the 3 standing lifts); he made the clips for the 2 stand-up lifts that were missing safety catch clips. He stated he took the original safety catch clip off and used it as his pattern to recreate the yellow-mustard color safety catch clips and put the original back on the stand-up stand and added the others to those stand-up lifts that were missing. The Maintenance Director stated he hadn't ordered any (clips) today yet; it's been a real busy day. In an interview on [DATE] at 3:11pm CNA #2 stated she had trouble twice recently with the safety catch clips because the harness would become loose as the resident began to stand when she had assisted R#5 in the same chair he fell out of. She stated that R#5 would tell her to stop because of the clip/strap was not on the hook. CNA #2 said she didn't ever tell anyone about the chair not working properly. In an interview on [DATE] at 3:15pm CNA #1 was asked if she used the knee/shin pad strap around R#5's legs when transferring him (when incident occurred) and she replied no she didn't because R#5's left leg was contracted at the knee, he would grimace when they tried. CNA #1 said she didn't strap the right leg because R#5 liked to spread his legs when sitting on the toilet so he could push his privates towards the toilet bowl. The Plan of Removal was accepted on [DATE] at 4pm. The Plan of Removal included: Immediate Action: 1. Lift was evaluated to determine there was no mechanical failure as to the lift itself. Reenactment was conducted to determine cause of the incident. 2. All residents using stand up and full body lifts for transfers were evaluated to ensure proper assignment, type of lift, and the number of staff required. 3. Care plans were reviewed and updated to reflect the newest policy and procedure on Lifts dated [DATE]. 4. New process put into place that requires a physician's orders [REDACTED]. 5. Placed order for 12 safety catch clips from the manufacturer to replace the ones that were missing on the standing lifts. 6. Transfers were demonstrated on how to use the lift. Education/In-service: 1. Began immediate in-service to all direct care staff working at the time of the incident, then continued as each new shift came on duty - prior to beginning their shift. In-servicing covered how the incident occurred, failure in securing the canvas strap, ways staff can ensure the strap is secure. Facility reminded staff of importance of being alert, monitoring of each other and taking ownership in resident safety. Reviewed lift procedures. 2. Second large group in-servicing of all direct care staff will occur on [DATE] to reiterate all aspects of use of lifts and policies including safe lifting and movement of residents, policy, safety and supervision of resident policy. Monitoring: Observed on [DATE] at 3:11 PM, CNA #2 and CNA #4 transfer resident #3 using a Hoyer lift. There were no issues noted. Observed on [DATE] at 8:31pm, CNA #3 and CNA #5 transfer resident #1 using a stand up lift. There were no issues noted. In an interview on [DATE] at 12:35pm, CNA #6 stated that she was in-serviced first thing on the morning of [DATE]. It included making sure the straps are on correctly, yanking on strap 3 times to make sure straps are on. CNA #6 stated prior to this incident; about a month ago, staff had an in-service on the lift; 2 to transfer at all times. CNA #4 stated when a new CNA starts, she (CNA #6) as a CNA shows the new CNA how to use the lifts. CNA #6 stated that no one watches staff do lifts but 1 time. In an interview on [DATE] at 12:52pm, LVN #3 stated she had been in-serviced that day by demonstration and discussed the possibilities of what could go wrong. In an interview on [DATE] at 12:55pm, LVN #4 stated he had been in-serviced that day on doing a triple check when using a stand up lift pulling on the strap to make sure it doesn't pop off. They went over the belt, harness and having the resident's knees up against the shin guards. In an interview on [DATE] at 1:00pm, CNA #6 stated that she was in-serviced when she came today. CNA #6 said when she began working at the facility, CNA #8 trained her; staff would supervise her and help with lift for one week. CNA #6 said she transferred resident #5 by herself last Saturday, at other times the transfer was with 2 people. In an interview on [DATE] at 2:17pm, the Administrator said the facility changed the process on how lifts chairs are determined for resident. She said the old way was using a communication note staff and it was implemented through therapy, not a doctor's order. She said the new way was going to be getting a doctor's order for all residents determined to need a lift. In an interview on [DATE] at 3:25pm, CNA #4 and LVN #2 and 4 were asked if they had been in-serviced regarding the use of lifts and all replied that they had been. Record review of facility's in-services on stand-up l lifts policies and procedures revealed on [DATE] at 10:30 AM nine staff members attended; [DATE] on the 2 PM to 10 PM shift 7 staff members attended. Interview on [DATE] at 8:00 PM, Administrator stated an in-service is schedule for all staff on that following Tuesday, [DATE]. The Administrator was informed on [DATE] at 4pm that the IJ had been removed and scope of Harm and severity of Isolation. However, the facility remained out of compliance at a scoped of isolated and a severity of actual harm that is not an IJ due to facility needing to train all staff and monitor their plan. Record review of a resident list that was provided by the Administrator on [DATE] documented there were 69 residents who resided at the facility, 3 of which required a standing lift and 1 Hoyer lift.

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for 1 of 5 residents (Resident #5) reviewed for neglect in that: A. Certified Nursing Assistant (CNA) #1 did not have Resident #5's standing lift harness properly attached to the lift. The harness slipped off causing resident #5 to fall hitting his head and resulted in death. B. The facility failed to ensure the mechanical lifts were working properly. C. The facility failed to have competency checks on staff regarding the use of mechanical lifts. On [DATE] at 9:25pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on ([DATE]) the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility's plan to monitor the plan of removal for effectiveness and train staff. This failure had the potential to affect the other 3 residents (#1, 2, and 4) who utilize a stand-up lift for transfers that reside in the facility. This failure could result in harm, injury, or death to these residents. The findings include: [DATE] Record review of the facilities policy and procedure dated [DATE] and titled Runningwater Draw Care Center, Inc. Abuse Prevention Policy reflected: The Facility prohibits abuse, neglect, involuntary seclusion and misappropriation of property for all residents by training and providing ongoing supervision for employees and volunteers who provide services, whether direct caregivers or in ancillary departments. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional stress. Record review of the facilities undated policy and procedure titled Runningwater Draw Care Center, Inc. Safe Lifting and Movement of residents reflected: Policy Interpretation and Implementation: 6. Staff will be observed for competency in using stand-up lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 11. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury- prevention strategies. Record review of the facilities undated policy and procedure titled Runningwater Draw Care Center, Inc. Safety and Supervision of residents reflected: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation an Implementation: Facility-Oriented Approach to Safety: 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring . 4. Employees shall be trained and in-serviced on potential accidents and how to identify and report accident hazards, and try to prevent avoidable accidents. Systems Approach to Safety: The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. Record review of the Lift Policy reflected there were 3 versions: Record review of the facilities undated policy and procedure titled Lift Policy reflected: (Version 1 of the Lift Policy) Proper number of staff assisting specified residents during lift transfers is determined by Manufacturer specifications; Pocket Worksheet notations; and/or Care Plan. Transfer procedures are to adhere to Manufacturer's specifications. (Version 2 of the Lift Policy dated [DATE]) Due to the small stature or weakness of certain nurse aides, their use of a Standing Lift with Therapy's approval - as an exception - on specifically identified residents may be approved. Minimum number of staff required in Lift transfers are: 2 for Standing Lift 3 for Total Lift (Version 3 of the Lift Policy dated [DATE]) Minimum number of staff required in Lift transfers are: ,[DATE] for Standing Lift 3 for Total Lift Record review of the lift manufacturer's manual dated [DATE] and titled EZ Way Smart Stand 400, 500, & 800 lb. Capacities. Operator's Manual reflected: Safety Notes: All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. Raise the patient: 2. With hand control in-hand stand beside the patient. Verify the loops are properly hooked inside the pigtail at the end of the EZ WAY Smart Stand arms and Safety Catch is in place, blocking the strap from exiting through the pigtail. EZ WAY Smart Stand Safety & Maintenance Checklist: 5) Safety tabs need to be checked to make sure they are in place. 