Every finding on record at Springside Rehabilitation and Skilled Care Center

Based on observation, interview, and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for one Resident (#39), of four applicable residents, out of 29 medication pass opportunities. The medication error rate was observed to be 6.9%. Specifically, 1. For Resident #39, the Resident was administered Memantine (a medication used to treat memory loss) capsule and Depakote Sprinkles (a medication used for seizures and various psychiatric symptoms) capsule by opening the capsules and crushing the inside sprinkle capsules placing the Resident at risk of having less efficacy of the prescribed medications. Findings include: Review of the Mayo Clinic's Drug and Supplement information (www.mayoclinic.org/drugs-supplements) for Memantine and Depakote Sprinkles indicated the following: -Memantine >Swallow the extended-release capsules whole. Do not break, crush, or chew them. >If you cannot swallow the extended-release capsule, you may open it and pour the medicine into a small amount of soft food such as applesauce. Stir this mixture well and swallow it without chewing. -Depakote Sprinkles >Swallow the sprinkle capsules whole. It may also be opened, and the contents may be sprinkled onto a teaspoonful of soft food, such as applesauce or pudding. This mixture must be swallowed immediately without chewing and followed with a glass of water to ensure complete swallowing of the sprinkles. Review of the facility policy titled Medication Management - General Policies, reviewed September 2024, indicated the following: -Purpose: to identify effective and safe medication management processes to improve resident safety. -Medications may be administered per resident choice consistent with plan of care ie. taken whole, crushed, in accordance with pharmacy standards, or other method. Resident #39 was admitted to the facility in February 2023, with diagnoses including Dementia, Mood Disorder and Psychotic Disturbance. Review of Resident #39's September 2025 Physician's Orders indicated the following: -an active order for Depakote Sprinkles Orla Capsule Delayed Release Sprinkle 125mg (milligrams) capsule, give 2 capsules by mouth two times a day for mood disorder initiated on 9/14/25 -an active order for Namenda XR (Memantine) Oral Capsule Extended Release 24 Hour 28mg capsule, give 1 capsule by mouth one time a day for dementia On 9/26/25 at 8:06 A.M., the surveyor observed Nurse #1 do the following during a Medication Administration Observation for Resident #39: -poured the Resident's morning tablet and capsule medications into a medication cup including Depakote Sprinkles delayed release capsule and Memantine Extended Release -performed hand hygiene, don (put on) gloves and open the Memantine and Depakote capsules into the medication cup with the tablet medications -poured contents of the medication cup into a pill crusher pouch and crush the tablets and opened contents of the Depakote Sprinkles and Memantine capsules -poured the crushed contents of the pill crusher pouch back into the medication cup, added applesauce and administered it to the Resident During an interview on 9/26/25 at 9:31 A.M., the surveyor reviewed the medication administration observation of Resident #39 with Nurse #1. Nurse #1 said she had crushed the contents of the opened Depakote Sprinkles and Memantine capsules. Nurse #1 said that she believed the medications could be crushed once opened but would speak to the Staff Development Coordinator. After a brief conversation with the Staff Development Coordinator, Nurse #1 said that the contents from the Depakote Sprinkles and Memantine should not be crushed. During an interview on 9/26/25 at 9:50 A.M., the Corporate Nurse said that she had spoken with the pharmacy, and they said the concern with crushing the contents of the Depakote Sprinkles and Memantine capsules was that the duration of effect of the medication would potentially be shorter than intended.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#112), of one applicable Resident reviewed with an intravenous access site, out of a total of 21 sampled Residents. Specifically, for Resident #112, the facility failed to ensure hand hygiene was performed as indicated after removal of gloves to prevent potential cross-contamination during an intravenous (IV) medication administration. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, reviewed August 2015, indicated the following: -This facility considers hand hygiene the primary means to prevent the spread of infections. -Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: >before and after direct contact with residents >before and after handling an invasive device (e.g., urinary catheters, IV access sites) >after removing gloves Resident #112 was admitted to the facility in September 2025 with diagnoses including Osteomyelitis (infection of the bone) of the right ankle and foot, Methicillin Resistant Staphylococcus Aureus (MRSA) Infection and Extended Beta Lactamase (ESBL) Resistance. Review of Resident #112's September 2025 Physician's Orders indicated the following: -an active order dated 9/18/25 to maintain enhanced barrier precautions (wear gloves and a gown for the following high contact care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, or wound care) for wound infection, central venous catheter (proline) [a type of IV access site that is inserted in the chest) and MRSA. On 9/26/25 at 2:30 P.M., the surveyor observed Unit Manager (UM) #1 do the following during a medication administration observation for Resident #112: -performed hand hygiene, donned (put on) a gown and gloves, and entered the room to clean and disinfect the Resident's overbed table -doffed (took off) the gown and gloves and performed hand hygiene before leaving the room -poured oral medication for Resident as ordered, pulled out a pre-packed set of supplies for IV administration from the medication cart -performed hand hygiene, donned a gown and gloves, gathered supplies off the medication cart and entered the Resident's room -set the pre-packaged IV administration supplies on the Resident's dresser, and administered the oral medication -doffed gloves and donned a new pair of gloves without performing hand hygiene -draped the overbed table, took supplies out of package and set them up on the overbed table - doffed gloves and donned a new pair of gloves without performing hand hygiene -prepared the IV medication, primed the IV tubing for administration and set up the IV pump as ordered - doffed gloves and donned a new pair of gloves after performing hand hygiene -cleaned the central venous catheter, flushed the catheter, hooked up the IV medication tubing and began the infusion. -cleaned off table, doffed gown and gloves and performed hand hygiene During an interview on 9/26/25 2:48 P.M., UM #1 said that she should have performed hand hygiene after every glove removal before she donned new gloves but did not. UM #1 further said that the risk of not performing hand hygiene during glove changes was that her hands could be dirty after removing the glove creating the potential that the glove could become contaminated.

Based on interview, record and policy review, the facility failed to ensure that staff assessed and offered COVID-19 vaccination as recommended by the Centers for Disease Control and Prevention (CDC) for three Residents (#13, #45, and #53) out of a total sample of five residents. Specifically, for Residents #13, #45, #53 the facility failed to offer a second dose of the current COVID-19 2023 - 2024 vaccination as recommended to by the CDC when a person is over the age of 65. Findings include: Review of the facility policy titled COVID-19 Vaccine Policy and Procedure, dated 11/21/23, indicated the following: -COVID-19 vaccinations will be offered to all staff and residents (or their representatives if they cannot make health care decisions) per CDC and/or Food and Drug Administration (FD) guidelines . Review of the CDC website Clinical Guidance for COVID-19 Vaccination | CDC, last reviewed 4/4/24, indicated the following: -Special situation for people ages [AGE] years and older: >People ages [AGE] years and older should receive 1 additional dose of any updated (2023-2024 Formula-current COVID-19 vaccine being offered) COVID-19 vaccine (i.e., Moderna, Novavax, Pfizer-BioNTech - manufacturers of the current available COVID-19 vaccine) at least 4 months following the previous dose of updated (2023-2024 Formula) COVID-19 vaccine. Review of the CDC Vaccine Schedule titled Updated (2023-2024 Formula) COVID-19 Vaccine, dated 4/3/24, indicated the following: -People [AGE] years of age and older: Administer 1 additional dose at least 4 months following the last recommended dose of 2023-24 COVID-19 Vaccine. 1. Resident #13 was admitted to the facility in June 2023, and was over the age of 65. Review of the Resident Immunization history indicated that he/she received his/her first dose of the COVID-19 2023-2024 Formula on 12/15/23. Review of the Vaccine Consent/Declination form dated 6/21/23, indicated the Resident and/or Resident Representative consented to receive COVID-19 vaccinations. Review of the COVID Vaccine Consent Questionnaire dated 6/7/24, indicated no documentation that the Resident had been assessed for, or if the Resident and/or Resident's Representative had been offered a second dose of the COVID-19 2023-2024 Formula. 2. Resident #45 was admitted to the facility in March 2023, and was over the age of 65. Review of the Resident Immunization history indicated that he/she received his/her first dose of the COVID-19 2023-2024 Formula on 1/5/24. Review of the Vaccine Consent/Declination form dated 3/1/23, indicated the Resident and/or Resident Representative consented to receive COVID-19 vaccinations. Review of the COVID Vaccine Consent Questionnaire dated 5/20/24, indicated no documentation that the Resident was assessed for, or if the Resident and/or Resident's Representative had been offered a second dose of the COVID-19 2023-2024 Formula. 3. Resident #53 was admitted to the facility in April 2024, and was over the age of 65. Review of the Resident Immunization history indicated that he/she reviewed his/her first dose of the COVID-19 2023-2024 Formula on 10/11/23. Review of the Vaccine Consent/Declination form dated 4/24/24, indicated the Resident and/or Resident Representative consented to receive COVID-19 vaccinations. Review of the COVID Vaccine Consent Questionnaire dated 6/1/24, indicated no documentation that the Resident was assessed for, or if the Resident and/or Resident's Representative had been offered a second dose of the COVID-19 2023-2024 Formula. During an interview on 7/16/24 at 3:36 P.M., Unit Manager (UM) #1 said she was the UM for the unit that Resident's #13, #45, and #53 resided on. UM #1 said she monitors vaccination information including who is up to date on vaccinations for residents that resided on her unit. UM #1 said she was unaware that it was recommended residents over the age of 65 have a second dose of the COVID-19 2023-2024 Formula to be considered up to date on their COVID-19 vaccinations. UM #1 further said she could not recall if any education had been provided regarding the CDC recommendation for offering a second dose of the 2023-2024 Formula to those residents who were over the age of 65. UM #1 said she had not been tracking when Resident's became eligible for a second dose of the COVID-19 2023-2024 Formula, and had not assessed the need for, or offered a second dose of the COVID-19 2023-2024 Formula to Resident's #13, #45, and #53. During an interview and review of the facility's document titled COVID Vaccine Consent Questionnaire on 7/16/24 at 3:46 P.M., the Director of Nursing (DON) said education should have been completed with staff when new guidance comes out that the facility needs to implement. The DON was unable to provide documentation that staff had been educated on the CDC guidance for those over [AGE] years of age to offer a second dose of the COVID-19 2023-2024 Formula. The surveyor and the DON reviewed the facilities COVID Vaccine Consent Questionnaire, dated March 2024, which indicated the following: Everyone aged [AGE] years and older-You are up to date when you have received two updated 2023-2024 COVID-19 vaccine doses. After reviewing the COVID Vaccine Consent Questionnaire used by the facility, the DON said she could not speak to whether or not Residents #13, #45, and #53 should have been offered a second dose of the COVID-19 2023-2024 Formula. During an interview on 7/16/24 at 4:21 P.M., the Infection Preventionist (IP) said she could not speak to whether Residents who needed a second dose of the COVID-19 2023-2024 Formula were being tracked as this information was being tracked by the Unit Managers from each unit. The IP said she was unsure how the UM's were tracking which Residents needed a second dose of the COVID-19 2023-2024 Formula.

