Every finding on record at Sherwood Nursing & Rehabilitation Center, Inc

Based on record review, observations, interview, and facility document review, the facility failed to ensure two staff assisted in transferring a resident using a mechanical lift as required by the resident's closet care plan and manufacturer's recommendations, to prevent a fall for one (Resident #98) of one resident reviewed. This failed practice resulted in Resident #98 sustaining a laceration to the right eyebrow and an injury to the right eye, causing bleeding from the eye. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 at a scope and severity of J. The IJ began on [DATE], after a review of a record provided by the Administrator regarding Certified Nursing Assistant (CNA) #1 performing a one-person transfer, using a mechanical lift, of Resident #98 who was care planned for a two-person mechanical lift transfer. Resident #98 fell during this transfer. The Administrator presented the nine-page Office of Long-Term Care (OLTC) Incident and Accident (I&A) Report Form 7734 and 762 as the facility investigation into a resident sustaining a fall from a mechanical lift. This IJ ended on [DATE] with the completion of staff re-education on proper use of mechanical lifts.The Administrator was notified of the Immediate Jeopardy (IJ), with an accepted plan of removal/correction of the facility's action developed prior to the state surveyors entering the building on [DATE] for the facility recertification survey on [DATE] at 11:20 AM. This failed practice will be cited as Past Non-Compliance (PNC) in accordance with Appendix Q. The findings include:On [DATE] at 8:00 AM, the facility filed an OLTC I&A Report 762 report. The report revealed that on [DATE] at 5:30 AM, CNA #1 transferred Resident #98 with a mechanical lift using a one-person transfer. Resident #98 fell from the lift, sustaining a severe head injury with laceration to the right eyebrow, and bleeding from the right eye. The resident complained of pain to the head and right shoulder. The resident was transferred to a local emergency room for further evaluation. The family member of Resident #98 said the resident died at the hospital five days following the incident, due to the injuries sustained during this fall. The family member reported Resident #98 sustained an orbital fracture because something, went through it ,and the resident sustained an injury to [pronoun] hip and shoulder.A review of Resident #98's Medical Diagnosis revealed diagnoses which included encephalopathy, altered mental status, heart failure, chronic pulmonary edema, intervertebral disc disorders in the lumbar region, shortness of breath, cognitive communication deficit, muscle wasting and atrophy, lack of coordination, ischemic cardiomyopathy, vitamin D deficiency, disorder of the eye and adnexa, cardiac pacemaker, chronic systolic congestive heart failure, type 2 diabetes, polyneuropathy, osteoarthritis, and lower back pain.A review of Resident #98's Care Plan, with an initiation date of [DATE], revealed an Activities of Daily Living self-care performance deficit related to activity intolerance and impaired balance, and diagnoses which include spinal stenosis, intervertebral disc degeneration: lumbar region, polyneuropathy. The care plan identified interventions/tasks of transfers for Resident #98 to be dependent upon staff with a mechanical lift to move between surfaces, as necessary.A review of Resident #98's Closet Care Plan, dated [DATE], instructed staff to use the mechanical lift with two staff and the purple sling (different colored slings are used following an assessment of the resident to ensure a proper fit) while transferring Resident #98.A review of Resident #98's Minimum Data Set with an Assessment Reference Date of [DATE], revealed the resident was to be dependent on helper to do all the effort, or the assistance of two or more helpers was required to complete the activity of transfer to chair or bed. A review of the Manual/Electric Portable Patient Lift user manual for the mechanical lift used to transfer Resident #98 during the incident, identified lift transfer recommendations of two assistants to be used for all lifting preparation, transferring from, and transferring to procedures. It included a warning that indicated failing to follow this recommendation could result in death or serious injury.A review of trainings for CNA #1, dated [DATE], indicated CNA #1 was trained on the mechanical lift. This training was completed by CNA #2. CNA #2's written statement for this training was provided in the investigation file. A review of Resident #98's Progress Note, dated [DATE] at 10:28 AM, revealed the Director of Nursing (DON) documented Resident #98 sustained a witnessed fall on [DATE] at 5:30 AM, with a visible head injury with a laceration to the right eyebrow. Resident #98 complaints of pain to head and right shoulder were noted. Resident #98 was transferred to the emergency room (ER) for further evaluation. Resident #98 was oriented to person. In-serviced staff and checked off staff on mechanical lift transfers, CNA #1 was terminated.During a phone interview on [DATE] at 12:13 PM, the family member of Resident #98 said the facility called and initially reported that an accident had occurred when Resident #98 fell out of bed. Later, the DON called and said Resident #98 had been dropped from the lift when a staff member tried to transfer the resident using the lift with a one-person transfer, instead of the two-person transfer, that was required. The family member said Resident #98 was dropped from the lift, which they believed led to Resident #98's death. Resident #98's family member said when the resident fell, something went through the resident's orbital fracture of their eyeball, and the resident's hip was broken on the right side, according to what the local ER nurse had told them. The family member said Resident 98's roommate witnessed the incident. The family member said the DON did fill out the police report. The family member said Resident #98 had lived at the facility for 7-8 years. The family member said Resident #98 was sent to a local ER and the CNA that performed the improper transfer was let go at the time of the incident. During an interview on [DATE] at 11:44 AM, CNA #8 said they had worked at the facility for over a year. CNA #8 said they did not know of any resident care planned for a one-person assistance mechanical lift transfer and it was always supposed to be two-staff when transferring residents with the mechanical lift. CNA #8 said they had to wait for the second person to assist them with a lift transfer. CNA #8 said they had been in-serviced on transferring a resident with a mechanical lift a few months ago, and when they were hired. CNA #8 said they were trained on using the mechanical lift a few times a year. CNA #8 recalled a lift transfer where a resident was lifted using a mechanical lift with one-staff, and the resident was hurt really bad, it was awful, and it wasn't that staff wasn't trained. CNA #8 said the facility in-serviced everyone after it happened, but we were taught before we started working on the floor. CNA #8 said the accident could have been prevented, had the CNA that performed the lift gotten a nurse or someone to help them.During an interview on [DATE] at 12:45 PM, Resident #61, who was the roommate of Resident #98 and present at the time of the incident, said they observed CNA #1 come in with the lift. Resident #61 said, I told the CNA they needed to have two people to use the lift. Resident #61 reported CNA #1 said they were going to wait for the other CNA, but then CNA #1 pulled the privacy curtain. Resident #61 said they heard a loud noise, pulled the curtain back, and could see Resident #98's face and head lying in a pool of blood. Resident #61 said I heard Resident #98 when they fell. Resident #61 said they gave a statement when it happened. Resident #61 said, [Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON)] wrote it for me and I signed it. The CNA's name was [CNA #1] who dropped [Resident #98], but [CNA #1] told me their name was a different name, but it was not, that I knew the CNAs name and their name was [CNA #1]. The other CNA that was supposed to help [CNA #1] told [CNA #1] that they would be right back to help and asked [CNA #1] to give them a couple minutes to finish something. But [CNA#1] did not wait for the other CNA, I don't know the other CNAs name. Resident #61 said I screamed for the nurse because [CNA#1] was just standing there. Resident #61 said CNA #1 finally went out to get the nurse, but the nurse was already coming in. Resident #61 said the nurse's name was [Licensed Practical Nurse #1] and they came in and helped Resident #98. Resident #61 said the ambulance and the Emergency Medical Technicians (EMTs) came in to help. Resident #61 said Resident #98 had lived here over 10 years, and they had been roommates since November of 2024. Resident #61 said they told CNA#1 they needed to get some help, and that they could not use the lift by themselves, and the sling was still on the lift when Resident #98 was on the floor. Resident #61 said the head part of the sling was not where it was supposed to be, it was upside down. Resident #61 said Resident #98 was not alert when the EMTs left the facility, and the whole side of Resident #98 face was blue. During an interview on [DATE] at 1:16 PM, CNA #2 said I did not see it (Resident #98's fall). I was on 300-Hall. I was doing orientation with another CNA. [CNA #1] came running and said [Resident #98] fell. I went to find a nurse. The nurse ran back there, and the nurse told me to get the other nurse. I had told [CNA#1] to go back in the room with the resident. [LPN #12] and [LPN #11] were the two nurses. I went down to [Resident #98's] room and peeked in. I saw [Resident #98] was on the floor and it was blood on the floor beside [Resident #98]. [Resident #98] was still talking at that time. It was a lot of blood beside [Resident #98's] head. I started talking to [CNA#1]. [CNA#1] told me they were getting [Resident #98] ready, and [Resident #98] fell out of the bed. I don't think that is what happened because where [Resident #98] fell was too far from the bed. The lift was 4-5 feet away from the bed. [Resident #98] was 1-2 feet from the lift. [CNA #1] did not say anything about using the lift. I just knew it was there. [Resident #98] went to ER and did not come back to the facility. I know [Resident #98] had a funeral because a staff member went to the funeral. During an interview on [DATE] at 12:19 PM, the LPN/ADON said the CNAs were all trained in competency on the mechanical lift. The CNAs did a skill check off during the first four days of orientation, and then every quarter they received a refresher training on tasks. The LPN/ADON said it was absolutely not okay for one person to transfer a resident using a mechanical lift. The LPN/ADON said a few months ago, according to investigation, an (unidentified) CNA attempted to use a mechanical lift alone, but that CNA had previously been instructed not to use a mechanical lift with one person. The LPN/ADON said the staff were retrained after the incident occurred.During an interview on [DATE] at 2:10 PM, the Director of Nursing (DON) said around 6:00 AM on [DATE], they were notified of the incident involving the lift transfer with Resident #98. The DON said the resident was already at the hospital by the time they were notified. The DON revealed they immediately went to the facility and completed the reportable to the OLTC. The DON said, I received a phone call from the nurse telling me to get up, you are fixing to be upset. CNA #1 initially said that Resident #98 rolled out of bed. The nurse said the resident already had the lift pad underneath them when they went to give the resident their meds about 20 minutes prior. The nurse said they asked CNA #1 again what happened. The nurse then said they told CNA #1 they knew Resident #98 was already on the lift pad. That was when CNA #1 admitted they had tried to lift Resident #98 in the lift by themself. The nurse told me there was blood everywhere. I asked the nurse if she called the family and the nurse said yes. When I got here, the nurse told me [Resident #61] had witnessed the entire thing. [Resident #61] told me (the DON) [CNA #1] came in the resident's room