12) Do a visual check for any damaged, missing, or loose parts. Repair as necessary. Record review of the facilities Job Description For Nurse Aide reflected: Qualifications: 4. Demonstrates competency in skills and techniques necessary to care for residents' needs . Responsibilities: 2. Handling and serving residents to assure safety and comfort. Work Performed: 4. Detecting and correcting situations that have a high probability of causing accidents or injuries to resident. Job Knowledge: 5. Care of equipment and supplies. SPECIAL DEMANDS: 1. Work under close supervision with awareness that error may have serious consequences. Record review of R#5's current physician's orders [REDACTED]. R#5's [DIAGNOSES REDACTED]. Review of R#5's Annual Minimum Data Set ((MDS) dated [DATE] and MDS (quarterly) dated [DATE]. These reports indicated R#5, under Activities of Daily Living Assistance, required extensive assistance for transfers with a 2+ person physical assist. In addition these reports indicated R#5 utilized a wheelchair for mobility. Review of R#5's Comprehensive Plan of Care reflected the ADL Functional / Rehabilitation Potential listed a 'problem' on [DATE] with an Approach start date: [DATE] which documented Follow PT/OT recommendations: Recommend standing chair lift (2 CNA's) for all transfers following OT screen. There was another Approach for this same 'problem' dated [DATE] which reflected Provide total X two persons assistance for transferring. Record review of the Occupational Therapist's progress note dated [DATE] reflected Recommend use of standing lift (2 CNA's) for all transfers following OT Screen. Record review of incident report dated [DATE] at 8:25 AM in room [ROOM NUMBER]A states: R#5's condition before incident: normal; Does R#5 have body alarms ordered? No; If body alarms are not ordered, would this incident initiate consideration for their use? No; Were bed rails ordered? N/A; Hospice resident? No; Describe what wound/injury is and how it occurred: CNA was transferring resident on standing lift. Once he was up on lift, she rolled lift toward bathroom. Resident fell backward, hitting head on inside edge of bathroom door. 2 nurses responded immediately. Resident's eye were open. Within a couple of minutes, resident grimaced and went unconscious. RN was not able to get a pulse. EMS arrived. Resident is a DNR. Resident was pronounced deceased at facility. Physician notified at 8:35 AM; R#5 was not seen by physician and was not taken to the hospital; Family (daughter) notified at 8:45 AM and had personal conversation; EMS was called; Temp ----, Pulse 62, Resp. 10, B/P ,[DATE], O2 Stat ----; Fall; CNA #1 witness of incident and reporting incident. In an interview on [DATE] at 5:15pm CNA #1 stated that she helped R#5 to the bathroom using the stand-up lift. CNA #1 stated that she had put the harness on the back torso wrapping around to the front of the torso of R#5 putting the harness straps into the pigtail harness hooks which holds the straps and she clicked the seat belt secure. Upon raising the chair, she and R#5 heard the chair pop. CNA #1 then went to adjust the right harness strap which snapped off the hook causing R#5 to Swing outward hitting the back of his head on the edge of the door. CNA #1 stated that R#5 slumped over with the seatbelt still attached so she unlatched the belt and lowered him to the floor. CNA #1 indicated the accident occurred because the strap was not properly attached to the lift. CNA #1 stated she was the only person assisting R#5 to the restroom. CNA #1 was asked if she had been trained on using the stand-up lifts; she said yes a couple of months ago. CNA #1 stated she always transfer R#5 by herself. She continued to state the strap had slipped a couple of times before but she was always able to slip the strap down onto the pigtail hook. She stated she had never told anyone about the strap slipping. Observation of CNA#1 demonstrating step by step of how she transferred R#5 in room [ROOM NUMBER]A on [DATE] at 3:15 PM. CNA #1 demonstrated with Administrator as the resident and stated: R#5 was in the wheelchair between the bed (left side of resident) and the dresser (right side of resident) and resident was facing towards the door and bathroom. CNA #1 pushed the stand-up lift to the front of the resident's wheelchair put his feet on the foot platform and the knees against the pads for the knees and shin. She stated she put the harness behind resident, put the straps in the pigtail hooks; she buckled the torso belt around his mid-section then with the remote, she pressed the button to lift the resident. CNA #1 backed the stand-up lift towards the door and swung the stand-up lift to the right towards the bathroom. The bathroom door was open half way, CNA #1 stated the stand -up lift got here (left side of resident was facing bathroom door way and door) when she heard a pop and R#5 had look on his face of startled when he heard the pop. CNA #1 stated she looked at the right side of the lift & when she tried to move the strap down it slipped up and off hook (observed the strap was on the tip of the pigtail hook). She stated the strap came off the hook harness swung resident's right side toward the bathroom entry way and the door. When R#5 swung out, his head hit the edge of the door that houses the knob. CNA#1 stated she was holding the stand-up lift to keep the lift from turning over; she then reached over to release the seat belt on the torso and guided the resident to the floor. CNA#1 stated she called for help on the radio and then stepped into the hall looking for help. CNA #1 was questioned about the leg belt, she stated she didn't use the leg belt because R#5's left leg was contracted @ the knee from a stroke and he couldn't straighten it out and they tried to straighten he would wince; and she would not belt the right leg because the resident liked to spread his legs out once he was sitting on the toilet so could push his private part towards the toilet bowl. CNA#1 continued state the stand-up lift would stay in the bathroom with R#5 still connected to stand-up lift with harness because he was unstable to sit on toilet. Record review of CNA #1's written statement reflected that she was helping R#5 to the restroom from his wheelchair. As I (CNA #1) lifted R#5 to standing position on stand lift, the stand jerked. I immediately stopped to adjust the canvas hook. As soon as I moved the hook to adjust it came loose off metal hook. The resident's right side of body swung left causing him to hit his back of head on the inside edge of door. Record review of the resident progress note for R#5 that was entered by LVN #2 dated [DATE] at 11:55am reflected the following: This nurse to room (LVN #2). CNA #1 standing outside of room stating that resident fell out of standing lift. This nurse (LVN #2) into room. This nurse (LVN #2) to begin VS. BP ,[DATE] P62. Resident making eye contact with me when I called his name. Resident then squeezed eyes shut, opened them, and then began to slowly close them. This nurse (LVN #2) unable to palpate pulse. 