Based on interview, record and policy review, the facility failed to provide a medication regimen that was free from unnecessary medications for one Resident (#296) out of a total sample of 18 residents. Specifically, the facility staff failed to ensure that a Physician's order for Torsemide (a potent loop diuretic [water pills that act on the kidneys to increase the flow of urine] medication used to treat fluid retention) medication was accurately transcribed resulting in Resident #296 receiving extra doses of medication and putting him/her at risk for dehydration, electrolyte imbalance, hypotension (low blood pressure) and sudden cardiac arrhythmias (irregular heartbeats). Findings include: Review of the facility policy titled Medication Reconciliation dated 9/2023, indicated the following: -Purpose: to prevent or reduce medication errors which occur when patients/residents transition from one healthcare setting to another. Review of the facility policy titled Administering Medications, dated 12/2012 indicated the following: -Medications must be administered in accordance with the orders, including required time frame. Resident #296 was admitted to the facility in July 2024 with diagnoses including Non-ST elevation Myocardial Infarction (NSTEMI - a type of heart attack that occurs when an artery is partially blocked, reducing blood flow and oxygen to the heart muscle). Review of the July 2024 Physician's orders indicated the following: -Torsemide 20 mg (milligrams), give by mouth one time a day, date initiated 7/11/24. -Torsemide 20 mg, give by mouth two times a day, date initiated 7/11/24. Review of the Medication Administration Record (MAR), indicated the following: -Torsemide 20 mg, give by mouth one time a day, scheduled for 6:00 A.M. -Torsemide 20 mg, give 20 mg by mouth in the afternoon, scheduled time 2:00 P.M. -Torsemide 20 mg, give 20 mg by mouth two times a day, scheduled for 7:30 A.M., and 4:30 P.M. Review of the MAR dated 7/11/24, indicated that Torsemide 20 mg was administered at 6:00 A.M., 7:30 A.M., 2:00 P.M., and 4:30 P.M. (4 doses total for the day). During an interview on 7/12/24 at 9:28 A.M., the Director of Nursing (DON) said the Physician's orders were inaccurate and that the order for Torsemide 20 mg once a day should have been discontinued when the order for twice a day was entered into the electronic medical record (EMR). The DON said the correct order was Torsemide 20 mg twice a day. The DON further said that the order for Torsemide twice a day had been entered into the EMR twice, with different times for administration which resulted in the Resident getting two extra doses. The DON said the process for transcribing orders is that one Nurse enters the orders and the second Nurse checks that the order is entered correctly but in this situation the checks and balances failed, and the Resident received two extra doses of Torsemide medication.

Based on observation, interview, policy and record review, the facility failed to ensure that the accuracy and safety of administered routine medications and pharmaceutical services were provided to meet the needs of each facility resident for one Resident (#30) out of a total sample of 18 residents, and one medication cart (Unit A-side one) out of four medication carts observed. Specifically, the facility staff failed to ensure that expired Insulin (a hormone used to control high blood sugar) medications for Resident #30 was removed from the Unit A- side one medication cart, so that they could not be administered to the Resident thus increasing his/her risk for high blood sugar levels (hyperglycemia) due to the decreased effectiveness of the expired medication. Findings include: Review of the facility policy titled, Storage of Medications, dated ,d+[DATE] indicated the following: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Review of the facility policy titled Administering Medications, dated ,d+[DATE] indicated the following: -The expiration/beyond use date on the medication label must be checked prior to administering. -When opening a multidose container, the date open [sic] shall be recorded on the container. Resident #30 was admitted to the facility in [DATE], with diagnoses including Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated blood glucose [sugar] levels in the blood). Review of the [DATE] Physician's orders indicated the following: -Humalog Kwikpen (a prefilled device containing fast acting insulin). Inject as per sliding scale: >if blood sugar ,d+[DATE] mg/dL (milligrams per deciliter): give one unit >,d+[DATE] mg/dL: give two units >,d+[DATE] mg/dL: give three units >,d+[DATE] mg/dL: give six units >above 400 mg/dL: call MD, subcutaneously (under the skin), with meals -Lantus Insulin (long-acting insulin)- inject 28 units subcutaneously in the evening. Review of the Medication Administration Record (MAR), dated [DATE], indicated the following medication administration for Resident #30: >Humalog Kwikpen Insulin: -[DATE]: three units given at 8:00 A.M., 12:00 P.M., and 5:00 P.M. -[DATE]: two units given at 12:00 P.M., 5:00 P.M. -[DATE]: three units given at 12:00 P.M. -[DATE]: two units given at 8:00 A.M., three units and 12:00 P.M. and 5:00 P.M. -,d+[DATE] 24: two units given at 8:00 A.M., 12:00 P.M., and 5:00 P.M. -[DATE]: two units at 12:00 P.M. >Lantus Insulin 28 units was administered on [DATE] and [DATE] at 8:00 P.M. On [DATE] at 3:15 P.M., during a medication cart inspection on Unit A-side one, the surveyor observed the following Insulin medication for Resident #30: -Humalog Insulin Kwik Pen - labeled with date opened [DATE], date vial expired [DATE]. -Lantus Insulin vial - labeled with date opened [DATE], date expired [DATE]. During an interview on [DATE] at 3:15 P.M., Nurse #2 said the Insulin medications were expired and should not be used. Nurse #2 said there was no other Insulin in the medication cart for Resident #30 and that the medications had most likely been used after the expiration date. During an interview on [DATE] at 3:41 P.M., the Director of Nursing (DON) said Resident #30's Humalog Insulin Kwik Pen and Lantus Insulin vial are expired, should not have been used, and should have been discarded.

Based on interview, record and policy review, the facility failed to ensure that the Physician documented the rationale for disagreeing with the Consultant Pharmacist recommendation from the Monthly Medication Review for one Resident (#34) out of a total sample of 18 residents. Specifically, for Resident #34, the Physician failed to document why he/she disagreed with the Consultant Pharmacist medication recommendation to change the Vitamin D3 (D3 - fat-soluble vitamin that helps the body to absorb calcium and phosphorus) medication to a monthly dose from a daily/weekly dose. Findings include: Review of the facility policy titled Timely Response to Pharmacist Comment, undated, indicated the following: -Physicians shall respond timely to the Pharmacist comment directed to Physicians on the Pharmacist/Physician Progress Note, sign, and date. Review of the facility policy titled Essential Guidelines for Licensed Independent Practitioners, dated 9/23, indicated the following: -Pharmacy recommendations require a written response within the medical record. Resident #34 was admitted to the facility in February 2021, with a diagnosis of Type 2 Diabetes (long-term condition where the pancreas is unable to produce enough insulin to regulate blood glucose [sugar] levels resulting in higher than normal blood sugar levels). Review of the May 2024 Physician's orders indicated the following: -Vitamin D (D3) Oral Capsule 1.25 milligram (mg) 50,000 International Unit (IU). -Give 1 capsule by mouth every 1 month .with a start date of 4/30/24 and end date of 5/7/24. Review of the May 2024 Medication Administration Record (MAR) indicated the following: -5/1/24 - 5/2/24: the Resident was administered Vitamin D3 once each day. -5/3/24 - 5/5/24: the Resident was administered Vitamin D3 twice each day. -5/6/24 - 5/7/24: the Resident was administered Vitamin D3 once each day. Review of the Monthly Medication Review conducted by the Consultant Pharmacist, dated 6/6/24, indicated the following recommendation: -Please review the following med error or clarify dose. -Vitamin D (D3) 50,000 IU should be a monthly dose . Further review of the 6/6/24 Monthly Medication Review indicated no documentation that the Physician had reviewed and signed the recommendation from the Consultant Pharmacist, agreed to the recommendation, or disagreed with the recommendation. Review of the June 2024 Physician's orders indicated the following: -Vitamin D3 Oral Capsule 1.25 mg (50,000 IU). -Give 1 capsule by mouth one time a day every 1 month .with a start date of 5/31/24 and end date of 6/6/24. Further Review of the June 2024 Physician's orders indicated that on 6/18/24, a new order was put into place for the following: -Vitamin D3 Oral Capsule 1.25 mg (50,000 IU) . -Give 1 capsule by mouth one time a day every 7 days, .with a start date of 6/13/24 Review of the June 2024 MAR indicated the following: -6/2/24 - 6/4/24: the Resident was administered Vitamin D3 once each day. -6/12/24 and 6/26/24: the Resident was administered Vitamin D3 once each day. During an interview on 7/16/24 at 9:33 A.M., the Director of Nursing (DON) said the Physician had reviewed the June 2024 Monthly Medication Review. The DON said she and the Physician had reviewed the Consultant Pharmacist's recommendation and the Physician disagreed with the recommendation (that the Vitamin B3 should be a monthly dose) and changed the order to a weekly dose of Vitamin D3. The DON said a rationale should have been documented somewhere in the Resident's medical record as to why the Physician disagreed with the Pharmacist's recommendation, and a rationale was not documented by the Physician.

