Every finding on record at Shady Lawn Nursing and Rehabilitation Center

Based on interview, and facility policy review, the facility failed to immediately notify a resident's representative of a decision to transfer/discharge the resident from the facility for 1 of 4 residents (Resident (R) 28) reviewed for transfer/discharge from the facility, out of the total sample of 12 residents. On 08/16/2026, the facility transferred R28 to a local hospital for a higher level of care; however, did not notify the resident's Power of Attorney (POA) of the transfer.The findings include:Review of the facility policy titled, Admission, Transfer, and Discharge Standard of Practice, revised 04/2025, revealed the purpose of the policy was to ensure the process of admission, discharge, and transfer met regulatory requirements. Continued review revealed before the facility transferred or discharged a resident, the facility was to notify the resident and resident's representative. Further policy review revealed the facility's notification was to include the reason in a language and manner they understood, and at the time of resident transfer for hospitalization of therapeutic leave, written notice of the facility's bed hold policy was to be provided.Review of the facility policy titled, Change in Condition Standard of Practice, reviewed 03/2026, revealed the purpose of the policy was to ensure all interested parties were involved with the resident's change in health status. Further policy review revealed having all interested parties involved was so a treatment plan could be developed which was in the best interest of the residents. In an interview with R28's Power of Attorney (POA) on 08/26/2026 at 2:03 PM, she stated she (R28) was her sister-in-law and she was her POA. She stated R28 had been at the facility since 02/2024, and that up until the incident there were no issues or concerns about her care at the facility. She stated a phone call was made to her from the facility, and they left her a voicemail asking her to call the facility back. She stated when she called the facility back, she spoke with Licensed Practical Nurse (LPN) 1 and the nurse told her R28 said Certified Nurse Aide (CNA) 1 got rough with her. R28's POA stated the facility ordered x-rays of the site (R28's right arm). She stated R28 had fallen in the past, and the facility did x-rays in-house, so she had not thought much about it after LPN 1's phone requesting the x-ray. The POA stated during the phone call LPN 1 had not told her they were sending R28 to the hospital. She stated if she had known the resident was being sent out to the hospital, she would have met her (R28) at the emergency room (ER). R28's POA stated no one contacted her about the ER visit or asked about the bed-hold when the resident left for the hospital. She stated after the phone call with LPN 1 she started receiving phone calls from the hospital ER to get information and consent to send R28 to a higher level of care. The POA stated the facility had not called her when R28 returned from the hospital and had not provided any other updates after the phone call to order the x-rays. The POA stated she had been very upset over not being contacted and felt she was led to believe it was a very minor incident. In continued interview with R28's POA on 08/26/2026 at 2:03 PM, she stated she had not talked to anyone until she came to the facility in person and spoke to the Director of Nursing (DON) and Administrator. She stated they apologized for not contacting her and said they were just focused on making sure R28 was taken care of and assured her that would not happen again. The POA stated she was never made aware when the facility completed their investigation and that the employee involved was allowed to return to work.In an interview with LPN1 on 08/27/2026 at 9:03 AM, she stated she had not notified R28's family to let them know she was sending the resident to the hospital, as it was an emergency situation. She stated she immediately sent R28 out in relation to her excruciating pain the resident had experienced ever since the CNA changed her. The LPN stated due to R28's pain she felt she needed to send her (the resident) out to be further evaluated. The nurse stated normally she would call and update the family when she did anything like that; however, said she had been busy as the only nurse in the entire facility. LPN 1 stated originally, she had not planned to send R28 out, and deeply regretted not notifying the family before doing so. In an interview with the Director of Nursing (DON) on 08/28/2026 at 10:29 AM, she stated it was very important that a family member be notified when a resident was transferred or discharged from the facility. The DON stated a potential outcome of not being notified of a potential transfer/discharge was it could make the family upset and feel as if they were not a part of the resident care process. In an interview with the Administrator on 08/28/2026 at 10:34 AM, she stated it was very important that a family member was notified of a resident's transfer or discharge, that it was a priority. The Administrator stated the facility could be deemed not in compliance with federal regulations if they failed to notify a resident representative of a transfer or discharge.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of ten (10) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #1). The facility assessed and care planned Resident #1 to require the use of a mechanical lift for all transfers. On 07/13/2022, Resident #1 sustained a fall from a mechanical lift while being transferred from the bed to the wheelchair, after staff tried to manually transfer the resident when the lift failed to operate properly. The resident was transferred to the Hospital emergency room (ER) immediately after the fall with no acute findings noted. However, during the ER visit the resident complained of severe right sided pain and [MEDICATION(S)] (a non-steroidal anti-[CONDITION(S)] drug used for moderate to severe pain) sixty (60) milligrams (mg) was administered intramuscularly for pain. The findings include: Review of the facility's policy titled, Falls Standard of Practice, revised 07/2020, revealed the facility would ensure compliance with the regulatory intent of F689 and the resident environment would remain as free of accident hazards as possible. Further review of the policy revealed each resident would receive adequate supervision and assistance devices to prevent accidents. Review of the facility's policy titled, Incidents/Accidents Standard of Practice, revised 02/2021, revealed the purpose of the policy was to ensure the facility environment was free from accident hazards over which the facility had control and ensure each resident received adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines for F689. Review of the Total Mechanical Lift Competency Checklist, revised 04/2008, revealed the competency criteria staff were observed on hire and annually. Further review of the checklist revealed Mechanical Lift Pre-Operations Check and actual Mechanical Lift Operation. Review of the Manufacturer's Guidelines, dated 2015, revealed the Bariatric Electric Patient Lift was designed to allow an attendant to ergonomically transfer a patient from one resting position to another. Use steering handles at all times to maneuver the lift. It is extremely important the lift be inspected before each use. All nuts and bolts should be tight. The lifter should move freely with [NAME] brakes off. Check the brakes on the rear casters for proper operation. Make sure base adjustment mechanism is operating easily. Double check to ensure the U bracket at the end of the boom and the S hook on the hanging bar are secured tightly. Work the [MEDICATION(S)] to ensure that the battery still has enough power. When the battery is fifty (50) percent below full capacity, it would give a beep warning and would need to be re-charged immediately. For transferring to wheelchair, when patient was seated, push down on boom to slacken hanging strips of sling. Patient could remain seated in sling. Review of the Delivery Order Slip # 3, dated 07/08/2022, revealed a six-hundred (600) pound Patient Lift with Scale was delivered to the facility. Review of Resident #1's medical record revealed the facility admitted the resident on 12/06/2018 with diagnoses which included [CONDITION(S)], Muscle wasting and atrophy, Contractures to shoulders and Chronic Pain. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/28/2022, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) which indicated the resident was unable to complete the interview. Further review of the MDS Assessment, revealed the facility assessed the resident as requiring two (2) person assist with transfers. Review of Resident #1's Comprehensive Care Plan, dated 12/01/2019, revealed the resident was at risk for falls related to decreased mobility resulting in need for mechanical lift for transfer, and wheelchair for locomotion on and off the unit. Interventions included keeping dark eye glasses available and in good repair, keep pathways unobstructed while maintaining a clutter free environment, offer bedpan as needed, remind the resident to use the call light, and place frequently used items within reach. On 12/01/2019, an intervention for a mechanical lift for transfers was added to the Care Plan. Review of the Fall Management Document, completed by Licensed Practical Nurse (LPN) #1 on 07/13/2022, revealed Certified Nurse Aide (CNA) #1 and Patient Care Aide (PCA) #1 requested help with transferring Resident #1 from the bed to the chair because the lift would not raise the resident high enough to clear the wheelchair. PCA #1 summoned the help of LPN #1 and the three (3) staff attempted to manually clear the chair at which time the resident fell out of the upper right side of the sling onto the floor landing on his/her right side. The lower part of the resident's body remained in the sling and staff lowered the resident to the floor. LPN #1 immediately assessed the resident and obtained the resident's vital signs which included temperature- 98 degrees Fahrenheit, pulse-73, respirations-18, and blood pressure- 127/69. Further, the resident was assessed to have oxygen saturation of ninety-five (95) percent. The resident complained of head and right knee pain and rated the pain a four (4) on a zero to ten (0-10) pain scale. Emergency Medical Services were called to transport the resident to the emergency department for evaluation. Further review revealed the resident was transferred to the local hospital emergency room at 5:00 AM and returned to the facility on [DATE] at 8:47 AM. Review of the hospital Emergency Department (ED) note, dated 07/13/2022 at 5:31 AM, revealed a Computerized tomography (CT) of the head without contrast, a CT of the cervical spine (C-spine), and CT of the Thorax were performed with no concerns. Continued review of the note, revealed a plain film x-ray of the right shoulder, right elbow, right wrist, right hip and pelvis, right knee, and right ankle were also performed. The x-ray/CTs were read by the radiologist with no acute findings noted. Additional review of the note revealed the resident complained of severe right sided pain and the physician ordered [MEDICATION(S)] (a non-steroidal anti-[CONDITION(S)] drug used for moderate to severe pain) sixty (60) milligrams (mg) to be administered intramuscularly for pain. Observation of Resident #1, on 08/29/2022 at 3:01 PM, revealed he/she was lying awake in the bed with the head of the bed slightly elevated. Interview was attempted during observation; however, the resident was unable to participate in interview related to cognitive status. Interview with Resident #1's spouse/roommate, on 08/29/2022 at 3:01 PM, revealed he/she was in the room when his/her spouse fell from the lift. He/she stated the curtain was pulled and he/she did not see anything. Interview with Certified Nursing Assistant (CNA) #1, on 08/30/2022 at 10:21 AM; and 09/01/2022 at 10:52 AM and 3:11 PM, revealed Resident #1 required a green sling and she (CNA #1) was familiar and trained on using mechanical lifts. Per interview, CNA #1 was transferring the resident with the mechanical lift, with PCA #1 assisting on 07/13/2022. CNA #1 further stated the lift would not raise as high as the facility's previous lift while transferring the resident from his/her bed to the wheelchair. She further stated they were unable to lift the resident up high enough to seat in the wheelchair. Per interview, PCA #1 summoned Licensed Practical Nurse (LPN) #1 to Resident #1's room and they collectively decided to manually lift the resident by the sling to get the resident in the wheelchair. They proceeded to lift the resident