with the lift and [Resident #61] had asked [CNA #]1 if they were going to get a second person to help them with the lift. Resident #61 said the staff member pulled the curtain and the next thing they knew Resident #98 was on the floor. The DON said when they first got the call, they (the DON) had told the staff to send CNA #1 home. The DON said they reviewed the camera, and CNA#1 never attempted to get another person to help them. The DON said at the time of the incident, Resident #98's care plan directed the staff to transfer with two-persons, using the mechanical lift. The DON said the resident's closet care plan indicated Resident #98 was to be transferred using the mechanical lift by two-persons and a purple sling. The DON said the purple sling was the one in the room. The DON said the two-person transfer had been in place ever since the DON had been at the facility, for nine years. The DON said they used one brand of lifts in the building and provided a copy of the manufacturer's guidelines.During a phone interview on [DATE] at 4:11 PM, LPN #12 said, I went down noticed [Resident #98] lying face down in blood. I called 911 and gave them a run-down of the situation. I told one of the CNAs to go get another nurse. The other CNA in the room noticed the blood and told the CNA to go and get me a pressure dressing. The police were the first ones on arrival. LPN #11 stopped the bleeding coming from Resident #98's head and the ambulance service showed up at that point. LPN #11 said they called the hospital to give them a run-down of the situation. LPN #11 said when they first walked in, they found Resident #98 face down, between the lift, and the sling was on lift, blood was coming out of (the resident's) eyeball. (The resident's) eyeball was in the socket, and the bleeding was coming from the eye. The eye was black and gushing blood. It looked like the blood was coming out the tears. It wasn't protruding, it was black and bleeding. Just above the eyebrow, there was an abrasion and there was some bleeding. The eye was black, and blood was pouring out of [Resident #98's] right eyeball. LPN #11 said when they first found [Resident #98], they were the nurse in the room. LPN #11 attempted to apply pressure to the wound and when LPN #12 came back from the treatment room with gauze, it was both of us after that. LPN #11 said they were not in the room once the ambulance service arrived. They (LPN #11) got a pressure dressing to stabilize Resident #98's wound. LPN #11 said they asked LPN #12 if it was okay for LPN #11 to step out to get the paperwork. LPN #11 said based on what they saw, [Resident #98's] head was facing the foot of the bed, lift above [the resident], CNA #1 said the resident fell out of bed and had fallen on [the resident's] face. LPN #11 said the scene did not add up. LPN #11 said Resident #98 was mostly immobile unless we moved them. LPN #11 said they told the CNA if [Resident #98] fell out of bed [the resident's] head would have been the other way. CNA #1 said they were trying to put the sling under the resident, but the sling was already attached to the lift. If the resident had fallen out of bed, the injuries would have been on the other side. LPN #11 said Resident #98 was able to talk to them, tell their name, report that their head was hurting, then started speaking more slowly and we had to do a sternal rub to get [the resident] alert. [Resident #98's] lips were a little cyanotic (appearing blue). Emergency Medical Services (EMS) had arrived and taken over at that point. LPN #11 said as far as they knew, the mechanical lift was the only kind they used. LPN #11 said the facility required two CNAs, at all times, to transfer a resident with a mechanical lift; it had always been that way. If they couldn't find somebody, they would come to get me or another nurse to assist. LPN #11 said as far as they were aware, the policy at the facility had always been two-person transfer with the mechanical lift. LPN #11 said they had never found anyone using a lift by themselves. LPN #11 revealed the facility provided in-services sporadically, the last one was after this incident, and staff were trained and had to give a return demonstration and do a skills check-off. LPN #11 said the Lead CNA and the ADON trained the CNAs. LPN #11 said the lift sling was about four feet off the floor following the incident, measured to the bottom of the sling. LPN #11 said they thought the sling was improperly placed on the resident, because of how it was on the lift and that it did not look right and the chair was not in place. I do not know for certain if it was upside down, but I do not recall the back where the handles are, I assume they were at the bottom. I remember looking at the lift sling and it did look like it was upside down. LPN #11 said CNA #1 was getting Resident #98 out of bed. The lift was out by the window, turned almost toward the door, it appeared the resident had fallen before the CNA could complete the turn. LPN #11 said from what they had witnessed in their time at the facility, there had always been a nurse and a CNA or two, to use a lift. During an interview on [DATE] at 8:45 AM, the DON said the monitoring sheets started on [DATE], after the incident occurred, and as a part of their plan of correction for conducting random checks of staff using the lift. The DON said the staff never know what hall or time I may pop in to check them using the lift. The DON said the monitoring sheets identified the date, time, lift used, condition/comments (this area is asking how the transfer was, not the condition of the lift), staff who monitored the random check and then verified by initialing the monitoring documentation.During an interview on [DATE] at 8:50 AM, LPN #14 reported conducting random monitoring of CNAs using the lifts to ensure two staff were assisting in the transfer, monitoring for proper use, use of the proper, sling and positioning of sling.During an interview on [DATE] at 10:09 AM, the Administrator said they were out of the country when the incident occurred. The Administrator said they had been the Administrator since 2017. The Administrator said the incident occurred when CNA #1 transferred a resident using a one-person lift transfer. The Administrator said the DON called them and said that a CNA was transferring the resident without assistance. The Administrator said the DON went to the facility to start the investigation and kept them informed throughout the week. The Administrator said they believed the CNA just made a poor decision, CNA #1 did not want to wait for the help, the CNA #1 just did not ask for help thinking they could just do it by themself, knowing it was a 2-person. The Administrator said the facility trains employees properly for the safety of our residents and unfortunately CNA #1 made a judgement call, despite the training, and that CNA was terminated. The Administrator revealed they continued training and in-servicing for their staff. The Administrator said CNA #1 did not consider the consequences of their decision, and it changed the lives of a lot of people. The Administrator said CNA #1 put their resident in jeopardy by doing that. The Administrator said they trained their staff on hire, annually, and as needed on the use of the mechanical lift. The Administrator said their last training was immediately following the incident and revealed they were monitoring transfers. The Administrator said prior to that date, we did a check off upon hire, annually, and as needed, such as when staff hear concerns from the residents or if they find Incidents & Accidents with bruising they feel may come from the lift. The Administrator said they have had complaints in the past about the staff going too fast during a transfer, and those staff were in-serviced on compassion and taking their time during a lift. The Administrator said they ensured all their staff were trained, with return demonstration, following the incident and prior to returning to work by the DON, the Lead CNA, and the ADON. The Administrator said they put a system in place to monitor lift transfers, complete checkoffs with the staff, staff put signs on all mechanical lifts stating two-persons must use the lift at all times, and in-serviced staff that they will be terminated if they try to transfer with one person. The Administrator revealed they were monitoring through morning meetings, Quality Assurance and Performance Improvement (QAPI), and by involving the DON and the ADON through reviews of the written monitoring sheets and the staff verbally tell them about their monitoring. The Administrator said they developed an entire plan of correction or performance improvement plan following the incident, and they would continue with all new hires, annually, and as needed or necessary in training. The Administrator said the Quality Assurance team and the Medical Director (MD) were all made aware of the incident and the steps being taken to prevent it from recurring and they were involved. During an interview on [DATE] at 3:00 PM, the MD said their involvement at the facility was to take care of all the LTC patients, oversee the Nurse Practitioner, and to manage the Medicare patients and the Rehabilitation staff. The MD said they recalled the incident where a resident was injured following a fall from the mechanical lift and was transferred to the hospital and died a few days later. The MD said the resident was transferred to a hospital in [location] and they did not use that hospital, so they were not the treating physician at that hospital. During an interview on [DATE] at 3:41 PM, the Physician Assistant (PA) said they had worked at the facility since April of 2023. The PA said they recalled the incident when a resident sustained a fall from the mechanical lift, which occurred when staff was transferring a resident with the mechanical lift using a one-person to complete the transfer. The PA said it happened at about 5:00 AM. The PA was notified about the event. The PA said I was told the patient was in a lift and there was just one CNA that was with the resident and there was supposed to be two staff with the resident, and the resident fell out of the lift. I don't remember who they called to send the resident out. The resident hit their head, had a rib fracture, bleeding from their eye and had a subdural hematoma (a serious collection of blood that forms between the brain's surface and its tough outer covering (dura mater), usually after a head injury, causing pressure on the brain). The PA said they were sure they talked about this incident with Resident #98 and the QA talked about the incident a lot. The PA said the cause was improper lift usage by the CNA and it was a decision somebody made to do the wrong thing. A review of CNA #1's Personnel Record reflected CNA #1 was hired on [DATE]. All required background checks were conducted; CNA #1 was terminated on [DATE], for using the mechanical lift with only one person. The CNAs Personnel Record revealed CNA #1 knew they were required to have two people to transfer a resident, but CNA #1 wrote they could not find anyone quick enough, so they transferred Resident #98 by themself. CNA #1's Functional Job Description was signed on [DATE], with responsibilities of assuring resident safety, follow established performance standards, perform duties according to nursing policies and procedures, identify safety hazards and emergency situations and initiate corrective action, observe all facility safety policies and procedures, infection control procedures, and other applicable nursing policies and procedures. CNA #1's Personnel Record revealed an Acknowledgement form for Abuse training that was signed by can #1 on [DATE] and a Resident Rights Acknowledgement signed on [DATE].This will be cited as Past Non-Compliance (PNC). Onsite verification:CNA #1 was terminated; Resident #98 was sent to ER. Notifications were made to the MD/PA & Family. PA was notified at the time of the incident.On [DATE], seven random employee files were reviewed for training with return demonstration documentation with no negative findings identified.Retraining for staff on proper use of a mechanical lift began on [DATE] and were completed [DATE] .On [DATE], a review of the Mechanical Lift monitoring log revealed random checks had been conducted with a beginning date of [DATE] and was ongoing.