Based on record review and interview, the facility failed to ensure that routine dental services were provided for one Resident (#18) out of a total sample of 18 residents. Specifically, the facility staff failed to assist Resident #18 in arranging for and obtaining routine dental services when the Resident consented to receive dental services while residing in the facility. Findings include: Review of the facility policy titled Dental Services, reviewed 9/2022, indicated the following: -The facility must provide or obtain from an outside resource, routine, and emergency dental services to meet the needs of each resident. -The facility is responsible for assisting residents in obtaining needed dental services, including routine and emergency dental services. Resident #18 was admitted to the facility in May 2023, with diagnoses including obstructive and reflux uropathy (occurs when urine cannot flow normally through the urinary tract due to obstructed urinary flow which can cause back-up of urine into the kidneys). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -Resident had obvious or likely cavity or broken natural teeth. -Resident is at risk for mouth discomfort. Review of the form titled Request For Services, signed by Resident #18 on 5/5/23, indicated the Resident wished to receive dental services through the company contracted with the facility to provide onsite dental services. Further review of the Resident's medical record indicated no documented evidence that the Resident had been seen by a Dentist since his/her admission in May 2023 (14 months). During an interview on 7/15/24 at 2:46 P.M., Unit Manager (UM) #1 said that the Dentist came to the facility in January 2024 but the Resident had not been seen by the Dentist at that time. During an interview on 7/15/24 at 3:04 P.M., the Director of Nursing (DON) provided an email correspondence with the contracted Dentist Provider that indicated the Resident was not currently enrolled in their dental services. During a follow-up interview on 7/15/24 at 3:15 P.M., the DON said that she could not speak to the process prior to her becoming the DON but she would expect that if a Resident signed off that they would like to receive dental services, the Resident would then be placed on the list to be seen. The DON said that Resident #18 was not on the list to be seen for dental services and should be as he/she had been identified through an audit/email correspondence in October 2023 with the contracted company, as someone who requested to be seen by a Dentist and as someone who had not yet received services.