at which time the resident fell out of the sling head first onto the floor. CNA #1 stated the resident had no obvious injury and was assessed by LPN #1 and transferred to the hospital emergency room . Further interview with CNA #1, revealed the mechanical lift used to transfer Resident #1 on 07/13/2022 had been rented, as the facility lift was out for repairs. She stated the rented lift used for Resident #1 had been used on other residents prior to the fall and staff reported the lift would not lift as high as the facility lifts. Per interview, prior to each use, the lifts were inspected by the user for any concerns and the slings were checked for tears and frayed areas. CNA #1 revealed she checked the lift prior to use on Resident #1 on 07/13/2022 and was aware it did not raise as high as the facility lift, but it had only been a problem with this particular transfer. The CNA revealed use of a faulty lift could lead to a resident injury, such as with Resident #1. Interview with LPN #1, on 08/30/2022 at 2:08 PM and 09/02/2022 at 1:04 PM, revealed on 07/13/2022, CNA #1 cracked the door and asked for him to come into the room to assist with transferring the resident. When he entered the room the resident was suspended about two (2) feet from the ground. LPN #1 stated the three (3) of them decided to manually lift the resident using the sling. He stated when they lifted the resident, he/she slid out of the sling head first hitting the floor and part of his/her body, hips and legs, remained in the sling as they lowered the resident to the floor. LPN #1 further revealed he assessed the resident and initiated neurological checks. Per interview, the resident complained of head pain and right knee pain. The Physician was notified on 07/13/2022 at 4:45 AM and the spouse was aware and was at bedside. LPN #1 stated he had been trained on lifts in the past, but had not been trained on how to operate this particular lift prior to the incident on 07/13/2022. Further interview revealed prior to transfers staff were to check the connections on the lift as well as observing the lift sling for rips, tears or frayed areas. Interview with Patient Care Aide (PCA) #1, on 09/01/2022 at 9:33 AM and 09/02/2022 at 11:44 AM, revealed she was one (1) of the three (3) staff who assisted with transferring Resident #1 from the bed to the wheelchair on 07/13/2022. She stated the lift was unfamiliar to her and she had not received education on the use of this lift or any lift prior to the 07/13/2022 incident. PCA #1 stated when lifting Resident #1 it became obvious the lift would not rise high enough for the resident's buttocks to be seated in the wheelchair. PCA #1 revealed CNA #1 had called for the nurse to assist, and when the nurse entered the room they decided to lift the resident into the wheelchair by using the sling/loops. She stated when they lifted the resident, he/she slipped out of the sling onto the floor head first. PCA #1 revealed they lowered the resident to the floor and the resident did not complain of anything. Interview with the Director of Nursing (DON), on 09/02/2022 at 10:09 AM, revealed the mechanical lift used to transfer Resident #1 on 07/13/2022 was rented and was only in the building for five (5) days prior to Resident #1's fall. The DON further stated she had not been aware of any problems with the rented lift until after Resident #1 sustained the fall. Per interview, the lift was removed from service immediately after the fall and tagged for maintenance. She stated she called the rental company to come pick the lift up and another mechanical lift was borrowed from a sister facility at that time. The DON further revealed the root cause of the fall was mechanical lift malfunction. The DON stated staff was to check the lift and sling prior to each use and maintenance checked each lift monthly, which was documented on the TELS system. Further, to her knowledge maintenance had not checked the rented mechanical lift prior to it being used for transferring Resident #1 on 07/13/2022. Review of the Pickup Order Slip # 2, dated 07/13/2022, revealed the lift was picked up and it was noted, lift does not go higher than one (1) foot off the ground and we were unable to transfer patients with it. Interview with the Maintenance Director, on 09/06/2022 at 12:28 PM, revealed he wasn't sure if the lift was raised to it maximum height at the time Resident #1 was being transferred on 07/13/2022. He stated after the fall incident he checked the lift and found no problems. However, the Maintenance Director stated he did not measure how high the lift would raise during his inspection of the lift after the fall. He stated he did regular preventative maintenance on facility mechanical lifts, but had not checked the rented mechanical lift that was used to transfer Resident #1 prior to the resident's fall. Interview with the Administrator, on 09/07/2022 at 1:42 PM, revealed she had completed an investigation after Resident #1's fall and the root cause was mechanical lift equipment malfunction. She stated the DON and Assistant Director of Nursing (ADON) had provided staff with education on mechanical lift use with competency to validate understanding after Resident #1 sustained the fall. The Administrator stated the faulty lift was not used after the resident's fall, but was replaced with a lift from a sister facility. Further interview revealed the fall/investigation/audits were taken to Ad Hoc and Quality Assurance and Performance Improvement (QAPI) where the fall was discussed during meetings held on 07/13/2022 and 07/25/2022. *The facility implemented the following actions to correct the deficient practice: 1. On 07/13/2022, Resident #1 fell from a mechanical lift during a transfer. The resident was assessed by LPN #1 and sent to the emergency room for evaluation. The lift was immediately removed from service and another lift was obtained from a sister facility. 2. On 07/13/2022, current residents that utilized a mechanical lift were reviewed by the DON and/or Assistant Director of Nursing (ADON) for appropriate sling size and usage. At the time of Resident #1's fall, eleven (11) residents were assessed for use of a mechanical lift. 3. On 07/13/2022, Resident #1 was assessed and treated for pain upon return from the emergency room . A head to toe assessment of the resident was completed by Registered Nurse (RN) #3, upon the resident's return with minimal bruising and raised area noted to the head. 4. On 07/13/2022 through 07/18/2022, Nursing staff were educated on mechanical lift use with competency to validate understanding by the DON and/or ADON. 5. On 07/18/2022 through 08/10/2022, the DON and/or ADON observed staff's use of the mechanical lift to include all shifts, five times (5x) a week for two (2) weeks, then three times (3x) weekly for two (2) weeks. The DON would report findings to Quality Assurance Performance Improvement (QAPI) team monthly for further recommendations. 6. On 07/13/2022, an Ad HOC Quality Assurance (QA) with the Medical Director, Administrator, DON, ADON was held. The purpose of the Ad HOC meeting was to discuss the fall incident as a team and ensure staff were trained on the use of mechanical lifts. On 07/25/2022 a monthly QAPI was held. **The State Survey Agency Validated the corrective action by the facility as follows: 1. Review of the Fall Management document, dated 07/13/2022 at 6:02 AM, revealed Resident #1's fall incident was charted with details noted on the form by LPN #1. Further review of the document revealed details included the resident reported pain to the head and right knee and rated the pain at four (4) on a zero to ten (0-10) pain scale. Notifications related to the fall were made to the spouse on 07/13/2022 at 4:45 AM and the physician was notified at 4:45 AM via text. Continued review revealed the resident was transferred to the Hospital ER for evaluation. Review of the Pickup Order Slip # 2, dated 07/13/2022, revealed the lift was picked up and it was noted, lift does not go higher than one (1) foot off the ground and we were unable to transfer patients with it. Interview with the DON, on 09/02/2022 at 10:09 AM, revealed the lift used to transfer Resident #1 at the time the resident sustained the fall was rented. Per interview, the lift was removed from service immediately after the fall and tagged for maintenance. Further, she called the rental company to come pick the lift up and another mechanical lift was borrowed from a sister facility at that time. Interview with the Maintenance Director, on 09/08/2022 at 12:41 PM, revealed he marked the faulty lift off from use and removed the lift from the building on 07/13/2022. 2. Review of the list of residents that used a mechanical lift, dated 07/13/2022, revealed all residents were measured and resident weights obtained by the ADON. Interview with the ADON, on 09/08/2022 at 10:20 AM, revealed she reviewed all residents that required the use of a lift on 07/13/2022. She further stated she measured each resident for size based on their weight and determined each resident was using the correct sling. 3. Review of the Nurse's Notes, revealed Resident #1 returned to the facility on [DATE] at 8:47 AM, at which time RN #3 completed a head to toe assessment and found bruising and abrasions on the right torso and a knot noted to the right side of the scalp. The resident requested medication for pain and [MEDICATION(S)]-Acetaminophen (narcotic pain medication) 7.5-325 mg was administered to the resident at 8:58 AM. For the resident's comfort, the facility arranged for the next two (2) [CONDITION(S)] days to be transported via EMS on a stretcher. Neurological (neuro) checks were initiated. Review of the Neurological Assessment Flowsheet revealed neuro checks were completed from 07/13/2022 until the 6:55 PM check on 07/16/2022. 4. Review of documentation provided by the Regional Quality Manager, revealed she had educated the DON on the use of the mechanical lift and observed her while she transferred a resident on 07/13/2022. Further review revealed the DON in turn educated and observed the ADON on the use of the mechanical lift and observed demonstration of the use of the lift. Review of Education Sign In Sheets revealed all clinical staff received education on the use of the mechanical lift and demonstrated proper use of the mechanical lift. Staff interviews with CNA #1 on 09/01/2022 at 3:11 PM, RN #3 on 09/05/2022 at 11:38 AM, CNA #7 on 09/07/2022 at 10:19 AM, ADON on 09/08/2022 at 10:20 AM, CNA #4 on 09/08/ 0:45 AM, LPN #4 on 09/08/2022 at 10:57 AM, CNA #6 on 09/08/2022 at 11:08 AM, CNA #3 on 09/08/2022 at 11:22 AM, CNA #9 on 09/08/2022 at 11:27 AM, CNA #8 on 09/08/2022 at 11:38 AM, CNA #10 on 09/08/2022 at 11:49 AM, LPN #3 on 09/08/2022 at 11:58 AM, CNA #11 on 09/08/2022 at 12:02 PM and CNA #5 on 09/08/2022 at 12:05 PM, revealed they had been educated recently by either the DON/ADON on proper use of the mechanical lift. Additionally, staff revealed they were also observed actually operating a mechanical lift. 5. Review of the Mechanical Lift Audit Sheet, revealed the DON conducted audits of staff transferring residents with a mechanical lift. Audits were initiated on 07/18/2022 and ended on 08/10/2022. On 07/18/2022 through 08/10/2022, the DON and/or ADON observed staff's use of the mechanical lift to include all shifts, five times (5x) a week for two (2) weeks, then three times (3x) weekly for two (2) weeks. Interview with the DON, on 09/07/2022 at 1:21 PM, revealed she and the ADON audited clinical staff on the use of a mechanical lift with observations being made of the staff transferring residents. The DON stated findings were reported to the Quality Assurance Performance Improvement (QAPI) team for further recommendations. Interview with the ADON, on 09/08/2022 at 10:20 AM, revealed she assisted the DON with auditing the clinical staff on the use of the mechanical lift. She further stated she had also observed staff using the lift during transfers. Interview with CNA #1, on 09/01/2022 at 3:11 PM, and PCA #1, on 09/02/2022 at 11:44 AM, revealed they were observed using the mechanical lifts with return demonstration for the DON on 07/13/2022. Interview with LPN #1, on 09/02/2022 at 1:04 PM; and RN #2, on 09/03/2022 at 12:23 PM; revealed they were observed using the mechanical lifts with return demonstration for the DON. 6. Review of Attendance Rosters, dated 07/13/2022 and 07/25/2022, revealed the facility had an Ad HOC meeting with the Medical Director, Administrator, DON, and ADON on 07/13/2022. Review of the Attendance Roster, dated 07/25/2022, revealed a QAPI meeting was held with the Medical Director, Administrator, DON and the ADON and the mechanical lift education and audits were discussed with no concerns identified.