0900 Resident noted with 0 breath sounds, 0 cardiac output, mottling to upper extremities. RN #1 pronounced resident (R#5) deceased . Record review of the resident progress note for R#5 that was entered by RN #1 dated [DATE] at 11:51am reflected the following: Resident had a pulse, was breathing, and would look at the person speaking to him. Charge nurse (LVN #2) had been maintaining palpable pulse and stated she couldn't feel it; Writer (RN #1) was assessing for carotid pulse and could not feel it. No heartbeat or breath sounds heard, no visible chest rise or expansion noted. Resident's hands were purple. Resident was not responsive at this point even with sternal rub. Observation on [DATE] at 5:15pm revealed the chair lift had only 1 safety catch clip attached to the pigtail harness hooks on the right side of chair, it was silver in color. The left side had the pigtail harness hook only. The stand-up lift manual was attached to the right side handle of the lift itself. In an interview on [DATE] at 8:45pm the Administrator was asked for documentation of training on stand-up lifts for the past year and she stated there wouldn't be any other in-services before [DATE] because the facility just decided this year to train on lifts annually. In an interview on [DATE] at 8:45pm the Administrator stated the facility had a Lift Policy they used for a long time but decided they needed to re-vise the policy ([DATE]) identifying how many staff is required to use the Standing lift and the Total lift because some CNAs are small statured and need help with transfers but other CNAs are larger and can do it by themselves. We changed the policy again on [DATE] after deciding to change the number of staff required for the Standing lift and the Total lift. An IJ was identified on [DATE] at 9:25pm; the Administrator and DON were informed at that time. [DATE] Record reviewed on [DATE] at 12:00 PM the in-services the Administrator provided that the facility had done earlier in the day on stand-up lift and Hoyer lift transfers. Observation on [DATE] at 1:20pm revealed both of the pigtail harness hooks had safety catch clips on it. The right side had the silver colored metal rectangular shape clip and the left side had a yellow-mustard colored metal rectangular shape clip. The facility's made yellow-mustard colored metal rectangular shape clip did not appear to be the same strength as the manufacture silver colored metal rectangular shape clip. In an interview on [DATE] at 1:28pm the DON stated that the Administrator told the Maintenance Director to put clips on the stand-up lift pigtail hooks that were missing (clips). In an interview on [DATE] at 1:35pm the Administrator was asked if the facility put new clips on the stand-up lift pigtail hooks and she stated yes this morning, the Maintenance Director made them. The administrator was then asked about the stand-up lift's manufacturers recommendations (would they allow 'home-made' safety catch clips to be used in place of the original clips) she responded saying they made them because you can't buy the clips by themselves, you have to buy the whole arm which is $100. In an interview on [DATE] at 1:45pm the DON was asked if there was any other documentation on lift training other than the [DATE], [DATE], and [DATE] in-services and she replied no. The DON was asked if the facility provided training on other equipment such as wheelchairs, shower chairs, she stated if an incident occurs, we probably would. (The [DATE] & [DATE] in-services on performing lift transfers were done in response to the incident/accident that occurred with R#5 on [DATE]). In an interview on [DATE] at 1:35pm the Administrator was asked if the facility did competency checks for the stand-up lifts; she said she didn't think so then looks at the DON across the table. DON stated that the CNA Supervisor is supposed to do the competency checks. In an interview on [DATE] at 2pm the DON was asked if she had the requested documentation of the CNA competency checks and she stated there's not any, nobody here does these. In an interview on [DATE] at 2:45pm the Maintenance Director was asked if he performed maintenance checkups on the stand-up lifts, he said yes every 6 months but that he did not have documentation of these checks. The Maintenance Director said he didn't know the clips (Safety Catch) were missing, no one had told him. He was asked if he serviced the stand-up lifts today and he stated that he did (2 of the 3 standing lifts); he made the clips for the 2 stand-up lifts that were missing safety catch clips. He stated he took the original safety catch clip off and used it as his pattern to recreate the yellow-mustard color safety catch clips and put the original back on the stand-up stand and added the others to those stand-up lifts that were missing. The Maintenance Director stated he hadn't ordered any (clips) today yet; it's been a real busy day. In an interview on [DATE] at 3:11pm CNA #2 stated she had trouble twice recently with the safety catch clips because the harness would become loose as the resident began to stand when she had assisted R#5 in the same chair he fell out of. She stated that R#5 would tell her to stop because of the clip/strap was not on the hook. CNA #2 said she didn't ever tell anyone about the chair not working properly. In an interview on [DATE] at 3:15pm CNA #1 was asked if she used the knee/shin pad strap around R#5's legs when transferring him (when incident occurred) and she replied no she didn't because R#5's left leg was contracted at the knee, he would grimace when they tried. CNA #1 said she didn't strap the right leg because R#5 liked to spread his legs when sitting on the toilet so he could push his privates towards the toilet bowl. The Plan of Removal was accepted on [DATE] at 4pm. The Plan of Removal included: Immediate Action: 1. Lift was evaluated to determine there was no mechanical failure as to the lift itself. Reenactment was conducted to determine cause of the incident. 2. All residents using stand up and full body lifts for transfers were evaluated to ensure proper assignment, type of lift, and the number of staff required. 3. Care plans were reviewed and updated to reflect the newest policy and procedure on Lifts dated [DATE]. 4. New process put into place that requires a physician's orders [REDACTED]. 5. Placed order for 12 safety catch clips from the manufacturer to replace the ones that were missing on the standing lifts. 6. Transfers were demonstrated on how to use the lift. Education/In-service: 1. Began immediate in-service to all direct care staff working at the time of the incident, then continued as each new shift came on duty - prior to beginning their shift. In-servicing covered how the incident occurred, failure in securing the canvas strap, ways staff can ensure the strap is secure. Facility reminded staff of importance of being alert, monitoring of each other and taking ownership in resident safety. Reviewed lift procedures. 2. Second large group in-servicing of all direct care staff will occur on [DATE] to reiterate all aspects of use of lifts and policies including safe lifting and movement of residents, policy, safety and supervision of resident policy. Monitoring: Observed on [DATE] at 3:11 PM, CNA #2 and CNA #4 transfer resident #3 using a Hoyer lift. There were no issues noted. Observed on [DATE] at 8:31pm, CNA #3 and CNA #5 transfer resident #1 using a stand up lift. There were no issues noted. In an interview on [DATE] at 12:35pm, CNA #6 stated that she was in-serviced first thing on the morning of [DATE]. It included making sure the straps are on correctly, yanking on strap 3 times to make sure straps are on. CNA #6 stated prior to this incident; about a month ago, staff had an in-service on the lift; 2 to transfer at all times. CNA #4 stated when a new CNA starts, she (CNA #6) as a CNA shows the new CNA how to use the lifts. CNA #6 stated that no one watches staff do lifts but 1 time. In an interview on [DATE] at 12:52pm, LVN #3 stated she had been in-serviced that day by demonstration and discussed the possibilities of what could go wrong. In an interview on [DATE] at 12:55pm, LVN #4 stated he had been in-serviced that day on doing a triple check when using a stand up lift pulling on the strap to make sure it doesn't pop off. They went over the belt, harness and having the resident's knees up against the shin guards. In an interview on [DATE] at 1:00pm, CNA #6 stated that she was in-serviced when she came today. CNA #6 said when she began working at the facility, CNA #8 trained her; staff would supervise her and help with lift for one week. CNA #6 said she transferred resident #5 by herself last Saturday, at other times the transfer was with 2 people. In an interview on [DATE] at 2:17pm, the Administrator said the facility changed the process on how lifts chairs are determined for resident. She said the old way was using a communication note staff and it was implemented through therapy, not a doctor's order. She said the new way was going to be getting a doctor's order for all residents determined to need a lift. In an interview on [DATE] at 3:25pm, CNA #4 and LVN #2 and 4 were asked if they had been in-serviced regarding the use of lifts and all replied that they had been. Record review of facility's in-services on stand-up l lifts policies and procedures revealed on [DATE] at 10:30 AM nine staff members attended; [DATE] on the 2 PM to 10 PM shift 7 staff members attended. Interview on [DATE] at 8:00 PM, Administrator stated an in-service is schedule for all staff on that following Tuesday, [DATE]. The Administrator was informed on [DATE] at 4pm that the IJ had been removed and scope of Harm and severity of Isolation. However, the facility remained out of compliance at a scoped of isolated and a severity of actual harm that is not an IJ due to facility needing to train all staff and monitor their plan. Record review of a resident list that was provided by the Administrator on [DATE] documented there were 69 residents who resided at the facility, 3 of which required a standing lift and 1 Hoyer lift.

