Every finding on record at Southwood Nursing and Retirement

Based on record review, Resident interview and staff interviews, the facility failed to obtain the blood sugar (BS) level and administer a Residents' insulin medication as ordered by the physician to treat hyperglycemia (a side effect of too much glucose (sugar) in the blood). This affected 1 of 5 residents reviewed for medication administration (Resident #25). The findings included: Resident #25 was readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus. The 5-day Minimum Data Set (MDS) dated [DATE] had Resident #25 coded as cognitively intact and was receiving insulin injections. The care plan dated 10/28/2024 had focus of a diagnosis of diabetes mellitus with risk for complications with interventions to include administration of diabetes medication as ordered by doctor and to monitor blood glucose levels as ordered by physician. A review of the physician order dated 10/28/2024 revealed Humalog Solution (Humalog is a fast-acting insulin that starts to work about 15 minutes after injection and peaks in about 1 hour and keeps working for 2-4 hours). Inject as per sliding scale subcutaneously before meals for diabetes. Give 30 minutes before meals, 8:00 AM, 11:30 AM and 4:30 PM. If BS is: 8 - 150 = 8 units 151 - 200 = 10 units 201 - 250 = 12 units 251 - 300 = 14 units 301 - 350 = 16 units 351 - 400 = 18 units 401+ Call provider Hours On 10/30/2024 there was no documentation in the medical record for 11:30 AM. An interview with the DON was conducted on 01/23/2025 at 2:46 PM. The DON stated on 10/30/2024 Resident #25 had an appointment and her Responsible Party (RP) came to pick her up. The Resident had gotten her BS checked at 11:05 AM and it was 128. The DON also stated she was not able to administer the Resident her sliding scale of 8 units because the RP came and got the Resident and left the building. The DON also stated she failed to document why there was a missed dosage of insulin. On 11/16/2024 at 8:00 AM and at 11:30 AM, the MAR revealed Resident #25's BS was documented as 312 and 16 units of insulin was administered. An interview with Nurse #1 was conducted on 01/23/2025 at 12:53 PM. The nurse stated she was the Nurse for Resident #25 on 11/16/2024. The Nurse also stated she followed the orders for Residents that needed BS checks. She got their BS and documented on a report sheet and then entered the amount in the MAR. If the Resident needed coverage, then she would gather her supplies and administer the dosage according to the sliding scale order. This documentation went straight to the MAR. The Nurse further stated the morning blood sugar documentation in the MAR was the accurate BS and she did not administer a second dose of 16 units of insulin at lunch time. If there was another BS level with the same amount at different times, then she would question it, especially since the Resident Received 16 units of Humalog at 8:30 AM. She could not recall what was happening at the facility at that time to make her put the same amounts in the MAR but the 11:30 AM BS could not be accurate, and she must have missed obtaining the BS. An interview with the DON was conducted on 01/23/2025 at 2:46 PM. The DON stated on 11/16/2024, there was documentation of 16 units of insulin administered at 8:00 AM and 11:30 AM, but Nurse #1 would not administer a BS that was the same value after that much time had passed, so it had to be documented incorrectly. The DON stated she did not know how it happened, but Nurse #1 did not usually make documentation errors. The DON also stated her expectation was that they exercise accurate documentation according to the Residents orders. An interview with Resident #25 was conducted on 01/24/2025 at 9:07 AM. The Resident stated she had a couple of BS and insulin coverages missing but it did not cause her any issues. An interview with the Medical Director (MD) was conducted on 01/24/2025 at 2:14 PM. The MD stated she was familiar with Resident #25, and the Resident had type 2 diabetes mellitus and insulin was needed to help regulate hyperglycemia in the blood. The missed BS and the missing dose of insulin did not cause a negative reaction for the Resident. The MD also stated she expected the staff to follow physician orders. An interview with the Administrator was conducted on 01/24/2025 at 3:05 PM. The Administrator stated she expected the nursing staff to administer the Residents' medications accordingly.

Based on observations, record review, and resident, staff and Nurse Practitioner interviews, the facility failed to administer oxygen at the physician prescribed rate for 1 of 3 residents reviewed for respiratory care (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and dependence on supplemental oxygen. A review of Resident #38's Physician Orders read, O2 [oxygen] at 2L [liters] continuous via nasal cannula (tubing that delivers oxygen from an oxygen source to the resident's nose) and was written on 11/21/23. A review of Resident #38's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact and was on oxygen therapy A review of Resident #38's Care Plan, last revised 12/26/24, revealed a focus of altered respiratory status/difficulty breathing related to an old healing trach [tracheostomy] site and a focus of receives oxygen therapy. Interventions included provide oxygen as needed. An observation of Resident #38 was made on 01/21/25 at 10:39 A.M. Resident #38 was observed awake, alert and sitting up in her bed. She was receiving oxygen via nasal cannula. The oxygen concentrator was placed next to her bed and was set to deliver oxygen at 1.5L per minute. A second observation and interview of Resident #38 was made on 01/21/25 at 12:36 P.M. Resident #38 was sitting up in her bed, awake and alert. Her oxygen concentrator was still set to deliver her oxygen at 1.5 L per minute. Resident #38 said it was supposed to be set at 2L per minute and denied changing the setting. She stated she was unaware of who changed the setting on the concentrator. An interview was conducted with Nurse #1 on 01/21/25 at 2:56 P.M. Nurse #1 stated she was unaware of Resident #38's oxygen concentrator 1.5L setting and confirmed she had not changed the setting. Nurse #1 explained she had checked Resident #38's oxygen saturation using a pulse oximeter around 11:00 A.M. and it had been 97%. She stated that she had checked the oxygen concentrator setting earlier that morning and it had been set correctly at 2L per minute. She was unaware of who might have changed the setting. An observation of Resident #38's oxygen concentrator setting was conducted with Nurse #1 on 01/21/25 at 3:00 P.M. The oxygen concentrator remained at the 1.5L setting. Nurse #1 checked Resident #38's oxygen saturation using a pulse oximeter which read 94%. Nurse #1 was observed changing the setting on the oxygen concentrator to 2L and Resident #38's oxygen saturation was rechecked and had improved to 97%. A telephone interview with Nurse Practitioner (NP #1) was conducted on 01/24/25 at 3:35 P.M. NP #1 indicated Resident #38 did not experience any respiratory distress when the oxygen concentrator had been set at 1.5L per minute. NP #1 stated it was her expectation nurses follow the physician's orders for oxygen therapy. An interview with the Director of Nursing (DON) was conducted on 01/24/25 at 11:02 A.M. The DON stated it was her expectation nursing staff adhered to policy and procedures for residents on oxygen therapy, making sure they check the physician's orders and apply the prescribed setting on the oxygen concentrators. An interview with the Administrator was conducted on 01/24/25 at 2:00 P.M. The Administrator stated it was her expectation that nursing staff taking care of residents who are on oxygen therapy ensure the oxygen concentrators are set to the physician order for oxygen.

Based on record review and staff interviews, the facility failed to have a complete and accurate electronic medical record (EMR) for a Resident with type 2 diabetes mellitus. This affected 1 of 5 residents reviewed for medical record accuracy (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus. A review of the October and November Medication Administration Record (MAR) revealed an order for Humalog Solution (Humalog is a fast-acting insulin that starts to work about 15 minutes after injection and peaks in about 1 hour and keeps working for 2-4 hours). Inject as per sliding scale subcutaneously before meals for diabetes. Give 30 minutes before meals, 8:00 AM, 11:30 AM and 4:30 PM. If BS is: 8 - 150 = 8 units 151 - 200 = 10 units 201 - 250 = 12 units 251 - 300 = 14 units 301 - 350 = 16 units 351 - 400 = 18 units 401+ Call provider Hours On 10/30/2024 at 8:00 AM, the MAR revealed Resident #25's BS was 172, and 10 units of insulin were administered, there was no documentation for 11:30 AM. An interview with the DON was conducted on 01/23/2025 at 2:46 PM. The DON stated on 10/30/2024 at 11:30 AM, Resident #25's BS was 128. She was not able to administer the Resident's sliding scale of 8 units because the RP came to take the Resident to an appointment and left the building before administering the medication. The DON also stated she did let the RP know she needed the coverage. The DON further stated she was supposed to document the Residents' 11:30 AM BS and missed dosage of insulin in the MAR but failed to do so. On 11/16/2024 at 8:00 AM and at 11:30 AM, the MAR revealed Resident #25's BS was documented as 312 and 16 units of insulin was administered. An interview with Nurse #1 was conducted on 01/23/2025 at 12:53 PM. The nurse stated she was the Nurse for Resident #25 on 11/16/2024 and the morning blood sugar documentation in the MAR at 8:30 AM was the accurate blood sugar level. She could not recall what was happening at the facility at that time to make her put the same amounts in the MAR twice, but the 11:30 AM blood sugar on 11/16/2024 could not be accurate. An interview with the DON was conducted on 01/23/2025 at 2:46 PM. The DON stated on 11/16/2024, Nurse # 1 would not have given 16 units of insulin twice and it had to be documented incorrectly. She did not know how it happened, but Nurse #1 did not usually make documentation errors. The DON also stated her expectation was that they exercise accurate documentation according to physicians' orders. An interview with the Administrator was conducted on 01/24/2025 at 3:05 PM. The Administrator stated she expected the nursing staff to document the EMRs accurately.