Based on observation, record review and interviews, the facility failed to ensure proper hand hygiene was performed during perineal care for one (Resident #106) of one resident reviewed. The findings include: Review of Medical Diagnosis revealed Resident #106 to have diagnoses of congestive heart failure, COPD (Chronic Obstructive Pulmonary Disease), and atrial fibrillation [fluttering heart palpitations]. Review of the admission Minimum Data Set with an Assessment Reference Date of 10/31/2025 revealed a Brief Interview of Mental Status score of 06, which indicates severe cognitive impairment. The MDS also indicated Resident #106 was incontinent of bowel, and occasionally incontinent of bladder. During an observation on 12/08/2025 at 1:37 PM, CNA (certified nursing assistant) #16 and CNA #9 assisted Resident #106 into bed and removed Resident #106's pajama bottoms while wearing gloves. CNA #9 folded down the front of Resident 106's brief and wiped the resident's perineal area. Resident #106 assisted in rolling to the right-side and CNA #16 wiped down the buttocks area twice in one direction then applied cream to the buttocks after removing a wet brief. CNA #16 removed skin cream from the drawer to the left side of the bed without changing gloves or performing hand hygiene. CNA #16 placed a clean brief under Resident #106, the resident rolled to the back, and the brief was secured. While still wearing the same dirty gloves, CNA #9 and CNA #16 pulled up Resident #106's clean pajama bottoms, adjusted linens, touched the resident's bedrails, and then CNA #16 returned skin cream to the left bedside drawer. CNA #9 touched the bed rails and bed remote to lower the bed and raised Resident 106's head while wearing the same dirty gloves. CNA #9 removed their dirty gloves then, without performing hand hygiene, offered fluids to the resident and opened the drawer to the left side of the bed, that was previously opened with CNA #16's dirty gloves. During an interview on 12/08/2025 at 1:53 PM, CNA #9 and CNA #16 revealed the process used to provide good hand hygiene during perineal care was to wash their hands and put on gloves prior to performing perineal care. CNA #16 revealed hand hygiene should be performed during perineal care and confirmed that dirty gloves should have been removed and hands washed before touching resident's clean brief, clothing, bed controls, and before putting cream back in the bedside drawer. CNA #16 said this practice was concerning due to germs. During an interview on 12/10/2025 at 12:08 PM, the Director of Nursing [DON] said staff were expected to wash their hands and put on gloves during perineal care and expected to change their gloves and use hand sanitizer frequently during perineal care, such as before putting a clean brief or clothing on residents. The DON displayed concern regarding staff providing perineal care without changing their gloves and performed hand hygiene, because there would be a concern for maintaining infection control. The DON said, Staff are in-serviced on perineal care on hire, annually, and if I start to see UTIs (urinary tract infections) or infections. During an interview on 12/11/2025 at 5:00 PM, the Administrator said, My expectation for staff is hand hygiene will be performed during perineal care when moving from dirty to clean areas to prevent the risk of infection The Administrator confirmed they do not have a hand hygiene policy. A review of Nursing Return Demonstrations, dated 09/18/2025 and 11/11 /2025, revealed CNA #9 and CNA #16 completed skills checkoffs that included personal care and hand hygiene. Review of a policy titled Perineal/Incontinence Care, revised 11/22/2016, revealed after providing perineal care staff should change out of dirty gloves, then place a clean brief under resident using barrier cream as indicated and replace the bedspread.

Based on observation, interview, and facility policy review, the facility failed to ensure dented food cans were promptly removed/ discarded; expired food items and spices were promptly removed/discarded on or before the expiration or use by date; food stored in the freezer and dry storage area were dated to ensure first in and first; dietary staff wore hairnets to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchens; serving dishes were stored properly to prevent the potential for cross contamination;1 of 2 ice machines was maintained in clean and sanitary condition and dietary staff handled glassware items properly to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect residents who received meals from 1 of 1 kitchen (total census: 94). The findings are: 1. On [DATE] at 9:43AM, the plate warmer full of plates to be used in portioning food items to be served to the residents for lunch were not covered, exposing them to debris or pests. 2. On [DATE] at 9:46AM, one can of instant food thickener was on a shelf in the storage room with no opened date on the can. The Dietary Manager acknowledged there should be a date on the opened food product. 3. On [DATE] at 9:47AM, one 6.63 pound can of corn intended to be served to residents had a creased dent on the middle back of the can. 4. On [DATE] at 9:54AM, 53 desert sized plates on a shelf in the kitchen had the serving surface exposed to debris or pests 5. On [DATE] at 12:14 PM, Dietary [NAME] (DC) #2 turned the hand washing sink on, washed his hands, turned off the faucet with his bare hands, contaminating his hands, and then used his contaminating hands to pick up clean plates and placed them on the steam table bar to be used in portioning food items to be served to the residents for noon meal. On [DATE] at 12:10 PM, DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment. DC #1 stated, I should have washed my hands. 6. On [DATE] at 12:18 PM, one container of potato salad on a shelf in the walk-in refrigerator had an expiration date of [DATE]. 7. On [DATE] at 12:29 PM, a container of poultry seasoning was on a spices rack above the food preparation and had expiration date of [DATE]. 8. On [DATE] at 12:42 PM, the following observations were made in the freezer in the dining room on 200 Hall: a. One container of orange sherbet ice cream with no opened or received date. The top of the sherbet was frosty. There was no name on the container to aid in identifying who the sherbet belongs to. The Dietary Manager stated it looks like it has melted and been refrozen. b. One container of butter pecan ice with no opened or received date. c. One container of vanilla ice cream with no opened or received date. 9. On [DATE] at 12:52 PM, the following observations were made on a shelf in the refrigerator in the dining room on 500 Hall: a. One box that contained one fried chicken leg and fries was on a shelf in the refrigerator with no received date on it. The Dietary Manager stated the fried chicken leg and fries were old. b. One container with leftover taco bowl was dated [DATE]. c. One container with leftover beef noodle mix was dated [DATE]. The Dietary Manager stated we keep leftover foods for 3 days. 11. A facility policy titled, Use and Storage of Foods brought to Residents by Family/Others initiated on [DATE] indicated that foods brought into the facility outside of its original container or packaging will be discarded three days after the date identified on the label. 10. On [DATE] at 4:10 PM, Dietary Aide (DA) #3 took out cartons of thickened water from the refrigerator and placed them on the counter and, without washing her hands, picked up glasses by their rims, and poured thickened water in them to be served to the residents who required thickened liquid with meals. At 4:50 PM, DA #3 was asked what she should have done after touching dirty objects and before handling equipment. DA #3 stated she should have washed her hands. 11. On [DATE] at 4:44 PM, three screws above the ice machine panel located on a Hall leading to 400 and 500 Halls had a wet, black residue that could drip on the ice. The Dietary Manager was asked to wipe the wet, black residue on the screws. She did so, and the wet, black residue easily transferred to the tissue. She was asked how often they cleaned the ice machine and who uses the ice from the ice machine. She stated they cleaned it once every week, and the Certified Nursing Assistants used it for the water pitchers in the resident's rooms. 12. A facility policy titled, Hand Washing, initiated on [DATE], indicated that staff will wash their hands after handling soiled utensils or equipment, during food preparation, and after engaging in other activities that contaminate the hands. 49413

Based on observations, interviews, record review, the facility failed to ensure baseline care plans were completed within 48 hours of admission for 4 (Resident #301, Resident #351, Resident #352, and Resident #357) of 4 residents reviewed for baseline care plans. Findings include: 1. On 09/12/2024 at 10:00 AM, the Administrator stated the facility did not have a policy for baseline care plans due to it being in the regulations. 2. A review of the Admission Record indicated the facility admitted Resident #301 on 04/25/2024 with diagnoses of congestive heart failure, dyspnea(shortness of breath) and fall. a. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2024, revealed Resident #301 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. b. A review of the electronic medical record revealed Resident #301 had no baseline care plan. 3. A review of the Admission Record indicated that the facility admitted Resident #351 on 08/16/2024 with diagnoses that included atrioventricular block, atherosclerotic heart disease, retention of urine, and end stage renal disease. a. The 5-day MDS, with an ARD of 08/20/2024, revealed Resident #351 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #351 was marked on the MDS as having hemodialysis. b. A review of the electronic medical record revealed Resident #351 had no baseline care plan. 4. A review of the Admission Record indicated the facility admitted Resident #352 on 08/22/2024 with diagnosis of post laminectomy syndrome (pain after spinal surgery). a. The 5-day MDS, with an ARD of 08/26/2024, revealed Resident #352 had a BIMS score of 15 which indicated the resident was cognitively intact. b. A review of the electronic medical record revealed that Resident #352 had no baseline care plan. 5.A review of the Admission Record indicated the facility admitted Resident #357 on 08/28/2024 with diagnoses that included fusion of spine, lumbar region, lumbar region and low back pain. a. The admission MDS, with an ARD of 09/01/2024, revealed Resident #357 had a BIMS score of 10 which indicated the resident had moderate cognitive impairment. b. A review of the electronic medical record revealed that Resident #357 had no baseline care plan. 6. During an interview on 09/11/2024 at 11:22 AM, the Medicare (MCR)/MDS Coordinator stated baseline care plans are done on admission and are signed by the responsible party or resident upon completion. The MCR/MDS Coordinator was asked to review and locate the baseline care plan for Resident #301, Resident # 351, Resident #352, and Resident #357. No baseline care plans were located. The MCR/MDS coordinator stated, I can do it and give it to you. 7. During an interview on 09/12/2024 at 10:25 AM, the Administrator and the Director of Nursing both confirmed the baseline care plans had not been completed for Resident #301, Resident #351, Resident #352 and Resident #357. The Administrator stated that Resident #301 had been discharged from the facility.