Based on record review and interview, the facility failed to ensure that complete and accurate information was maintained for one Resident (#18) out of a total sample of 18 residents. Specifically, the facility staff failed to document urinary output each shift per the Physician orders for a Resident with urinary retention (condition that occurs when a person is unable to empty their bladder completely or partially of urine) placing him/her at an increased risk of further retention, urinary tract infections, and compromised bladder and kidney function. Findings include: Resident #18 was admitted to the facility in May 2023, with diagnoses including obstructive and reflux uropathy (occurs when urine cannot flow normally through the urinary tract due to obstructed urinary flow which can cause back-up of urine into the kidneys). Review of the facility policy titled Intake and Output, reviewed 9/2023 indicated the following: -All residents/patients with a Foley (urinary) catheter will have output recorded for the duration of their therapy. On 7/11/24 at 11:49 A.M., the surveyor observed Resident #18 lying in bed with a urinary catheter located on the right side of the bed. Review of the Catheter Care Plan initiated on 6/21/24, indicated the following: -Resident has a catheter related to inability to void and urinary retention, failed voiding trials 6/28/24 replaced catheter[sic] -Monitor and document intake and output as per facility policy Review of July 2024 Physician orders indicated the following order: -Monitor urine output each shift (start date 7/3/24) Review of the July 2024 Treatment Administration Record (TAR) indicated no evidence that the urinary output had been documented 6 out of 24 times on the following shifts: -Day Shifts: 7/7/24, 7/9/24 -7/11/24, and 7/14/24 -Evening Shift: 7/10/24. During an interview on 7/16/24 at 9:50 A.M., Nurse #3 said that Resident #18 has a urinary catheter in place and that the staff are documenting the Resident's urinary output. Nurse #3 said the urinary output is being monitored once a shift due to his/her recent episode of urinary retention. Nurse #3 said that the urinary output should be documented on the TAR and if it is not documented there it might be in a Nurses note. Nurse #3 said that if it is not documented in either the TAR or Nurses notes, then it is assumed that the urinary monitoring had not been completed as ordered. During an interview on 7/16/24 at 11:14 A.M., Unit Manager (UM) #1 reviewed the July 2024 TAR and the July 2024 Nurses notes. UM #1 said that she did not find any documented evidence that the urinary output had been monitored on 7/7/24, 7/9/24 - 7/11/24 and 7/14/24 day shifts, and on the evening shift on 7/10/24, as the TAR boxes were blank and there were no Nurses notes indicating the urinary output had been monitored per the Physician orders.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2) who had moderate cognitive impairment, but could make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when at 5:00 A.M. on 09/02/23 and witnessed by Nurse #1, Certified Nurse Aide (CNA) #1 directed profanities at Resident #2 and unplugged his/her television (TV) after threatening to do so, if he/she would not be quiet. Findings include: Review of the Facility's Code of Conduct, dated as revised 03/28/23, indicated that staff must ensure that its residents are treated with dignity and respect, and that residents are never subject, at any time, to any verbal, mental or physical abuse, corporal punishment, or involuntary seclusion. Resident #2 was admitted to the Facility in April 2023 with diagnoses including muscle weakness and partial intestinal obstruction. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 07/19/23, indicated he/she was moderately cognitively impaired with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact). Review of the Facility's Investigation Summary, undated, indicated that at 5:00 A.M. on 09/02/23, CNA #1 and Nurse #1 responded to Resident #1 having rolled out of bed. The Summary indicated that Nurse #1 said that CNA #1 loudly told Resident #1, you are going to break my back, in response to him/her rolling out of bed. The Summary indicated that Nurse #1 alleged that CNA#1 swore and spoke in a very loud voice when Resident #2 intervened in the situation with Resident #1. The Summary indicated that Nurse #1 heard CNA #1 tell Resident #2 to mind his (expletive) business. The Report also indicated that Nurse #1 said that CNA #1 threatened to turn off Resident #2's television and then witnessed CNA #1 unplug the TV because he (CNA #1) had been telling Resident #2 to keep quiet. The Summary also indicated Resident #1 was unable to participate in an interview due to severe cognitive deficits. Review of Resident #2's statement, written by the Administrator, undated, indicated that when he/she tried to tell the nurse that Resident #1 needed to go to the bathroom, CNA #1 used the F-word. The statement indicated Resident #2 was watching a movie when CNA #1 unplugged his/her TV because CNA #1 had been trying to get him/her to be quiet. During an interview on 09/27/23 at 10:30 A.M., Resident #2 said he recalled an altercation that occurred a few weeks ago with CNA #1 (identified him by name). Resident #2 said that his/her roommate at the time (Resident #1) was on the floor and CNA #1 had come to help him/her up. Resident #2 said that Resident #1 had been on the floor a few times that night. Resident #2 said he/she had tried to watch a movie on his/her TV, but CNA #1 and Resident #1 were swearing back and forth. Resident #2 said that Nurse #1 was present during the altercation when he/she (Resident #2) interjected and told them that maybe Resident #1 was getting out of bed because he/she needed to use the bathroom. Resident #2 said that CNA #1 responded by telling him/her, mind your own fucking business. Resident #2 said that CNA #1 threatened to unplug his/her TV while he/she was watching a movie and then proceeded to unplug the TV. During an interview on 09/28/23 at 3:39 P.M., Nurse #1 said she had worked from 11:00 P.M. to 7:00 A.M. on the morning of the altercation between CNA #1 and Resident #2, but could not recall the date. Nurse #1 said she was getting the medication cart ready at 4:00 A.M. when CNA #1 called for her help because Resident #1 had rolled out of bed onto the floor mat, for the third time that night. Nurse #1 said CNA #1 stood in the doorway to the room and said, Resident #1 is on the fucking floor again. Nurse #1 said the curtain was drawn between Resident #1 and Resident #2, so she peeked around the curtain and asked if Resident #2 was okay and observed he/she was watching a movie. Nurse #1 said that Resident #2 suggested that maybe Resident #1 was getting out of bed because he/she needed to use the bathroom and CNA #1 responded by telling Resident #2 to mind his own fucking business. Nurse #2 said that Resident #2 responded to CNA #1 by yelling, Don't talk to me like that! Nurse #1 said that CNA #1 threatened to turn off Resident #2's TV if he/she would not be quiet. Nurse #1 said that Resident #2 told CNA #1 to stop using F-words, and as Resident #2 continued talking, CNA #1 unplugged the TV from the wall. Nurse #1 said that CNA #1 stormed out of the room and banged the door shut, while she stayed behind and calmed Resident #2. Nurse #1 said CNA #1 was sent home after the incident. During an interview on 10/03/23 at 11:05 A.M., Certified Nurse Aide (CNA) #1 said he discovered Resident #1 was on the floor mat next to his/her bed, on 09/02/23 at around 5:30 A.M., and asked Nurse #1 for help. CNA #1 said Nurse #1 stuck her head around the curtain and got Resident #2 involved when she asked how he/she was doing. CNA #1 said he was annoyed at Resident #2 for interjecting but denied swearing at him/her. CNA #1 said he unplugged Resident #2's TV without him/her knowing. During an interview on 09/27/23 at 2:08 P.M., the Administrator said that Resident #2 told her that he/she liked CNA #1, but he/she did not like it when he swore. The Administrator said that CNA #1 admitted to her that he may have possibly sworn at Resident #2 and admitted to unplugging Resident #2's TV. On 09/27/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey with an alleged date of compliance of 09/05/23. The Plan of Correction provided is as follows: A) On 09/02/23, Resident #1 and Resident #2 were immediately assessed by Nursing for any injuries. B) On 09/2/23, CNA #1 was suspended during the Facility's internal investigation and was terminated on 09/14/23. C) On 09/03/23, daily behavioral health monitoring visits for Residents #1 and #2 were initiated by the Administrator and social services. D) On 09/03/23, other residents on CNA #1's assignment were interviewed by the Unit Manager, to identify any additional issues. E) On 09/03/23, Resident #2's Care Plan was updated by the MDS Nurse to monitor for psychosocial harm. F) On 09/03/23, Abuse Prohibition and Resident Rights education was initiated for all staff, by the Administrator. Education included a post test. Staff were not allowed to work until education was completed. G) On 09/03/23, select nurses were assigned to perform random observations of staff and resident interactions, for 14 days. H) On 09/04/23 and 09/05/23, an ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting was held to develop and implement a plan of correction. I) On 09/05/23, Resident #1 and Resident #2 were assessed by Behavioral Health Services. J) Residents will continue to be interviewed by Unit Managers, to identify any concerns, as part of the Guardian Angel Program and the Ambassador Program. Results will be shared with the Administrator at morning meetings. K) The QAPI committee will review the effectiveness of the plan of correction weekly for four weeks, then monthly. The Administrator is responsible for bringing the results to QAPI. L) The Administrator is responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required extensive assistance of two staff members and the use of a mechanical lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and that assistive equipment (lift pad) was positioned correctly, in an effort to maintain Resident #1's safety during a mechanical lift transfer to prevent incidents/accidents resulting in an injury. On 05/16/23, Certified Nurse Aide (CNA) #1, without another staff member present to assist her, attempted to transfer Resident #1 with a mechanical lift. Per the facility's investigation they also determined that CNA #1 had not positioned the mechanical lift pad properly under Resident #1, so when she (CNA #1) raised Resident #1 up in the lift, his/her body tipped forward, his/her head hit the lift, and he/she toppled out of the lift pad onto the floor. Resident #1 was transferred to the Hospital Emergency Department (ED), where he/she was diagnosed with a right frontal scalp laceration, an acute nondisplaced fracture of the acetabulum (hip socket), an acute nondisplaced type II odontoid (C2, cervical neck) fracture, and an acute nondisplaced fracture of the anterior nasal bones and the anterior nasal septum (nose). Findings include: Review of the Facility Policy titled 2-Mechanical lift, dated as reviewed 09/2022, indicated at least two nursing staff members were needed to safely move a resident with a mechanical lift. The Policy also indicated to lift the resident from the surface to check the stability of the attachments, fit of the lift pad and weight distribution. Review of the Manufacturer Guidelines for the mechanical lift pads, indicated an illustration of the divided leg pad when in use. The Guidelines show the leg straps crossed and flat against the resident's inner thighs when the pad is properly placed and connected to the mechanical lift. Resident #1 was admitted to the Facility in June 2018, diagnoses included dementia with mood disturbance, anxiety disorder and abnormal posture. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 03/29/22, indicated his/her cognitive skills were severely impaired. The Assessment indicated he/she was dependent for his/her care needs and required the assistance of two staff members for transfers. Review of Resident #1's Care Card (Certified Nurse Aide, reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), in effect at the time of the fall, indicated he/she was non-ambulatory and required the assistance of two staff members for transfers with a mechanical lift. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/22/23, indicated that on 05/16/23 at 5:00 A.M., Resident #1 fell to the floor while being transferred out of bed with a mechanical lift, by Certified Nurse Aide #1. The Report indicated CNA #1 transferred Resident #1 with a mechanical lift, by herself, and didn't cross the leg straps (to secure his/her legs in the mechanical lift pad) when she positioned Resident #1 in the lift. The Report indicated that when CNA #1, raised Resident #1 up in the lift, and pulled the lift from away from the bed (while he/she was suspended three feet above the floor), Resident #1 tipped forward out of the sling, and struck his/her head on the lift and landed on the floor. The Report indicated that CNA #1 had not asked a second staff member for assistance, despite there being a nurse available at the nursing station, and two additional CNAs available upon request, at the time of the fall. The Report indicated that the Facility's investigation concluded that CNA #1 had not followed safe practices when utilizing a mechanical lift for transfers and that staff were available to assist CNA #1, but she did not seek assistance. Review of CNA #1's Witness Statement, dated 05/16/23, indicated that she transferred Resident #1 alone, with the mechanical lift and had not crisscrossed the straps, on the lower half of the lift pad. Resident #1 fell from the mechanical lift, onto the floor during a mechanical lift transfer. During an interview on 06/07/23 at 3:27 P.M., Certified Nurse Aide (CNA) #1 said she worked the 11:00 P.M. to 7:00 A.M. shift on 05/16/23, and Resident #1 was on her assignment. CNA #1 said that around 5:00 A.M., she transferred Resident #1 out of bed, alone, using a mechanical lift, when he/she tipped forward out of the lift pad, hit his/her head on the lift, and landed on the floor. CNA #1 said she had not crossed the straps of the divided leg style lift pad when she fastened them to the lift, prior to initiating the transfer. CNA #1 said she knew that mechanical lift transfers required the assistance of two staff members, per Facility policy, and that she should have asked for help. CNA #1 further said she had not asked anyone else for assistance because she thought they were busy doing their rounds. Review of the Assistant Director of Nurses (ADON's) Written Summary of her interview with CNA #1, dated 05/16/23, indicated that CNA #1 told her she was working alone and did not have the split leg style lift pad donned (put on or placed) properly when she transferred Resident #1. The Summary indicated that CNA #1 said she knew that she was supposed to have a second staff member to assist with the mechanical lift transfer but there was no one around. The Summary also indicated CNA #1 said she had not crossed the legs straps when donning the lift pad. Review of Nurse #1's Written Witness Statement, dated 05/16/23, indicated that when she responded to Resident #1's fall, she found him/her on the floor and noticed the lift was still positioned about three feet above the floor, the mechanical lift pad was still hanging from the lift, and it was not crisscrossed. The Statement also indicated Nurse #1 was available at the desk for approximately 30 minutes prior to the fall. The Statement indicated Nurse #1 assessed Resident #1 immediately after the fall and sent him/her to the Hospital ED for evaluation. During an interview on 06/07/23 at 2:50 P.M., the Assistant Director of Nurses (ADON) said she arrived at the Facility around 6:30 A.M. on 05/16/23 and was notified by Nurse #1 that Resident #1 had been sent to the ED after a fall during a mechanical lift transfer with CNA #1. The ADON said she immediately interviewed CNA #1, and CNA #1 told her that she had performed the transfer alone and had not crisscrossed the leg straps of the lift pad. Review of Resident #1's Hospital Discharge Summary, dated 05/16/23, indicated that he/she was transferred to the Hospital ED after a fall from a mechanical lift at the Facility. The Summary indicated Resident #1 was diagnosed with a right frontal scalp laceration, an acute nondisplaced fracture of the acetabulum, an acute nondisplaced type II odontoid fracture, an acute nondisplaced fracture of the anterior nasal bones and the anterior nasal septum (nose). Resident #1 was discharged back to the facility on [DATE] with an Aspen cervical collar (rigid collar for neck stabilization) and a five-staple repair of the right forehead laceration. During an interview on 05/07/23 at 3:19 P.M., the Director of Nurses (DON) said that per Facility policy, two staff members were required to be present when performing a mechanical lift transfer, for safety. The DON said Facility policy also indicated the resident should be partially raised up while in the lift pad, to check placement and weight distribution before completing the mechanical lift transfer. The DON further said that Resident #1's Care Card, in place at the time of the fall, also indicated the requirement for two staff members to be present for the mechanical lift transfers. The DON said that the Facility investigation concluded that CNA #1 had not followed Facility policy when she performed the mechanical lift transfer without assistance from a second staff member, and when she had not positioned the lift pad correctly and had not checked the lift pad placement prior to performing the transfer (both required by Facility policy), resulting in Resident #1's fall from the lift and subsequent injury. On 06/07/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) On 05/16/23, Resident #1 was immediately assessed by Nursing for any injuries sustained during the fall and sent to the Hospital ED for evaluation and treatment. B) On 05/16/23, CNA #1 was placed on administrative leave pending the investigation. Her contract was terminated with the facility and the agency was notified of the incident. C) On 05/16/23 an Emergency Quality Assurance Performance Improvement (QAPI) meeting was held to determine a plan of correction. Additional meetings were held on 05/22/23 and 05/31/23. D) On 05/16/23 through 05/19/23, the DON and Unit Managers completed mechanical lift competencies with return demonstration, including proper application of divided leg lift pads, for all nurses, CNAs and rehabilitation therapists. Staff will not return to work until they have completed the mechanical lift competency. E) Random observations of mechanical lift transfers were initiated on 05/17/23 and completed each shift for 14 days by the DON and/or designee. F) Random mechanical lift transfer quizzes were initiated on 05/17/23 and completed each shift for 14 days by the DON and/or designee. G) On 05/19/23, the DON and Clinical Nurse Consultant completed a facility wide audit of all residents requiring a mechanical lift transfer and updated the Care Plan and Kardex for lift pad size and type as indicated. H) On 05/19/23, the DON compiled a binder containing a list of residents requiring mechanical lift transfers including name, room number, mechanical lift with the assistance of two staff members, lift pad color/type/size. The binder will be kept on the units. I) On 05/19/23, mechanical lift assessments were completed by the Unit Managers or designee, on residents who required mechanical lifts, and were reviewed for accuracy to ensure correct lift pad type/color are noted and correct. J) On 05/19/23, the DON and Unit Managers reached substantial compliance with completing mechanical lift education on the mechanical lift and care plan policy for all nursing and rehabilitation staff. K) The QAPI committee will review the effectiveness of the plan of correction for four weeks, then monthly. L) The Administrator and DON are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that Certified Nurse Aide (CNA) #1 had the appropriate competency and skill set related to providing safe mechanical lift transfers. On 05/16/23, CNA #1 placed the mechanical lift pad under Resident #1 (per facility investigation the pad was not positioned properly) and when CNA #1 raised Resident #1 up in the lift, without the assist of a second staff member, his/her body tipped forward, his/her head hit the lift, and he/she toppled out of the lift onto the floor. Findings include: Review of the Facility Policy titled 2-Mechanical lift, dated as reviewed 09/2022, indicated at least two nursing staff members were needed to safely move a resident with a mechanical lift. The Policy indicated staff should ensure the lift pad is securely attached to the clips and it is properly balanced, the resident's head, neck and back are properly supported, and before the resident is lifted, double check the security of the lift pad attachment. The Policy also indicated that staff should lift the resident from the surface to check the stability of the attachments, fit of the lift pad and weight distribution. Review of the Manufacturer Guidelines for the mechanical lift pads, indicated an illustration of the divided leg pad when in use. The Guidelines show the leg straps crossed, and flat against the resident's inner thighs, when the pad is properly placed and connected to the mechanical lift. Resident #1 was admitted to the Facility in June 2018, diagnoses included dementia with mood disturbance, anxiety disorder and abnormal posture. Review of Resident #1's Care Card (Certified Nurse Aide, reference guide, identifies residents specific care needs, including number of staff required to provide assistance during tasks), in effect at the time of the fall, indicated he/she was non-ambulatory and required the assistance of two staff members for transfers with a mechanical lift. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 05/22/23, indicated that on 05/16/23 at 5:00 A.M., Resident #1 fell to the floor while being transferred out of bed with a mechanical lift, by CNA #1. The Report indicated CNA #1 transferred Resident #1 with a mechanical lift, by herself, and didn't cross the leg straps (to secure his/her legs in the mechanical lift pad) when she positioned Resident #1 in the lift. The Report indicated that when CNA #1 raised Resident #1 up in the lift, and pulled the lift from away from the bed (while he/she was suspended three feet above the floor), Resident #1 tipped forward out of the sling and struck his/her head on the lift, and landed on the floor. The Report indicated that the Facility's investigation concluded that CNA #1 had not followed safe practices when utilizing a mechanical lift for transfers and that staff were available to assist CNA #1 but she did not seek assistance. Review of CNA #1's Witness Statement, dated 05/16/23, indicated that CNA #1 transferred Resident #1 alone, with the mechanical lift and did not crisscross the straps, on the lower half of the lift pad. Resident #1 fell from the mechanical lift, onto the floor during a mechanical lift transfer. Review of the Facility's Agency Binder Checklist, that included the Mechanical Lift Policy, indicated CNA #1 signed on 05/10/23, acknowledging review of the policies in the binder. During an interview on 06/07/23 at 3:27 P.M., Certified Nurse Aide (CNA) #1 said she worked the 11:00 P.M. to 7:00 A.M. shift on 05/16/23, and Resident #1 was on her assignment. CNA #1 said that around 5:00 A.M., she transferred Resident #1 out of bed, alone, using a mechanical lift, when he/she tipped forward out of the lift pad, hit his/her head on the lift, and landed on the floor. CNA #1 said she did not cross the straps of the divided leg style lift pad when she fastened them to the lift, prior to initiating the transfer. CNA #1 further said she had started working at the Facility a few nights before the incident, on 05/10/23, as a traveling CNA and said she had not received orientation on the use of the mechanical lift. CNA #1 said she did not recall signing off on the Mechanical Lift policy. During an interview on 05/07/23 at 3:19 P.M., the Director of Nurses (DON) said that although CNA #1 had signed off on the Mechanical Lift policy, said she had no documentation to support that CNA #1 had demonstrated competency to safely operate a mechanical lift, prior to providing care to residents at the Facility. The DON said it was the Facility's expectation that the contracted staffing agencies maintain current competencies on the staff they refer to the Facility. The DON said that when she requested a copy of CNA #1's mechanical lift competency, after the incident on 05/16/23, from the Agency that employed and referred CNA #1, they were unable to provide any documented evidence that CNA #1 had been provided education or testing of her competency for safely using a mechanical lift for resident transfers. On 06/07/23, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) On 05/16/23, Resident #1 was immediately assessed by Nursing for any injuries sustained during the fall and sent to the Hospital ED for evaluation and treatment. B) On 05/16/23, CNA #1 was placed on administrative leave pending the investigation. Her contract was terminated with the facility and the agency was notified of the incident. C) On 05/16/23 an Emergency Quality Assurance Performance Improvement (QAPI) meeting was held to determine a plan of correction. Additional meetings were held on 05/22/23 and 05/31/23. D) On 05/16/23 through 05/19/23, the DON and Unit Managers completed mechanical lift competencies with return demonstration, including proper application of divided leg lift pads, for all nurses, CNAs and rehabilitation therapists (including agency staff). Staff will not return to work until they have completed the mechanical lift competency. All new hires and new agency staff will complete a mechanical lift competency with return demonstration, upon orientation. E) Random observation of mechanical lift transfers were initiated on 05/17/23 and completed each shift for 14 days by the DON and/or designee. F) Random mechanical lift transfer quizzes were initiated on 05/17/23 and completed each shift for 14 days by the DON and/or designee. G) On 05/19/23 the DON compiled a binder containing a list of residents requiring mechanical lift transfers including name, room number, mechanical lift with assistance from two staff members, lift pad color/type/size. Binder kept on the units. H) On 05/19/23, mechanical lift assessments were completed on residents who required mechanical lifts to review for accuracy and ensure the correct sling type/color are noted and correct. I) On 05/19/23, the DON and Unit Managers reached substantial compliance with completing mechanical lift education on the mechanical lift and care plan policy for all nursing and rehabilitation staff. J) Mechanical Lift Pad guides were posted at the nursing stations on 05/19/23, by the Unit Managers, including an illustration of the proper application of the leg straps on the divided leg mechanical lift pads. K) The QAPI committee will review the effectiveness of the plan of correction for 4 weeks, then monthly. L) The Administrator and DON are responsible for overall compliance.