Based on record reviews, Physician, staff and Resident interviews, the facility failed to provide a safe transfer when Nurse Aide (NA) #7 failed to utilize a mechanical lift when transferring Resident #2. She was transferred to hospital and diagnosed with a fractured femur. Resident #2 expressed the knee felt like it had been bashed and it was painful. This was for 1 of 3 residents reviewed for falls (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, heart failure, end-stage renal disease and osteoporosis. A review of the care plan that was revised on 9/20/23 revealed Resident #2 required full mechanical lift equipped with the green sling for all transfers with 2 staff during transfers. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and was dependent with transfers from bed to the chair. Review of an incident report initiated dated 5/27/24 revealed Resident #2 was transferred with Nurse Aide #7 when Resident # 2 expressed discomfort in her left leg at the knee area and was lowered to the floor, by the Nurse Aide #7. Nurse #3 was notified, and Resident #2 was transported to hospital by Emergency Services. Review of the hospital Emergency Department Physician note dated 5/26/24 revealed left knee pain after a fall that morning. The results of the X-ray revealed total knee joint replacement with intact hardware. No evidence of acute fracture or dislocation. Record review of the medication order and administration record (MAR) for May 2024 revealed Resident #2 received Tramadol 50 MG (milligrams) by mouth every 6 hours for pain. On 5/27/2024 she received a dose at 6:00AM for a pain level of seven with effective relief. A dose of 50MG was administered at 12:00 PM and 6:00 PM with a pain level of zero. On 5/28/27 at 12:00PM and 6:00AM doses were administered, for a pain level of zero. Resident #2 was out of the facility on 5/28/24 at 12:00PM. She returned to the facility, and she had a pain level of seven and was administered a dose of Tramadol 50 MG by mouth at 6:00PM, which was effective. Review of hospital history and physical dated 5/29/24 revealed a CT scan (computed tomography scan was diagnostic imagining that used an x-ray and computers to view cross sections of the anatomy to identify injury) identified a fracture in the distal lateral left femoral metaphysis (a weight -bearing part of the lower end of the femur, or the thighbone, that forms the top of the knee joint). Resident #2 was not a candidate for surgery and was discharged back to the facility with a brace on her knee. An interview via telephone on 6/19/24 at 2:29 PM Agency Nurse Aide #7 (NA) revealed this was the first time she had worked in this facility. She had finished Resident #2's morning bath, Resident #2 then asked to sit in the recliner. NA #7 stated she wanted to get help, but she felt pressured to move Resident #2 to the chair. Resident #2 stated that she could stand. She had Resident # 2 put her arms around her neck and stood her up. Resident #2 complained of knee pain and stated to sit her on the floor. Another NA came into the room and was asked by NA #7 to assist with moving Resident #2. The NA expressed that she would go get the nurse and did not assist with moving the resident. Resident #2 was sent to the hospital. NA #7 stated afterwards NA# 5 told her that Resident #7 used a mechanical lift for transfer. She indicated that being rushed was why she did not use a mechanical lift or ask for help. An interview was conducted on 6/20/24 at 10:24 AM with Resident #2. She stated that NA #7 had finished her bath and she wanted to sit in the recliner. She told NA #7 to get help. NA #7 stated she didn't see anyone in the hall. Resident #2 stated she again told NA #7 to get the nurse to help. NA #7 looked out the door and stated she didn't see anyone. NA #7 moved the recliner from the bathroom to beside the bed and stood her up. When she stood up her knee hurt like someone had 'bashed' it. NA #7 put her on the floor and her knee 'hit' the floor and the pain was terrible. The nurse came into the room and called 911. Interview with Nurse #3 on 6/20/24 at 11:38 AM revealed when she walked into Resident #2's room Resident #2 was sitting on the floor next to the bed, she stated that she knew Nurse Aide #7 was new and she told her she needed the mechanical lift and told her to get the nurse. NA #7 stated she did not have help. Nurse #3 stated NA #7 did not say why she did not use the mechanical lift. An interview with Nurse Aide #5 on 6/20/24 at 11:42 AM revealed Nurse Aide #7 came out into the hall and asked for assistance, and when she entered the room, Resident #2 was on the floor. Nurse Aide #7 asked for help to get Resident #7 up off the floor. Nurse Aide #5 returned with Nurse #3, who called Emergency Services. An interview with the facility Physician on 6/20/24 at 3:37 PM revealed after Resident #2 fell on [DATE] the hospital documentation revealed no injury to the knee. The pain was addressed with medication. Resident #2 continued to complain of knee pain the evening of 5/27/24 during a visit. Another x-ray with a mobile x-ray provider was ordered. The morning of 5/28/24 Resident #2 went to a scheduled appointment. Resident #2 returned to the facility with complaints of knee pain and was sent to a different hospital before the mobile x-ray was obtained. The CT scan identified a fracture. Resident #2 was not a surgical candidate, and a knee brace was continued. The Physician indicated that the facility provided appropriate care. The physician did state the fracture was a result of the fall on 5/26/24. The facility provided the following Corrective Action Plan with a completion date of 6/3/24. The facility identified concerns regarding Resident #2's fall caused by the lack of orientation education of Nurse Aide #7 that was required of all new agency staff. 1. Corrective action for resident(s) affected by the alleged deficient practice: On 5/26/24 Resident #2 was immediately assessed by Nurse #3. The Medical Director and Patient Representative was notified, and orders were obtained to send Resident #2 to hospital for further evaluation. After hospital discharge 6/3/24 Resident #2 returned to the facility and remained in a knee brace and continued with pain medication ordered as needed. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice. On 5/28/24 the Director of Nursing and Administrator identified residents that were potentially impacted by this practice by completing interviews with resident with BIMS of 13 or greater to identify any concerns of unreported falls or concerns with method used for transferring. This was completed on 5/28/2024. The results included: No identified concerns. The Unit Manager completed body audits for residents with BIMS 12 or less to identify any concerns of post fall injuries and indications of any further falls or incidents that did not have a corresponding incident report. This was completed on 5/28/24. The results included: No identified concerns. On 5/28/24 all residents were assessed for falls by the Director of Nursing, Assistant Director of Nursing or the MDS Coordinator. Then care plans were reviewed to ensure accuracy, task initiated and Kardex accuracy. This was completed on 5/29/2024. The results included: 15/70 residents noted with additional required interventions. On 5/28/2024 the facility Interdisciplinary team implemented corrective action for those residents which includes updated care plan and Kardex. On 5/28/24 the Director of Nursing reviewed incident reports for the last 14 days to ensure that no other adverse events occurred due to inaccurate transfer status and that the MD and family were notified. This was completed on 5/28/2024. The results included: 0/9 residents were identified as having no concerns. On 5/28/2024 the Director of Nursing and Staff Development Coordinator assessed all residents who sustained a fall in the past 14 days for adequate pain control and potential injuries. This was completed on 5/28/2024. The results included there were no identified concerns. On 5/28/24 the Director of Nursing and Staff Development Coordinator reviewed resident progress notes for the past 14 days to ensure that incident reports were completed for fall events. This was completed on 5/28/2024. The results included: There were no identified concerns. On 5/28/24 the Director of Nursing and Interdisciplinary team determined no implemented corrective action were needed for those residents which includes completion of incident report, notification to Medical Director/Patient Representative and assessment for any change in condition. 3. Measures /Systemic changes to prevent reoccurrence of alleged deficient practice: On 5/28/24, the Staff development Coordinator began in servicing all full time, part time and prn Registered Nurses, Licensed practical Nurse, Nurse Aides and medication aide staff (including agency) on Transfer safety and Fall prevention and post fall process. This training will include all current staff including the agency. This training included: - Importance of checking Kardex prior to any Resident Transfer - How to check the Kardex - Importance of following Kardex to ensure resident safety. - Reporting adverse events - What are the common causes of falls? -Identifying Falls Risk - General Falls Prevention Strategies - What should I do if I see a resident fall or see a resident on the floor? - Nursing immediate actions - Post Fall Documentation and Ongoing Assessment - Completing the incident report On 5/30/2024 Education was added for: - Handling resident behaviors - The Director of Nursing will ensure that any of the above-mentioned staff who does not complete the in-service training by 5/30/2024 will not be allowed to work until the training is completed. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. 4. Monitoring Procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. The Director of Nursing will monitor by observation audits the transfer safety, and audits of fall prevention and Agency Orientation process weekly for 2 weeks and monthly for 3 or until resolved. Reports will be presented to the weekly Quality Assurance committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and an ongoing auditing program reviewed at the weekly Quality Assurance Meeting. The weekly Quality Assurance Meeting is attended by the Administrator, Director of Nursing, Minimum data set Coordinator, Therapy, Health Information management, and the Dietary Manager. All items listed on this self-imposed action plan were complete and implemented on 5/28/24with ongoing monitoring to ensure compliance. This includes the action plan and any potential citation associated with this action plan should be considered past noncompliance as of 6/3/24. The corrective action plan was validated on 6/20/24 and concluded the facility implemented an acceptable corrective action plan. Interviews conducted with staff revealed the facility provided education and training on patient transfers and the utilization of lifts. The ongoing monitoring audits were validated as completed on 6/3/24. The facility's corrective action plan's completion date was verified as 6/3/24.