Based on observations, interviews, record review, facility document review, the facility failed to ensure discharge Minimum Data Set (MDS) was completed and transmitted for 2 (Resident #44 and Resident #93) of 2 residents reviewed for MDS accuracy and timing of assessments. Findings include: 1. On 09/12/2024 at 12:30 PM, the Administrator stated the facility did not have a policy for the MDS and stated that the facility uses the Resident Assessment Instrument (RAI) guidelines. 2. A review of the Admission Record indicated the facility admitted Resident #44 on 03/18/2024 with diagnoses that included pulmonary embolism and acute respiratory failure with hypoxia. Resident #44 was discharged from the facility on 04/25/2024. a. The 5-day MDS with an Assessment Reference Date (ARD) of 03/22/2024 revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. 3. A review of the Admission Record indicated the facility admitted Resident #93 on 04/05/2024 with diagnoses that included sepsis, acute kidney failure and acute cholecystitis (infection of the gallbladder). Resident #93 was discharged from the facility on 04/25/2024. a. The 5-day MDS with an ARD of 04/09/2024 revealed Resident #93 had a BIMS score of 15, which indicated the resident was cognitively intact. 4. On 09/12/2024, a review of the closed electronic medical record indicated there was no discharge MDS assessment completed or transmitted for Resident #44 and Resident #93. 5. During an interview on 09/12/2024 at 11:25 AM, the Medicare (MCR)/MDS Coordinator confirmed Resident #44 was discharged on [DATE] and Resident #93 was discharged on [DATE] and that no discharge MDS had been completed or transmitted for either resident. The MCR/MDS Coordinator stated no reason could be given as to why the discharge MDS for Resident #44 and #93 had not been completed. The MCR/MDS Coordinator stated the MDS should have been completed and transmitted by day 14 after discharge. 6. During an interview on 09/12/2024 at 11:45 AM, the Administrator acknowledged the missed discharge MDS on Resident #44 and Resident #93. The Administrator stated the error most likely occurred due to the MCR/MDS Coordinator being busy and forgetting and that it was not normal for things like that to be missed.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure resident rooms were clean, safe, and homelike for 1 (Resident #357) of 1 resident reviewed for homelike environment. Findings include: A review of the facility's undated policy titled ,Housekeeping indicated, Housekeeping services are planned, operated, and maintained to provide a safe and sanitary environment. 1. Housekeeping staff will be skilled in the six basic functions of sweeping, mopping, dusting, cleaning, waxing, and polishing. 2. Housekeeping staff will strive to keep the facility free from offensive odors, accumulation of dirt, rubbish, dust, and safety hazards . 4. Walls and floors shall be cleaned during periods when the least amount of food is exposed, such as between meals. 5. Floors will be cleaned regularly, and any floor polish will have a non-slip finish . 7. Bedpans, commodes, and urinals will be covered after use, emptied promptly, and thoroughly cleaned after use. This may be done by nursing personnel. A review of an Admission Record indicated the facility admitted Resident #357 with diagnoses that included fusion of spine and lower back pain. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/01/2024, revealed Resident #357 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. During an observation on 09/09/2024 at 11:48 AM, trash was noted along the wall under the closet area, behind the room door, along the wall beside the trashcan, beside the nightstand, under the bed, and between the air unit and a chair. Upon entering Resident #357's bathroom, an uncovered bedpan was on the floor beside the toilet, an uncovered bath basin was on the floor of the shower stall and a brown stain was noted on the floor of the shower stall. During an observation on 09/10/2024 at 8:08 AM, it was noted upon entering the room of Resident #357, a pair of used gloves and a pile of linens were on the table as you step into the threshold of the room, one glove was hanging off the table and one glove was on the floor under the table. Trash was noted along the wall under the closet area, behind the door, along the wall, beside the trashcan, beside the nightstand, under the bed, and between the air unit and a chair. During an observation on 09/10/2024 at 12:40 PM, Resident #357 stated housekeeping had cleaned the room, however upon inspection the surveyor observed trash remained behind the door, along the walls, in the corners of the room and behind the chair. A sack of towels and linens were in a clear plastic bag on the floor. Resident #357 stated the bag had been there since earlier in the morning after bathing and had not been picked up. During an observation on 09/11/2024 at 7:20 AM, Resident #357's room was checked for cleanliness and the trash was still noted under the bed, along the walls of the room and behind the door to the room. During an observation on 09/12/2024 at 8:06 AM, upon entering Resident #357's room, trash was noted behind the door to the room, by the trash can, beside the nightstand, under the bed, under the air conditioner, beside the chair, and along the wall under the closet. A cushion was lying on the floor beside the chair, and dirty gloves were on top of the table as you entered the resident's room. The bathroom had an uncovered bedpan on the floor beside the toilet, an uncovered wash basin on the floor of the shower stall along with a brownish stain on the tile of the shower stall floor, and an uncovered wash basin under the sink. During an interview with the Administrator on 09/12/24 at 8:31 AM, confirmation was given that the room was littered with trash and had not been swept, and the table was littered with used gloves. The shower had a bed pan on the floor behind the toilet and the shower had a stain, and a bath basin was in the floor. The Administrator stated the housekeeping supervisor would take care of it and that it is not what was expected of room cleaning. During a concurrent observation and interview on 09/12/2024 at 8:48 AM, the Housekeeping Supervisor was shown Resident #357's room. Confirmation was given that the room was littered with trash and debris in all areas of the room. The Housekeeping Supervisor stated, I am sorry that you had to see this. I will take care of it.

Based on observations, interviews, record review, and facility document review, the facility failed to ensure proper hand hygiene and proper wearing and removal of personal protective equipment for 1 (Resident #355) of 1 resident reviewed for enhanced barrier precautions. Findings include: 1. A review of a facility policy titled, Handwashing/Hand Hygiene, dated 11/16/2016, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 4. Use an alcohol-based hand rub if no visible soiling, 5. Hand hygiene is the final step after removing and disposing of personal protective equipment. A review of the facility's undated policy titled, Isolation Precautions, Categories of, dated 11/22/2016 indicated Gloves and Hand washing:1. Wear gloves (clean, nonsterile) when entering the room. 2. During the course of caring for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage. 3. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. and Gown: 1. Wear a gown (clean/nonsterile) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. 2. Remove the gown before leaving the patient's environment. 3. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces. 3. A review of the Admission Record, indicated the facility admitted Resident #355 with diagnoses that included infection and inflammatory reaction due to other internal joint prosthesis, presence of right artificial knee joint, sepsis and ulcerative colitis. Resident was admitted to the facility on [DATE]. a. Review of a document titled, Admit/Readmit/Quarterly Assessment with C/P V7, revealed Resident #355 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. b. A review of Resident #355's Care Plan, initiated on 09/10/2024, revealed Resident #355 was on enhanced barrier precautions (EBP). Interventions included ensuring staff are wearing correct personal protective equipment (PPE) when performing care and educate staff, family, and guests on facility procedure of EBP. c. A review of Order Summary Report, revealed Resident #355 had an order for ertapenem sodium, one gram intravenous (IV) one time a day. Resident #355 had an order for peripherally inserted central catheter (PICC) to the left upper arm. Change dressing every week and as needed. d. A review of Medication Administration Record, revealed Resident #355 had received ertapenem sodium, one gram IV one time a day as prescribed. 4. During an observation on 09/10/2024 at 8:35 AM, Licensed Practical Nurse (LPN) #1 was standing at the medication cart one doorway down from Resident #355's door. Once LPN #1 completed gathering medications to be administered, proceeded to put on a pair of gloves without prior sanitization of hands, went over to the plastic bin that was outside of the doorway to Resident #355's room and withdrew an isolation gown, put it on, went back to his medication cart, picked up the medication cup, IV (intravenous) antibiotic, syringe and tubing and went into the resident's room. LPN #1 went over to Resident #355 and handed the resident the medication cup then went over to an over-the-bed table that was on the left side of the bed and was cluttered with resident's personal items. LPN #1 placed the IV supplies on the table. Without removing gown and gloves or sanitizing hands, LPN #1 went out into the hallway to the medication cart, opened the cart and removed alcohol pads, then returned to Resident #355's room. LPN #1 placed the alcohol pads on the table, went into the resident's bathroom and obtained a towel to place under the resident's arm. Without removing gloves and sanitizing hands and replacing with new gloves, LPN #1 opened the tubing, then mixed the antibiotic vial with the normal saline, shook the IV bag, then spiked the antibiotic mixture bag, primed the IV tubing to remove excess air, draped the IV tubing over the IV pole that was next to the over-the-bed table. LPN #1 went over to Resident #355, without removing gloves or gown, unscrewed the cap on the PICC line, scrubbed the port site with the alcohol pad, opened the syringe filled with normal saline and flushed the PICC line with 10 milliliters (ml) of normal saline. After flushing the PICC line, LPN #1 left the line dangling from the resident's arm, went over to the IV pump, placed the tubing inside the IV pump, set the rate on the IV pump, took the IV tubing and connected the tubing to the PICC line port, and then turned on the IV pump. Without removing his gloves or sanitizing hands, LPN #1 went over to Resident #355's closet per the resident's request to obtain an ostomy bag for the resident. LPN #1 removed gloves, went outside in the hallway wearing the isolation gown, removed the gown in the hallway, went back into the resident's room and noticed there was not a trashcan, returned to the hallway, balled the isolation gown up in his hands and walked down the hallway to the soiled utility room to dispose of the isolation gown. Once LPN #1 exited the soiled utility room, stopped at a resident room to use the hand sanitizer that was right inside the doorway before continuing back to the medication cart. 5. During an interview on 09/10/2024 at 8:45 AM with LPN #1 he stated that hands were sanitized prior to putting on gloves. LPN #1 confirmed the isolation gown should have not been put on at the medication cart and that the gown should have been put on before entering Resident # 355's room. LPN #1 confirmed gloves and gown should have been removed and hands sanitized prior to leaving Resident #355's room and going to the medication cart. LPN #1 confirmed that hands should have been sanitized and new gloves applied whenever an unclean surface was touched. LPN #1 was asked if gown should be removed in the hallway and then carried down the hallway before disposing of the gown? LPN #1 stated there wasn't a trashcan and I didn't know. 6. During an interview on 09/10/24 at 9:18 AM, the Director of Nursing (DON) stated LPN #1 was a new employee and education would be provided on infection control and EBP to LPN #1. The DON confirmed that hands should be sanitized before putting on gloves, after touching unclean items and before starting a procedure and after completing a procedure. The DON stated that isolation gowns and gloves should never be taken off out in the hallway.