Based on record review and interview, the facility and its staff failed to provide a designated person that met regulatory requirements, to serve as the Director of Food and Nutrition Services when a full-time Dietitian was not employed. Findings include: During an interview on 3/3/23 at 1:01 P.M., the Food Service Director (FSD) said that she had worked as the FSD at the facility for about one week. The FSD said she was not a Certified Dietary Manager (CDM), or Certified Food Service Manager (CFSM), did not have an associate degree or higher in food service management, and did not have two years' experience in the position of Director of Food and Nutrition Services in a nursing facility setting. During an interview on 3/3/23 at 1:44 P.M., the Administrator said the Dietitian worked part-time at the facility. She said that the FSD was not a CDM or CFSM and did not have a qualifying degree or experience as required.

Based on interview and record review, the facility failed to ensure its staff obtained labs timely for a possible urinary tract infection (UTI), resulting in a delay of treatment of an active infection for one Resident (#43), out of a sample of 20 residents. Findings Include: Review of the facility policy titled Urinary Tract Infection (UTI) Protocol, reviewed 9/22, indicated the following: -Start resident on UTI Protocol in PCC (the electronic medical record-EMR that the facility utilized) if showing signs of potential UTI such as (elevated temperature, dysuria (pain/difficulty when urinating), frequency, etc). -Nurse to assess resident daily - monitor for improvement or worsening of symptoms, can assist in identifying when or if a urine sample should be obtained for testing. Resident #43 was admitted to the facility in April 2021 with a diagnosis of Urinary Retention. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview on 3/1/23 at 9:19 A.M., Resident #43 said he/she thought they had a UTI and had recently had a urine sample obtained by staff so that labs for a UTI could be done but he/she had not heard about the results of the lab yet. Review of the Physician's Office Note dated 2/25/23 indicated the Resident was seen by the Physician due to a history of UTIs and was complaining of dysuria. Further review of the Physician's note indicated the Physician requested a urinalysis (urine test to check for bacteria or other germs in a urine sample) for leukocytes esterase test (increase in white blood cells in the urine that may suggest a UTI). Review of the Lab slip dated 2/25/23, indicated a lab order for a Urine Culture (a lab test for specific bacteria or other germs in a urine sample). Further review of the chart indicated no lab results that would correspond with the 2/25/23 lab order. Review of the nursing progress note dated 3/1/23, indicated the Resident's urine was cloudy and bloody and the facility was awaiting test results. Review of the nursing progress note dated 3/3/23, indicated the Resident had urine collected and sent to the lab for a urine culture. The urine sample was collected six days after the Physician had ordered the labs. Review of the Resident's Lab Report dated 3/5/23 (results from the urine culture) indicated the Resident was positive for a UTI. Review of the March 2023 Physician's Orders indicated on 3/6/23, the Resident was started on Bactrim (an antibiotic used to treat UTIs). Antibiotic treatment for the UTI began nine days after the Physician initially saw the Resident and ordered labs. During an interview on 3/6/23 at 8:26 A.M., the Infection Preventionist (IP) said the Physician requested a urinalysis on 2/25/23 and the urine was obtained and was set to be picked up on 2/28/23 when the lab staff routinely came into the facility. The IP said the Resident's name was never put on the lab draw sheet, therefore the lab staff were unaware of the urine sample and did not take the sample to the lab. During a subsequent interview on 3/6/23 at 8:53 A.M., the IP said a delay in having a urine analysis or urine culture completed timely put the Resident at risk for a delay in treatment and/or exacerbation in symptoms. During an interview on 3/6/23 at 9:23 A.M., the Director of Nursing (DON) said it was not realized until 3/3/23 that the lab staff did not pick up the urine sample, causing a delay in treatment.

Based on observations and interviews, the facility failed to ensure its staff afforded dignity and privacy for one Resident (#34), out of a sample of 20 residents. Specifically, posted personal information related to the Resident's care and condition was viewable from his/her bedroom doorway. Findings include: Resident #34 was admitted to the facility in April 2022 with a colostomy (an artificial opening in the large intestine/colon to the outside of the body (stoma) created if one could not pass stool through the anus due to illness, injury, or a problem with the digestive system). During an observation and interview on 3/1/23 at 9:40 A.M., the surveyor stood in the hallway outside the Resident's room and observed a sign on the wall that indicated: When changing colostomy bag (a pouch that collects stool from the stoma), please do not throw away the clip to the bag. During an interview at this time, the Resident said he/she did not like the sign there and was afraid people would laugh at him/her. During an observation and interview on 3/1/23 at 4:05 P.M., the surveyor observed the sign was still visible from the hallway. The Resident was seated in his/her wheelchair in the hallway with his/her colostomy bag containing evidence of stool, visible from beneath the Resident's shirt. At this time, Unit Manager (UM) #1 was observed approaching the Resident attempting to cover the colostomy bag with his/her shirt and told the Resident that she had been meaning to find a cover for the bag. The surveyor then brought UM #1 to the Resident's room to observe the sign. UM#1 said that the sign was a violation of the Resident's privacy and should not have been there.

Based on observation, interview and policy/procedure review the facility and its staff failed to maintain a safe, clean, comfortable, and homelike environment for one Resident (#74) out of 20 total residents sampled. Specifically, the facility staff failed to: 1. clean soiled walls, curtains and floors of the resident's room, 2. address infestation of fruit flies, and 3. provide repairs where needed. Findings include: Review of the Professional Health Care (PHS) (company the facility contracts with for housekeeping services) Cleaning Procedure guide indicated in part the following steps (for daily cleaning of resident rooms): -Dry mop the floor in the entire room and bathroom, under beds, behind doors, closets, and corners -Clean sink, mirror, and shelf (in the bathroom) -Toilet both inside and out -Wet mop the floor in the entire room and bathroom, under beds, behind doors, closets and corners Review of the February PHS Light Housekeeper cleaning checklist, provided by the housekeeping staff indicated no documented evidence that Resident #74's room had been cleaned during the month of February. On 3/1/23 at 11:08 A.M., the surveyor observed the following in Resident #74's room, while he/she laid sleeping in bed: -Fruit flies on floor, directly under the Resident's bed -The floor to be sticky directly upon entering the room and all throughout, including the bathroom -Dry, yellow stains on the toilet seat -Brown colored debris on the wall and the privacy curtain located directly next to the Resident's bed -Peeling wallpaper near the closet -Top dresser drawer in disrepair During an interview and observation on 3/1/23 at 11:12 A.M., Certified Nursing Assistant (CNA) #1 entered the Resident's room with the surveyor and said that there was food on the floor, the overbed table was sticky, the floors were sticky, there were fruit flies in the room, the bathroom was not clean, the walls had things dripping down them and that the privacy curtain was dirty. During an interview on 3/2/23 at 9:16 A.M., the Director of Nursing (DON) said that the facility recently started using a new company and they are still in transition working through some bumps in the road. She further indicated the room should have been cleaned prior to the surveyor's observation on 3/1/23.

Based on interview and record review the facility failed to ensure its staff completed a Comprehensive Minimum Data Set (MDS) Assessment within the required 14 days of admission to the facility for one Resident (#18), out of a sample of 20 residents. Findings include: Resident #18 was admitted to the facility in January 2023. Review of Resident #18's MDS Assessments indicated that as of 3/2/23, an Admission MDS Assessment had not been completed for Resident #18. During an interview on 3/2/23 at 1:51 P.M., the Director of Nursing (DON) said the Resident's Admission MDS Assessment should have been completed for 1/28/23, it was not realized the Assessment was missed until 2/26/23, and at the time of survey the Assessment had not been completed and submitted yet, as required.

Based on observation, policy review, record review, and interview, the facility failed to ensure staff provided care consistent with professional standards and facility policy, related to replacing and dating oxygen tubing and providing oxygen humidification as ordered by the Physician for one Resident (#86), out of a total sample of 20 residents. Specifically, the facility staff failed to: a) change oxygen tubing as ordered to prevent possible airway infection, and b) monitor and maintain humidification bottles to prevent airway dryness and infection. Findings include: Review of the facility policy titled, Use of Oxygen, dated January 2023, indicated: -Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. -Periodically re-check water level in humidifying jar. -All oxygen administration should adhere to specified infection control policies, including changing nasal cannulas weekly. -All oxygen delivery devices and bottles should be dated and changed every 7 days and PRN (as needed). Resident #86 was admitted to the facility December 2022 with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD-condition blocking airflow in the airways and causing difficulty and/or discomfort in breathing). Review of the Physician's Orders dated 3/2/23, indicated the following orders: -Oxygen via nasal cannula at 1 to 4 liters to maintain oxygen saturation greater than 91%. -Utilize humidified oxygen while connected to room concentrator, every shift, dated initiated 1/29/23. -Change oxygen tubing, water bottle and rinse (oxygen concentrator) filter weekly on Fridays, dated initiated 1/6/23. On 3/1/23 at 11:31 A.M., the surveyor observed Resident #86 lying in bed wearing Oxygen at 3 liters per minute (LPM) via nasal cannula attached to an oxygen concentrator. The oxygen tubing was labeled 2/17/23, and the humidification bottle attachment was empty. On 3/2/23 at 10:00 A.M., the surveyor observed Resident #86 sitting in bed wearing Oxygen at 3 LPM via nasal cannula attached to an oxygen concentrator. The oxygen tubing was labeled 2/17/23, and the humidification bottle was still empty. During an interview on 3/2/23 at 10:00 A.M., Nurse #1 said that she could see that the tubing was labeled 2/17/23, but she was not sure of the facility policy for changing oxygen tubing. She said that the humidification bottle was empty and should have water in it. She said she was not sure how long the humidification bottle had been empty. During an interview on 3/2/23 at 10:44 A.M., the Director of Nursing (DON) said the oxygen tubing should have been changed on 2/24/23, as ordered by the Physician and as indicated on Treatment Administration Record.