Based on observation, interview, and record review, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (#5): A. The facility failed to ensure the stand-up lifts were in working order in which a resident (#5) died ; B. The facility failed to properly secure the harness straps for Resident #5 into a stand-up lift causing the resident to fall out resulting in death. On [DATE] at 9:25pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on ([DATE]) the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility's plan to monitor the plan of removal for effectiveness and train staff. This failure had the potential to affect the other 3 residents (#1, 2, and 4) who utilize a stand-up lift for transfers that reside in the facility. This failure could result in harm, injury, or death to these residents. The findings include: [DATE] Record review of R#5's current physician's orders [REDACTED]. R#5's [DIAGNOSES REDACTED]. Review of R#5's Annual Minimum Data Set ((MDS) dated [DATE] and MDS (quarterly) dated [DATE]. These reports indicated R#5, under Activities of Daily Living Assistance, required extensive assistance for transfers with a 2+ person physical assist. In addition these reports indicated R#5 utilized a wheelchair for mobility. Review of R#5's Comprehensive Plan of Care reflected the ADL Functional / Rehabilitation Potential listed a 'problem' on [DATE] with an Approach start date: [DATE] which documented Follow PT/OT recommendations: Recommend standing chair lift (2 CNA's) for all transfers following OT screen. There was another Approach for this same 'problem' dated [DATE] which reflected Provide total X two persons assistance for transferring. Record review of the Occupational Therapist's progress note dated [DATE] reflected Recommend use of standing lift (2 CNA's) for all transfers following OT Screen. Record review of incident report dated [DATE] at 8:25 AM in room 23A states: R#5's condition before incident: normal; Does R#5 have body alarms ordered? No; If body alarms are not ordered, would this incident initiate consideration for their use? No; Were bed rails ordered? N/A; Hospice resident? No; Describe what wound/injury is and how it occurred: CNA was transferring resident on standing lift. Once he was up on lift, she rolled lift toward bathroom. Resident fell backward, hitting head on inside edge of bathroom door. 2 nurses responded immediately. Resident's eye were open. Within a couple of minutes, resident grimaced and went unconscious. RN was not able to get a pulse. EMS arrived. Resident is a DNR. Resident was pronounced deceased at facility. Physician notified at 8:35 AM; R#5 was not seen by physician and was not taken to the hospital; Family (daughter) notified at 8:45 AM and had personal conversation; EMS was called; Temp ----, Pulse 62, Resp. 10, B/P ,[DATE], O2 Stat ----; Fall; CNA #1 witness of incident and reporting incident. In an interview on [DATE] at 5:15pm CNA #1 stated that she helped R#5 to the bathroom using the stand-up lift. CNA #1 stated that she had put the harness on the back torso wrapping around to the front of the torso of R#5 putting the harness straps into the pigtail harness hooks which holds the straps and she clicked the seat belt secure. Upon raising the chair, she and R#5 heard the chair pop. CNA #1 then went to adjust the right harness strap which snapped off the hook causing R#5 to Swing outward hitting the back of his head on the edge of the door. CNA #1 stated that R#5 slumped over with the seatbelt still attached so she unlatched the belt and lowered him to the floor. CNA #1 indicated the accident occurred because the strap was not properly attached to the lift. CNA #1 stated she was the only person assisting R#5 to the restroom. CNA #1 was asked if she had been trained on using the stand-up lifts; she said yes a couple of months ago. CNA #1 stated she always transfer R#5 by herself. She continued to state the strap had slipped a couple of times before but she was always able to slip the strap down onto the pigtail hook. She stated she had never told anyone about the strap slipping. Observation of CNA#1 demonstrating step by step of how she transferred R#5 in room 23A on [DATE] at 3:15 PM. CNA #1 demonstrated with Administrator as the resident and stated: R#5 was in the wheelchair between the bed (left side of resident) and the dresser (right side of resident) and resident was facing towards the door and bathroom. CNA #1 pushed the stand-up lift to the front of the resident's wheelchair put his feet on the foot platform and the knees against the pads for the knees and shin. She stated she put the harness behind resident, put the straps in the pigtail hooks; she buckled the torso belt around his mid-section then with the remote, she pressed the button to lift the resident. CNA #1 backed the stand-up lift towards the door and swung the stand-up lift to the right towards the bathroom. The bathroom door was open half way, CNA #1 stated the stand -up lift got here (left side of resident was facing bathroom door way and door) when she heard a pop and R#5 had look on his face of startled when he heard the pop. CNA #1 stated she looked at the right side of the lift & when she tried to move the strap down it slipped up and off hook (observed the strap was on the tip of the pigtail hook). She stated the strap came off the hook harness swung resident's right side toward the bathroom entry way and the door. When R#5 swung out, his head hit the edge of the door that houses the knob. CNA#1 stated she was holding the stand-up lift to keep the lift from turning over; she then reached over to release the seat belt on the torso and guided the resident to the floor. CNA#1 stated she called for help on the radio and then stepped into the hall looking for help. CNA #1 was questioned about the leg belt, she stated she didn't use the leg belt because R#5's left leg was contracted @ the knee from a stroke and he couldn't straighten it out and they tried to straighten he would wince; and she would not belt the right leg because the resident liked to spread his legs out once he was sitting on the toilet so could push his private part towards the toilet bowl. CNA#1 continued state the stand-up lift would stay in the bathroom with R#5 still connected to stand-up lift with harness because he was unstable to sit on toilet. Record review of CNA #1's written statement reflected that she was helping R#5 to the restroom from his wheelchair. As I (CNA #1) lifted R#5 to standing position on stand lift, the stand jerked. I immediately stopped to adjust the canvas hook. As soon as I moved the hook to adjust it came loose off metal hook. The resident's right side of body swung left causing him to hit his back of head on the inside edge of door. Record review of the resident progress note for R#5 that was entered by LVN #2 dated [DATE] at 11:55am reflected the following: This nurse to room (LVN #2). CNA #1 standing outside of room stating that resident fell out of standing lift. This nurse (LVN #2) into room. This nurse (LVN #2) to begin VS. BP ,[DATE] P62. Resident making eye contact with me when I called his name. Resident then squeezed eyes shut, opened them, and then began to slowly close them. This nurse (LVN #2) unable to palpate pulse. 0900 Resident noted with 0 breath sounds, 0 cardiac output, mottling to upper extremities. RN #1 pronounced resident (R#5) deceased . Record review of the resident progress note for R#5 that was entered by RN #1 dated [DATE] at 11:51am reflected the following: Resident had a pulse, was breathing, and would look at the person speaking to him. Charge nurse (LVN #2) had been maintaining palpable pulse and stated she couldn't feel it; Writer (RN #1) was assessing for carotid pulse and could not feel it. No heartbeat or breath sounds heard, no visible chest rise or expansion noted. Resident's hands were purple. Resident was not responsive at this point even with sternal rub. Observation on [DATE] at 5:15pm revealed the chair lift had only 1 safety catch clip attached to the pigtail harness hooks on the right side of chair, it was silver in color. The left side had the pigtail harness hook only. The stand-up lift manual was attached to the right side handle of the lift itself. In an interview on [DATE] at 8:45pm the Administrator was asked for documentation of training on stand-up lifts for the past year and she stated there wouldn't be any other in-services before [DATE] because the facility just decided this year to train on lifts annually. Record review of the facilities policy and procedure dated [DATE] and titled Runningwater Draw Care Center, Inc. Abuse Prevention Policy reflected: The Facility prohibits abuse, neglect, involuntary seclusion and misappropriation of property for all residents by training and providing ongoing supervision for employees and volunteers who provide services, whether direct caregivers or in ancillary departments. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional stress. Record review of the facilities undated policy and procedure titled Runningwater Draw Care Center, Inc. Safe Lifting and Movement of residents reflected: Policy Interpretation and Implementation: 6. Staff will be observed for competency in using stand-up lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 9. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. 11. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury- prevention strategies. Record review of the facilities undated policy and procedure titled Runningwater Draw Care Center, Inc. Safety and Supervision of residents reflected: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation an Implementation: Facility-Oriented Approach to Safety: 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring . 4. Employees shall be trained and in-serviced on potential accidents and how to identify and report accident hazards, and try to prevent avoidable accidents. Systems Approach to Safety: The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. Record review of the Lift Policy reflected there were 3 versions: Record review of the facilities undated policy and procedure titled Lift Policy reflected: (Version 1 of the Lift Policy) Proper number of staff assisting specified residents during lift transfers is determined by Manufacturer specifications; Pocket Worksheet notations; and/or Care Plan. Transfer procedures are to adhere to Manufacturer's specifications. (Version 2 of the Lift Policy dated [DATE]) Due to the small stature or weakness of certain nurse aides, their use of a Standing Lift with Therapy's approval - as an exception - on specifically identified residents may be approved. Minimum number of staff required in Lift transfers are: 2 for Standing Lift 3 for Total Lift (Version 3 of the Lift Policy dated [DATE]) Minimum number of staff required in Lift transfers are: ,[DATE] for Standing Lift 3 for Total Lift Record review of the lift manufacturer's manual dated [DATE] and titled EZ Way Smart Stand 400, 500, & 800 lb. Capacities. Operator's Manual reflected: Safety Notes: All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. Raise the patient: 2. With hand control in-hand stand beside the patient. Verify the loops are properly hooked inside the pigtail at the end of the EZ WAY Smart Stand arms and Safety Catch is in place, blocking the strap from exiting through the pigtail. EZ WAY Smart Stand Safety & Maintenance Checklist: 5) Safety tabs need to be checked to make sure they are in place. 12) Do a visual check for any damaged, missing, or loose parts. Repair as necessary. Record review of the facilities Job Description For Nurse Aide reflected: Qualifications: 4. Demonstrates competency in skills and techniques necessary to care for residents' needs . Responsibilities: 2. Handling and serving residents to assure safety and comfort. Work Performed: 4. Detecting and correcting situations that have a high probability of causing accidents or injuries to resident. Job Knowledge: 5. Care of equipment and supplies. SPECIAL DEMANDS: 1. Work under close supervision with awareness that error may have serious consequences. In an interview on [DATE] at 8:45pm the Administrator stated the facility had a Lift Policy they used for a long time but decided they needed to re-vise the policy ([DATE]) identifying how many staff is required to use the Standing lift and the Total lift because some CNAs are small statured and need help with transfers but other CNAs are larger and can do it by themselves. We changed the policy again on [DATE] after deciding to change the number of staff required for the Standing lift and the Total lift. An IJ was identified on [DATE] at 9:25pm; the Administrator and DON were informed at that time. [DATE] Record reviewed on [DATE] at 12:00 PM the in-services the Administrator provided that the facility had done earlier in the day on stand-up lift and Hoyer lift transfers. Observation on [DATE] at 1:20pm revealed both of the pigtail harness hooks had safety catch clips on it. The right side had the silver colored metal rectangular shape clip and the left side had a yellow-mustard colored metal rectangular shape clip. The facility's made yellow-mustard colored metal rectangular shape clip did not appear to be the same strength as the manufacture silver colored metal rectangular shape clip. In an interview on [DATE] at 1:28pm the DON stated that the Administrator told the Maintenance Director to put clips on the stand-up lift pigtail hooks that were missing (clips). In an interview on [DATE] at 1:35pm the Administrator was asked if the facility put new clips on the stand-up lift pigtail hooks and she stated yes this morning, the Maintenance Director made them. The administrator was then asked about the stand-up lift's manufacturers recommendations (would they allow 'home-made' safety catch clips to be used in place of the original clips) she responded saying they made them because you can't buy the clips by themselves, you have to buy the whole arm which is $100. In an interview on [DATE] at 1:45pm the DON was asked if there was any other documentation on lift training other than the [DATE], [DATE], and [DATE] in-services and she replied no. The DON was asked if the facility provided training on other equipment such as wheelchairs, shower chairs, she stated if an incident occurs, we probably would. (The [DATE] & [DATE] in-services on performing lift transfers were done in response to the incident/accident that occurred with R#5 on [DATE]). In an interview on [DATE] at 1:35pm the Administrator was asked if the facility did competency checks for the stand-up lifts; she said she didn't think so then looks at the DON across the table. DON stated that the CNA Supervisor is supposed to do the competency checks. In an interview on [DATE] at 2pm the DON was asked if she had the requested documentation of the CNA competency checks and she stated there's not any, nobody here does these. In an interview on [DATE] at 2:45pm the Maintenance Director was asked if he performed maintenance checkups on the stand-up lifts, he said yes every 6 months but that he did not have documentation of these checks. The Maintenance Director said he didn't know the clips (Safety Catch) were missing, no one had told him. He was asked if he serviced the stand-up lifts today and he stated that he did (2 of the 3 standing lifts); he made the clips for the 2 stand-up lifts that were missing safety catch clips. He stated he took the original safety catch clip off and used it as his pattern to recreate the yellow-mustard color safety catch clips and put the original back on the stand-up stand and added the others to those stand-up lifts that were missing. The Maintenance Director stated he hadn't ordered any (clips) today yet; it's been a real busy day. In an interview on [DATE] at 3:11pm CNA #2 stated she had trouble twice recently with the safety catch clips because the harness would become loose as the resident began to stand when she had assisted R#5 in the same chair he fell out of. She stated that R#5 would tell her to stop because of the clip/strap was not on the hook. CNA #2 said she didn't ever tell anyone about the chair not working properly. In an interview on [DATE] at 3:15pm CNA #1 was asked if she used the knee/shin pad strap around R#5's legs when transferring him (when incident occurred) and she replied no she didn't because R#5's left leg was contracted at the knee, he would grimace when they tried. CNA #1 said she didn't strap the right leg because R#5 liked to spread his legs when sitting on the toilet so he could push his privates towards the toilet bowl. The Plan of Removal was accepted on [DATE] at 4pm. The Plan of Removal included: Immediate Action: 1. Lift was evaluated to determine there was no mechanical failure as to the lift itself. Reenactment was conducted to determine cause of the incident. 2. All residents using stand up and full body lifts for transfers were evaluated to ensure proper assignment, type of lift, and the number of staff required. 3. Care plans were reviewed and updated to reflect the newest policy and procedure on Lifts dated [DATE]. 4. New process put into place that requires a physician's orders [REDACTED]. 5. Placed order for 12 safety catch clips from the manufacturer to replace the ones that were missing on the standing lifts. 6. Transfers were demonstrated on how to use the lift. Education/In-service: 1. Began immediate in-service to all direct care staff working at the time of the incident, then continued as each new shift came on duty - prior to beginning their shift. In-servicing covered how the incident occurred, failure in securing the canvas strap, ways staff can ensure the strap is secure. Facility reminded staff of importance of being alert, monitoring of each other and taking ownership in resident safety. Reviewed lift procedures. 2. Second large group in-servicing of all direct care staff will occur on [DATE] to reiterate all aspects of use of lifts and policies including safe lifting and movement of residents, policy, safety and supervision of resident policy. Monitoring: Observed on [DATE] at 3:11 PM, CNA #2 and CNA #4 transfer resident #3 using a Hoyer lift. There were no issues noted. Observed on [DATE] at 8:31pm, CNA #3 and CNA #5 transfer resident #1 using a stand up lift. There were no issues noted. In an interview on [DATE] at 12:35pm, CNA #6 stated that she was in-serviced first thing on the morning of [DATE]. It included making sure the straps are on correctly, yanking on strap 3 times to make sure straps are on. CNA #6 stated prior to this incident; about a month ago, staff had an in-service on the lift; 2 to transfer at all times. CNA #4 stated when a new CNA starts, she (CNA #6) as a CNA shows the new CNA how to use the lifts. CNA #6 stated that no one watches staff do lifts but 1 time. In an interview on [DATE] at 12:52pm, LVN #3 stated she had been in-serviced that day by demonstration and discussed the possibilities of what could go wrong. In an interview on [DATE] at 12:55pm, LVN #4 stated he had been in-serviced that day on doing a triple check when using a stand up lift pulling on the strap to make sure it doesn't pop off. They went over the belt, harness and having the resident's knees up against the shin guards. In an interview on [DATE] at 1:00pm, CNA #6 stated that she was in-serviced when she came today. CNA #6 said when she began working at the facility, CNA #8 trained her; staff would supervise her and help with lift for one week. CNA #6 said she transferred resident #5 by herself last Saturday, at other times the transfer was with 2 people. In an interview on [DATE] at 2:17pm, the Administrator said the facility changed the process on how lifts chairs are determined for resident. She said the old way was using a communication note staff and it was implemented through therapy, not a doctor's order. She said the new way was going to be getting a doctor's order for all residents determined to need a lift. In an interview on [DATE] at 3:25pm, CNA #4 and LVN #2 and 4 were asked if they had been in-serviced regarding the use of lifts and all replied that they had been. Record review of facility's in-services on stand-up l lifts policies and procedures revealed on [DATE] at 10:30 AM nine staff members attended; [DATE] on the 2 PM to 10 PM shift 7 staff members attended. Interview on [DATE] at 8:00 PM, Administrator stated an in-service is schedule for all staff on that following Tuesday, [DATE]. The Administrator was informed on [DATE] at 4pm that the IJ had been removed and scope of Harm and severity of Isolation. However, the facility remained out of compliance at a scoped of isolated and a severity of actual harm that is not an IJ due to facility needing to train all staff and monitor their plan. Record review of a resident list that was provided by the Administrator on [DATE] documented there were 69 residents who resided at the facility, 3 of which required a standing lift and 1 Hoyer lift.