Based on observations, interviews, and record review, the facility failed to ensure a dialysis care plan was initiated for 1 (Resident #351) of 1 resident reviewed for dialysis care planning. Findings include: 1. On 09/12/2024 at 10:00 AM, the Administrator stated the facility did not have a policy for care planning due to it being in the regulations. 2. A review of the Admission Record, indicated the facility admitted Resident #351 with diagnoses that included heart disease, retention of urine, and end stage renal disease. a. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2024, revealed Resident #351 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Resident #351 was marked on the MDS as receiving hemodialysis. b. A review of Resident #351's Care Plan, initiated on 08/19/2024, revealed the resident had no dialysis care plan with interventions. 3. During an interview with the Director of Nursing (DON) on 09/11/24 at 11:15 AM, verification was received that there was no order for dialysis and no dialysis care plan. DON stated, I've known Resident #351 and know that the resident has a quinton (Quinton catheters are non-tunneled central line catheters, which are often used for acute, ie temporary, access for hemodialysis or infusion of medicine) for dialysis. The DON stated that the Medicare (MCR)/MDS coordinator initiates and develops the care plans. During an interview with the MCR (Medicare)/MDS coordinator on 09/11/24 at 11:22 AM, confirmation was obtained that no order was noted for dialysis and there was no care plan for dialysis. No explanation was given as to why it was not completed.

Based on record review and interview, the facility failed to ensure two staff members were present when transferring a resident who required two-person assistance to prevent accident and injury for 1 (Resident #1) of 3 sampled residents. The findings are: These findings were determined to be an Immediate Jeopardy. The Surveyor provided the State Operations Manual Appendix Q Immediate Jeopardy template to the Administrator and informed of the Immediate Jeopardy on 10/16/23 at 2:28 PM. The findings are: Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/23 showed the resident is an extensive assistance of two person physical assist for transfer. Review of Resident #1's closet care plan showed transfers with assist of 2, mechanical lift with 2 staff. Review of Resident #1's care plan dated 02/17/2023 showed Resident will adapt to being transferred times 2 staff via mechanical lift. Resident #1 had a witnessed fall on 10/07/2023 CNA (Certified Nursing Assistant) was using the mechanical lift alone and Resident slid out of lift pad. A hematoma was noted to back of her head & a skin tear was noted to her right lower extremity. The CNA was suspended. A review of the Arkansas Department of Health and Human Services Division of Medical Services Office of Long-Term Care form (DMS-762) dated 10/07/2023 showed the following: a. Description of Incident: On Saturday, October 7, 2023, the CNA, [CNA #1], reported to the charge nurse that she was transferring [Resident #1] with the mechanical lift by herself, and she slid off the sling and onto the floor. [Resident #1] who is a [AGE] year-old female, who requires extensive assist with transfers and is a mechanical lift for transfers, is required to have 2 CNAs with all transfers. [LPN name] LPN assessed [Resident #1] and noted a skin tear to her RLE [right lower extremity].Vital signs were within normal limits, and she was alert at her baseline. b. Findings and Actions Taken: [CNA #1] has been relieved of her duties pending the investigation, neuro checks were initiated, CNAs are in serviced for proper mechanical use and to have 2 CNAs at all times with transferring. Also, the CNAs are being checked off for proper use of a mechanical lift during transfers with a resident after they have been checked off. As of 10/11/2023, based from my investigation, [CNA #1] will be termed from [Named Facility]. The surveyors confirmed the above was completed. Review of the Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities OLTC [Office of Long Term Care] Treatment Form showed the following witness statements: a. Dated 10/07/2023 CNA #1 reported the following: I [CNA #1] was assisting the patient [Resident #1] at 5:00 pm in getting her up out of bed for dinner, at the time of assisting her she slid out of the lift pad on to the floor bumping her head as well as the lift pad scraping her right leg as soon as the incident happened, I went to get the Charge Nurse. b. Dated 10/07/2023 [LPN name] reported the following: [CNA #1] came and told me to come to resident's room she had fallen. When we got in the room [CNA #1] told me that she used the mechanical lift alone and resident slid out of the lift pad & hit her head and has a skin tear to RLE. Hematoma noted to head too. We got resident into her chair. She was awake and alert to her baseline. Vitals were WNL [within normal limits]. DON [Director of Nursing (DON)], Hospice, & son notified. c. Dated 10/10/2023 [CNA name] reported the following, around 5pm on Saturday I only had one person to get up on 300 and I see [CNA #1] grab the lift I asked her did she need any help and she told me no. I said you sure she said yea, so I said okay and continued going to the cafeteria to pass out drinks and get stuff ready for dinner. d. Dated 10/10/2023 the DON reported the following: Upon interview w/ [CNA #1] CNA she stated that I did not hook the lift pad appropriately and the resident tilted and fell out of the lift. e. Dated 10/10/2023 the Administer reported the following: During my investigation I interviewed [CNA #1] regarding the incident, and @ that time [Resident #1] admitted to transferring the resident by herself. She also stated that she did not use all the hooks on the lift while transferring the resident. Based on our interview is what lead me to decide to term [CNA #1]. Review of facility Counseling Report dated 10/07/2023 showed reason for counseling of CNA #1 was due to an incident regarding Resident #1, and CNA was suspended until an investigation was completed. Review of the Manual/Electric Portable Patient Lift Guidelines showed although two assistants is recommended for all lifting preparation, the equipment will permit proper operation by one assistant based on the evaluation of the health care professional for each individual case. Review of Mechanical Lift Usage Inservice dated 10/08/2023 showed Please review information attached on how to use a mechanical lift. Two certified/ licensed personnel MUST be used anytime a mechanical lift is used to transfer a resident. There are NO exceptions. Review of the check off list showed CNA #1 had a check off on 10/03/2023 that covered mechanical lifts. Review of the Competency Training Log showed CNA #1 was checked off for competency in transfers- mechanical lift, 2 persons with gait belt, and 1 person with gait belt with return demonstration on 03/15/2023 and 10/03/2023 On 10/16/2023 at 9:32 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) #1 and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, Two. The Surveyor asked, Should one staff member use a mechanical lift by themselves? She stated, No. The Surveyor asked, Why does it take two staff to do a mechanical lift transfer? She stated, One to operate the lift and the other to support the resident. On 10/16/2023 at 9:42 AM, the Surveyor interviewed Certified Nurse Aide (CNA) #2 and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, Two. The Surveyor asked, Should one staff member use a mechanical lift by themselves? She stated, No. When asked, Why does it take two staff to do a mechanical lift transfer? She stated, For safety. On 10/16/2023 at 9:46 AM, the Surveyor interviewed LPN #3 and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, It takes two. The Surveyor asked, Should one staff member use a mechanical lift by themselves? She stated, Never. When asked, Why does it take two staff to do a mechanical lift transfer? She stated, Safety precautions. When asked, Do you know what happened on 10/07/2023 with Resident #1? She stated, I wasn't here, but I'm aware she was lifted with one person and they either forgot to attach one or came undone and she fell . On 10/16/2023 at 9:48 AM, the Surveyor interviewed CNA #3 and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, Two. The Surveyor asked, Should one staff member use a mechanical lift by themselves? She stated, No, we aren't supposed to do that. When asked, Why does it take two staff to do a mechanical lift transfer? She stated, For their safety and ours. On 10/16/2023 at 9:59 AM, the Surveyor interviewed Lead CNA #4 and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, Two. When asked, Should one staff member use a mechanical lift by themselves? She stated, Never. The Surveyor asked, Why does it take two staff to do a mechanical lift transfer? She stated, Because there could be a malfunction in the machine causing it to jerk, or the battery could die in the middle of the transfer. We want no falls. Never, never should someone use it by themselves, and make sure it is functioning with all mechanical parts in working order. On 10/16/2023 at 10:02 AM, the Surveyor interviewed LPN #4 and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, Two. When asked, Should one staff member use a mechanical lift by themselves? She stated, No. When asked, Why does it take two staff to do a mechanical lift transfer? She stated, Safety. Someone to guide the person and someone to operate the lift. On 10/16/2023 at 11:17 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, How many staff does it require to do a mechanical lift transfer with a resident? She stated, Two. The Surveyor asked, Should one staff member use a mechanical lift by themselves? The DON stated, No. When asked, Why does it take two staff to do a mechanical lift transfer? She stated, For the safety of the resident. When asked, Do you know what happened on 10/07/23 with resident #1? She stated, I received a call from the Charge Nurse and she stated a CNA was transferring a resident with a lift and she fell . I immediately asked if there were two staff in the room. She said no she said she was on the floor. The nurse asked her why she didn't come get help and CNA kept saying I don't know. When asked, Do you know what type of sling was used? She stated, I do not. It was a four point, should've been blue sling with purple trim, but I'm not sure about that day I wasn't here. She was suspended immediately and wrote a witness statement; she was vague compared to what the nurse wrote. The other CNA on the hall was asked if she asked her for help and she said no.