Based on observation, record review, and interview, the facility failed to ensure staff maintained medical records that were accurate for three Residents (#86, #18, and #39) out of a sample of 20 residents. Specifically, the facility staff failed: 1. For Resident #86, documented oxygen tubing changes and oxygen humidification maintenance. 2. For Resident #18, recorded meal percentages (the amount of each meal eaten) as requested by the dietitian. 3. For Resident #39, documented catheter (tubing inserted into the bladder that allows urine to be drained) care and urine output every shift. Findings include: 1. Resident #86 was admitted to the facility December 2022 with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD-condition blocking airflow in the airways and causing difficulty and/or discomfort in breathing). Review of the Physician's orders dated March 2, 2023, indicated the following orders: -Oxygen via nasal cannula at 1- 4 liters. Utilize humidified oxygen while connected to room concentrator, every shift, date initiated 1/29/23. -Change oxygen tubing, water bottle and rinse filter 9oxygen concentrator) weekly on Fridays, initiated 1/6/23. Review of the Treatment Administration Record (TAR) dated February 2023, indicated the oxygen tubing had been changed on 2/3/23, 2/10/23, 2/17/23 and 2/24/23. Review of the TAR dated March 2023, indicated the Resident was provided humidified oxygen while connected to the room oxygen concentrator on March 1, 2023, on the day, evening, and night shifts. On 3/1/23 at 11:31 A.M., the surveyor observed Resident #86 lying in bed wearing Oxygen at 3 liters per minute (LPM) via nasal cannula attached to an oxygen concentrator. The oxygen tubing was labeled 2/17/23 and the humidification bottle was empty. On 3/2/23 at 10 A.M., the surveyor observed Resident #86 sitting in bed wearing Oxygen at 3 LPM via nasal cannula attached to an oxygen concentrator. The oxygen tubing was still labeled 2/17/23 and the humidification bottle was empty. During an interview on 3/2/23 at 10:00 A.M., Nurse #1 said she could see that the tubing was labeled 2/17/23, but she was not sure of the facility policy for changing oxygen tubing. She also said that the humidification bottle was empty and should have water in it. She said she was not sure how long the humidification bottle had been empty. During an interview on 3/2/23 at 10:44 A.M., the Director of Nursing (DON) said the oxygen tubing should have been changed on 2/24/23, as was documented on the TAR. The DON further said the oxygen humidification should have been provided as was documented on the TAR, and this was not being done as ordered. She said the documentation on the TAR was not accurate. 42741 2. Resident #18 was admitted to the facility in January 2023 with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and recent weight loss of 37 pounds. Review of Resident #18's Nutrition Care Plan initiated 1/12/23 indicated the following goal: -Resident will maintain adequate nutritional status as evidenced by .consuming 75% of at least three meals daily . Review of the Nutritional assessment dated [DATE] indicated the following recommendation made by the facility's Dietitian: -Monitor PO (Per Orally-by mouth) intake Review of the February 2023 TAR indicated an order to document the percent of meal intake every shift. Further review of the TAR indicated the percentages of meal intake was left blank for 25 out of 84 shifts. During an interview on 3/6/23 at 11:49 A.M., Nurse #3 said meal intake percentages are documented for Resident #18 after each meal and it should be recorded on the TAR. During an interview on 3/6/23 at 12:24 P.M., the Contracted Dietitian Supervisor said meal intakes should be recorded in the medical record every shift for Resident #18 as recommended by the facility Dietitian. She further said lack of documentation regarding meal percentages would not be helpful when the Dietitian went to calculate the number of calories the Resident needed to maintain his/her current weight, as the amount the Resident ate on average is factored into how the Dietitian prescribed the Resident's diet. During an interview on 3/6/23 at 1:33 P.M., the DON said meal percentage intakes should be documented every shift for Resident #18 per the order on the TAR and this was not being done, as required. 3. Resident #39 was admitted to the facility in October 2018 with diagnoses including Urinary Retention, Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms (enlargement of the prostate that can cause obstructive uropathy-difficulty urinating), and had a urinary catheter in place. Review of the Catheter Care Plan .initiated 11/4/18 indicated the following interventions: -Catheter care every shift, initiated 3/3/20 -Empty catheter and record output every shift, initiated 11/4/18 Review of the March 2023 Physician's orders indicated the following orders: -Provide catheter care every shift with a start date of 4/7/21 Review of the February 2023 TARs indicated the following: -For 10 out of 84 shifts, there was no documentation to show catheter care had been provided -For 18 out of 84 shifts, there was no documentation to show total catheter output had been recorded During an interview on 3/2/23 at 10:20 A.M., Nurse #1 said nursing staff should be providing and documenting catheter care every shift as well as documenting any urine output every shift on the TAR for residents who had a catheter. She further said she would be unable to tell if catheter care had been provided during the shifts where there was no documentation on the TAR and would not know how much urine output the Resident had on those shifts where the documentation was blank. She also said if a resident refused catheter care there should be documentation to indicate the resident refused care, the documentation should never just be left blank. During an interview on 3/2/23 at 11:18 A.M., the DON said documentation for catheter care and urine output should be documented on the TAR every shift. She further said on the days where there was no documentation, she was not able to tell if catheter care had been completed and what the Resident's urine output had been.

Based on record review and interview, the facility failed to ensure its staff maintained a record that contained a plan of care including what individualized services Hospice will provide for one Resident (#47), out of a total sample of 20 residents. Findings include: Review of the facility manual titled Care and Treatment, End of Life, Hospice Program, reviewed 9/2022, indicated the following: -Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care . -The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status. -Hospice shall establish and maintain a written plan of care for each Hospice patient . Resident #47 was admitted to the facility in September 2020. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was receiving Hospice services. Record review indicated no documented evidence of a Hospice plan of care or an assessment/evaluation identifying services that the Hospice would provide to Resident #47 based on his/her level of care and needs. During an interview on 3/2/23 at 1:16 P.M., Unit Manager (UM) #1 said that there was no schedule or plan of care in Resident #47's medical record. UM #1 was not able to identify what services Hospice was providing for the Resident.

Based on observation, record review, and interview, the facility failed to ensure its staff provided access to a call light/bell (a button tethered to the wall in a resident's room, indicating in the hallway and at the nurses station that a resident required assistance) for two Resident's (#72 and #141), out of a total sample of 20 residents. Specifically, the call light/bell was not located within easy reach for the residents to summon assistance when needed. Findings include: Review of the facility procedure for Call Bells, reviewed on 12/2022 indicated when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 1) Resident #72 was admitted to the facility in January 2023. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating Resident #72 had moderately impaired cognition. During an interview and observation on 3/1/23 at 10:01 A.M., Resident #72 requested the surveyor turn on the call light because he/she could not find it and he/she wanted coffee with his/her breakfast that had just been delivered. The surveyor located the call light on the floor behind the Resident who was seated in a wheelchair next to his/her bed. The surveyor stepped out of the room and requested assistance. Nurse #3 entered the room and found the call light to be on the floor, out of the Resident's reach. She placed it near the Resident and said that the call light did not have a clip on it which helps it to stay in place. 2) Resident #141 was admitted to the facility in February 2023. On 3/1/23 at 10:40 A.M., the surveyor observed Resident #141's door to be closed. Upon entering the Resident's room, the following was observed: -Resident #141 was in bed -A wheelchair was on one side of the bed and a walker on the other -Call light located on the floor behind the head of the bed During this observation, the surveyor asked the Resident how he/she asked for assistance from the staff when he/she needed help. The Resident began to look around the bed but was unsure where the call light was located. During an interview on 3/1/23 at 10:47 A.M., Certified Nurse Assistant (CNA) #1 said that the Resident was new to the facility, was alert and oriented to him/herself, and could transfer him/herself but required staff supervision to do so. She further said that the call light was in fact on the floor out of the Resident's reach, inhibiting him/her from calling for assistance.

Based on records reviewed and interviews, for one of two nursing units, the COVID (positive) Unit (A-Wing), during the second week of January 2021 (with an average daily census of 50 residents), the Facility failed to ensure sufficient staffing levels were maintained to safely and adequately meet resident's needs per their plans of care. The Facility failed to ensure that there was sufficient staffing levels to provide the level of assistance needed for residents with physical limitations, failed to ensure call lights were responded to timely, and failed to ensure residents received assistance with toileting and personal hygiene care needs when requested and per the plan of care, which resulted in residents becoming, angry, upset and crying after being left in soiled briefs and unable to obtain assistance from staff for extended periods of time. Findings include: The Facility Policy, titled Staffing, dated 10/2017, indicated that they will provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and the facility assessment. Nurses and Certified Nurse Aides (CNA) are available 24 hours a day to provide direct resident care services. The Continuity of Operations Plan Program, dated 3/2020, indicated that the Administrator, Scheduling Coordinator or Member of the Clinical Team are responsible for the daily assessment of staffing status and needs and will implement back up plans as needed. The Minimum Data Sheet, Summary of Residents care needs, dated 1/12/21, for the 55 residents identified as residing on the COVID Unit indicated: - 6 residents required mechanical lift transfers, with a minimum of two staff member assist - 35 residents required 1 to 2 staff members for assist with bathing - 31 residents required 1 to 2 staff members for assist with dressing - 20 residents required 1 to 2 staff members for assist with toilet use - 17 residents were incontinent of bladder and required a toileting program - 10 residents were incontinent of bowel and required a toileting program During an interview on 2/5/21 at 2:46 P.M., Resident #5 said he/she was angry and upset, said his/her call light was left unanswered for greater than 45 minutes, he/she had a bowel movement while on the commode and required staff assistance with personal care needs. Resident #5 said due to being left sitting on the commode, his/her legs became numb and by the time he/she was finally assisted by staff, it was difficult to stand and walk. During an interview on 2/4/21 at 3:30 P.M., Resident #1 said that the average call light wait time was one hour. Resident #1 said on one-night in January 2021 (unable to recall exact date) his/her call light and roommate's call lights were not answered at all, and said they both remained in urine soaked briefs for approximately 7.5 hours. Resident #1 said he/she was so upset by not having incontinence care provided. During an interview on 2/4/21 at 6:15 A.M., Nurse #2 said that the Nursing Staffing on the COVID Unit A-Wing was awful on 1/13/21, 1/14/21 and 1/15/21. Nurse #2 said for a census of approximately 50 Residents, there were usually 2 Certified Nurse Aides (CNA), a ratio of 1:25 residents during the 7:00 A.M. to 3:00 P.M. shift. Nurse #2 said the acuity on the unit was high due to the high volume of COVID positive residents who were acutely ill. Nurse #2 said staff kept asking Administration for staffing assistance, but no additional staff arrived in a timely manner to address the resident's immediate needs. Nurse #2 said, as a result of low staffing, resident vital sign monitoring was not consistently performed every four hours, for early detection of a decline in the resident's condition. During an interview on 2/4/21 at 10:00 A.M., the Acting Director of Nursing said the Facility did not have an acuity tool to identify the resident acuity. During an interview on 2/4/21 at 7:15 A.M., Certified Nurse Aide (CNA) #2 said staffing was horrible on the COVID Unit, and said at one point in January 2021, there was only one CNA during the 3:00 P.M. to 11:00 P.M. shift and the 11:00 P.M. to 7:00 A.M CNA #2 said due to the resident's being so ill from COVID 19, every single resident was complete care, and incontinence care could not be performed as needed. CNA #2 said it took eight hours to perform one round of incontinence care on the unit. CNA #2 said they could not reposition the residents in bed every two hours as required and said there were residents with skin rashes. CNA #2 said with the increased resident census and acuity of the residents, there should have been at least three CNAs to adequately care for these residents. During an interview on 2/5/21 at 1:55 P.M., CNA #1 said on 1/11/21 and 1/12/21 during the 3:00 P.M. to 11:00 P.M. shift there was only one CNA to care for approximately 53 residents, and residents were not taken care of properly. CNA #1 said the Residents were angry because they were not provided incontinence care and remained in urine and feces for most of the shift. CNA #1 said the residents were repositioned and turned only once in eight hours, instead of every two hours. CNA #1 said some residents needed supervision to prevent falls, and said there just was not enough staff to provide supervision. CNA #1 said one resident did fall on his/her shift because of the lack of required supervision. Review of the Facility Assessment, dated 1/20/2020, the staffing plan for CNAs on A-Wing was: - 7:00 A.M. to 3:00 P.M. - 4 CNAs - 3:00 P.M. to 11:00 P.M. - 4 CNAs - 11:00 P.M. to 7:00 A.M. - 2 CNAs During an interview on 2/4/21 at 7:25 A.M., Unit Manager #1 said the COVID Unit, A- Wing was not fully staffed in January 2021, that usually staffing for CNAs was: - 7:00 A.M. to 3:00 P.M. - 3 CNAs - 3:00 P.M. to 11:00 P.M. - 3 CNAs - 11:00 P.M. to 7:00 A.M. - 2 CNAs According to the Facility Census Report for 11 days (1/11/2021 to 1/21/2021), the average daily census was 50 residents (ranging from 45 to 55). During these 11 days, the staffing sheets indicated: - 6 of the 11 days had 2 or fewer CNAs during the 7:00 A.M. to 3:00 P.M. shift - 8 of the 11 days had 2 or fewer CNAs during the 3:00 P.M. to 11:00 P.M. shift - 5 of the 11 days had 1 CNA during the 11:00 P.M. to 7:00 A.M. shift During an interview on 2/16/21 at 10:58 A.M., Nurse #4 said even prior to their COVID outbreak in January 2021, the Facility had inadequate staffing for Certified Nurse Aides on the 3:00 P.M. to 11:00 P.M. shifts and on the 11:00 P.M. to 7:00 A.M. shifts, but with the increased patient acuity due to COVID positive residents and inadequate staffing the COVID Unit, they could not meet the basic care and acute care needs of the residents.