Based on interview, record review, review of facility policy, and review of the facility investigation, it was determined the facility failed to ensure a mechanical lift was maintained in safe operating condition prior to use for one (1) of ten (10) sampled residents (Resident #1). On 07/13/2022, Resident #1 sustained a fall from a Bariatric Electric Patient Lift, while being transferred from the bed to the wheelchair. The lift malfunctioned, not allowing the resident to be elevated into his/her wheelchair. As a result, staff attempted to manually transfer the resident, causing the resident to slide out of the sling and onto the floor. The resident was transferred to the Hospital emergency room (ER) with no acute findings noted according to the Emergency Department (ED) note. However, during the ER visit the resident complained of severe right sided pain and [MEDICATION(S)] (a non-steroidal anti-[CONDITION(S)] drug used for moderate to severe pain) sixty (60) milligrams (mg) was administered intramuscularly to treat the resident's pain. The findings include: Review of the facility Total Mechanical Lift Competency Checklist, revised 04/2008, revealed the competency criteria staff were observed on hire and annually. Additional review of the checklist revealed Mechanical Lift Pre-Operations Check and actual Mechanical Lift Operation. Interview with the Director of Nursing (DON), on 09/02/2022 at 9:14 AM, revealed the facility assessed eleven (11) residents who required the use of the mechanical lift, as of 07/13/2022. Review of Resident #1's medical record revealed the facility admitted the resident on 12/06/2018 with diagnoses which included [CONDITION(S)], Muscle Wasting and Atrophy, Contractures to shoulders and Chronic Pain. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/28/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) which indicated the resident was unable to complete the interview. Additional review of the MDS Assessment, revealed the facility assessed the resident as requiring two (2) person assist with transfers. Review of the Delivery Order Slip # 3, dated 07/08/2022, revealed a six-hundred (600) pound Patient Lift with Scale was delivered to the facility. Review of the Manufacturer's Guidelines, dated 2015, revealed the Bariatric Electric Patient Lift was designed to allow an attendant to ergonomically transfer a patient from one resting position to another. Use steering handles at all times to maneuver the lift. It is extremely important the lift be inspected before each use. All nuts and bolts should be tight. The lifter should move freely with [NAME] brakes off. Check the brakes on the rear casters for proper operation. Make sure base adjustment mechanism is operating easily. Double check to ensure the U bracket at the end of the boom and the S hook on the hanging bar are secured tightly. Work the [MEDICATION(S)] to ensure that the battery still has enough power. When the battery is fifty (50) percent below full capacity, it would give a beep warning and would need to be re-charged immediately. For transferring to wheelchair, when patient was seated, push down on boom to slacken hanging strips of sling. Patient could remain seated in sling. Review of the Fall Management document, completed by Licensed Practical Nurse (LPN) #1 on 07/13/2022, revealed Certified Nurse Aide (CNA) #1 and Patient Care Aide (PCA) #1 requested help to transfer Resident #1 from the bed to the chair because the lift would not raise the resident high enough to clear the wheelchair. PCA #1 summoned the help of LPN #1 and the three (3) staff attempted to manually clear the chair at which time the resident slid out of the upper right side of the sling onto the floor landing on his/her right side. The lower part of the resident's body remained in the sling and staff lowered the resident to the floor. LPN #1 immediately assessed the resident and obtained the resident's vital signs- temperature 98 degrees Fahrenheit, pulse 73, respirations 18 and blood pressure 127/69. The resident's oxygen saturation was assessed at 98 percent. The resident complained of head and right knee pain and rated the pain a four (4) on a zero to ten (0-10) pain scale. Emergency Medical Services were called to transport the resident to the emergency department for evaluation. Further review revealed the resident was transferred to the emergency room at 5:00 AM and returned to the facility on [DATE] at 8:47 AM. Review of the Emergency Department (ED) note, dated 07/13/2022 at 5:31 AM, revealed a Computerized tomography (CT) of the head without contrast, a CT of the cervical spine (C-spine), and CT of the Thorax were performed with no concerns. Additional review revealed a plain film x-ray of the right shoulder, right elbow, right wrist, right hip and pelvis, right knee, and right ankle were also performed. The x-ray/CTs were read by the radiologist with no acute findings noted. Further, the resident complained of severe right sided pain and the physician ordered [MEDICATION(S)] (a non-steroidal anti-[CONDITION(S)] drug used for moderate to severe pain). sixty (60) milligrams (mg) to be administered intramuscularly for pain. Interview with CNA #1, on 08/30/2022 at 10:21 AM, 09/01/2022 at 10:52 AM and 3:11 PM, revealed Resident #1 required a green sling and she (CNA) #1 was familiar and had been trained on using mechanical lifts. Per interview, CNA #1 was transferring the resident with the mechanical lift, with PCA #1 assisting on 07/13/2022. She stated the lift being used during the resident's fall had been rented, as the other one was out for repairs. CNA #1 stated the lift would not raise as high as the facility's previous lift while transferring the resident from his/her bed to the wheelchair. She stated they were unable to lift the resident up high enough to seat in the wheelchair. Further, PCA #1 summoned LPN #1 to Resident #1's room and they collectively decided to manually lift the resident by the sling to get the resident in the wheelchair. Per interview, they proceeded to lift the resident at which time the resident fell out of the sling head first onto the floor. CNA #1 stated the resident had no obvious injury and was immediately assessed by LPN #1 and transferred to the emergency room . Additional interview with CNA #1, revealed the rented lift used for Resident #1 had been used on other residents prior to the fall and staff reported the lift would not lift as high as the facility lifts. She stated, prior to each use, the lifts were inspected by the user for any concerns and the slings were checked for tears and frayed areas. CNA #1 stated she checked the lift prior to use on Resident #1 on 07/13/2022 and was aware it did not raise as high as the facility lift, but it had only been a problem with this particular transfer. The CNA further stated use of a faulty lift could lead to a resident injury, such as with Resident #1. Interview with the Director of Nursing (DON), on 09/02/2022 at 10:09 AM, revealed the mechanical lift used to transfer Resident #1 was rented and was only in the building for five (5) days prior to the resident sustaining the fall. The DON stated she had not been aware of any problems with the rented lift until after the fall. Further, the lift was removed from service immediately after the fall and tagged for maintenance. Per interview, she called the rental company to come pick the lift up and another mechanical lift was borrowed from a sister facility at that time. The DON further stated the root cause of the fall was a lift malfunction. The DON revealed staff was to check the mechanical lift and sling prior to each use and maintenance checked each lift monthly, which was documented on the TELS system. Further interview revealed to her knowledge maintenance had not checked the rented mechanical lift prior to it being used for transferring Resident #1 on 07/13/2022. Review of the Pickup Order Slip # 2, dated 07/13/2022, revealed the rented mechanical lift was picked up and it was noted, lift does not go higher than one (1) foot off the ground and we were unable to transfer patients with it. Interview with the Maintenance Director, on 09/06/2022 at 12:28 PM, revealed he wasn't sure if the lift used to transfer Resident #1 on 07/13/2022 was raised to its maximum height at the time of transfer. He stated after the fall incident he did check the lift and found no concerns. However, the Maintenance Director revealed he did not measure how high the lift would raise during his inspection of the lift after the fall. Per interview, the Maintenance Director did regular preventative maintenance on facility mechanical lifts, but had not checked the rented mechanical lift that was used to transfer Resident #1 prior to the resident's fall. Interview with the Administrator, on 09/07/2022 at 1:42 PM, revealed she had completed an investigation after Resident #1's fall and identified the root cause of the fall was mechanical lift equipment malfunction. She stated the DON and Assistant Director of Nursing (ADON) provided staff with education on mechanical lift use with competency to validate understanding after Resident #1 sustained the fall. The Administrator further stated the faulty lift was not used after the resident's fall, but was replaced with a lift from a sister facility. Additional interview revealed the fall/investigation/audits were taken to Ad Hoc and Quality Assurance and Performance Improvement (QAPI) where the fall was discussed during meetings held on 07/13/2022 and 07/25/2022. *The facility implemented the following actions to correct the deficient practice: 1. On 07/13/2022, Resident #1 fell from a mechanical lift during a transfer. The resident was assessed by LPN #1 and sent to the emergency room for evaluation. The lift was immediately removed from service and another lift was obtained from a sister facility. 2. On 07/13/2022, current residents that utilized a mechanical lift were reviewed by the DON and/or Assistant Director of Nursing (ADON) for appropriate sling size and usage. At the time of Resident #1's fall, eleven (11) residents were assessed for use of a mechanical lift. 3. On 07/13/2022, Resident #1 was assessed and treated for pain upon return from the emergency room . A head to toe assessment of the resident was completed by Registered Nurse (RN) #3, upon the resident's return with minimal bruising and raised area noted to the head. 4. On 07/13/2022 through 07/18/2022, Nursing staff were educated on mechanical lift use with competency to validate understanding by the DON and/or ADON. 5. On 07/18/2022 through 08/10/2022, the DON and/or ADON observed staff's use of the mechanical lift to include all shifts, five times (5x) a week for two (2) weeks, then three times (3x) weekly for two (2) weeks. The DON would report findings to Quality Assurance Performance Improvement (QAPI) team monthly for further recommendations. 6. On 07/13/2022, an Ad HOC Quality Assurance (QA) with the Medical Director, Administrator, DON, ADON was held. The purpose of the Ad HOC meeting was to discuss the fall incident as a team and ensure staff were trained on the use of mechanical lifts. On 07/25/2022 a monthly QAPI was held. **The State Survey Agency Validated the corrective action by the facility as follows: 1. Review of the Fall Management document, dated 07/13/2022 at 6:02 AM, revealed Resident #1's fall incident was charted with details noted on the form by LPN #1. Further review of the document revealed details included the resident reported pain to the head and right knee and rated the pain at four (4) on a zero to ten (0-10) pain scale. Notifications related to the fall were made to the spouse on 07/13/2022 at 4:45 AM and the physician was notified at 4:45 AM via text. Continued review revealed the resident was transferred to the Hospital ER for evaluation. Review of the Pickup Order Slip # 2, dated 07/13/2022, revealed the lift was picked up and it was noted, lift does not go higher than one (1) foot off the ground and we were unable to transfer patients with it. Interview with the DON, on 09/02/2022 at 10:09 AM, revealed the lift used to transfer Resident #1 at the time the resident sustained the fall was rented. Per interview, the lift was removed from service immediately after the fall and tagged for maintenance. Further, she called the rental company to come pick the lift up and another mechanical lift was borrowed from a sister facility at that time. Interview with the Maintenance Director, on 09/08/2022 at 12:41 PM, revealed he marked the faulty lift off from use and removed the lift from the building on 07/13/2022. 2. Review of the list of residents that used a mechanical lift, dated 07/13/2022, revealed all residents were measured and resident weights obtained by the ADON. Interview with the ADON, on 09/08/2022 at 10:20 AM, revealed she reviewed all residents that required the use of a lift on 07/13/2022. She further stated she measured each resident for size based on their weight and determined each resident was using the correct sling. 3. Review of the Nurse's Notes, revealed Resident #1 returned to the facility on [DATE] at 8:47 AM, at which time RN #3 completed a head to toe assessment and found bruising and abrasions on the right torso and a knot noted to the right side of the scalp. The resident requested medication for pain and [MEDICATION(S)]-Acetaminophen (narcotic pain medication) 7.5-325 mg was administered to the resident at 8:58 AM. For the resident's comfort, the facility arranged for the next two (2) [CONDITION(S)] days to be transported via EMS on a stretcher. Neurological (neuro) checks were initiated. Review of the Neurological Assessment Flowsheet revealed neuro checks were completed from 07/13/2022 until the 6:55 PM check on 07/16/2022. 