Based on observation and interview the facility failed to ensure that resident equipment and living space was maintained in a clean, serviceable manner to maintain resident health and dignity for all 91 residents who currently reside in the facility. The findings included: The following observations were made on 09/18/2023. a. At 11:06 AM, the wheelchair of Resident in room [ROOM NUMBER] B had dirt and debris covering the spokes and the metal was covered in food crumbs and dust. b. At 11:21 AM, room [ROOM NUMBER] had multiple areas of dust, lint, and the trash can was overflowing. c. At 11:47 AM in room [ROOM NUMBER] bathroom, a raised toilet chair had dark brown rust on the metal bar which supports the toilet seat. The following observations were made on 09/18/2023 at 11:50 AM in room [ROOM NUMBER]. a. The pole supporting the Resident's tube feeding had what appeared to be dried formula on the metal base. b. The floor around the base of the pole was covered with dried areas of liquid, dirt, dust, and debris. The debris on the floor extended under the bed and along the baseboard behind the bed. c. The nightstand had splatters of dried liquid on the side and the top was circled with dried liquid. d. A walker had dust and debris covering the body of the walker, brakes, and seat. The walker caddy was covered with a brownish tan colored dried greasy substance. During observation on 09/18/2023 at 1:45 PM, the bed in room [ROOM NUMBER] A had 2 pillows with no pillowcases. The Resident in the B bed stated, she has been sleeping on those like that for weeks, they won't even give us so much as a washcloth sometimes. During observation on 09/19/2023 at 8:55 AM, a Resident was observed in the hallway sitting in a wheelchair. In and around the wheelchair cushion was littered with debris including food particles, lint, and dirt. The spokes of the wheels and the metal bars that cross under the seat of the chair had dried spills, lint, and dirt. During interview on 9/22/2023 at 8:05 AM, the head of housekeeping confirmed the findings in room [ROOM NUMBER]. During interview on 09/22/2023 at 08:19 AM, the administrator confirmed the is no policy concerning daily housekeeping or upkeep of equipment and confirmed the raised toilet chair in room [ROOM NUMBER] had rust and corrosion .

Based on observations and interviews the facility failed to ensure that staff sanitized hands between assisting residents with eating during lunch in the main dining room. The facility failed to ensure foods stored in the kitchen freezer were properly sealed to prevent freezer burn and food cans were not damaged to prevent the growth of bacteria. These failed practices had the potential to affect 89 residents who receive meals from the kitchen. The findings included: During observation on 09/18/2023 at 10:55 AM in the kitchen inside the walk-in refrigerator, was 1 box containing an unsealed bag of 7 chicken patties. The Assistant Dietary Manger (ADM) confirmed the chicken patties should be sealed. During observation on 09/18/2023 at 11:03 AM, there were 2 dented cans in the kitchen. During observation on 09/18/2023 at 12:49 PM Nurse Aid (NA) #1 was assisting one female resident with her food, then turned to assist another female resident with her food. There was no handwashing or hand sanitizing observed between assisting the Residents. During observation on 09/18/2023 at 12:50 PM, Certified Nurse Aid (CNA) #1 assisted one resident with the lunch meal then assisted another resident. There was no handwashing or hand sanitizing observed between assisting the Residents. During interview on 09/18/2023 at 12:50 PM, the CNA confirmed her hands should be sanitized between assisting Residents with eating their meal. The CNA said she does not have any sanitizer. During interview on 09/21/2023 at 10:35 AM, the Director of Nurses (DON) confirmed hands should be sanitized between assisting Residents with eating their meals. During interview on 09/21/2023 at 2:30 PM, the Administrator said the facility does not have a policy concerning hand hygiene in the dining room.

Based on observation, record review and interview, the facility failed to ensure medications were stored safely. The failed practice had the potential to affect 1 Resident (Resident #36) sampled resident. The findings included: Review of Resident #36's medical diagnosis form showed diagnoses of cerebral infarction, dementia, anxiety, and major depression. During observation on 09/18/2023 03:11 PM, Resident #36's bathroom had multiple medicine cups with a clear white cream inside, and one medicine cup with a tan colored powder. Several unlabeled toothbrushes that belonged to Resident #36 and the roommate. A bottle labeled peri wash, and a bottle labeled odor eliminator. During observation on 09/19/2023 12:44 PM, Resident #36's bathroom counter had 3 medicine cups of clear white thick cream and 1 medicine cup with a tan colored powder. A bottle of Peri wash, and a bottle of odor. Eliminator. During observation on 09/20/2023 11:32 AM, Resident #36's bathroom counter had 1medicine cup with a thick white cream inside and 1 medicine cup with a tan powder inside. On Resident ' s bedside table was a can of hair spray and a bottle of fingernail polish. During interview on 09/21/2023 at 10:23 AM, Licensed Practical Nurse (LPN) confirmed medications that are creams and powders should be stored in the medication cart. During interview on 09/21/2023 at 10:28 AM, the Director of Nurses (DON) said medications, creams, and powders should be stored on the nurses' cart, treatment cart, or in the medication room. During interview on 09/21/2023 at 1:36 PM, the Administrator said there was no policy concerning medication storage.

Based on observation, interview and record review, the facility failed to ensure failed to ensure food items stored in the refrigerator and dry storage area were sealed/closed; drinks stored in the refrigerator on the 200 Hall were dated when opened or received; the deep fryer cabinet was clean and free of stains and spills and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 81 residents who received meals from the kitchen (total census:85), as documented on a list provided by Dietary Supervisor on 6/30/2022 at 9:09 AM. The findings are: 1. On 6/27/2022 at 10:18 AM, the following observations made in the dry storage area and the refrigerator: a. Upon entrance into the kitchen there were 3 muffin pans of yeast rolls sitting on top of the steam table to rise. The rolls were not covered. b. Two opened 1 gallon pitchers, filled with Health Shake were stored on a shelf in the 2 door refrigerator. The pitchers were not sealed. c. Above the freezer to the right was a two level spice rack where spices were stored. Each container on the spice rack holds 1 pound 2 ounces of product. The containers of Black Pepper, Garlic Powder, Onion Powder and Garlic Salt were open to air and contaminants. 2. On 6/29/22 at 7:44 AM, an opened bottle of lemon juice was stored on a shelf in the storage room. Most of the juice had been used from it. The manufacturer specification on the bottle documented, .refrigerate after opening . The Dietary Supervisor was asked, What do you use lemon juice for? She stated, We use it on fish. 3. On 6/29/22 at 8:06 AM, one can opener attached at the end of the food preparation counter had shavings of metal on the blade. 4. On 6/29/22 at 8:09 AM, the bottom shelf of the deep fryer had an accumulation of grease and caked-on food crumbs across the surface. One pallet to the shelf of the deep fryer had grease on it. The Dietary Supervisor was asked how often the shelf was cleaned and to describe the appearance of what was found on the bottom shelf of the deep fryer. She stated, It had grease on it. We clean it once a week. 5. On 6/29/22 at 8:12 AM, the following observations were made in 200 Hall refrigerator: a. A bottle of tea was stored on a shelf in the refrigerator. There was no name or date when it was opened or when it was received. b. An opened cup of milk shake with a straw was on a shelf in the refrigerator. The top of the milk shake was congealed. There was no name to identify whom it belonged to or date when it was stored. There were unidentified particles floating at the bottom of the shake. The Dietary Supervisor was asked to describe the sediments found floating at the bottom of the shake. She stated, It was ice cream that separated from the milk. 6. On 6/29/22 at 10:11 AM, Dietary Employee #1 was wearing gloves on her hands. She removed one pan of buttermilk pie from a rack and placed it on the counter. She picked up a box of saran wrap and placed it on the counter shelf above the food preparation counter contaminating her gloves in the process. She lifted the buttermilk pies from the pan with the same gloves and placed them on the tray. She then placed her gloved hand on top of the pie and sliced and placed it into individual bowls to serve to the residents for lunch. At 11:00 AM, Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment and or food items? She stated, Removed gloves and washed my hands. 7. On 6/29/22 at 10:15 AM, Dietary Employee #2 opened the oven door and removed a pan that contained baked pork loin and placed it on the food counter contaminating his hand. Without washing his hands, he picked a clean blade from the clean side of the dish washing machine and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. He was immediately stopped when he was ready to place pork loin in the blender. He was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? He stated, I should have washed my hands. 8. The facility's policy titled, Hand Washing, provided by the Dietary Supervisor on 6/30/2022 at 9:09 AM documented, Staff will wash hands after engaging in other activities that contaminate the hands.