Based on Physician, staff, resident interviews and record review the facility failed to ensure 1 of 4 agency Nurse Aides (NAs) interviewed were oriented on the first day of assignment to the facility kiosk system, Kardex and residents' transfer method. NA #7 did not use a mechanical lift with assistance to transfer Resident #2 to her recliner. Resident #2 was transferred to the hospital and diagnosed with a fractured femur. This was for 1 of 3 residents reviewed for falls (Resident #2). Findings included: This tag was cross referenced to F 689: Based on record reviews, Physician, staff and Resident interviews, the facility failed to provide a safe transfer when Nurse Aide (NA) #7 failed to utilize a mechanical lift when transferring Resident #2. She was transferred to hospital and diagnosed with a fractured femur. Resident #2 expressed the knee felt like it had been bashed and it was painful. This was for 1 of 3 residents reviewed for falls (Resident #2). An interview via telephone on 6/19/24 at 2:29 PM Agency Nurse Aide (NA) #7 revealed 5/26/24 was the first time she had worked in this facility. NA #7 stated afterwards another NA# 5 told her that Resident #7 used a mechanical lift for transfer. She indicated she had no competency training prior to starting her assignment. An interview with the Scheduler on 6/20/24 at 9:15 AM revealed she did not have an orientation competency packet for NA #7. The Scheduler stated she had not prepared an orientation competency packet for the nursing staff to provide orientation training to NA #7 because she came in to replace another agency staff that called out. When an agency staff worked for the first time on a weekend or after hours, the charge nurse signed off with the agency staff on the orientation packets. The Scheduler confirmed Agency Nurse #3 was the charge nurse on 5/26/24. Interview with Agency Nurse #3 on 6/20/24 at 11:38 AM revealed she was the charge nurse on 5/26/24. On the weekends, a new agency staff had a packet at the nursing station, and she helped agency staff members to complete the orientation packet. The orientation packet included instructions on how to use the kiosk system (used to provide patient care information and view transfer information). NA #7 did not have an orientation packet as she was called in to cover a shift. During an interview on 6/20/24 at 4:44 PM the Assistamt Director of Nursing (ADON) indicated she had not come into the facility to complete an orientation packet with NA #7. The charge nurse in the facility was tasked with orientation. The ADON indicated NA #7 contacted the IT (information technology) department to get access to the medical record and time clock. An interview on 6/20/24 at 8:45 AM with the Director of Nursing revealed when staff reported to work for the first time an orientation packet was reviewed and signed off by the agency staff and the Scheduler prior to the staff member working the floor. On weekends the charge nurse reviewed the packets with the agency staff before they began work. There was no orientation packet available for NA #7 on 5/26/24. An interview with the Administrator on 6/19/24 at 3:00 PM revealed all agency staff were trained with an orientation packet before work. The facility identified that Nurse Aide #7 did not get the orientation packet and was not trained by the Scheduler or the nursing staff. The Administrator explained there was no orientation packet available for NA #7 on 5/26/24, and it was a weekend. The procedure for training agency staff was put into place after this accident.

Based on observations, staff, and resident interviews the facility failed to provide a dependent resident with nail care and facial shaving for 1 of 3 residents (Resident #9) reviewed for Activities of Daily Living (ADL) care. The findings included: Resident #9 was admitted into the facility on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart disease with heart failure, chronic pain, and spinal stenosis. A review of Resident #9's care plan dated 10/25/22 with a revision on 8-17-23 included a problem of ADL Self Care Performance Deficit status post history of left hip fracture and surgical left hip fixation nailing with a goal of will receive staff assistance with all aspects of daily care to ensure that all needs are met over the next 90 days. The interventions in part included: required staff assistance with grooming and personal hygiene. A review of Resident #9's quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #9 was severely cognitively impaired, had no behaviors or refusal of care and was dependent on staff for her personal hygiene. An observation and interview conducted on 1/2/24 at 10:30 AM with Resident #9. A dark substance was observed under each nail of both hands and white facial hair approximately 1/2 inches long was observed on her chin. Resident #9 stated her nails need to be cleaned but I can't do it myself. An observation on 1/2/24 at 2:30 PM revealed that Resident #9's nails and facial hair remained unchanged. Observations conducted on 1/3/24 at 11:00 AM and 3:30 PM revealed that Resident #9's nails and facial hair remained unchanged. An observation on 1/4/24 at 9:00 AM revealed that Resident #9's nails and facial hair remained unchanged. An interview with Nurse #1 conducted on 1/4/24 at 11:10 AM indicated that fingernails should be cleaned at least once a week and facial hair from female residents removed when it was noticed. She further indicated that any nursing assistant or nurse was able to clean a resident's fingernails and shave a resident, however it was usually the nursing assistants assigned to the resident who performed the task. She also indicated that she had not noticed Resident #9's nail or facial hair when passing medications. An interview with Nurse #2 conducted on 1/4/24 at 11:15 AM revealed that fingernails and facial hair should be noticed by the nurse on that hall during skin checks and on shower days by the nursing assistant giving the shower. At any time, facial hair or dirty fingernails were noticed removal of facial hair or cleaning the fingernails should be performed by the staff member who noticed it, or the nursing assistant informed so she could take care of the issue. An interview with Nursing Assistant #1 assigned to Resident #9 was conducted on 1/4/24 at 11:20 AM indicated that she checked her assigned residents' fingernails and facial hair daily and if needed she the cleaned the fingernails and removed the facial hair that day. She further indicated that she usually checked the residents assigned to her in the afternoons. She stated that this was the first day she had been assigned to Resident #9 in over a week. An observation on 1/4/24 at 12:15 PM revealed that the dark substance from Resident #9's nails had been removed but the facial hair remained. An interview with the Director of Nursing and Administrator conducted on 1/4/24 at 11:30 AM indicated that fingernails and facial hair should be taken care of each day by either the nurse or nursing assistant assigned to the hall. The Director of Nursing further indicated that she tried to monitor residents' personal hygiene weekly and unfortunately Resident #9 was simply missed by everyone. The Director of Nursing and Administrator both revealed that there had been no issues regarding facial hair or nails that they could remember.