4. Review of documentation provided by the Regional Quality Manager, revealed she had educated the DON on the use of the mechanical lift and observed her while she transferred a resident on 07/13/2022. Further review revealed the DON in turn educated and observed the ADON on the use of the mechanical lift and observed demonstration of the use of the lift. Review of Education Sign In Sheets revealed all clinical staff received education on the use of the mechanical lift and demonstrated proper use of the mechanical lift. Staff interviews with CNA #1 on 09/01/2022 at 3:11 PM, RN #3 on 09/05/2022 at 11:38 AM, CNA #7 on 09/07/2022 at 10:19 AM, ADON on 09/08/2022 at 10:20 AM, CNA #4 on 09/08/ 0:45 AM, LPN #4 on 09/08/2022 at 10:57 AM, CNA #6 on 09/08/2022 at 11:08 AM, CNA #3 on 09/08/2022 at 11:22 AM, CNA #9 on 09/08/2022 at 11:27 AM, CNA #8 on 09/08/2022 at 11:38 AM, CNA #10 on 09/08/2022 at 11:49 AM, LPN #3 on 09/08/2022 at 11:58 AM, CNA #11 on 09/08/2022 at 12:02 PM and CNA #5 on 09/08/2022 at 12:05 PM, revealed they had been educated recently by either the DON/ADON on proper use of the mechanical lift. Additionally, staff revealed they were also observed actually operating a mechanical lift. 5. Review of the Mechanical Lift Audit Sheet, revealed the DON conducted audits of staff transferring residents with a mechanical lift. Audits were initiated on 07/18/2022 and ended on 08/10/2022. On 07/18/2022 through 08/10/2022, the DON and/or ADON observed staff's use of the mechanical lift to include all shifts, five times (5x) a week for two (2) weeks, then three times (3x) weekly for two (2) weeks. Interview with the DON, on 09/07/2022 at 1:21 PM, revealed she and the ADON audited clinical staff on the use of a mechanical lift with observations being made of the staff transferring residents. The DON stated findings were reported to the Quality Assurance Performance Improvement (QAPI) team for further recommendations. Interview with the ADON, on 09/08/2022 at 10:20 AM, revealed she assisted the DON with auditing the clinical staff on the use of the mechanical lift. She further stated she had also observed staff using the lift during transfers. Interview with CNA #1, on 09/01/2022 at 3:11 PM, and PCA #1, on 09/02/2022 at 11:44 AM, revealed they were observed using the mechanical lifts with return demonstration for the DON on 07/13/2022. Interview with LPN #1, on 09/02/2022 at 1:04 PM; and RN #2, on 09/03/2022 at 12:23 PM; revealed they were observed using the mechanical lifts with return demonstration for the DON. 6. Review of Attendance Rosters, dated 07/13/2022 and 07/25/2022, revealed the facility had an Ad HOC meeting with the Medical Director, Administrator, DON, and ADON on 07/13/2022. Review of the Attendance Roster, dated 07/25/2022, revealed a QAPI meeting was held with the Medical Director, Administrator, DON and the ADON and the mechanical lift education and audits were discussed with no concerns identified.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff properly utilized personal protective equipment (PPE), which included the donning (putting PPE on) and doffing (taking PPE off) when entering one (1) of two (2) sampled isolation rooms. This had the potential to affect all facility residents. The findings include: Review of the Centers of Disease Control and Prevention (CDC) publication, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/ , revealed it provided guidance for the proper use of Personal Protective Equipment (PPE). Review revealed, healthcare professionals who entered the room of a patient (resident) with suspected or confirmed Severe Acute Respiratory Syndrome Coronavirus 2 ([NAME]-CoV-2) infection were to adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 (filtering facepiece respirator) or equivalent respirator, gown, gloves, and eye protection. Review of the facility's policy titled, Vaccination and Symptom Based Resident Room Assignment Guide, revealed For new admissions: the unvaccinated residents- was admitted into the YELLOW [contact precautions initiated] zone to monitor for COVID related symptoms following the CDC's (Centers for Disease Control and Prevention's) guidance. Per review the CDC's guidance was currently ten (10) to fourteen (14) days with no symptoms observed during daily monitoring. Record review revealed the facility admitted Resident #1 on 11/11/2021, and the facility placed the resident in isolation due to being a new admission with no vaccination history for the Coronavirus. 1. Observation on 11/16/2021 at 8:18 AM, revealed Registered Nurse (RN) #2 enter room [ROOM NUMBER], only wearing a mask. Per observation, room [ROOM NUMBER] was on isolation precautions, as there was a sign noting the resident's precautions on the outside of the resident's room door. Further observation of the sign revealed the green/yellow indicator on the sign was circled, the sign noted persons entering the room were to wash and/or sanitize their hands before and after providing resident care. Continued observation of the sign revealed staff were to wear a gown if there was a risk of becoming soiled, all persons were to wear a mask when entering the room, wear goggles or a face shield if splashing was likely, and wear gloves when delivering direct care. Interview with Registered Nurse (RN) #2, on 11/16/2021 at 8:20 AM, revealed the resident in room [ROOM NUMBER] (Resident #1) was on isolation precautions because the resident was a new admission to the facility, and therefore had been placed on the COVID protocol. RN #2 stated only a mask was required unless it was a possibility a staff person might become soiled and then a gown was required to be worn. Continued interview with RN #2 revealed staff would not know if they were going to get into a situation where they might get soiled after entering the room. RN #2 further revealed staff wore gloves only if coming into contact with the resident. Further interview revealed RN #2 did not know how long the resident (Resident #1) would be on isolation precautions, as it depended on his/her vaccination status. RN #2 additionally stated Resident #1 had not been vaccinated. Interview on 11/16/2021 at 10:23 AM, with Registered Nurse (RN) #3 revealed staff were to wear a gown, gloves, and mask to enter room [ROOM NUMBER], Resident #1's room. She stated she would wear a gown, gloves, and mask when administering the resident his/her medications. RN #3 stated Resident #1 could not swallow oral medications and had a Percutaneous Endoscopic Gastrostomy (PEG) tube which was utilized for medication administration. Further interview revealed the RN was not sure if Resident #1 had been vaccinated or not. She further stated the resident was on isolation precautions because he/she was a new admission to the facility. Interview on 11/16/2021 at 10:27 AM, with Certified Nursing Assistant (CNA) #1, revealed that when providing care to Resident #1, she was to wear a mask, gown, and gloves. The CNA stated she did not wear a face shield when providing care for the resident. Further interview revealed Resident #1 was on isolation precautions because he/she had only arrived at the facility a few days ago. 2. Observation on 11/17/2021 at 8:16 AM, revealed Certified Nursing Assistant (CNA) #3 walked down the hallway and placed a soda can on the isolation cart outside of room [ROOM NUMBER], Resident #1's room, and entered the resident's room without applying any type of PPE. Interview on 11/17/2021 at 8:19 AM, with CNA #3 revealed she should not have entered an isolation room without wearing PPE. Per interview, CNA #3 stated she answered Resident #1's call light and assisted the resident on his/her bedpan. Further interview revealed she should have worn a gown, mask, gloves, and face shield when providing the bedpan for Resident #1. Interview on 11/17/2021 at 9:45 AM, with the Interim Director of Nursing (IDON), regarding an in-service dated 08/19/2021 related to isolation precautions, revealed it was staff's responsibility to know why a resident was on isolation, and should ask the nurse what Personal Protective Equipment (PPE) staff were to wear prior to entering a resident's room. Further interview revealed the department head staff were informed, during their morning meeting, the reasoning behind a resident being placed on isolation precautions and the date the resident was placed on precautions. In an additional interview on 11/17/2021 at 10:31 AM, the IDON revealed Resident #1, who resided in room [ROOM NUMBER], was on contact isolation precautions and not droplet isolation precautions. Per interview, contact isolation meant the resident had tested negative for COVID-19 and had no COVID-19 symptoms. The IDON revealed a resident was placed on droplet isolation precautions when the resident had a fever. Per interview, the IDON stated staff were only to wear a surgical mask in the green/yellow isolation room when staff were not touching the affected resident. She further stated she was unsure if nurses were to wear face shields when administering medications to a resident with a PEG tube, which would increase the chances of staff's contact with the resident's body fluids. Further interview revealed the IDON acknowledged it was a possibility for a resident to become positive for COVID-19 at any time.

Based on observation, interview, record review, and facility policy review, was determined the facility failed to ensure infection control practices were implemented. The Advanced Registered Nurse Practitioner (ARNP) failed to remove personal protective equipment (PPE) prior to leaving a resident's room where the resident was on isolation precautions. The findings include: Review of facility policy titled, Novel Coronavirus last revised 03/25/2020, revealed isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the environment outside the patient's room. Remove PPE at doorway before leaving patient room or in anteroom, which includes gown, gloves, goggles, and mask. Review of facility policy titled, Personal Protective Equipment Guidance for COVID 19, revealed to remove all PPE before exiting the room except for respirator. Observation on 05/21/2020 at 10:30 AM revealed the ARNP exited Resident #1's room who was on isolation precautions wearing PPE (gown gloves, and mask), then removed the PPE outside of the room. The ARNP stood outside of Resident #1's room door, looked at surveyor, and stated she did not see the bin to dispose of the PPE in the room, only a red bin that had dirty linen written on it. ARNP was then observed to roll up PPE in her hands and go down hall to the back exit hallway and then go back up the hall past Resident #1's room and ask the Activities Director about disposal of the PPE, The ARNP then walked past the next room (room past Resident #1's room) to ask an aide about disposal of PPE. Certified Nursing Assistant (CNA) #2 informed the ARNP, the PPE disposal bin should be in Resident #1's room. The ARNP then returned to Resident #1's room donning another set of PPE and went in the room to dispose of the PPE she was wearing and the PPE still in her hand. Interview with the ARNP, on 05/21/2020 at 4:08 PM revealed she normally takes off PPE at the door and normally there is a red bag to drop the used PPE in, but she did she did not see one in Resident #1's room. The ARNP stated that she had the PPE in her hand and went to the left where no other patient rooms were located. The ARNP revealed the PPE is usually taken off in resident room and disposed of in resident room. Interview with Registered Nurse (RN) #1 on 05/21/2020 at 3:40 PM revealed, if have PPE on in a room, staff should take the PPE off in the room and put in the red bag before exiting the room. Review of Specific Facts provided to state entity on 05/22/2020 by Administrator revealed: Psychiatric ARNP donned PPE and entered Resident #1's room (located at the very end of the hallway) to visit a resident for an assessment. It should be noted that this resident is a [MEDICAL TREATMENT] patient, and is in an observation room as a precautionary measure due to required trips to [MEDICAL TREATMENT]; upon exiting the room, the ARNP doffed the PPE and was unable to locate the red trash bin. Unknown to the ARNP, Resident B (roommate/spouse) had moved the red trash bin into the bathroom as the ARNP was preparing to leave the room. ARNP reports stepping out of the room with clean gloves to go dispose of PPE in the Janitor closet next door, which was locked. The ARNP immediately returned to room, donned new PPE and discarded all PPE (prior use PPE and the PPE just donned) properly in the red bin, and exited the room. Again, this room is considered observation, with isolation PPE in use only as precaution for the [MEDICAL TREATMENT] resident. Interview on 05/21/2020 at 3:15 and on 05/21/2020 at 3:17 PM with Administrator and Director of Nursing (DON) revealed Resident #1 was on isolation precautions as she was a [MEDICAL TREATMENT] patient and left the facility routinely for [MEDICAL TREATMENT]. The Administrator stated all resident that leave the facility on [MEDICAL TREATMENT] are placed on isolation precautions. The DON and Administrator further revealed PPE is to be removed at the door and disposed of inside the resident's room, before exiting. The Administrator stated it is not acceptable to be going up/down the hallway carrying PPE.