Based on interview and record review, the facility failed to ensure oxygen therapy was provided according to the physician's order for 1 (Resident #2) of 1 sampled resident who had physician orders for oxygen. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with a Assessment Reference Date of 5/12/22 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and did not receive oxygen therapy. a. The Physician's Orders dated 05/08/22 documented, O2 [oxygen] at 1-4 L/M [liters per minute] via nasal cannula for SPO2 [oxygen saturation] less than 93% [percent] room air . b. The Care Plan with a revision date of 05/10/22 did not address oxygen therapy. c. The May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . d. The June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 06/26/22 11:22 [AM] 92% . e. On 6/28/22 at 11:15 AM, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . f. On 6/29/22 at 9:56 AM, Licensed Practical Nurse (LPN) #2 who was assigned to Resident #2 was asked to review his order for oxygen. As she is pulling up the relevant screen she stated, .He is never on oxygen . She read off the order to apply oxygen if the resident's oxygen saturation dropped below 93% on room air. She was asked if there had been instances Resident #2's oxygen dropped below 93%. She stated, .it was 92 on the 26th [June], 92 on the 24th, 93 on the 21st and 91 on the 16th. She was asked where the documentation would be located if oxygen had been applied on these dates. She stated, .I think they would just make a note, no let me look at the e-MAR, no they would have to write a note . She was asked how often the oxygen saturations were checked. She reported one time per shift and that she was working on June 16th, 2022, when the resident received a reading of 91. She stated, .I didn't put the oxygen on him. I sat with him for 10 minutes, checked him again and it was up . She continued to state that the resident is frequently resistant to placement of nasal cannula, so she elected to not attempt to follow the order to place the oxygen. The medical record did not contain documentation of any attempts to place oxygen on the resident or that the resident was resistance to its placement. g. On 6/29/22 at 10:15 AM, the Director of Nursing (DON) was asked what her expectations are of her staff if a resident has an order to apply oxygen if their oxygen saturation drops below 93%. The DON stated, .At the very least they should reassess . The DON was asked if the oxygen should be applied. She stated, .Yes . The DON was asked what the complications could be of not placing the oxygen. She stated, .Hypoxic injury . The DON was asked to review the order and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked if this was a problem. She stated, .Yes .

Based on interview and record review, the facility failed ensure an Advance Directive was available in the clinical record for immediate access for 4 of 4 (Residents #73, #19, #69 and #63) sampled resident who did not have an advance directive in the clinical record. The findings are: 1. Resident #73 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data (MDS) with an Assessment Reference Date (ARD) of 3/19/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. As of 6/27/22 at 2:30 PM, Resident #73's electronic medical record did not contain an Advance Directive. 2. Resident #19 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 6/12/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS. a. As of 6/27/22 at 2:23 PM, Resident #19's electronic medical record did not contain an Advance Directive. 3. Resident #69 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 4/28/22 documented the resident had modified independence in cognitive skills for daily decision-making per a Staff Assessment for Mental Status. a. As of 6/27/22 at 2:10 PM, Resident #69's electronic medical record did not contain an Advance Directive. 4. Resident #63 was admitted on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 3/30/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a BIMS. a. As of 6/27/22 at 2:41 PM, Resident #63's the electronic medical record did not contain an Advance Directive. 5. On 6/28/22 at 1:17 PM, the Social Worker was asked for the Advance Directives for Residents #73, #19, #69, and #63. This surveyor accompanied the Social Worker to her office. The Social Worker pulled a book from a shelf in her office, and pulled out the Advance Directive for Residents #19, #69 and #63. She stated, [Resident #73] is under administration, but you can't get to it. I will have to print it off. She was asked, Can you tell me why the Advance Directives are not in the clinical record? She stated, I'm not exactly sure, sometimes I don't scan them in. She was asked, When you leave for the day is your office locked? She stated, Yes ma'am. She was asked, If the nurse has to send a resident to the emergency room how would they get a copy of the Advance Directive if you are gone for the day? She stated, The nurses have the key to the office. She was asked, Has anyone ever informed you that the Advance Directive is part of the clinical record and that it should be readily accessible at all times? She stated, Yes. 6. On 6/28/22 at 1:34 PM, Licensed Practical Nurse (LPN) #1 was asked, If you needed to send a resident to the emergency room where would you get the Advance Directive from? She stated, Under miscellaneous. She was asked, Can you show me where the Advance Directive is for [Resident #63]? She looked in the electronic record then stated, I don't see it, so no I wouldn't know where to find it. 7. On 6/30/22 at 10:25 AM, the Administrator was asked, Where should the Advance Directive be kept at all times? He stated, Resident's chart. He was asked, Do you know why [Resident #73], [Resident #19], [Resident #69] and [Resident #63's] Advance Directive wasn't in the medical record? He stated, No. He was asked, Why is it important that the Advance Directives be kept in the medical record? He stated, To be available at all times. 8. The facility policy titled, Advance Directive, provided by the Nurse Consultant on 6/29/22 at 2:14 PM documented, .A copy of the advance directive, if any, will be included in the resident's medical record .

Based on interview and record review, the facility failed to ensure the comprehensive plan of care addressed the care and monitoring required related to oxygen therapy to minimize the risk of complications for 1 (Resident #2) of 1 sampled resident who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with a Assessment Reference Date of 5/12/22 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status and did not receive oxygen therapy. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .O2 [oxygen] at 1-4 L/M [liters per minute] via nasal cannula for SPO2 [oxygen saturation] less than 93% [percent] room air . b. The Care Plan with a revision date of 05/10/22 did not address oxygen therapy. c. On 6/29/22 at 11:31 AM, the Director of Nursing (DON) was asked, Who is responsible for the completion of the Minimum Data Set? She stated, .We actually have two, one for Long Term Care (LTC) and one for Medicare. The one for Medicare is [Name]. The DON was asked, Who is responsible for the Care Plan? She stated, .They also do the care plans for their people . d. On 6/29/22 at 11:40 AM, the MDS Coordinator for LTC reported she is responsible for completing the MDS and the care plans for the resident's in LTC. The MDS Coordinator was asked what the possible complications are of not identifying the resident's health concerns upon admission. She stated, .We wouldn't know how to care for them, so that they could be the best of their ability . The MDS Coordinator was asked, What problems could arise if the care plans are not updated? She stated, .Then we might be using interventions that are no longer suitable and there might be things that we might not be able to address as a team . The MDS Coordinator was asked when updates should be completed. She stated, .Initially we have one in the chart within 24 hours, then we have 21 days to do the first comprehensive and then quarterly or as needed. e. On 6/30/22 at 9:40 AM, the MDS Coordinator was asked if the respiratory care of the resident as ordered by the physician should be addressed on the care plan. She stated, .Yes . The MDS Coordinator was asked what the potential consequences of the omission could be. She stated, .Improper care . f. On 6/30/22 at 9:47 AM, the DON was asked if the respiratory care of the resident as ordered by the physician should be addressed on the care plan. She stated, .Yes . She was asked what the potential consequences of the omission could be. She stated, Hypoxic injury .

Based on record review and interview, the facility failed to ensure a discharge Minimum Date Set (MDS) assessment was completed for 1 of 1 (Resident #1) of 1 sampled resident who triggered for MDS accuracy. The findings are: Resident #1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date of 1/7/22 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Status. a. The Nurses Note dated 2/11/22 documented, .R [Resident] D/C [discharged ] from facility . A Discharge MDS was not completed. b. On 6/29/22 at 10:30 AM, the MDS Coordinator was asked, When a resident discharges from the facility when should a discharge MDS be completed? She stated, In seven days. She was asked, Can you tell me why [Resident #1's] discharge MDS wasn't completed? She stated, That was before my time. I've been here since March [2022]. The Medicare Coordinator was in this position before me. c. On 6/29/22 at 10:41 AM, the Medicare Coordinator was asked, Were you ever the coordinator for long term care? She stated, Yes ma'am. She was asked, When a resident discharges from the facility when should a discharge MDS be completed? She stated, Within seven days. She was asked, Can you tell me why [Resident #1's] discharge MDS wasn't completed? She stated, The only thing I can say is during that time frame I was leaving the facility. I quit, and I believed it got overlooked. d. On 6/30/22 at 10:28 AM, the Administrator was asked, When a resident discharges from the facility when should the discharge MDS be completed? He stated, Within 14 days of discharge date . He was asked, Can you tell me why [Resident #1's] discharge MDS wasn't completed when she discharged in February? He stated, No.