Based on observations and staff interviews, the facility failed to date leftover food stored for use in one of one kitchen walk-in refrigerator and failed to date leftover food in one of one nourishment room (300 hall) refrigerator. This had the potential to effect 70 of 70 residents. Findings included: 1. A tour was conducted on 9/6/22 at 9:50 AM with the facility's cook of the kitchen walk-in refrigerator. Observations were made of a large container of tomato sauce with no label, a large container of tomato soup with no label, and a bag of cheese with no label. During an interview on 9/6/22 at 9:55 AM, the cook indicated staff should be labeling everything in the walk-in refrigerator with the date opened and the discard date. Staff monitored the refrigerators daily. An observation was made on 9/7/22 at 9:50 AM of the walk-in refrigerator with the dietary manager present of a container of mixed vegetables with no label. During an interview on 9/7/22 at 9:55 AM, the dietary manager revealed the cook should check the refrigerators daily and sign off on the task list. Staff should label every item placed in the walk-in refrigerator with the date it was opened and the discard date. During an interview on 9/8/22 at 9:35 AM, the Administrator revealed the dietary manager should be monitoring the walk-in refrigerator to ensure items are labeled and dated. 2. A tour was conducted on 9/6/22 at 10:15 AM of the facility's 300 hall nourishment room with the cook present. Observations were made of a Styrofoam to-go box of food with a resident's name and room number with no date, another Styrofoam to-go box of food with a resident's room number and no date, a bag of meat with a resident's name and room number with no date. During an interview on 9/6/22 at 10:15 AM, the cook revealed housekeeping staff was responsible for discarding food from the nourishment room refrigerator. Nursing staff was responsible for labeling with the resident's name and date. During an interview on 9/7/22 at 3:30 PM, the housekeeping manager revealed housekeeping staff monitored the nourishment room refrigerators daily and should discard any food that was not dated. He revealed he had not audited the nourishment room in about a month. During an interview on 9/8/22 at 9:35 AM, the Administrator revealed the housekeeping manager should be monitoring the nourishment room refrigerator to ensure items are labeled and dated. Nursing staff was responsible for labeling and dating items placed in the nourishment room refrigerator.

Based on record review and staff interviews, the facility failed to develop and implement a Legionella Prevention program. This had the potential to effect 70 of 70 residents. Findings included: Review of the Emergency Preparedness and Infection Control Programs with review date 8/2/22 revealed the facility did not have a procedure or program for water safety management for Legionella. During an interview on 9/8/22 at 4:10 PM, the Maintenance Director indicated he had received an email from corporate with changes regarding water safety management for Legionella, but they had not implemented the changes. The facility did not complete risk assessment as recommended by corporate. During an interview on 9/8/22 at 4:30 PM, the Administrator revealed she was not aware of the new requirement. She indicated the was involved in the Emergency Preparedness review in August 2022 but water safety management was not reviewed.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure a resident identified with hearing difficulties was referred for treatment to maintain hearing ability for 1 of 1 resident (Resident #266) reviewed for communication. Findings included: Resident #266 was admitted to the facility on [DATE]. Resident #266's significant change Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. Resident #266 had minimal difficulty with hearing without a hearing aid. A Care Area Assessment indicated a referral to another discipline was warranted for hearing difficulty. A Care Plan dated 8/25/22 focused on communication problem related to hearing deficit/wax build up/no hearing aids included a goal for Resident #266 to maintain current level of communication through the review period. Interventions included anticipate needs as much as possible, review factors effecting underlying cause of communication deficit. An interview and observation were conducted on 9/7/22 at 8:50 AM of Resident #266 with difficulty hearing the surveyor and frequently requested repeat of words and answered questions inappropriately. Resident #266 admitted to being hard of hearing and would love to have hearing aids. She indicated the facility had not discussed hearing aids with her recently, but she had some many years ago. She stated she did not think she could afford new hearing aids. Resident #266 indicated that she did not like the group activities because of her difficulty hearing in crowds. She added that she liked to watch TV and do word searches in her room as well. She reported she was content with these activities in her room. During an interview on 9/7/22 at 2:40 PM, the Social Worker revealed she spoke with Resident #266 weekly, and she had not mentioned wanting hearing aids. She did indicate Resident #266 was hard of hearing. The Social Worker revealed she was new to the facility and was unsure if Resident #266 had seen a hearing specialist in the past. During an interview on 9/8/22 at 9:00 AM, Nurse Aid #1 indicated that Resident #266 was hard of hearing but could communicate without difficulty. She did not recall Resident #266 having trouble understanding or making her needs known. During an interview on 9/8/22 at 1:20 PM, the MDS nurse indicated that she had marked yes for a referral to another specialist but had not discussed with Resident #266 a referral to a hearing specialist. She indicated she should have discussed this with Resident #266 and gotten a referral if requested. The MDS Nurse indicated that she worked with the social worker to get appointments with the facility's hearing specialist or an outside agency. During an interview on 9/8/22 at 4:45 PM, the Administrator revealed if a resident triggered in the MDS for a hearing problem, they should be referred to a hearing specialist. The MDS nurse and the social worker worked together to get appointments as needed.

Based on observations and staff interviews, the facility failed to secure a medication for one of four medication carts observed (medication cart #1). Findings included: On 9/7/22 at 10:30 AM through 10:36 AM, a continuous observation was made. Nurse #1 was observed preparing medications. The nurse locked medication cart #1, leaving a bottle of [MEDICATION(S)] Spray (nasal spray) on top of medication cart #1. Nurse#1 stated she had to store the nasal spray in another medication cart (medication cart #2). Nurse #1 was observed left the bottle of [MEDICATION(S)] spray on top of the medication cart #1 and then proceeded to go into a resident's room where medication cart #1 was out of direct sight of Nurse #1. Nurse #1 returned to medication cart #1 and the bottle of [MEDICATION(S)] Spray (nasal spray) was still observed on top of medication cart #1. An interview with Nurse #1 was conducted on 9/7/22 at 10:36 AM. Nurse #1 stated the bottle of nasal spray should not have been left on top of medication cart #1 unattended. Nurse #1 proceeded to pick up the bottle and gave it to Medication Aide #1 to store in medication cart #2. An interview with the Director of Nursing (DON) on 9/7/22 at 3:40 PM was conducted. The DON stated medications should not be left unattended on top of medication carts. During an interview conducted on 9/8/22 at 11:51 AM, the Administrator stated nurses should complete their medication pass in compliance with medication administration and medication storage.

Based on observation and staff interviews, the facility failed to date an opened medication vial and discard expired medications in 1 of 1 medication rooms and failed to date opened liquid supplements and discard expired medications in 2 of 4 medication carts (100, 400 hall). The findings included: 1 a. An observation was made on 08/12/21 at 10:20 AM of the facility's medication room. An opened 5 milliliter multidose vial of influenza vaccine was in the refrigerator with no date indicating when it was opened. The manufacture's label on the bottle instructed to discard thirty days after opening. The medication room refrigerator was observed to have 8 sealed boxes of influenza vaccine vials with the expiration date 06/30/21. Further observation revealed a bottle of 100-25 milligram tablets of [MEDICATION(S)] (an over-the-counter allergy medication) available for use with an expiration date of 03/2021 stamped on the bottle. During an interview on 08/12/21 at 10:45 AM, the Assistant Director of Nursing (ADON) confirmed the influenza vaccine and [MEDICATION(S)] medications were expired and should have been discarded. She further indicated nursing staff should check for expired medications and vaccines daily and discard them. The influenza vaccine vial should have been labeled with the date opened. b. An observation of 400 hall medication cart on 08/12/21 at 10:50 AM revealed the following: -A [MEDICATION(S)] and salmeterol inhalation powder 250/50 inhaler belonging to a resident with the date opened of 4/2/21 handwritten on the label. The manufacturer instructions indicated the inhaler should be discarded 30 days after opening. -An opened 30-fluid ounce bottle of liquid protein supplement with no opened date indicated on bottle. The manufacturer label indicated the product did not need to be refrigerated and should be discarded 3 months after opening. -A half-full bottle of [MEDICATION(S)] (a medication given for high blood pressure) was labeled with a distributed date of 05/07/20 and potassium supplementation with 2 tabs left was labeled with a distributed date of 05/07/20 for Resident #1. During an interview 8/12/21 at 10:50 AM, Nurse #1 indicated all nurses should monitor the medication cart for expired medications and any nurse could remove expired medication from the cart. She stated medications received from the pharmacy were good for one year per facility policy. She further stated the protein supplement should have been dated with the date opened. During an interview on 08/12/21 at 11:30 AM, the Vice President of Operations revealed nursing staff should check for expired medications. She stated a nurse manager oversaw conducting audits on medications room and medication carts but could not recall how often. c. An observation of the 100 hall medication cart on 8/12/21 at 11:00 AM revealed an opened 30-ounce bottle of liquid protein supplement with no date indicating when it was opened. The manufacturer label indicated the product did not need to be refrigerated and should be discarded 3 months after opening. During an interview on 08/12/21 at 11:05 AM, Nurse #2 revealed the bottle of protein supplement should have been labeled with the date opened. During an interview on 08/12/21 at 11:30 AM, the Vice President of Operations revealed nursing staff should check for expired medications and discard as needed. Nurses should label items after opening when needed. She stated a nurse manager oversaw conducting audits on medications room and medication carts.

Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission related to physicians' orders and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #300 and 307). Findings included: 1. Resident #300 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of care plan revealed that the care plan was initiated on 07/19/21. Most recent Minimum Data Set (MDS) dated [DATE] revealed that Resident #300 was cognitively impaired and required extensive assistance from staff for activities of daily living (ADLs). During an interview with the Director of Nursing (DON) on 08/11/21 at 10:00 am revealed that the MDS Nurse completed the baseline care plan for all new admissions. She stated that the baseline care plan was usually done within 48 hours. She reported that the baseline care plan was to be completed within 48 hours of admission. During an interview with the MDS Nurse on 08/12/21 at 10:31 am revealed that Resident #300's care plan initiated on 07/19/21 was the baseline care plan. She reported that she was responsible to complete the baseline care plan and that it should be completed within 48 hours of admission. She stated she would usually complete the baseline care plan as soon as the new admission came to facility but was unable to determine why the baseline care plan was not completed timely for Resident #300. 2. Resident #307 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of care plan revealed that the care plan was initiated on 08/09/21. During an interview with the MDS Nurse on 08/10/21 at 4:27 pm revealed that the care plan dated 08/09/21 was the baseline care plan for Resident #307. She revealed that Resident #307 admitted to the facility late Friday evening and the baseline care plan was completed on Monday when she returned to the facility. She stated that the baseline care plan was not completed within 48 hours of admission. During an interview with the DON on 08/11/21 at 10:00 am revealed that the MDS Nurse completed the baseline care plan for all new admissions. She stated that the baseline care plan was typically completed within in the first two days of admission but reported that a weekend admission posed a problem for timely completion. The DON reported that the MDS Nurse would have completed the baseline care plan on Monday for those residents admitted late Friday or over the weekend.

Based on record review, observation and staff interviews the facility failed to accurately code information correctly for 1 of 18 sampled resident (Resident #8) whose Minimum Data Set (MDS) assessments were reviewed. The findings included: Resident #8 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data set (MDS) dated on 04/19/19 revealed that in section H the resident was coded as having an indwelling catheter. During an observation on 08/07/19 at 9:00 AM revealed that the resident did not have an indwelling catheter. During an interview with the MDS Coordinator on 08/07/19 at 9:00 AM, stated that she made a coding error and that the Resident #8 never had an indwelling catheter. During an interview with the Director of Nursing on 08/08/19 at 10:00 AM, she stated that it is her expectation that the MDS be coded accurately. During an interview with the Administrator on 08/08/19 at 10:15 AM, he stated that it is his expectation that the MDS be coded accurately.

Based on record review and staff interview, the facility failed to make a referral for re-evaluation after a change in mental health status for 2 of 3 sampled residents reviewed for Preadmission Screening and Resident Review(PASARR). (Resident # 7 and 16) Findings included: 1. Resident #7 was admitted to the facility on [DATE]. Resident # 7's neurological [DIAGNOSES REDACTED]. The Significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7's cognition was severely impaired. Her active [DIAGNOSES REDACTED]. Review of Resident # 7 medical record revealed a new [DIAGNOSES REDACTED]. An observation was conducted of Resident # 7 on 8/7/2019 at 11:30 AM. There were no observed behavioral issues noted. An interview was conducted with Social Worker (SW) on 8/8/18 at 11:40 AM. SW confirmed that Resident # 7 had a level I PASARR. Resident # 7's 4/16/2019 MDS assessment that indicated the active [DIAGNOSES REDACTED]. SW confirmed Resident # 7 was not admitted to the facility with the [DIAGNOSES REDACTED]. She revealed she had not referred Resident # 7 to the PASARR authority for a re-evaluation related to these new diagnoses. An interview was conducted with the MDS nurse on 8/8 /19 at 1:44 PM. She stated that she was not aware that when a resident was newly diagnosed with [REDACTED]. The MDS added that SW was responsible for making this referral. An interview was conducted with the Director of Nursing on 8/8/19 at 2:00 PM. She stated that she was not very familiar with the regulations related to PASARR, but that she expected the regulations to be followed in reference to completing a PASARR for a newly identified mental illness diagnosis. 2. Resident # 16 was admitted to the facility on [DATE]. Resident # 16's neurological [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16's cognition was severely impaired. Her active [DIAGNOSES REDACTED]. Further it indicated the Resident # 16 was given antipsychotic medication 7 times in a week. Review of Resident # 16's medical record revealed a new [DIAGNOSES REDACTED]. An observation was conducted of Resident # 16 on 8/7/2019 at 10:30 AM. There were no observed behavioral issues noted. An interview was conducted with Social Worker (SW) on 8/8/18 at 11:40 AM. SW confirmed that Resident # 16 had a level I PASARR. SW confirmed also that Resident # 16 was not admitted to the facility with the [DIAGNOSES REDACTED].# 16 to the PASARR authority for a re-evaluation related to these new diagnosis. An interview was conducted with the MDS nurse on 8/8 /19 at 1:44 PM. She stated that she was not aware that when a resident was newly diagnosed with [REDACTED]. The MDS added that SW was responsible for making this referral. An interview was conducted with the Director of Nursing on 8/8/19 at 2:00 PM. She stated that she was not very familiar with the regulations related to PASARR, but that she expected the regulations to be followed in reference to completing a PASARR for a newly identified mental illness diagnosis.

Based on record review and staff interview the facility failed to notify the PASRR office for a resident who had a significant mental health change for 1 of 4 residents reviewed for Pre-Admission Screening and Resident Review (PASRR). (Resident #60) Findings included: A review of the PASRR level I screen dated 4/12/18 had mental health [DIAGNOSES REDACTED]. A review of the PASRR level II determination notification dated 9/10/18 with the PASRR number ending in an F read: the physical and mental health needs of the above-named individual had determined the nursing facility placement is appropriate for a 90-day period. A review of the PASRR level 1 determination notification dated 12/7/18 read: PASRR number ending in an A and without an expiration date, did not need further screening unless a significant change occurs with the individual's status which suggests a [DIAGNOSES REDACTED]. Resident #60 was readmitted to the facility 3/5/19 with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE], sections 1500 is coded: no, for consideration by the state PASRR level II process to have serious mental illness and sections A1700 and A1800 had resident codes as reentry from psychiatric hospital. The comprehensive care plan dated 6/17/19 had focuses of Resident #60 to receive Antipsychotic medication [MEDICATION NAME] related to [DIAGNOSES REDACTED]. A review of the PASRR level I screen dated 8/7/19 had mental health [DIAGNOSES REDACTED]. The 08/2019 Medication Administration Record [REDACTED]. During an interview with the Social Worker (SW) on 8/08/19 at 09:58 AM, the SW stated Resident #60 had a PASRR level II in 9/10/2018 ending in F for a [DIAGNOSES REDACTED]. There wasn't a PASRR II screening done when until 8/7/19. It was an oversight and audits are being done throughout the facility to check for eligible [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 08/08/19 at 10:09 AM, the DON stated when there is a mental health significant change in a resident, they should be re-evaluated for PASARR II and it wasn't done. It was missed. Going forward we are auditing all residents to make sure it is done, and the Social worker is going to go over the new [DIAGNOSES REDACTED].