Based on observation, interview, and review of facility policies, it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observation of the kitchen, on 01/15/19, revealed food stored in the refrigerator and freezer was not dated. Review of the facility Census and Condition, dated 01/15/19, revealed thirty-five (35) of thirty-five (35) residents received their meals from the kitchen. The findings include: Review of the facility policy titled, Labeling and Dating, not dated, revealed proper labeling and dating of food ensures that all foods are stored, rotated, and utilized in a First In and First Out manner. Guidelines for Labeling and Dating 1. All foods should be dated upon receipt before being stored. 2. Food labels must include the food item name, the date of preparation/receipt removal from the freezer, and the use by date as outlined in the attached guidelines. 3. Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date as outlined. Observation of the freezer, on 01/15/19 at 12:44 PM, revealed a bag of breadsticks opened and not dated. Further observation of the refrigerator revealed a bag of breadsticks not dated. Review of the facility policy titled, Glove Usage, not dated, revealed gloves should be changed when they are dirty, torn, damaged, discolored, or contaminated. Further review of the facility policy revealed staff must always remember to wash their hands in between glove changes. Observation during a lunch meal, on 01/16/19 at 11:33 AM, revealed Dietary Aide #1 touched her shirt and pulled her shirt downward. Further observation revealed she did not wash her hands after touching her shirt or prior to touching the clean dishes. Interview with Dietary Aide #1, on 01/16/19 at 12:16 PM, revealed she should have removed her gloves and washed her hands after she touched her shirt. She stated after touching contaminated items, she should have removed her gloves and washed her hands. Interview with the Dietary Manager, on 01/16/19 at 12:23 PM, revealed she expected all food items stored in the refrigerator and freezer to be dated when prepared or opened. She further stated the Dietary Aide should have changed her gloves after touching her shirt during a meal pass.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to implement a comprehensive person-centered care plan, for one (1) of fourteen (14) sampled residents (Resident #22), related to [MEDICAL TREATMENT] services. Resident #22 received [MEDICAL TREATMENT] and had a comprehensive care plan with interventions to check the Arterio-venous graft (AVG) for the pulsing feeling, thrill, and assess for signs/symptoms of infection each shift. However, review of the clinical record revealed the assessments were not conducted and documented per the care plan. The findings include: Review of the facility policy titled Comprehensive Care Plans Standard of Practice, dated November, (YEAR), and last revised November, (YEAR), revealed it is the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review revealed the facility admitted Resident #22 on 12/06/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 12/14/18, revealed the facility assessed Resident #22's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. In addition, the Annual MDS assessment revealed the resident received [MEDICAL TREATMENT]. Review of the Physician's Order Sheet, dated January, 2019, revealed Resident #22 was to receive [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays; no blood pressure or blood draws from the left arm; check bruit/thrill of the left upper extremity arterio-vascular site every shift; [MEDICAL TREATMENT] will be monitored for signs and symptoms of infection and bleeding every shift and as needed. Review of the Comprehensive Care Plan for [MEDICAL TREATMENT], not dated, revealed Resident #22 went to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays; check bruit and thrill every shift, call the Physician if there was a problem noted with the bruit/thrill; [MEDICAL TREATMENT] will be monitored for signs and symptoms of infection and bleeding every shift and as needed. Review of the December, (YEAR) and the January, 2019 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed there was no documented evidence licensed staff conducted assessments of Resident #22's AVG site each shift. Review of the Nurse's Notes, dated December, (YEAR), and January, 2019, revealed Resident #22's AVG site was assessed appropriately on the days he/she received [MEDICAL TREATMENT]. However, further review revealed site assessments were not completed or documented, according to the facility policy, on the days the resident did not receive [MEDICAL TREATMENT]. Additionally, on the days the resident did not receive [MEDICAL TREATMENT], assessments were only done one (1) time during a twenty-four (24) hour period or not at all. Interview with Resident #22, on 01/16/19 at 8:37 AM, revealed he/she went to [MEDICAL TREATMENT] three (3) times a week. The resident stated the nurses checked the AVG site as needed, but not with any regularity. Interview with Licensed Practical Nurse (LPN) #2, on 01/17/19 at 4:33 PM, revealed she assessed Resident #22's AVG for thrill, bruit and signs and symptoms of infection every shift. However, she did not document the assessment anywhere. She stated it's normal to check for thrill, bruit and signs and symptoms of infection, but didn't think about documenting the assessment. Interview with LPN #3, on 01/17/19 at 4:43 PM, revealed he checked the AVG site every day. He further stated he had not documented the assessment every day, but when he did, he documented in the nurse's progress notes. Interview with the Director of Nursing (DON), on 01/17/19 at 4:16 PM, and on 01/17/18 at 5:14 PM, revealed there were no entries on the TAR, indicating to check for thrill/bruit, signs and symptoms of infection, or bleeding. She stated nursing had been documenting the assessments in the Nurse's Notes. The DON further stated it was her expectation for nurses to check the AVG for thrill, bruit and signs and symptoms of infection every shift and after [MEDICAL TREATMENT], as ordered and care planned. Additionally, she stated she expected staff to be familiar with the care plans and familiar with any updates to the care plans.

Based on interview, record review, and review of the facility policy, the facility failed review and revise the care plan, for one (1) of fourteen (14) sampled residents (Resident #27). Resident #27 had a fall on 12/13/18 when he/she became dizzy after toileting and lost his/her balance. However, the intervention on the care plan was a duplicate intervention of 10/23/18. The findings include: Review of the facility policy titled Comprehensive Care Plans Standard of Practice, dated November, (YEAR), and last revised November, (YEAR), revealed it is the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, significant change of condition and quarterly Minimum Data Set (MDS) assessment. Record review revealed the facility admitted Resident #27 on 07/06/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/18/18, revealed the facility assessed Resident #27's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Additionally, the facility assessed the resident as requiring limited assistance of one (1) staff for transfers and ambulation in the room; balance was steady at all times during transition; had no range of motion limitations; was continent of bowel and bladder and received anti-depressant and diuretic medications. Review of the Comprehensive Care Plan, dated 07/06/18, revealed a problem of potential for fall secondary to weakness, decreased strength, and does not always ask for assistance. Review of the approaches included verbal cueing to place the call light on for assistance, dated 10/23/18. Review of a Facility Investigation Worksheet, dated 12/13/18, revealed Resident #27 took cardiovascular, diuretic, and antihypertensive medications up to four (4) hours before having a fall on 12/13/18. The resident was alert and oriented to person, place, and time. The floor was dry and the lighting was adequate. Immediate intervention was to send the resident to the emergency room (ER) for evaluation related to rectal bleeding. Further review of the Comprehensive Care Plan approaches listed for 12/13/18 included verbal cueing to place the call light on for assistance when the resident felt dizzy (a duplicate approach); vital signs and neuro checks as indicated; and therapy screen as needed. Review of the Fall Risk Data Set, dated 12/18/18, completed by Registered Nurse (RN) #1, revealed Resident #27 required minimal assistance with transfers, was full weight bearing, used a walker and a wheelchair, and received two (2) or more medications which may contribute to falls. The score for the assessment was eight (8), indicating the resident was at high risk for falls. Review of the notes on the Fall Risk Assessment revealed any resident with previous falls should be considered high risk until fall free for six (6) months. Further review of the notes revealed the resident had a fall on 12/13/18 related to dizziness and weakness. ER evaluation revealed no major injury, urinalysis obtained, culture and sensitivity results received, and started on [MEDICATION NAME] (antibiotic) 100 (milligrams) mg orally (po) twice a day (BID), continue to assess. Review of the Therapy Referral Form, not dated, revealed the root cause of the 12/13/18 fall was that Resident #27 became dizzy when getting up from the toilet, as well as having low blood pressure. Further review of the Therapy Referral Form revealed a response from rehabilitation services as nursing reporting (patient) presenting with Urinary Tract Infection [MEDICAL CONDITION], so services are not required at this time. Interview with RN #1, on 01/17/19 at 2:39 PM, revealed Resident #27 fell due to dizziness. The RN stated the immediate intervention was to send him/her to the ER due to rectal bleeding. Interview with the Assistant Director of Nursing (ADON), on 01/17/19 at 2:35 PM, revealed the root cause of the fall was dizziness after toileting. The ADON stated the immediate intervention was to send the resident to the ER for evaluation due to rectal bleeding and the intervention put in place upon Resident #27's return was to verbally cue him/her to place the call light on for assistance when he/she felt dizzy, even though a 10/23/18 intervention for verbal cue to place call light on for assistance was initiated on 10/23/18. The ADON further stated she updated the care plan on 12/13/18 and added the new intervention. She further stated the intervention was a new and different intervention, because it stated when he/she feels dizzy. Interview with the Director of Nursing (DON), on 01/17/19 at 2:40 PM and at 5:14 PM, revealed the Interdisciplinary Team (IDT) met to discuss the resident's fall and collaboratively come up with an intervention. The IDT determined Resident #27 needed to be reminded to call for assistance before getting up, and the intervention was added to the care plan on 12/13/18. However, it was documented throughout the care plan that the resident got up without calling for assistance. The DON further stated she expected a more problem-oriented intervention for the specific root cause to be initiated rather than a duplicate intervention. Additionally, the DON stated the wording of the 12/13/18 intervention was poor and should have raised a flag for the person updating the care plan. The DON stated the ADON and the MDS Coordinator were responsible for updating the care plans.

Based on interview, closed record review, and review of the facility policy, it was determined the facility failed to complete a discharge summary and recapitulation of the resident's stay, for one (1) of three (3) residents' closed records reviewed for discharge planning (Resident #36). Resident #36 was discharged home on[DATE]; however, there was no documented evidence a recapitulation of stay and discharge summary was completed per the facility policy. The findings include: Review of the facility policy titled, Discharge Planning Standard of Practice, last reviewed (MONTH) (YEAR), revealed the discharge summary should include completion of a discharge form by the charge nurse or designee for anticipated discharge to home or to another facility; a medication reconciliation of medications or pre-discharge medications with post discharge medications and discharge teaching instructions/when to call the doctor. Closed record review revealed the facility admitted Resident #36 on 10/02/18 and discharged the resident home on 10/22/18. Further review of the closed record revealed no documented evidence the discharge summary had been completed by nursing. Interview with Medical Records, on 01/17/19 at 12:53 PM, revealed she filed the resident's discharge summary when each department completed their section. She further stated she did not notice Resident #36's discharge summary had not been completed by nursing. She stated she would be checking the forms in the future to ensure they were completed. Interview with the Director of Nursing (DON), on 01/17/19 at 5:20 PM, revealed each department completed a section on the discharge summary. She further stated it was the responsibility of the nurse on duty to complete the discharge summary for the resident and she was not aware the nurse had not completed the discharge summary for Resident #36. She stated the nurse working that day was no longer employed by the facility. She stated she expected a discharge summary to be completed on each resident upon the resident's discharge.