Based on interview and record review, the facility failed to implement their policies and procedures to prohibit neglect for 2 of 5 residents (Resident #1 and Resident #2) reviewed for neglect. LVN A administered 100 units of [MEDICATION NAME] to Resident #1 at 8:00pm on 12/3/15 when the physician order [REDACTED]. On 12/4/15 at 8:00pm, LVN A again administered 100 units of [MEDICATION NAME] to Resident #1 when the physician order [REDACTED]. Resident #1 suffered a drop in blood sugar (blood sugar measuresd 37) after receiving the incorrect dose on 12/4/15, causing dizziness and nausea and required emergency medical treatment and hospitalization . LVN A administered 100 units of [MEDICATION NAME] to Resident #2 at 8:00pm on 12/3/15 and 8:00pm on 12/4/15 when the physician order [REDACTED]. An Immediate Jeopardy was identified that existed from 12/3/15 through 12/8/15. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice affected two residents (Resident #1 and Resident #2) who are diagnosed with [REDACTED]. Findings include: Resident #1 Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS admission assessment completed 11/30/15 documented a BIMS score of 6 with some inattention and disorganized thinking. MDS indicated Resident #1 required total 1-2 person assistance with activities of daily living. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's December 2015 Medication Administration Record [REDACTED]. Record review of the Provider Investigation Report dated 12/7/15 documented: On 12/4/15 at 8:00pm, LVN A administered 100 units of [MEDICATION NAME] to Resident #1 when physician order [REDACTED]. Blood sugars dropped and Resident #1 was transferred to hospital via ambulance. Resident #1 was admitted to hospital and blood sugars stabilized. Record review of the facility's Medication Error Report dated 12/5/15 documented a medication error existed when Resident #1 received 100 units of [MEDICATION NAME] at 8:00pm on 12/4/15 when the physician order [REDACTED]. The Medication Error Report did not address the incorrect dose administered on 12/3/15. Record review of Resident #1's daily skilled nurse's note for 12/4/15 revealed: 2pm-10pm shift (completed and signed by LVN A): Blood sugar at 4:00pm is 93. Rechecked blood sugar at 8:00pm. Blood sugar is 37. Administered OJ. Night Shift (completed and signed by LVN B): Checked Blood sugar - 37. Contacted DON and MD. Received orders to transport to emergency room via ambulance. Ambulance to facility. Resident alert and responding to verbal stimuli. Orange juice adminstered before transport. Resident #2 Record review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 is [AGE] years old. Record review of Resident #2's MDS annual assessment completed 11/4/15 documented a BIMS score of 8 and extensive to total assistance required for activities of daily living. Record review of Resident #2's physician orders [REDACTED]. [MEDICATION NAME] 50 units subcutaneously daily. Record review of Resident #2's December 2015 Medication Administration Record [REDACTED]. Record review of the facility's Medication Error Report dated 12/5/15 documented: Description of error: [MEDICATION NAME] 100 units administered subcutaneously by LVN A. Outcome to resident: monitoring of blood sugars every 2 hours for 24 hours. Zero adverse reactions noted. Record review of LVN A's written statement documented: Day 2 Side A - At report, I voice a 'complaint' to LVN B about how much [MEDICATION NAME] a resident was getting. It was at this time we discovered the error I had made. When I read the MAR for both Resident #1 and Resident #2, I misread the MAR, reading 100u. We then rechecked blood sugars. Resident #2 was 129 and Resident #1 was at 37. After discussing the matter, we decided LVN B would monitor the BS (blood sugars) and call the MD if necessary .After a few minutes, LVN B called back and said she went ahead called MD and DON. MD decided to send Resident #1 to ER. During an interview on 12/17/15 at 10:05am, ADM stated LVN A voiced to another nurse that the dose of insulin she administered to Resident #1 and Resident #2 seemed like alot but she administered it anyway. ADM stated LVN A did not follow the 6 steps of medication administration. ADM stated LVN A's employment was terminated 12/7/15. ADM stated all nursing staff were inserviced on 12/8/15 on the 6 rights of medication administration. During an interview on 12/17/15 at 12:50pm, LVN A stated: I worked the 2pm-10pm shift on 12/4/15. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. I did question it. I had been told her (Resident #1's) blood sugar fluctuates so I thought it ([MEDICATION NAME]) was ordered so high for that reason. I drew up 100 units (1ml) and I gave it even though I questioned it. LVN A stated she administered 100 units of [MEDICATION NAME] to Resident #1 on 12/3/15 and 12/4/15 at 8:00pm. LVN A stated she also administered 100 units of [MEDICATION NAME] to Resident #2 on 12/3/15 and again on 12/4/15 when the physician order [REDACTED]. When asked what steps she should have taken because she questioned the order, LVN A stated, I've never really had that happen. I guess I should've called the DON. During an interview on 12/17/15 at 1:05pm, DON stated she was notified on 12/4/15 by LVN B that there was an emergency at the facility due to LVN A administering 100 units of [MEDICATION NAME] to Resident #1. DON stated she immediately went to the facility and removed LVN A from the nursing schedule. DON stated LVN A admitted to her that she felt 100 units of [MEDICATION NAME] was too much to administer to Resident #1 and Resident #2 but she gave it anyway. DON stated she believes LVN A just misread the order. DON stated she inserviced all nursing staff on medication administration and the difference between medication dosage and strength. During an interview on 12/17/15 at 3:22pm, DON stated Resident #1 experienced dizziness and diarrhea after receiving the incorrect dosage of insulin on 12/4/15. DON stated the following procedures were implemented as a result of the incident: 1. Dosages are highlighted on MARs. 2. New nurses are trained at hire on the 6 rights of medication administration and the difference between dosage and [MEDICATION NAME]. 3. Medication administration training will be completed During an interview on 12/17/15 at 4:20pm, Resident #1 stated she takes insulin in the morning and evening. Resident #1 stated she is supposed to receive 20 units every evening. Resident #1 stated she was recently in the hospital but she was not aware it was because of a medication error. Resident #1 states she went to the hospital because her blood sugar was low and she was dizzy. Record review of inservice records indicated all nursing staff (10 LVNs and 3 RNs) were inserviced on the following on 12/8/15: Six Rights of Medication Administration (right individual, right medication, right dose, right time, right route and right documentation); Distinguishing between the dosage and the strength. During an interview on 12/17/15 at 4:10pm, LVN G stated that on 12/8/15, staff were inserviced on the six rights of medication administration and how to differentiate between dosage and strength of medications Record review of the facility's undated Abuse Prevention Policy revealed: The resident has the right to be free of abuse, neglect and misappropriation of resident property, corporal punishment and involuntary seclusion . Neglect means failure to provide goods and services to avoid physical harm, mental anguish or mental illness. Record review of the facility's undated policy titled Drug Administration revealed: All drugs and biologicals are administered in accordance with the physician's orders [REDACTED]. Drugs are administered in accordance with facility policies established and reviewed by he Quality Assessment and Assurance Committee which ensures that: a. Drugs to be administered are checked against physician orders. Record review of the facility's undated policy titled Adverse Consequences and Medication Errors revealed: .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED]. 6. Examples of medication errors include: .c. Wrong dose (e.g. [MEDICATION NAME] 12ml ordered, [MEDICATION NAME] 2ml given) . On 12/17/15 at 4:05pm, ADM was notified that an Immediate Jeopardy situation had been identified that existed from 12/3/15 to 12/8/15. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to a facility-generated report dated 12/17/15 for Insulin orders, 11 residents in the facility have MEDICATION ORDERS FOR [REDACTED]

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 2 of 5 residents (Resident #1 and Resident #2) reviewed for neglect. The facility failed to provide Resident #1 with care and services to ensure her safety and well-being. LVN A administered 100 units of [MEDICATION NAME] to Resident #1 at 8:00pm on 12/3/15 and again at 8:00pm on 12/4/15 when the physician order [REDACTED]. After receiving the incorrect dose of insulin on 12/4/15, Resident #1 suffered a drop in blood sugar (blood sugar measured 37), causing dizziness and nausea and required emergency medical treatment and hospitalization . LVN A administered 100 units of [MEDICATION NAME] to Resident #2 at 8:00pm on 12/3/15 and 8:00pm on 12/4/15 when the physician ordered stated to administer 50 units daily. An Immediate Jeopardy was identified that existed from 12/3/15 through 12/8/15. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice affected two residents (Resident #1 and Resident #2) who are diagnosed with [REDACTED]. ****Non Immediate Jeopardy**** Based on interview and record review, the facility failed to implement its written policies that prohibit abuse and neglect of residents when the facility failed to ensure that alleged violations involving abuse or neglect were reported to the State regulatory agency in accordance with state law for 2 of 5 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to implement its written policies that prohibit abuse and neglect for 6 of 6 employees (LVN A, CNA C, RN D, RN E, CNA F and CNA G) reviewed for educational instruction on abuse/neglect/misappropriation during new employee orientation. The facility failed to immediately report an allegation of neglect involving Resident #1. LVN A administered 100 units of [MEDICATION NAME] to Resident #1 at 8:00pm on 12/3/15 and 8:00pm on 12/4/15 when the physician order [REDACTED]. After receiving the incorrect dose on 12/4/15, Resident #1 suffered a drop in blood sugar, causing dizziness and nausea and required emergency medical treatment and hospitalization . The facility did not report the allegation to the state agency until 12/7/15. The facility failed to immediately report an allegation of negelct involving Resident #2. LVN A administered 100 units of [MEDICATION NAME] to Resident #2 at 8:00pm on 12/3/15 and 8:00pm on 12/4/15 when the physician order [REDACTED]. The facility did not report the allegation to the state agency until 12/7/15. Personnel files of LVN A, CNA C, RN D, RN E, CNA F and CNA G did not contain documentation indicating they were provided educational instruction on abuse/neglect/misappropriation during new employee orientation. This deficient practice has the potential to place 63 residents at risk of ongoing abuse or neglect in the facility, resulting in pain, emotional distress, injury or death. This deficient practice has the potential to affect 63 residents in the facility by placing them at risk of abuse, neglect and/or misappropriation by employees who are not trained and could also affect the residents' quality of life and safety. Findings include: Record review of the facility's undated Abuse Prevention Policy revealed: The resident has the right to be free of abuse, neglect and misappropriation of resident property, corporal punishment and involuntary seclusion . Neglect means failure to provide goods and services to avoid physical harm, mental anguish or mental illness. Resident #1 Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS admission assessment completed 11/30/15 documented a BIMS score of 6 with some inattention and disorganized thinking. MDS indicated Resident #1 required total 1-2 person assistance with activities of daily living. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's December Medication Administration Record [REDACTED]. Record review of the Provider Investigation Report dated 12/7/15 documented: On 12/4/15 at 8:00pm, LVN A administered 100 units of [MEDICATION NAME] to Resident #1 when physician order [REDACTED]. Blood sugars dropped and Resident #1 was transferred to hospital via ambulance. Resident #1 was admitted to hospital and blood sugars stabilized. Record review of the facility's Medication Error Report dated 12/5/15 documented a medication error existed when Resident #1 received 100 units of [MEDICATION NAME] at 8:00pm on 12/4/15 when the physician order [REDACTED]. The Medication Error Report did not address the incorrect dose of insulin administered on 12/3/15. Record review of Resident #1's daily skilled nurse's note for 12/4/15 revealed: 2pm-10pm shift (completed and signed by LVN A): Blood sugar at 4:00pm is 93. Rechecked blood sugar at 8:00pm. Blood sugar is 37. Administered OJ. Night Shift (completed and signed by LVN B): Checked Blood sugar - 37. Contacted DON and MD. Received orders to transport to emergency room via ambulance. Ambulance to facility. Resident alert and responding to verbal stimuli. Orange juice adminstered before transport. Resident #2 Record review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 is [AGE] years old. Record review of Resident #2's MDS annual assessment completed 11/4/15 documented a BIMS score of 8 and extensive to total assistance required for activities of daily living. Record review of Resident #2's physician orders [REDACTED]. [MEDICATION NAME] 50 units subcutaneously daily. Record review of Resident #2's December 2015 Medication Administration Record [REDACTED]. Record review of the facility's Medication Error Report dated 12/5/15 documented: Description of error: [MEDICATION NAME] 100 units administered subcutaneously by LVN A. Outcome to resident: monitoring of blood sugars every 2 hours for 24 hours. Zero adverse reactions noted Record review of LVN A's written statement documented: Day 2 Side A - At report, I voice a 'complaint' to LVN B about how much [MEDICATION NAME] a resident was getting. It was at this time we discovered the error I had made. When I read the MAR for both Resident #1 and Resident #2 , I misread the MAR, reading 100u. We then rechecked blood sugars. Resident #2 was 129 and Resident #1 was at 37. After discussing the matter, we decided LVN B would monitor the BS (blood sugars) and call the MD if necessary .After a few ninutes, LVN B called back and said she went ahead and called MD and DON. MD decided to send Resident #1 to ER. During an interview on 12/17/15 at 10:05am, ADM stated LVN A voiced to another nurse that the dose of insulin she administered to Resident #1 and Resident #2 seemed like alot but she administered it anyway. ADM stated LVN A did not follow the 6 steps of medication administration. ADM stated LVN A's employment was terminated on 12/7/15. ADM stated all nursing staff were inserviced on 12/8/15 on the 6 rights of medication administration. During an interview on 12/17/15 at 12:50pm, LVN A stated: I worked the 2pm-10pm shift on 12/4/15. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. I did question it. I had been told her (Resident #1's) blood sugar fluctuates so I thought it ([MEDICATION NAME]) was ordered so high for that reason. I drew up 100 units (1ml) and I gave it even though I questioned it. LVN A stated she administered 100 units of [MEDICATION NAME] to Resident #1 on 12/3/15 and 12/4/15 at 8:00pm. LVN A stated she also administered 100 units of [MEDICATION NAME] to Resident #2 on 12/3/15 and again on 12/4/15 when the physician order [REDACTED]. When asked what steps she should have taken because she questioned the order, LVN A stated, I've never really had that happen. I guess I should've called the DON. During an interview on 12/17/15 at 1:05pm, DON stated she was notified on 12/4/15 by LVN B that there was an emergency at the facility due to LVN A administering 100 units of [MEDICATION NAME] to Resident #1. DON stated she immediately went to the facility and removed LVN A from the nursing schedule. DON stated LVN A admitted to her that she felt 100 units of [MEDICATION NAME] was too much to administer to Resident #1 and Resident #2 but she gave it anyway. DON stated she believes LVN A just misread the order. DON stated she inserviced all nursing staff on medication administration and the difference between medication dosage and strength. During an interview on 12/17/15 at 3:22pm, DON stated Resident #1 experienced dizziness and diarrhea after receiving the incorrect dosage of insulin on 12/4/15. DON stated the following procedures were implemented as a result of the incident: 1. Dosages are highlighted on MARs. 2. New nurses are trained at hire on the 6 rights of medication administration and the difference between dosage and [MEDICATION NAME]. 3. Medication administration training will be completed yearly for all nursing staff. During an interview on 12/17/15 at 4:20pm, Resident #1 stated she takes insulin in the morning and evening. Resident #1 stated she is supposed to receive 20 units every evening. Resident #1 stated she was recently in the hospital but she was not aware it was because of a medication error. Resident #1 states she went to the hospital because her blood sugar was low and she was dizzy. During an interview on 12/17/15 at 3:22pm,DON stated the following procedures were implemented as a result of the incident: 1. Dosages are highlighted on MARs. 2. New nurses are trained at hire on the 6 rights of medication administration and the difference between dosage and [MEDICATION NAME]. 3. Medication administration training will be completed yearly for all nursing staff. Record review of inservice records indicated all nursing staff (10 LVNs and 3 RNs) were inserviced on the following on 12/8/15: Six Rights of Medication Administration (right individual, right medication, right dose, right time, right route and right documentation); Distinguishing between the dosage and the strength. During an interview on 12/17/15 at 4:10pm, LVN G stated that on 12/8/15, staff were inserviced on the six rights of medication administration and how to differentiate between dosage and strength of medications On 12/17/15 at 4:05pm, ADM was notified that an Immediate Jeopardy situation had been identified that existed from 12/3/15 through 12/8/15. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to a facility-generated report dated 12/17/15 for Insulin orders, 11 residents in the facility have MEDICATION ORDERS FOR [REDACTED] ****Non Immediate Jeopardy**** Record review of the facility's undated Abuse Prevention Policy revealed: The resident has the right to be free of abuse, neglect and misappropriation of resident property, corporal punishment and involuntary seclusion . Neglect means failure to provide goods and services to avoid physical harm, mental anguish or mental illness .Facility responsibility in reporting suspected resident abuse and neglect: This facility follows the requirements of Senate Bill #9. All alleged incidents are reported to the appropriate local/state/federal agencies immediately, regardless of the time of day. As defined in 19.602, the following incidents will be reported: .neglect allegations. Record review of the facility's undated Abuse Prevention Policy revealed: The facility prohibits abuse/neglect, involuntary seclusion and misappropriation of property for all residents by training and providing ongoing supervision for employees and volunteers who provide services, whether direct caregivers or in ancillary departments. Procedures implemented: Training - Orientation is provided upon hire and ongoing training is provided to all employees. An orientation checklist is utilized with signatures to document the completion of general orientation. All full and part time employees will attend in-services according to State and Federal regulations. As part of orientation and annually. Each employee will receive instruction regarding .ethical and legal issues regarding advance directives, abuse and neglect, guardianship and confidentiality. During an interview on 12/17/15 at 10:05am, ADM stated LVN A voiced to another nurse that the dose