Based on record reviews, observation, resident interview, Nurse Practitioner (NP) interview and staff interviews, the facility failed to correctly secure a resident in a mechanical lift when using the lift to perform a resident transfer for 1 of 3 sampled residents reviewed for accidents (Resident #56). As a result of not properly securing Resident #56 in the mechanical lift and hitting the resident ' s wheelchair against the lift during the transfer the resident fell from the lift to the floor and hit her head on the floor. The resident sustained [REDACTED]. The findings included: A review of the manufacturer ' s manual instructions for the mechanical lift used at the facility, dated (MONTH) 2012, included the following instructions: Ensure that the mechanical lift is close enough to be able to attach the sling ' s shoulder clips to the spread bar. Once the mechanical lift is in position, attach the shoulder strap attachment clips to the sling attachment lugs on the spreader bar. Press down on the positioning handle on the spreader bay and attach the leg strap attachment clips. Review of the manufacturer ' s manual also revealed the lift could be used by one staff during transfer of a person. Resident # 56 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident # 56 ' s cognition had been moderately impaired and she had been totally dependent with assistance of 2 staff for bed mobility and toileting. MDS also indicated Resident # 56 had been totally dependent with the assistance of 1 staff for transfers. The MDS indicated Resident #56 was not steady when moving from a seated position to a standing position and was only able to stabilize with staff assistance. Resident # 56 ' s care plan, updated on 7/11/2018 indicated Resident # 56 required assistance for mobility due to weakness. The interventions included the following: transfers using mechanical lift, use yellow sling (121 lbs-165 lbs). Resident # 56 weighed 127 lbs. The care plan did not specify the number of staff required when using the mechanical lift during the transfers. A review of Resident #56 ' s current Care Guide dated 8/3/2018 indicated the following: the resident required Activity of Daily Living (ADL) care. Transfers: Total mechanical lift. The care guide did not specify the number of staff required when using the mechanical lift during the transfers. A review of the nurse ' s note, dated 8/3/2018 and written by Nurse #1, indicated I was on the hall passing medication when Nurse Aide (NA) # 1 called me to room. Resident # 56 was noted lying on the floor on the left beside the bed. NA # 1 reported she was transferring Resident # 56 from wheelchair to bed and the resident fell from the lift. The blood was noted from wound to right side of head. Wound care was provided. Resident # 56 was alert and verbal. Nurse Practitioner (NP) was notified and assessed Resident # 56. She gave order to transfer the resident to emergency room for evaluation. A review of the emergency room report dated 8/3/2018 indicated Resident # 56 head exam found a 3 centimeter linear laceration to right side of her head frontal/temporal aspect with mild active bleeding. Resident # 56 ' s laceration was closed with 8 staples and 6 sutures. A review of the facility ' s investigation report dated 8/3/2018 revealed Resident # 56 returned from [MEDICAL TREATMENT] in her wheelchair. [MEDICAL TREATMENT] lift pad removed from under her and replaced with the facilities total lift pad. NA # 1 named in report stated she went to return resident to bed from the wheelchair and resident fell out of lift face first. NA # 1 reported Resident # 56 was secured in the lift by hooking the lower clasp first between legs then the upper clasp lastly. Lift elevated resident from the wheelchair. While airborne NA# 1 attempted to move wheelchair improperly by trying to roll the wheelchair over the legs of the lift. In doing so she bumped the resident and the lower leg clasp became unloosened resulting in the resident sliding out of the sling onto the legs of the lift. The investigation report further indicated Resident # 56 received 8 staples to right side of her head due to scalp laceration. A review of NA # 1 ' s statement dated 8/3/2018 indicated NA # 1 entered the room at 4:00 p.m. Resident # 56 was in her room sitting in her wheelchair. I got the total lift pad and put up under her and connected lift pad to the machine. She was in the upright position in the air. So I pulled the wheelchair from under her and she fell on the floor on her stomach. I called for help to Nurse # 1 and she and some other nurses came to help. Resident # 56 was in good spirits and the ambulance came and got her but she said she was alright. During an interview with Resident #56 ' s on 8/28/2018 at 10:00 AM, Resident # 56 reported about 4 weeks ago, she came back to the facility from [MEDICAL TREATMENT] and during the process of NA # 1 getting ready to transfer her from the wheelchair to bed, she dropped her on the floor. Resident # 56 further reported since she was blind, she was not sure what had just happened. Resident # 56 further reported she found herself on the floor and felt blood coming from the side of her head. Resident # 56 stated currently she was doing fine. During an interview with Nurse #1 on 8/28/2018 at 3:20 PM, Nurse # 1 stated she had been assigned to care for Resident #56 on 8/3/2018. Nurse #1 stated NA # 1 reported to her that Resident # 56 had fallen off the lift after she (NA # 1 )was trying to move wheel chair under the lift and had improperly secured the resident on the lift by hooking the lower clasp first between legs then the upper clasp lastly. Nurse # 1 also reported she saw the resident on the floor lying under the lift and the blood was observed on the floor. Nurse # 1 stated she reported the incident to Nurse Practitioner (NP) who was present in the facility. Nurse # 1 stated she called 911 as the NP was holding a gauze on Resident # 56 ' s wound to stop the blood from flowing from the scalp. During an interview with the Nurse Practitioner (NP) on 8/28/2018 at 3:30 PM, the NP indicated on 8/3/2018 while she was at the facility, she was made aware of Resident # 56 falling from a lift. NP reported she immediately went to Resident # 56 room and saw the resident on the floor with blood coming from the side of her scalp. NP states she proceeded to put a gauze on Resident # 56 ' s scalp to stop the bleeding while waiting for the EMS to arrive. She reported the resident was alert and oriented to herself and her surroundings. During an interview with the MDS nurse on 8/28/2018 at 3:40PM, the MDS nurse reported when Resident # 56 ' s fell from a mechanical lift on 8/3/2018, the resident ' s care plan not indicate the number of staff required when transferring Resident # 56 using the mechanical lift. The MDS nurse stated Resident # 56 mechanical lift transfers from bed to chair were being done by one person at the time of the resident ' s fall on 8/3/18. During an interview with the Staff Development Coordinator (SDC) on 8/28/2018 at 3:50 PM, the SDC stated on 8/3/2018, NA # 1 failed to secure Resident # 56 properly on a mechanical lift by hooking the lower clasp first between legs then the upper clasp mechanical lift, causing Resident # 56 to fall off the mechanical lift. SDC stated the NAs used one staff to transfer Resident # 56 which was according to the training on the use of the total mechanical lift. SDC stated the staff at the facility had been in serviced in reference to proper use of the mechanical lift and NA # 1 was last trained 10/1/2017 During an interview with the Director of Nursing (DON) on 8/28/2018 at 4:00 PM, the DON reported on 8/3/2018, she was made aware immediately of Resident # 56 ' s falling off the lift. The DON indicated her expectation of the nursing staff would have been to have to follow the manufacturer manual guidelines to prevent any accident at the facility. She indicated NA# 1 was trained before she started working on the floor when using the mechanical lift to hook the upper clasp first then lower clasp between legs. DON reported after Resident # 56 came back from [MEDICAL TREATMENT] and NA # 1 was attempting to transfer the resident and she raised the resident up in the lift. While the resident was in the sling, NA # 1 began to attempt to remove the wheel chair from underneath the resident by pulling/picking it over the lift legs. During this movement the lower leg attachment became unhooked and the resident slipped from the sling and fell to the floor. DON stated the clasp should not have loosened if NA # 1 had secured it per manufacturer ' s instruction. She added the facility had already completed 100 % in-service training on the proper use of a mechanical lift. DON also reported during the investigation they were unable to identify the reason NA # 1 used the lift inappropriately while transferring Resident # 56 by hooking the lower clasp first between legs then the upper clasp, causing Resident # 56 to fall off the mechanical lift. DON stated before Resident # 56 ' s fall incident of 8/3/2018, NA#1 had been trained on proper use of a mechanical lift on 10/1/2017. DON further indicated after the accident, the lift was removed from the resident ' s room and inspected. No concerns were found with mechanical lift. She stated there were no tears or something wrong with the clips. DON also reported before 8/3/2018, Resident # 56 was transferred using one staff and that was appropriate according to the manufacturer instruction. She added the facility is now using 2 staff for total mechanical lift transfers at the facility for precaution. DON stated she did reenactment in her office and it was found the resident fell because the straps were done in the wrong order and also NA# 1 attempting to remove the chair underneath the mechanical lift which knocked the straps and caused the resident to fall on the floor. During an interview with the Administrator on 8/28/2018 at 4:40 PM, the Administrator reported on 8/3/2018, she was made aware immediately of the incident of Resident #56 ' s falling off the mechanical lift. The Administrator stated his expectation would have been for the staff to follow the manufacturer manual guidelines so that they can prevent accidents from occurring. She further indicated an in-service on the proper use of the mechanical lift had been completed. During an observation of a mechanical lift transfer made on 8/29/2018 at 10:30 AM, Resident # 56 ' s was secured properly on the total mechanical lift. 2 nurse assistants assisted with the transfer. NA#1 who was accused of improper use of a total mechanical lift was unavailable for interview. She (NA #1) was terminated from employment on 8/3/2018. The corrective action for past non-compliance dated 8/3/2018 included: 1-The NA # 1demonstrated a reenactment of the lift procedure: On 08/03/2018 at approximately 4:30PM, NA #1 took the resident to her room to place her back to bed after the resident returned from [MEDICAL TREATMENT]. The NA #1 utilized the Total Mechanical Lift and a yellow sling. After removing the [MEDICAL TREATMENT] sling, the NA # 1 placed the yellow sling under the resident and attached the lower leg attachments to the sling and then attached the upper shoulder attachments to the to the lift attachment points. The NA # 1 then raised the resident up in the lift. While the resident was in the sling, NA # 1began to attempt to remove the wheel chair from underneath the resident by pulling/picking it over the lift legs. During this movement the lower leg attachment became unhooked and the resident slipped from the sling and fell to the floor. Immediately the NA # 1 called out for assistance. The resident was assessed by the nurse and noted a wound to the right side of her head. The Nurse Practitioner (NP) was onsite and made aware of the fall as well as the Responsible Party (RP). The resident was alert and oriented at all times and was transferred to the ER for evaluation. The resident was returned to the facility with 7 staples to her scalp wound. 2-The resident was tasked for 2 assistants when transferring the resident on 08/03/2018 by the MDS Nurse. Task will fire to the Nurse ' s Aide for notification to use a mechanical lift with a yellow sling and 2 assistants. A review of the NA# 1 employee file revealed that on hire 10/17/2017 the employee went through the new hire orientation process, the NA #1 was skills checked on the use of the Mechanical lifts by the SDC. 3-On 08/09/2018 the MDS Nurse, Director of Nursing, and Therapy Director audited 100 % current residents to ensure that if the resident was assigned a lift Total or stand aide, that the lift was tasked to the resident kardex along with the sling size to use. This was completed on 08/10/2018. 4-100 % Employees to receive education. The DON will ensure that all staff receive the education prior to working starting on 08/08/2018. Additional education was provided to the SDC and DON by the nurse consultant regarding completing skills check off with all nurses and NA ' s on hire. During orientation, the mechanical lift Return demonstration check off list for the Maxi-move and Sara 300 lifts should be utilized. After showing the Mechanical lift videos, each nurse and Nurse Aides will perform a return demonstration to the SDC and performance will be documented on the mechanical lift skills check list. This was completed on 08/08/2018. This training was incorporated into the general orientation program and will be discussed during all general orientation programs that is completed for identified staff. Completion date 8/10/2018 5- The DON will monitor mechanical lift skills check completion on all new hires and observe transfers utilizing the total mechanical lift weekly for 2 weeks and monthly for 3 months for completion of skills check off on hire and observe total mechanical lift for correct procedure. Reports will be presented to the weekly Quality Assurance (QA) committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, and the Dietary Manager. The Administrator will be the person responsible for implementing the Quality Improvement Plan. As part of the validation process on 8/30/2018, the entire plan of correction was reviewed including re-education of staff and observations of the use of a lift transfer on residents (Resident # 56) at the facility. Interviews of the nurse aides and nurses revealed they were aware of proper usage of the mechanical lift for the transfer of the residents at the facility. A review of the monitoring tools revealed that the facility had completed the 100 % in-service of the use of mechanical lift and return demonstration on 8/8/2018. The facility ' s completion date of 8/10/18 was validated.