Based on observation, interview, record review, and review of the facility policy, the facility failed to provide adequate supervision and assistive devices to prevent accidents, for one (1) of fourteen (14) sampled residents (Resident #27), related to fall interventions not being revised as appropriate. Resident #27 had a fall on 12/13/18 when he/she became dizzy after toileting and lost his/her balance. However, the intervention placed on the care plan was a duplicate intervention, dated 10/23/18. The findings include: Review of the facility policy titled Fall Assessment/Intervention Process, last updated 10/2015, revealed all residents on admission, re-admission, and at least quarterly will be assessed for fall risk and appropriate interventions initiated immediately to reduce the risk of injuries with falls. Fall/Incident Investigation tool must accompany any fall. The Interdisciplinary team (IDT)/designee will review and ensure implementation of any recommendation offered by utilization of this investigation tool. Therapy will screen all falls and document their recommendations for interventions, equipment and/or possible therapy services. The care plan will be updated to reflect any changes to risk factors or needed interventions. Record review revealed the facility admitted Resident #27 on 07/06/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/18/18, revealed the facility assessed Resident #27's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Additionally, the facility assessed the resident as requiring limited assistance of one (1) staff for transfers and ambulation in the room; balance was steady at all times during transition; had no range of motion limitations; was continent of bowel and bladder and received anti-depressant and diuretic medications. Review of the Comprehensive Care Plan, dated 07/06/18, revealed problem of potential for fall secondary to weakness, decreased strength, does not always ask for assistance. Approaches included verbal cue to place call light on for assistance, dated 10/23/18. Observation, on 01/16/19 at 9:35 AM, revealed there were anti-skid strips on the bathroom floor and on the floor at his/her bedside, a raised toilet seat in the bathroom, and a low bed. Interview with Resident #27, on 01/16/19 at 9:35 AM, revealed he/she had fallen while at the facility. Review of the Nurse's Progress Notes, dated 12/13/18 at 11:20 AM, revealed Resident #27 was found on the floor on his/her back. Further review of the Nurse's Progress Notes revealed the resident complained of being dizzy when assisted by three (3) staff with standing. Blood was noted in the toilet as a result of a previous bowel movement. Blood was also noted on the resident's right lower neck, and appeared that a mole had been torn during the fall. Review of the Facility Investigation Worksheet, dated 12/13/18, revealed Resident #27 had taken cardiovascular, diuretic, and antihypertensive medications up to four (4) hours before the fall. The resident was alert and oriented to person, place, and time. Further review of the Facility Investigation Worksheet revealed the floor was dry and the lighting was adequate. The immediate intervention was to send the resident to the emergency room (ER) for an evaluation related to rectal bleeding. Further review of the Comprehensive Care Plan approaches listed for 12/13/18 included verbal cueing to place the call light on for assistance when the resident felt dizzy (a duplicate approach); vital signs and neuro checks as indicated; and therapy screen as needed. Review of the Fall Risk Data Set, dated 12/18/18, completed by Registered Nurse (RN) #1, revealed Resident #27 required minimal assistance with transfers, was full weight bearing, used a walker and a wheelchair, and received two (2) or more medications which may contribute to falls. The score for the assessment was eight (8), indicating the resident was at high risk for falls. Review of the notes on the Fall Risk Assessment revealed any resident with previous falls should be considered high risk until fall free for six (6) months. Further review of the notes revealed the resident had a fall on 12/13/18 related to dizziness and weakness. ER evaluation revealed no major injury, urinalysis obtained, culture and sensitivity results received, and started on [MEDICATION NAME] (antibiotic) 100 (milligrams) mg orally (po) twice a day (BID), continue to assess. Review of the Therapy Referral Form, not dated, revealed the root cause of the 12/13/18 fall was that Resident #27 became dizzy when getting up from the toilet, as well as having low blood pressure. Further review of the Therapy Referral Form revealed a response from rehabilitation services as nursing reporting (patient) presenting with Urinary Tract Infection [MEDICAL CONDITION], so services are not required at this time. Interview with RN #1, on 01/17/19 at 2:39 PM, revealed Resident #27 fell due to dizziness. The RN stated the immediate intervention was to send him/her to the ER due to rectal bleeding. Interview with the Assistant Director of Nursing (ADON), on 01/17/19 at 2:35 PM, revealed the root cause of the fall was dizziness after toileting. The ADON stated the immediate intervention was to send the resident to the ER for evaluation due to rectal bleeding and the intervention put in place upon Resident #27's return was to verbally cue him/her to place the call light on for assistance when he/she felt dizzy, even though a 10/23/18 intervention for verbal cue to place call light on for assistance was initiated on 10/23/18. The ADON further stated she updated the care plan on 12/13/18 and added the new intervention. She further stated the intervention was a new and different intervention, because it stated when he/she feels dizzy. Interview with the Director of Nursing (DON), on 01/17/19 at 2:40 PM and at 5:14 PM, revealed the Interdisciplinary Team (IDT) met to discuss the resident's fall and collaboratively come up with an intervention. The IDT determined Resident #27 needed to be reminded to call for assistance before getting up, and the intervention was added to the care plan on 12/13/18. However, it was documented throughout the care plan that the resident got up without calling for assistance. The DON further stated she expected a more problem-oriented intervention for the specific root cause to be initiated rather than a duplicate intervention. Additionally, the DON stated the wording of the 12/13/18 intervention was poor and should have raised a flag for the person updating the care plan. The DON stated the ADON and the MDS Coordinator were responsible for updating the care plans.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure residents who required [MEDICAL TREATMENT] received services consistent with the professional standards of practice, for one (1) of fourteen (14) sampled residents (Resident 22). Resident #22 was receiving hemodialyis; however, the facility failed to check the Arterio-venous graft (AVG) for the pulsing feeling, thrill each shift per facility policy. The findings include: Interview with the Director of Nursing (DON), on 01/17/19 at 4:16 PM, revealed the facility does not have a policy for [MEDICAL TREATMENT] care. The DON further stated a nursing manual was used for reference. Review of the Nursing Services, Policy and Procedure Manual for Long-Term Care, Volume 2, Revised in 04/2012, revealed care of the AVG involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). To prevent infection and/or clotting: keep the access site clean at all times; do not use the access site arm to take blood samples, administer intravenous (IV) fluids or give injections; check for signs of infections (warmth, redness, tenderness, or [MEDICAL CONDITION]) at the access site when performing routine care and at regular intervals; do not use the access arm to take blood pressure; advise the resident not to sleep on, wear tight jewelry or lift heavy objects with the access arm; check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals; and check patency of the site at regular intervals, palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flowing through the access. The general medical nurse should document in the resident's medical record every shift as follows: location of the catheter; condition of the dressing (interventions if needed); if [MEDICAL TREATMENT] was done during the shift; any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given; and observations post-[MEDICAL TREATMENT]. Record review revealed the facility admitted Resident #22 on 12/06/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 12/14/18, revealed the facility assessed Resident #22's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. In addition, the Annual MDS assessment revealed the resident received [MEDICAL TREATMENT]. Review of the Physician's Order Sheet, dated January, 2019, revealed Resident #22 was to receive [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays; no blood pressure or blood draws from the left arm; check bruit/thrill of the left upper extremity arterio-vascular site every shift; [MEDICAL TREATMENT] will be monitored for signs and symptoms of infection and bleeding every shift and as needed. Review of the Comprehensive Care Plan for [MEDICAL TREATMENT], not dated, revealed Resident #22 went to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays; no blood draws from the left arm AVG site or arm of AVG placement; check bruit and thrill every shift, call the Physician if there was a problem noted with the bruit/thrill; [MEDICAL TREATMENT] will be monitored for signs and symptoms of infection and bleeding every shift and as needed. Review of the December, (YEAR) and the January, 2019 Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed there was no documented evidence licensed staff conducted assessments of Resident #22's AVG site each shift. Review of the Nurse's Notes, dated December, (YEAR), and January, 2019, revealed Resident #22's AVG site was assessed appropriately on the days he/she received [MEDICAL TREATMENT]. However, further review revealed site assessments were not completed or documented, according to the facility policy, on the days the resident did not receive [MEDICAL TREATMENT]. Additionally, on the days the resident did not receive [MEDICAL TREATMENT], assessments were only done one (1) time during a twenty-four (24) hour period or not at all. Interview with Resident #22, on 01/16/19 at 8:37 AM, revealed he/she went to [MEDICAL TREATMENT] three (3) times a week. The resident stated the nurses checked the AVG site as needed, but not with any regularity. Interview with Licensed Practical Nurse (LPN) #2, on 01/17/19 at 4:33 PM, revealed she assessed Resident #22's AVG for thrill, bruit and signs and symptoms of infection every shift. However, she did not document the assessment anywhere. She stated it's normal to check for thrill, bruit and signs and symptoms of infection, but didn't think about documenting the assessment. Interview with LPN #3, on 01/17/19 at 4:43 PM, revealed he checked the AVG site every day. He further stated he had not documented the assessment every day, but when he did, he documented in the nurse's progress notes. Interview with the Director of Nursing (DON), on 01/17/19 at 4:16 PM, and on 01/17/18 at 5:14 PM, revealed there were no entries on the TAR, indicating to check for thrill/bruit, signs and symptoms of infection, or bleeding. She stated nursing had been documenting the assessments in the Nurse's Notes. The DON further stated it was her expectation for nurses to check the AVG for thrill, bruit and signs and symptoms of infection every shift and after [MEDICAL TREATMENT], as ordered and care planned. Additionally, she stated she expected staff to be familiar with the care plans and familiar with any updates to the care plans.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. On [DATE], observation of two (2) of two (2) medication carts on the Long Hall and Short Hall, revealed medication not dated when opened. The findings include: Review of the facility's policy titled, Medication Administration, dated ,[DATE], revealed certain products or package-types such as multi-dose vials and ophthalmic drugs have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. When the date open expiration dating is not available from the manufacturer, the following may be considered in determining facility policy: Position statements from American Society of Ophthalmic, Registered Nurses and American Society of Cataract and Refractive Surgery (ASCRS) state the multi-use eye drops and ointments should be disposed of twenty-eight (28) days after initial use. These position statements are based on safety guidelines that have been established for safe use and are considered as best practice. Observation of the Long Hall medication cart, on [DATE] at 2:25 PM, revealed one (1) bottle of Fluorometholone 0.1% eye drops, dated [DATE]. Observation of the Short Hall medication cart, on [DATE] at 2:30 PM, revealed one (1) bottle of Ketotifen 0.025% eye drops, dated [DATE]. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:45 PM, revealed if medications were expired, they should be removed from the medication cart and reordered. She further stated the expired eye drops may have been overlooked because the expiration dates were different depending on the type of eye drop. Interview with the Director of Nursing (DON), on [DATE] at 5:19 PM, revealed she expected the nurses to be aware of the expiration dates of eye drops on the medication carts. She further stated if medications were approaching the expiration date, the medication should be reordered. Any expired medication should be removed from the cart, and the medication should be disposed. She stated nursing staff were educated on labeling of medication during their orientation period.