of insulin she administered to Resident #1 seemed like alot but she administered it anyway. ADM stated LVN A did not follow the 6 steps of medication administration. ADM stated LVN A has been terminated. ADM stated all nursing staff have been inserviced on the 6 rights of medication administration. ADM stated she was informed of the incident on 12/5/15 but did not report the incident to State until she investigated the incident. ADM stated she did not investigate the incident until 12/7/15 because she did not feel like it was an issue because the resident was in the hospital and the nurse had been suspended and was not working. Record review of LVN A's personnel file revealed LVN A was hired 5/18/15 and did not receive abuse education training until 8/18/15. Record review of CNA C's personnel file revealed a hire date of 8/28/15. There was no signed orientation checklist in the personnel file to indicate CNA C had received abuse education training. Record review of RN D's personnel file revealed a hire date of 11/24/15. There was no signed orientation checklist in the personnel file to indicate RN D had received abuse education training. Record review of RN E's personnel file revealed RN E was hired 10/1/15 and did not receive abuse education training until 10/9/15. Record review of CNA F's personnel file revealed a hire date of 9/3/15. There was no signed orientation checklist in the personnel file to indicate CNA F had received abuse education training. Record review of CNA G's personnel file revealed a hire date of 9/3/15. There was no signed orientation checklist in the personnel file to indicate CNA G had received abuse education training. During an interview on 12/17/15 at 4:05pm, ADM stated the orientation checklist indicates employees receive abuse education training during orientation. ADM stated they do not ask the employee to sign and date the form to acknowledge they have received training. CMS Form 802 provided by the facility on 12/17/15 documented a census of 63.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Resident #1 and Resident #2) reviewed for medication errors. LVN A administered 100 units of [MEDICATION NAME] to Resident #1 at 8:00pm on 12/3/15 when the physician order [REDACTED]. On 12/4/15 at 8:00pm, LVN A again administered 100 units of [MEDICATION NAME] to Resident #1 when the physician order [REDACTED]. Resident #1 suffered a drop in blood sugar (blood sugar measured 37) after receiving the incorrect dose on 12/4/15, causing dizziness and nausea and required emergency medical treatment and hospitalization . LVN A administered 100 units of [MEDICATION NAME] to Resident #2 at 8:00pm on 12/3/15 and 8:00pm on 12/4/15 when the physician order [REDACTED]. An Immediate Jeopardy was identified that existed from 12/3/15 through 12/8/15. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice affected two residents (Resident #1 and Resident #2) who are diagnosed with [REDACTED]. Findings include: Resident #1 Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS admission assessment completed 11/30/15 documented a BIMS score of 6 (severe cognitive impairment) with some inattention and disorganized thinking. MDS indicated Resident #1 required total 1-2 person assistance with activities of daily living. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's December 2015 Medication Administration Record [REDACTED]. Record review of the Provider Investigation Report dated 12/7/15 documented: On 12/4/15 at 8:00pm, LVN A administered 100 units of [MEDICATION NAME] to Resident #1 when physician order [REDACTED]. Blood sugars dropped and Resident #1 was transferred to hospital via ambulance. Resident #1 was admitted to hospital and blood sugars stabilized. Record review of the facility's Medication Error Report dated 12/5/15 documented a medication error existed when Resident #1 received 100 units of [MEDICATION NAME] at 8:00pm on 12/4/15 when the physician order [REDACTED]. The Medication Error Report did not address the incorrect dose administered on 12/3/15. Record review of Resident #1's daily skilled nurse's note for 12/4/15 revealed: 2pm-10pm shift (completed and signed by LVN A): Blood sugar at 4:00pm is 93. Rechecked blood sugar at 8:00pm. Blood sugar is 37. Administered OJ. Night Shift (completed and signed by LVN B): Checked Blood sugar - 37. Contacted DON and MD. Received orders to transport to emergency room via ambulance. Ambulance to facility. Resident alert and responding to verbal stimuli. Orange juice adminstered before transport. Resident #2 Record review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 is [AGE] years old. Record review of Resident #2's MDS annual assessment completed 11/4/15 documented a BIMS score of 8 (moderately impaired) and extensive to total assistance required for activities of daily living. Record review of Resident #2's physician orders [REDACTED]. [MEDICATION NAME] 100units/ml - 50 units subcutaneously daily. Record review of Resident #2's December 2015 Medication Administration Record [REDACTED]. Record review of the facility's Medication Error Report dated 12/5/15 documented: Description of error: [MEDICATION NAME] 100 units administered subcutaneously by LVN A. Outcome to resident: monitoring of blood sugars every 2 hours for 24 hours. Zero adverse reactions noted. Record review of LVN A's written statement dated 12/7/15 documented: Day 2 Side A - At report, I voice a 'complaint' to LVN B about how much [MEDICATION NAME] a resident was getting. It was at this time we discovered the error I had made. When I read the MAR for both Resident #1 and Resident #2 , I misread the MAR, reading 100u. We then rechecked blood sugars. Resident #2 was 129 and Resident #1 was at 37. After discussing the matter, we decided LVN B would monitor the BS (blood sugars) and call the MD if necessary .After a few minutes, LVN B called back and said she went ahead and called MD and DON. MD decided to send Resident #1 to ER. During an interview on 12/17/15 at 10:05am, ADM stated LVN A voiced to another nurse that the dose of insulin she administered to Resident #1 and Resident #2 seemed like alot but she administered it anyway. ADM stated LVN A did not follow the 6 steps of medication administration. ADM stated LVN A's employment was terminated 12/7/15. ADM stated all nursing staff were inserviced on 12/8/15 on the 6 rights of medication administration. During an interview on 12/17/15 at 12:50pm, LVN A stated: I worked the 2pm-10pm shift on 12/4/15. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. I did question it. I had been told her (Resident #1's) blood sugar fluctuates so I thought it ([MEDICATION NAME]) was ordered so high for that reason. I drew up 100 units (1ml) and I gave it even though I questioned it. LVN A stated she administered 100 units of [MEDICATION NAME] to Resident #1 on 12/3/15 and 12/4/15 at 8:00pm. LVN A stated she also administered 100 units of [MEDICATION NAME] to Resident #2 on 12/3/15 and again on 12/4/15 when the physician order [REDACTED]. When asked what steps she should have taken because she questioned the order, LVN A stated, I've never really had that happen. I guess I should've called the DON. During an interview on 12/17/15 at 1:05pm, DON stated she was notified on 12/4/15 by LVN B that there was an emergency at the facility due to LVN A administering 100 units of [MEDICATION NAME] to Resident #1. DON stated she immediately went to the facility and removed LVN A from the nursing schedule. DON stated LVN A admitted to her that she felt 100 units of [MEDICATION NAME] was too much to administer to Resident #1 and Resident #2 but she gave it anyway. DON stated she believes LVN A just misread the order. DON stated she inserviced all nursing staff on medication administration and the difference between medication dosage and strength. During an interview on 12/17/15 at 3:22pm, DON stated Resident #1 experienced dizziness and diarrhea after receiving the incorrect dose of insulin on 12/4/15. DON stated the following procedures were implemented as a result of the incident: 1. Dosages are highlighted on MARs. 2. New nurses are trained at hire on the 6 rights of medication administration and the difference between dosage and [MEDICATION NAME]. 3. Medication administration training will be completed yearly for all nursing staff. During an interview on 12/17/15 at 4:20pm, Resident #1 stated she takes insulin in the morning and evening. Resident #1 stated she is supposed to receive 20 units every evening. Resident #1 stated she was recently in the hospital but she was not aware it was because of a medication error. Resident #1 states she went to the hospital because her blood sugar was low and she was dizzy. Record review of inservice records indicated all nursing staff (10 LVNs and 3 RNs) were inserviced on the following on 12/8/15: Six Rights of Medication Administration (right individual, right medication, right dose, right time, right route and right documentation); Distinguishing between the dosage and the strength. During an interview on 12/17/15 at 4:10pm, LVN G stated that on 12/8/15, staff were inserviced on the six rights of medication administration and how to differentiate between dosage and strength of medications Record review of the facility's undated policy titled Drug Administration revealed: All drugs and biologicals are administered in accordance with the physician's orders [REDACTED]. Drugs are administered in accordance with facility policies established and reviewed by he Quality Assessment and Assurance Committee which ensures that: a. Drugs to be administered are checked against physician orders. Record review of the facility's undated policy titled Adverse Consequences and Medication Errors revealed: .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED]. 6. Examples of medication errors include: .c. Wrong dose (e.g. [MEDICATION NAME] 12ml ordered, [MEDICATION NAME] 2ml given) . On 12/17/15 at 4:05pm, ADM was notified that an Immediate Jeopardy situation had been identified that existed from 12/3/15 through 12/8/15. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to a facility-generated report dated 12/17/15 for Insulin orders, 11 residents in the facility have MEDICATION ORDERS FOR [REDACTED]