Based on observations, record review, resident and staff interviews, the facility failed to accurately code the MDS (Minimum Data Set) for 1 of 1 resident (Resident #5) reviewed for a trunk restraint and 1 of 1 resident (Resident #6) reviewed for Level II Preadmission Screening and Resident Review (PASRR). The findings included: 1. Resident #5 was admitted to the facility on [DATE] and readmitted into the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change ((MDS) dated [DATE] indicated that Resident #5 had no short or long term memory problems, was cognitively intact and total dependence on staff for all activities of daily living. The resident was not coded for a trunk restraint used in chair. During an observation on 10/04/17 at 11:00 AM, Resident #5 was sitting up in wheelchair in his room with seatbelt in place. During an interview with Resident #5 on 10/04/17 at 11:05 AM, Resident #5 indicated that he requested the seatbelt because it made him feel safe while he was in the wheel chair. Resident #5 indicated that he could not release the seatbelt. During an interview with the MDS (Minimum Data Set) Coordinator on 10/04/17 at 2:00 PM, the MDS Coordinator stated that she did not code the seatbelt as a restraint due to it was being used as an enabler to assist with the resident with independence. The MDS Coordinator further stated that the resident will not get in the wheel chair without the seatbelt. During an interview with the Administrator on 10/04/17 at 2:10 PM, the Administrator stated that the seatbelt was being used as an enabler and not a restraint. During an interview with the Administrator on 10/05/17 at 8:00 AM, the Administrator stated that it is her expectation that the MDS Coordinator completes the MDS accurate to the best of her ability. During an interview with the Director of Nursing (DON) on 10/05/17 at 8:15 AM, the DON indicated that it is her expectation that the MDS Coordinator completes the MDS accurately. 2. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Preadmission Sreening and Resident Review (PASRR) Level II number for Resident # 6 revealed that the resident had a permanent number, dated 8/26/2003. Review of Resident # 6's most recent annual Minimum Data Set (MDS), dated [DATE], indicated the resident was not coded for PASRR Level II meaning the resident was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability. The results of this screening and review were used for formulating a determination of need, determination of an appropriate care setting and a set of recommendations for servicing to help develop an individual's plan of care. In an interview on 10/ 04/17 at 10:37 AM with the MDS Coordinator, she revealed that it was an oversight that the resident was not coded as a Level II PASRR. In an interview on 10/04/17 at 10:45AM with the DON, she revealed that it was her expectation that the MDS Coordinator makes sure that the PASRR Level II residents were coded accurately. In an interview on 10/04/17 at 10: 50 AM with the Administrator, she revealed that it was her expectation that the MDS Coordinator codes the MDS accurately by making sure that the PASRR Level II residents were coded accurately.