Based on observation, interview, record review and review of the facility policy and procedure, it was determined the facility failed to protect and ensure two (2) of three (3) sampled residents were free from sexual abuse (Resident #1 and #3). On [DATE], the Medical Records Director/ (CNA) #1, observed Resident #2 in the TV lounge with his/her hand between Resident #3's legs, over the resident's clothing attempting to rub the resident's private parts. A sensor alarm was placed on Resident #2's door with no further sexually inappropriate behavior noted and the sensor alarm was discontinued on [DATE] with no other intervention put in place. On [DATE], Certified Nurse Assistant (CNA) #2 observed Resident #2 in the TV lounge with his/her hand under Resident #1's blouse touching his/her breast. The findings include: Review of the facility's policy and procedure, titled Abuse Prohibition Standards of Practice, last revised (MONTH) (YEAR), revealed each resident had the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. In addition, to prevent abuse the facility should assess, monitor, and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents. Review of Attachment A revealed Abuse is any willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Sexual Abuse is any touching of the anus, breast, or any part of the genitals of a resident with voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault. 1. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #3's Brief Interview of Mental Status was coded as a ninety-nine (99) which indicated the resident was not interviewed. Resident #3 expired at the nursing facility on [DATE]. Interview with Certified Nurse Aide (CNA) #1, on [DATE] at 4:41 PM, revealed a couple of months ago ([DATE]) she witnessed Resident #2 go in the TV lounge and sit beside Resident #3 with his/hand between Resident #3's legs over the resident's clothing rubbing him/her in the crotch area. She stated Resident #3 was not aware of what was happening and appeared to be sleeping. She revealed she believed Resident #2 was aware of what he/she was doing because when she moved toward him/her, he/she moved his/her hand away. Interview with the Business Office Manager, on [DATE] at 3:20 PM, revealed she witnessed Resident #2 fondling Resident #3. She stated Resident #2 had his/her hand between Resident #3's legs rubbing his/her crotch area and as soon as he/she saw her coming toward him/her, he/she removed their hand away immediately. She revealed she believed he/she knew he/she was acting inappropriately and when the opportunity presented itself he/she went for it. Additionally, she stated Resident #3 was sleeping and had no idea what was happening. 2. Record review revealed the facility admitted Resident #1 on [DATE] and readmitted him/her on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS score of five (5) which indicated the resident was not interviewable. Review of the facility's final investigation, dated [DATE], revealed Resident #2 was witnessed with his/her hand up Resident #1's blouse holding his/her breast and Resident #1 was sleeping and had no idea of what was happening; however, interview with CNA #2 revealed she heard Resident #1 yelling and crying out which was normal for the resident but this time the resident sounded different so she checked on the resident and that's when she found Resident #2 with his/her hand up Resident #1's blouse holding his/her breast. Interview with CNA #2, on [DATE] at 1:37 PM, revealed on [DATE], she was in the hallway and heard Resident #1 crying and yelling, which was not uncommon, however, she stated this time the yelling out sounded different and when she went to the TV lounge to check on him/her, she witnessed Resident #2 with his/her hand up Resident #1's shirt holding his/her breast. CNA #2 stated when she told Resident #2 to stop what he/she was doing, he/she looked at her like he/she was confused. She stated she did not believe Resident #2 thought what he/she was doing was inappropriate. 3. Record review revealed the facility admitted Resident #2 on [DATE] and readmitted him/her on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated [DATE], revealed the facility assessed Resident #2's cognition as moderately impaired with a BIMS score of nine (9) which indicated the resident was interviewable (resident hospitalized during the investigation) Further review of the MDS and Comprehensive Care Plan [DATE], revealed the resident had a history of [REDACTED]. Review of the Resident #2's Comprehensive Care Plan, last revised [DATE], revealed after the incident on [DATE], a sensor alarm was placed over the resident's door to alert staff of him/her leaving the room unattended. Review of Interdisciplinary Team (IDT) Notes, dated [DATE], revealed the alarm was discontinued on [DATE] after the Interdisciplinary Team (ID) met and discussed the alarm being more of a restraint for the resident than being helpful, with no other interventions put in place to address the resident's sexually inappropriate behavior on [DATE]. The resident was involved in another sexually inappropriate incident six (6) days later. Interview with the Social Services Director (SSD), on [DATE] at 4:51 PM, revealed the nursing facility was not an appropriate place for Resident #2 to live related to his/her sexual behaviors; and, referrals had been made to other facilities. Interview with the Director of Nursing (DON), on [DATE] at 5:17 PM, revealed she did not feel Resident #2 had abused the residents because she did not believe Resident #2 had willful intent to harm anyone.

Based on interview, record review, and review of the facility's policy and procedure, titled Abuse Prohibition Standards of Practice, it was determined the facility failed to develop a policy that addressed assessing vulnerable residents after an allegation of abuse had been alleged to determine the extent of the abuse for one (1) of three (3) sampled residents (Resident #1 and #3). The findings include: Review of the facility policy titled, Abuse Prohibition Standards of Practice, last revised (MONTH) (YEAR), revealed each resident had the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident had the right to be free from mistreatment, neglect and misappropriation of property. The following standards of practice would be operationalized in order that residents would not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Further review revealed the investigation should include interviewing the resident and all witnesses; however, the policy did not address what would be done to determine the extent of the possible abuse. Record review revealed the facility admitted Resident #1 on 08/29/17 and readmitted him/her on 05/06/18 with [DIAGNOSES REDACTED]. Record review revealed the facility admitted Resident #2 on 02/05/15 and readmitted him/her on 01/01/18 with [DIAGNOSES REDACTED]. Review of the facility's final investigation, dated 05/05/18, revealed Resident #2 was witnessed with his/her hand up Resident #1's blouse holding his/her breast and Resident #1 was sleeping and had no idea of what was happening. Further review of the investigation revealed the facility interviewed all interviewable residents with no negative outcomes or statements of inappropriate behavior towards them from Resident #2; and residents with a BIMS score under eight (8) were assessed for injury and no injuries were noted; however, the facility could provide no documented evidence the non-interviewable residents were assessed for possible abuse to determine the possible extent of the alleged abuse. Interview with the Administrator, on 05/15/18 at 05/17/18, revealed assessing the vulnerable residents was not mentioned in the facility policy and although it had been done in the past, it was not done for this incident because it occurred in a common area where anyone was able to witness the incident; therefore, she did not believe the vulnerable residents were in any danger.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. Review of the Census and Condition, dated 01/31/17, revealed thirty-five (35) of thirty-five (35) residents received their meals from the kitchen. On 01/31/17, observation of a lunch meal tray line service and food temperatures being obtained revealed the Dietary Cook contaminated her gloved hands multiple times and did not change her gloves or wash her hands and failed to sanitize the thermometer prior to use in each food item on the tray line. The findings include: Review of the facility's policy and procedure titled, Food Preparation, dated May 2014, revealed the Food Services Director insures that all staff practice proper hand washing technique and practice proper glove use. The Food Services Director or Cook (s) are responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. The Food Services Director/Cook (s) are responsible to ensure that all utensils, food contact equipment, and food contact surfaces are cleaned and sanitized after every use. 1. Observation, on 01/31/17 at 11:32 AM of food temperatures being obtained revealed the Dietary Cook took food temperatures and cleaned/wiped the thermometer with a wet dish rag laying on the counter. She then dropped the thermometer and caught it in between her shirt and her arm and did not clean it before continuing with temperatures. Further observation revealed she also used alcohol wipes to clean the thermometer; however, did not change the wipe each time, dropped a wipe on the floor, picked it up and used it to wipe the thermometer and continued to obtain food temperatures. 2. Observation of the lunch tray line meal services on 01/31/17 at 11:32 AM revealed the Dietary Cook touched the lid to trash cans four (4) times and did not change her gloves or wash her hands prior to returning to the tray line to serve food. Then she left the tray line area and did not wash her hands upon returning to the tray line. She used scissors to cut open a bag of chicken and placed them back in the holder on the wall without cleaning them and took her eye glasses off the top of her head and placed them on her face without changing her gloves or washing her hands. Interview was attempted with the Dietary Cook; however, she left early due to illness and was not able to be reached by phone. Interview with the Dietary Manager, on 02/01/17 at 10:12 AM, revealed she expected the Dietary Cook to clean the thermometer with alcohol wipes and to use a new one after each temperature was taken. She stated the dish rag should be placed in the sanitizer bucket and not left out on the counter and she expected the Cook to change her gloves and wash her hands after each time they were contaminated. Interview with the Administrator, on 02/02/17 at 9:46 AM, revealed he expected dietary staff to be re-educated on the food service policy and procedure and he held the entire kitchen staff accountable and the Dietary Cook should have been taken off of tray line meal service.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. Observation of one (1) of two (2) medication carts revealed one (1) vial of Novolog Insulin and one (1) vial of Humulin 70/30 Insulin was not dated when opened. The findings include: Review of the facility's policy and procedure, titled Medication Storage, dated September 2010, revealed to note the date on the label for insulin vials and pens when first used. Observation a medication cart, on 02/02/17 at 8:15 AM, revealed one (1) vial of Novolog Insulin and one (1) vial of Humulin 70/30 Insulin, which belonged to two (2) different residents were opened with no date as to when they were opened. Interview with Licensed Practical Nurse (LPN) #1, on 02/02/17 at 8:29 AM, revealed the facility's policy was insulin was to be dated when opened. Interview with the Assistant Director of Nursing (ADON), on 02/01/17 at 8:35 AM, and the Director of Nursing (DON) on 02/02/17 at 8:31 AM revealed they expected insulins would be dated when opened.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure a written description of legal rights regarding liability and appeal notices of non-coverage of Medicare stay were provided for three (3) unsampled residents (Resident A, B, and C). Review of discharged records revealed a forty-eight (48) to seventy-two (72) hour notice of discharge of Medicare coverage was not provided to Unsampled Residents A, B, and C or to the legal representatives for the residents. The findings include: Review of the facility's policy and procedure, titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- , dated 12/31/2011, revealed: · When to Deliver the NOMNC: A Medicare provider or health plan must give an advanced, completed copy of the NOMNC to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services not later than two days before the termination of services. · Valid Notice of Delivery: This notice must be validly delivered. Valid delivery means that the beneficiary/enrollee must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The beneficiary must be able to understand that he or she may appeal the termination decision. If the beneficiary/enrollee is not able to comprehend the contents of the notice, it must be delivered to and signed by the representative. Further policy review revealed the NOMNC would not be issued if Medicare coverage was being terminated for the following reasons: · Medicare benefits had exhausted · Denial of Medicare admission · Denial of a service that was not a Medicare benefit · Due to a reduction or termination of a Medicare service, that does not end the skilled Medicare stay. 1. Record review revealed the facility admitted Unsampled Resident A, on 12/09/15, with diagnoses, which included Depression, [MEDICAL CONDITION] Disorder, Hypertension, [MEDICAL CONDITIONS], Anxiety, and [MEDICAL CONDITION]. Further review revealed Unsampled Resident A resided at the facility from 12/09/15 through 01/01/16 and he/she was covered by Medicare A benefits. On 01/01/16, he/she was discharged to the community, which required a NOMNC to be issued by the facility; however, the notice was not issued to the resident. 2. Record review revealed Unsampled Resident B was admitted to the facility, on 11/12/15, with diagnoses, which included Hypertension, Gastro [MEDICAL CONDITION] Reflux, Dementia, [MEDICAL CONDITION], and Depression. Further record review revealed Unsampled Resident B resided at the facility from 11/12/15 through 12/04/15 and he/she was covered by Medicare A benefits. On 12/04/15, he/she was discharged to the community, which required a NOMNC to be issued by the facility; however, the notice was not issued to the resident. 