Based on observation, record review and interview, the facility failed to ensure placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube was checked prior to changing of the feeding for 1 (Resident #3) and failed to ensure tube feeding syringes were changed per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated 04/23/2021 documented, . Eating: The resident requires total resident NPO [nothing by mouth] receive nutrition/fluids via [by way of] peg tube . The resident requires tube feeding [MEDICATION(S)] 1.5 @ [at] 35 cc/hr [cubic centimeters per hour]. with 100 cc H2O [water] q [every] 4 hrs [hours] via cont. [continuous] pump r/t [related/to] Dysphagia . Check for tube placement and gastric contents/residual volume per facility protocol and record . The resident is dependent with tube feeding and water flushes. See MD [Medical Doctor] orders for current feeding orders . b. The July 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check placement of peg tube prior to meds and feedings every shift . Flush Tube with 30 cc [cubic centimeters] of H2O only before and after all medications every shift. Order Date 04/02/2021 . Enteral Feed Order every shift [MEDICATION(S)] 1.5 @ 50 ml/hr [milliliters per hour], flush 27 ml/hr . Order Date 05/21/2021 c. On 07/26/2021 at 5:20 p.m., Resident #3 was lying in bed with the head of the bed elevated. A tube feeding was in progress. The tube feeding bottle was almost empty. Licensed Practical Nurse (LPN) #1 entered Resident #3's room. LPN #1 placed the feeding pump on hold and disconnected the tubing from the PEG tube. LPN #1 then hung a new bottle of [MEDICATION(S)] 1.5, on the feeding pole. LPN #1 connected new tubing from the [MEDICATION(S)] bottle to the PEG tube, placement of PEG tube was checked. A full water bag was hung. Pump turned on, tube feeding infusing at 50cc/hr. Water at 27cc/hr. Tube Feeding syringe was dated 07/24/2021. At completion of task, LPN #1 was asked if she should have checked placement of the PEG tube prior to connecting new tubing and turning on pump. She stated, I forgot my stethoscope. I should have checked it. 2. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference date of 06/23/2021 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and received 51% [percent] or more of total calories through a feeding tube. a. The Care Plan dated 04/04/2018 documented, .The resident requires tube feeding r/t [related to] Dysphagia following CVA [Cerebrovascular Accident], NPO [nothing by mouth] . The resident dependent on staff with tube feeding and water flushes. See MD orders for current feeding orders (changed [MEDICATION(S)] 1.5 Cal @ 45 ml/hr.) [MEDICATION(S)] 1.5 @ 50 ml/hr with automatic H2O flushes at 35 cc/hr. via pump . Check for tube placement and gastric contents/residual volume per facility prior to flushes or medications . b. The July 2021 Physician Order's dated 12/06/2020 documented . Flush Tube with 30 CC H2O only before and after all medications . Check placement of peg tube prior to meds and feedings every shift related to Dysphasia following Cerebral Infarction . Change peg tube feeding bag/bottle, syringe and tubing q 24 hours every night shift related to Dysphasia following Cerebral Infarction Order Date 12/06/2020 . Enteral Feed every shift [MEDICATION(S)] 1.5 cal @ 50 ml/hour with automatic 35 ml/hr. H20 flushes via pump continuous per [APN (Advanced Practice Nurse)] until [MEDICATION(S)] 1.5 Cal is back in stock Order Date 12/12/2020 . c. On 07/26/2021 at 5:40 p.m., Resident #4 was lying in bed with a tube feeding in progress. Head of bed elevated. A tube feeding syringe was in a plastic bag on nightstand dated 07/24/2021. The tube feeding of [MEDICATION(S)] 1.5 at 50 ml/hr with approximately 1000cc's remaining in the bag was dated 07/26/2021 at 1518 [3:18 p.m.]. The water was at 35ml/hr with approximately 1000cc's remaining in bag. d. On 07/30/2021 at 11:38 a.m., the DON (Director of Nursing) stated, PEG tubes should be checked prior to medication administration, changing the tube feeding bottle or reconnecting it. The tube feeding syringes should be changed every 24 hours, daily. 3. An Enteral Feeding Policy received from the DON on 07/30/2021 at 1:11 p.m. documented, . A. Gastrostomy Tube: 1. Auscultate for air bolus over epigastric area or follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Aspirate gastric contents .

Based on record review and interview, the facility failed to ensure the resident's representative was notified of a change in treatment orders to provide the family member the opportunity to provide input on any care decisions for 1 (Resident #1) of 1 sampled resident. The findings are: Resident #1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 05/21/2021 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and received 51 percent or more of total calories through tube feedings. a. The Care Plan dated 04/27/2021 documented . Eating: The resident is totally dependent on 1 staff for eating secondary to resident NPO [nothing by mouth] receives all nutrition/fluids via [by way of] peg tube assisted by nurse . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. A Nsg [Nursing] - Order Note dated 07/12/2021 at 10:51 p.m. documented, . New Order: [MEDICATION(S)] @ [at] 63 cc/hr with 41 cc/hr H2O flush, via pump . d. On 07/30/2021 at 11:14 a.m., Registered Nurse (RN) #1 stated, Family members should be notified of any change in resident's condition. I always call the APN [Advanced Nurse Practitioner] first and then the family. e. On 07/30/2021 at 11:38 a.m., the Director of Nursing (DON) stated, To my knowledge there is no documentation of the family being notified of the increase in the tube feeding for [Resident #1]. You are supposed to notify the family of any changes in orders. f. On 07/30/2021 at 1:28 p.m., Licensed Practical Nurse (LPN) #1 stated, I did take an order to increase [Resident #1's] tube feeding. I did not call the family. It was late and I did not want to disturb them. I usually do call the family. Families should be notified with any new orders. g. A Change of Condition or Status policy received from the DON on 7/30/2021 at 1:11 p.m. documented . This facility, specifically, the DON, Charge Nurse, or designee, will promptly notify the resident, the physician, and the resident's legal representative or responsible party (defined as the resident's interested family member or other individual so designated by the resident) when: c. There is a need to alter the resident's treatment significantly, defined as a need to discontinue an existing form of treatment due to adverse circumstances, or to commence a new form of treatment .

Based on observation and interview, the facility failed to ensure family request were honored regarding the provision of care. This failed practice had the potential to affect all 83 residents in the building as documented on the Daily Census received by the Director of Nursing (DON) on 7/25/21. The findings are: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set with an Assessment Reference Date of 07/15/2021 documented the resident was severely impaired in cognitive skills on a Staff Assessment for Mental Status. His wife is listed as the responsible party in the electronic chart. 1. On 7/14/21, Resident #2's the spouse talked with the Administrator regarding request for Certified Nurse's Aide (CNA) #1 not to take care of resident. 2. On 7/26/21 the May, June and July 2021 grievances were reviewed. No grievance regarding Resident #2 was found. 3. On 7/29/21 at 12:15 p.m., CNA #1 was assisting with perineal [peri-care] care on Resident #2. 4. On 7/30/21 at 10:24 a.m., the Administrator was asked, Have you had any family member complain to you about any CNA? He stated, Yes, I have had a few. I have an open door policy for family issues. They can come talk to me at any time. [Resident #2's wife] came to me. [Resident #2] has been here for 3 or 4 years. I heard through the grapevine that she wanted him to transfer. She told me, she comes in a lot and has a lot of concerns and comes in for meals to assist him frequently. She told me she was looking at other facilities. Anyway, he is in a Geri chair and she is in a rollator; a four wheeled walker. So [CNA #1] who is the lead CNA, was coming to assist the wife as she was pushing him and dragging rollator. She said [CNA #1] was running with him and by the time she got to the room the door was shut and when she came in, he was already in bed. She complained that [CNA #1] was being fake and didn't want her doing his care. So, I agreed to her request and I went and told [CNA #1] to be off of his care. But she is lead CNA and she does supervise the other CNA's and I told her she may have to be in there and take care of his roommate. We have had multiple occasions where she has said he's wet and we go down there to change him and he's dry. She also said [CNA #1] cleaned him and he had another bowel movement and [CNA #1] didn't clean him to her satisfaction and we went and checked him, and he was clean. He was asked, Did you know [CNA #1] provided peri-care for him yesterday, would [Resident #2's wife] have been upset if she had come in and [CNA #1] was caring for him? He stated, I don't know, she changes from one day to the next. 5. On 7/30/21 at 11:43 a.m., the DON was asked, Did you know that there had been a complaint against [CNA #1]? She stated, No, I didn't. Usually complaints for CNAs go to my Assistant Director of Nursing (ADON) or the Administrator. She was asked, [CNA #1] was scheduled to perform peri-care on [Resident #2] by you. If you had known about that, would you have sent her in there? She stated, No. When I was ADON she [Resident #2's wife] complained about every 3 [3:00] p.m. to 11 [11:00] p.m. aide on that hall. We won't have anyone to take care of him eventually if we moved them all. She was asked, So how do you handle complaints from her? She stated, Whenever complaints come in from her, I try to talk to her and clarify the complaint. I would educate the staff and try to validate her concerns and find a solution that will work for her. If it's about a specific staff member we try to move or resolve the conflict between them. Sometimes it's just a simple misunderstanding. One time she complained about the shower aid. Well we only have two, so if it's not one then it'll be the other that takes care of him and they have to help each other sometimes. She decided she didn't want that shower aid off of his care. 6. On 7/30/21 at 12:46 p.m., CNA #1 was asked about the situation. She stated, It was 2:00 p.m. and she [Resident #2's wife] had just got done feeding him. She was trying to push him, and I asked if I could push him and I helped get him changed and put to bed. We positioned him in the bed with a wedge and put his room temperature where she likes. She asked what his behind looked like, but I hadn't seen it. I told her I would ask the nurse. At the end of the shift [Administrator] told me not to care for him anymore. She was asked, So when you cared for him yesterday, you were told to go do it? She stated, Yes, by the DON. She was asked, Did you tell the DON you weren't supposed to be in there doing care? She stated, Yes, I told [DON]. She was asked, But you were asked to go in there anyway? She stated, Yes. She was asked, Does [Resident #2's wife] know you are the lead CNA? She stated, I don't know but if they need help, I go relieve another CNA on another hall so she can go help. 7. On 7/30/21 at 1:30 p.m., the DON was asked, Did [CNA #1] tell you yesterday that she wasn't supposed to give care to [Resident #2]? She stated, Yes, she did but I assumed that it came from [Resident #2's wife] and it's not official until it goes through management. I only found out today for sure when I asked the Administrator.