Based on record review and staff interviews, the facility failed to notify the doctor when complaints of pain were made after a fall had occurred for 1 of 3 sampled residents, Resident #1. An x-ray completed after the fall revealed the resident had sustained a right [MEDICAL CONDITION]. The findings include: Resident #1 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to an Admission Minimum Data Set ((MDS) dated [DATE], Resident #1 was moderately cognitively impaired. In the area of bed mobility and transfers, he required extensive assistance, two person physical assistance. In the area of dressing, eating and personal hygiene, Resident #1 required total assistance. Resident #1's care plan dated 12/12/16 addressed increased risk for falls related to deconditioning (loss of muscle tone or loss of function) with actual fall. The interventions included to monitor and document for pain x 72 hours post fall follow up and to report pain, bruising, change in mental status or agitation to the physician. During an interview on 3/19/17 at 3:05 AM, the Third Shift Nurse Supervisor revealed she was on another hall Christmas morning and she came back toward the nurse's station toward the medication cart. She revealed a Nursing Assistant told her Resident #1 was on the floor outside his door. She stated there was a lot going on at the time. The Third Shift Nurse Supervisor stated she assessed Resident #1 and he did not exhibit any signs of pain. She recalled the resident was alert and there was no grimacing. She stated she did not see anything to keep from moving him. The Third Shift Nurse Supervisor revealed she brought Resident #1 to the front of the nursing station in a special chair to watch him more closely. She stated she forgot to write up everything that morning, to report the fall to the next shift, and to contact the family and doctor. She revealed she went home at the end of her shift and forgot about it. The Third Shift Nurse Supervisor continued by stating Resident #1 complained of pain two or three days later and she found out later there was a possibility of a small fracture. The Third Shift Nurse Supervisor recalled prior to Resident #1's fall, she gave him medication when he became agitated. She stated when she came back to work Monday (12/26/16) or Tuesday (12/27/16) night after the fall, he started complaining of pain. The Third Shift Nurse Supervisor did not explain why she did not call the doctor when Resident #1 started complaining of pain on 12/26/16 or 12/27/16 after the resident had fallen. In reference to reporting the fall to the doctor, the Third Shift Nurse Supervisor stated if there were no injuries after a fall, she would fax the doctor and if there was an injury she would get an order to send the resident out to the emergency room . She stated she did not fax the doctor the night of Resident #1's fall because it slipped her mind. The Third Shift Nurse Supervisor said a lot was going on, such as a lot of people needing care at one time. During an interview on 3/19/17 at 2:47 PM, Staff Nurse #1 revealed she worked on first shift with Resident #1 every day during the week and he denied pain, prior to 12/28/16. She stated the Nursing Assistant was doing her rounds on 12/28/16 and told her Resident #1 was complaining of pain. She stated Resident #1 did not talk much and each time she picked up his right side he grabbed her hand as if he was hurting. She stated she turned him over and he guarded his right side. She revealed his family was in the room with him when he indicated he was hurting. Staff Nurse #1 revealed she gave Resident #1 Tylenol for pain and called the doctor on call at 4:29 PM. She revealed she did not know Resident #1 had fallen. She stated she looked for information regarding a fall and she did not see anything about him having a fall. During an interview on 3/20/17 at 2:13 PM, the Director of Nursing (DON) revealed an investigation probably was not done when the fall happened because the Third Shift Nurse Supervisor went home. The DON revealed the Third Shift Nurse Supervisor was careless in not calling Resident #1's family and not doing an incident report. The DON revealed she could not find a nurse's note written on 12/25/16 regarding the fall and she did not see an incident report or a fax to the doctor or a phone call to the family. She emphasized for a fall with an injury, the procedure was to call the DON, Administrator, family and doctor and for a fall without injury, make notifications and put something in place to prevent the fall from happening again such as putting a mattress beside the bed or bringing the resident up to the nurse's station. The DON revealed on 12/28/17 an X-ray was done and on 12/29/16 it was determined Resident #1 had a fracture. Resident #1 had surgery, due to the fracture for right hip repair on 12/30/16. The DON revealed after it was discovered through interviews that Resident #1 had a fall and fracture, she revealed the doctor and Resident #1's family were notified on 12/30/16 at 10:25 AM. During an interview on 3/21/17 at 12:00 PM, the Administrator stated on the day Resident #1 was X-rayed and it was determined he had a fracture on 12/29/16, they started interviewing staff. She revealed once they started interviewing staff they found out Resident #1 had fallen. She revealed the Third Shift Nurse Supervisor did not call her to let her know when Resident #1 had fallen. During an interview on 3/21/17 at 1:03PM, the Administrator stated it was her expectation that when a resident had a fall incident, the nurse must immediately notify the resident's family and doctor.

Based on record review and staff interviews, the facility failed to document an assessment of a fall and also failed to document resident's complaints of pain and medication given for pain relief after a fall had occurred, for 1 of 3 sampled residents, Resident #1. An x-ray completed after the fall revealed the resident had sustained a right [MEDICAL CONDITION]. The findings included: Resident #1 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 3/19/17 at 3:05 AM, the Third Shift Nurse Supervisor revealed she was on another hall Christmas morning and she came back toward the nurse's station toward the medication cart. She revealed a Nursing Assistant told her Resident #1 was on the floor outside his door. The Third Shift Nurse Supervisor stated she assessed Resident #1 and he did not exhibit any signs of pain. She recalled the resident was alert and there was no grimacing. She stated she did not see anything to keep from moving him. She stated she forgot to write up everything that morning, to report the fall to the next shift, and to contact the family and doctor. She revealed she went home at the end of her shift and forgot about it. The Third Shift Nurse Supervisor continued by stating Resident #1 complained of pain two or three days later and she found out later there was a possibility of a small fracture. The Third Shift Nurse Supervisor recalled prior to Resident #1's fall, she gave him medication when he became agitated. She stated when she came back to work Monday (12/26/16) or Tuesday (12/27/16) night after the fall, he started complaining of pain. During an interview on 3/19/17 at 2:47 PM, Staff Nurse #1 revealed she worked on first shift with Resident #1 every day during the week and he denied pain, prior to 12/28/16. She stated the Nursing Assistant was doing her rounds on 12/28/16 and told her Resident #1 was complaining of pain. She stated Resident #1 did not talk much and each time she picked up his right side he grabbed her hand as if he was hurting. She stated she turned him over and he guarded his right side. She revealed his family was in the room with him when he indicated he was hurting. Staff Nurse #1 revealed she gave Resident #1 Tylenol for pain and called the doctor on call at 4:29 PM. She revealed she did not know Resident #1 had fallen. She stated she looked for information regarding a fall and she did not see anything about him having a fall. During an interview on 3/20/17 at 2:13 PM, the Director of Nursing (DON) revealed an investigation probably was not done when the fall happened because the Third Shift Nurse Supervisor went home. The DON revealed the Third Shift Nurse Supervisor was careless in not calling Resident #1's family and not doing an incident report. The DON revealed she could not find a nurse's note written on 12/25/16 regarding the fall and she did not see an incident report or a fax to the doctor or a phone call to the family. She emphasized for a fall with an injury, the procedure was to call the DON, Administrator, family and doctor and for a fall without injury, make notifications and put something in place to prevent the fall from happening again such as putting a mattress beside the bed or bringing the resident up to the nurse's station. The DON revealed on 12/28/17 an X-ray was done and on 12/29/16 it was determined Resident #1 had a fracture. Resident #1 had surgery, due to the fracture for right hip repair on 12/30/16. The DON revealed after it was discovered through interviews that Resident #1 had a fall and fracture, she revealed the doctor and Resident #1's family were notified on 12/30/16 at 10:25 AM. During another interview on 3/21/17 at 1:03 PM, the Administrator revealed her expectation would be for the Nurse to complete fall report and notify them through the fall reporting system.

Based on observation and staff interview the facility failed to discard expired medications from one (1) of one (1) medication rooms. Findings include: On 1/28/16 at 9:02 AM, the medication room was observed. In the stock medication, the following expired stored medications were noted: one unopened bottle of Fiber Therapy by Equate (lot # ) with an expiration date of 9/2015 and one unopened 500 cc bag of D51/2NS intravenous fluid (lot #C 5) with an expiration date of 11/2015. On 1/28/16 at 9:05 AM Nurse #1 was observed to remove the expired Fiber Therapy bottle and bag of intravenous fluid from the stock medication and gave the medication to the Unit Director to give back to the pharmacy for disposal. The Unit Director stated in an interview on 1/28/16 at 9:07 AM, the bottle of Fiber Therapy and bag of intravenous fluid was in the stock medication that could be used on the residents in the facility. She further stated the expired medications should have been removed from the stock medication supplies and sent back to the pharmacy for disposal. The Administrator stated in an interview on 1/28/16 at 9:40 AM, the expired medications in the medication room should have been removed and sent back to the pharmacy for disposal.