3. Record review revealed the facility admitted Unsampled Resident C, on 07/01/15, with diagnoses, which included [MEDICAL CONDITION], Hypertension, Type II Diabetes Mellitus, Arthritis, Anxiety, Depression, [MEDICAL CONDITION] Disorder, and [MEDICAL CONDITION]. Further record review revealed Unsampled Resident C resided at the facility from 07/01/15 through 07/31/15 and he/she was covered by Medicare A benefits. On 07/31/15, he/she was discharged to the community, which required a NOMNC to be issued by the facility; however, the notice was not issued to the resident. Interview with the Social Services Director (SSD), on 01/14/16 at 10:30 AM, revealed she forgot to issue the notices and had no other excuse for not providing the residents with the appropriate notices of discharge. Interview with the Administrator, on 01/15/16 at 8:35 AM, revealed she expected appropriate discharge and appeal notices to be provided per facility policy by the SSD.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator or allegations of misappropriation of property (narcotics) were investigated and reported to the appropriate State authorities for three (3) of ten (10) sampled residents (Residents #3, #4, and #6) and one (1) unsampled resident (Resident E). Certified Nurse Aide (CNA) #1 failed to report an allegation of mistreatment of [REDACTED].#3, #4, and #6; and Unsampled Resident E. The findings include: Review of the facility's Abuse/Neglect policy/procedure, undated, revealed personnel, residents, visitors, etc., are encouraged to promptly report incidents of suspected resident abuse or neglect to the facility administration. Any person, who suspects that abuse, neglect, or misappropriation of property may have occurred, will immediately report the alleged violation to the facility Administration and any necessary advocacy agencies. Further review revealed Misappropriation of Resident Property was defined as the misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent. The facility Administration will immediately suspend staff that is alleged to have or be suspicious for abuse and or neglect, notify the Office of Inspector General, Adult Protective Services, and local law enforcement authority. The facility administration will initiate the investigation process by interviewing all staff and residents with any knowledge of allegation, and complete an investigation within five (5) days of the allegation and document all interviews, including date, time, and content of interview. Facility administration will suspend staff member who was named in the allegation until the investigation has been completed; upon completion of investigation summary of findings, whether substantiated or unsubstantiated, will be forwarded to agencies notified at the beginning of the investigation, as well as physicians and resident representative. 1. Record review revealed the facility readmitted Resident #3 on 10/21/14, with diagnoses, which included [MEDICAL CONDITIONS], Diabetes Mellitus Type II, Dementia, and [MEDICAL CONDITION]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 11/19/15, revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was non-interviewable. During a routine interview regarding abuse/neglect with Certified Nurse Aide (CNA) #1, on 01/14/16 at 2:35 PM, the CNA reported an allegation of verbal abuse to the surveyor involving Resident #3 and Licensed Practical Nurse (LPN) #1. The CNA stated she has heard the LPN tell Resident #3, you're getting on my nerves, stop crying and observed LPN #1 push him/her down the hallway in his/her wheelchair, and tell him/her, if you want to cry, you can sit here and cry. CNA #1 said the resident cried when the LPN spoke to him/her like that, and the LPN did not try to console (him/her), she would just let the resident cry. The CNA revealed she had witnessed other instances of verbal abuse between LPN #1 and Resident #3, but could not recall specific dates. CNA #1 stated LPN #1 has yelled at Resident #3, but she has never heard her curse the resident. She stated she had not reported the verbal abuse to anyone until now. She revealed she was aware of the facility's policy/procedure for reporting, and stated she had been in-serviced regarding abuse/neglect. When asked why she had not reported the allegation of abuse to her supervisors, she stated she tried to talk to (LPN #1) about it; however, (LPN #1) just ignored anything I said about it. CNA #1 revealed she should have reported it to another nurse on the floor, the Director of Nursing (DON), or the Administrator immediately. CNA #1 provided no further explanation as to why she had not previously reported the allegation of verbal abuse. Review of CNA #1's Personnel Record revealed she was hired on 11/17/15, and inserviced regarding reporting allegations of abuse on the same date. Interview with LPN #1, on 01/14/16 at 4:25 PM, revealed she was familiar with the Abuse/Neglect policy/procedure and has attended Abuse/Neglect training within the last month or so. LPN #1 revealed she hardly ever worked the hall where Resident #3 resided. She stated she has asked the resident why he/she was crying, and at times, the resident will go from crying to laughing. She revealed the resident has spells of crying, but not real crying. She denied she told the resident you can sit here and cry. The LPN also stated she has told co-workers it (resident's crying) was nerve-wracking, but not where the resident could hear me say it. Observations of Resident #3, on 01/13/16 at 10:00 AM, 10:25 AM, 11:25 AM, 12:25 PM, and 4:00 PM, revealed no behaviors or crying. Observation of Resident #3's skin assessment conducted by Registered Nurse (RN) #1, and assisted by CNA #9, on 01/14/16 at 11:15 AM, revealed no obvious signs of abuse/neglect. Interview with the Administrator, on 01/14/16 at 3:00 PM and 5:15 PM, revealed she was unaware of the allegation of verbal abuse involving Resident #3 until reported by the surveyor on 01/14/16. She stated she initiated an investigation immediately and LPN #1 was suspended pending outcome of the investigation. She stated CNA #1 had previously worked in the facility's kitchen and was new to being a CNA in the facility (as of 11/17/15). The Administrator stated CNA #1 has had abuse training and knew to report any type of abuse; however, she was unsure why the CNA had not reported the abuse allegation. 2. Interview with Registered Nurse (RN) #2, on 01/15/16 at 9:49 AM, revealed she told the Administrator and the DON in November 2015 that they needed to look at the narcotics because it seemed the same staff were wasting narcotics. She stated she did not know what was done but the excessive wasting continued after she had informed the Administrative staff. Interview with LPN #4, on 01/15/16 at 4:49 PM, revealed she had informed the Director of Nursing (DON) and Assistant Director of Nursing multiple times about the excessive wasting of narcotics by LPN #2 and LPN #1. She stated she reported it to the Administrator on 01/11/16. Review of Resident #4's Drug Control Record Sheet revealed [MEDICATION NAME]-[MEDICATION NAME] 10-325 was wasted on 09/23/15, 09/25/15, 10/01/15, 10/03/15, 10/15/15, 10/17/15, two times on 11/18/15, 11/19/15, two times on 11/22/15, 11/25/15, 11/29/16, 12/08/15, 12/11/15, 12/12/15, two times on 12/28/15, and 12/30/15. Further review revealed the medication was wasted by LPN #2 or LPN #1 with one of them cosigning or no cosigner. Review of Resident #3's Controlled Drug Record Sheet revealed [MEDICATION NAME]-[MEDICATION NAME] 10-325 was wasted on 10/21/15, 10/28/15, 10/31/15, 11/16/15, 11/18/15, 11/25/15, 01/09/16 and 01/11/16 by LPN #1 with LPN #2 cosigning. Review of Resident #6's Drug Control Record Sheet revealed [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg was wasted on 11/17/15, 11/18/15, and 12/09/15 by LPN #2 with LPN #1 cosigning. Review of Unsampled Resident E's Controlled Drug Record Sheet revealed [MEDICATION NAME] HCL 10 mg tablet was wasted on 09/23/15, 09/24/15, 10/01/15, 10/03/15, 10/04/15, 10/22/15, 10/24/15, and 10/29/15. Further review revealed the medication was wasted by LPN #2 or LPN #1 with one of them cosigning or no cosigner. Interview with the DON, on 01/15/16 at 10:57 AM and 2:53 PM, revealed LPN #5 had said something to her two (2) weeks ago, she had looked at the Controlled Drug Record, and they were decent. The DON stated she did not document anything because she did not consider it an allegation. Interview with the Administrator, on 01/14/15 at 4:31 PM and on 01/15/16 at 2:44 PM, revealed she had been informed by a licensed staff member of a concern with excessive narcotic wasting on 01/11/16, but she did not consider it an allegation. She stated she and the DON talked with LPN #1 and LPN #2 about the narcotics and they denied taking medications. She said the DON and herself went over the facility policy and procedure for wasting narcotics with the LPN's at that time. When asked if an investigation was conducted, she stated they did not consider it an allegation of misappropriation of property so there was no documentation of an investigation and nothing was reported to the State Agencies. She stated they did interviews with interviewable residents to ensure they were receiving their medications but the interviews were not documented.

Based on observation, interview, record review and review of the facility Abuse/Neglect Policy, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, abuse and misappropriation of property for three (3) of ten (10) sampled residents (Resident #3, #4 and #6) and one (1) Unsampled resident (Resident E). Certified Nurse Aide (CNA) #1 reported to the Surveyor she witnessed Licensed Practical Nurse (LPN) #1 mistreat Resident #3 on more than one (1) occasion; however, CNA #1 failed to implement the facility's policy and immediately report the mistreatment to the Administrator. In addition, Administration failed to implement the facility Abuse/Neglect policy related to reporting and investigating when staff reported LPN #1 and LPN #2 were wasting an excessive amount of narcotics. The findings include: Review of the facility's Abuse/Neglect policy/procedure, undated, revealed any person who suspects abuse, neglect, or misappropriation of property may have occurred, will immediately report the alleged violation to the facility Administration and any necessary advocacy agencies. 1. Record review revealed the facility admitted Resident #3 on 04/18/14, and readmitted him/her on 10/21/14, with diagnoses, which included [MEDICAL CONDITIONS], Diabetes Mellitus Type II, Dementia, and [MEDICAL CONDITION]. During a routine interview regarding abuse/neglect with another CNA (#1), on 01/14/16 at 2:35 PM, the CNA reported an allegation of verbal abuse stating Licensed Practical Nurse (LPN) #1, whom CNA #1 stated she worked with on a frequent basis, has yelled at Resident #3, but never cursed him/her. The CNA stated she has heard the LPN tell the resident, you're getting on my nerves, stop crying, observed her to push the resident down the hallway in his/her wheelchair, and also him/her, if you want to cry, you can sit here and cry. She stated the resident cried when the LPN spoke to him/her like that, and the LPN did not try to console (him/her), she would just let the resident cry. The CNA revealed she had witnessed other instances of verbal abuse between LPN #1 and Resident #3; however, she could not recall specific dates. She stated she had not reported any of this information to anyone but she was aware of the facility's policy/procedure for reporting, and stated she had been in-serviced regarding abuse/neglect. CNA #1 revealed she should have reported it to another nurse on the floor, the Director of Nursing (DON), or the Administrator immediately. CNA #1 provided no further explanation as to why she had not previously reported the allegation of verbal abuse. Interview with the Administrator, on 01/14/16 at 3:00 PM and 5:15 PM, revealed she was unaware of the allegation of verbal abuse involving Resident #3 until reported by the surveyor on 01/14/16. Further interview with the Administrator and the DON, on 01/15/16 at 11:35 AM, revealed the CNA should have reported the suspected abuse immediately to her (Administrator), the DON, or the Charge Nurse. 2. Interviews on 01/15/16 with Registered Nurse (RN) #2 at 9:49 AM, and Licensed Practical Nurse (LPN) #4 at 4:49 PM revealed they had reported multiple times to the Administrator, Assistant Director of Nursing (ADON), and DON, that they needed to look at the narcotics because it seemed like LPN #2 and #1 were wasting excessive narcotics. RN #2 stated she reported it as far back as November 2015 and LPN #4 stated the last time she reported it was to the Administrator on 01/11/16. Review of Resident #3's, 4's, and 6's and Unsampled Resident E's Drug Control Record Sheets revealed a total of thirty-eight (38) Oxycodon-[MEDICATION NAME] 10-325 and 7.5-325 mg tablets and [MEDICATION NAME] 10 mg tablets were wasted between 09/23/15 and 01/11/16. Interview with the DON, on 01/15/16 at 10:57 AM and 2:53 PM, and the Administrator, on 01/14/16 at 4:31 PM and on 01/15/16 at 2:44 PM, revealed they did not consider staff reporting a great amount of narcotics were being wasted by LPN #1 and #2 as an allegation of misappropriation of property. They stated the facility policy on misappropriation was not followed.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure food was stored under sanitary conditions. Initial tour of the kitchen revealed items opened with no opened date and a container of ham slaw was dated 01/08/16. Review of the Census and Condition, dated 01/12/16, revealed there were forty (40) residents residing at the facility and all residents received meals from the kitchen except one (1) resident who recieved tube feedings. The findings include: Review of the facility's policy and procedure, titled Food and Supply Storage Procedures, not dated, revealed Refrigerated Storage, date and rotate items, discard leftovers not utilized within 48 hours. Observation in the refrigerator during the initial tour of the kitchen, on 01/14/16 at 6:05 PM, revealed: 1. Items (block of margarine, gallon of milk, and block of cheese) opened and not labeled with an opened date. 2. A container of ham slaw in the refrigerator, dated 01/08/16, which was past the forty-eight (48) hours for discarding leftovers. Interview with the Dietary Manager (DM), Dietary Aide, and Dietary Cook, on 01/14/16 at 12:07 PM, revealed the facility's policy was to label and date when foods were delivered and when opened.