Based on records reviewed and interviews, for two of six sampled residents (Resident #1 and Resident #5), who resided on the COVID Unit, and required staff assistance with incontinence care, the Facility failed to ensure they were free from abuse, including neglect with emotional harm, when Resident #1 and Resident #5 reported being in physical pain, emotionally upset and angry, when staff failed to respond to their call lights and requests for assistance with personal care needs. Findings include: Review of the Facility Policy titled Freedom from Abuse, Neglect & Exploitation, dated 4/27/17, indicated that all residents are protected from any form of abuse, which includes neglect. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. Prevention included staffing patterns are in place daily to meet the needs of the residents. Review of Resident #1's Impaired Skin Integrity Care Plan, dated 10/30/20, indicated he/she had a potential for skin breakdown due to fragile skin, decreased mobility, deconditioning, and incontinence. Interventions included to keep skin clean and dry, apply house barrier cream to the peri area, coccyx and buttocks during every shift and with each incontinent episode. Review of Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 11/16/20, indicated he/she was cognitively intact, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/30/21 at 2:00 P.M., Family Member #1 said in January 2021 on the COVID Unit, there was inadequate nursing staffing levels to meet the needs of the residents. Family Member #1 said Resident #1 was so upset he/she was crying because he/she was incontinent of urine and feces, and no staff members responded to Resident #1's request for assistance in changing his/her incontinent briefs. Family Member #1 said on one occasion in January 2021 (unable to recall exact date), Resident #1 was left in a soiled incontinence brief from approximately 10:30 P.M. to 6:00 A.M. During an interview on 2/04/21, Resident #1 said that the average call light wait time was at least one hour. Resident #1 said that on the COVID Unit in January 2021, during the evening and night shift on more than one occasion, (unable to recall exact dates) he/she became upset and had been crying because no staff members came to respond to his/her request to be changed out of his/her soiled brief. Resident #1 said his/her peri-area was sore, painful, and said he/she had a rash after remaining in the same soiled brief for long periods of time. Resident #1 said on another occasion, in January 2021, (unable to recall exact date) his/her call light and his/her roommate's call lights were not answered at all, and said they both remained in urine soaked briefs for approximately 7.5 hours. Resident #1 said he/she was extremely upset by not having incontinence care provided by staff. Review of Resident #5's Quarterly MDS, dated [DATE], indicated he/she was cognitively intact, able to make his/her needs known to staff, and required extensive assistance of one staff person with ambulation, transfers and toilet use. During an interview on 2/5/21 at 2:46 P.M., Resident #5 said he/she was angry and upset about the lack of assistance with care by staff. Resident #5 said his/her call light was left unanswered for greater than 45 minutes, on more than one occasion. Resident #5 said he/she had been on the commode, required staff assistance with hygiene, rang his/her call light for assistance and said staff took 45 minutes to respond. Resident #5 said due to being left sitting on the commode for so long, his/her legs became numb and said that once assisted by staff, he/she had difficulty walking. During an interview on 1/29/21 at 1:11 P.M., Witness #1 said on 1/15/21 some of the residents who were incontinent of bladder and bowel at baseline, that required staff assistance to meet all of their personal care needs, were not provided incontinence care for an entire shift and into part of the next shift (approximately 12 hours). During an interview on 2/5/21 at 1:55 P.M., Certified Nurse Aide (CNA) #1 said on 1/11/21 and 1/12/21 on the COVID Unit, during the 3:00 P.M. to 11:00 P.M. shift, there was only one CNA assigned to care for approximately 53 residents. CNA #1 said the residents were angry because they were not taken care of properly. CNA #1 said residents were not assisted by staff with incontinence care needs and remained in soiled briefs for most of the shift. During an interview on 2/4/21 at 7:15 A.M., CNA #2 said the CNA staffing in January 2021, was horrible on the COVID Unit, that there was only one CNA during the 3:00 P.M. to 11:00 P.M. shift and the 11:00 P.M. and 7:00 A.M. shift. CNA #2 said the residents were so ill from COVID, that every single resident required complete care, and said incontinence care could not be performed as needed. CNA #2 said it took eight hours (an entire shift) to perform one round of incontinence care for the residents. CNA #2 said they could not reposition the residents in bed every two hours as required and said there were residents with skin rashes. CNA #2 said there should have been at least three CNAs on that shift to adequately care for these residents. During an interview on 1/29/21 at 11:45 A.M., Nurse #1 said he/she had communicated to the Facility Administration that residents were suffering and laying in their own excrement for eight to twelve hours due to not having enough staff on the COVID Unit.

Based on records reviewed and interviews for one of six sampled residents (Resident #3), who was assessed as being at increased risk for falls, was non-ambulatory and totally dependent on staff for all care needs, the Facility failed to maintain his/her safety to prevent an incident/accident with injury, when on 1/19/21 after Resident #3 had attempted to get out of bed unassisted by staff earlier in the shift, Resident #3 was found an hour later on the floor after an unwitnessed fall, he/she had an abrasion to his/her right knee and right shoulder, complained of back pain, and was transferred to the Hospital Emergency Department for further evaluation. Findings include: The Facility's Policy titled, Managing Falls and Fall Risk, dated 02/26/15, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes and to try to prevent the resident from falling and to try to minimize complications from falling. Resident #3 was admitted to the Facility in September 2019, medical history included non-union of a right periprosthetic distal femur fracture (injury occurred 2019) and he/she was diagnosed with dementia and [CONDITION(S)]. Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that he/she was severely cognitively impaired, was non-ambulatory, totally dependent on staff for care, required an assist of two staff members for bed mobility, transfers and toilet use. Resident #3's Falls Care Plan, indicated he/she was at risk for falls due to confusion, gait and balance problems, interventions included use of a wireless bed alarm, floor mat on side of bed near the chair, non-skid strips on floor to right side of bed, to anticipate and meet the resident needs, and he/she required prompt response to all requests for assistance. Review of the Facility's Investigation Report, dated 1/19/21, indicated that at 5:20 A.M., Resident #3 had an unwitnessed fall, was found on the floor beside his/her bed lying on his/her right side, 911 was called, and Emergency Medical Services was activated. The Report indicated Resident #3 was at high risk for falls, had an unsteady gait, and poor balance. The Report indicated Resident #3 had been witnessed by staff, earlier in the shift, trying to get out of bed unassisted. Review of Resident #3's medical record and the Facility's Investigation Report, indicated there was no documentation to support that his/her wireless bed alarm was in place at the time of the unwitnessed fall. Review of Certified Nurse Aide #2's written Witness statement, dated 1/19/21, indicated CNA #2 said prior to the unwitnessed fall (at 5:20 A.M.), at approximately 4:10 A.M., Resident #3 was trying to get out of bed and he/she was assisted back into bed. During an interview on 2/4/21 at 7:15 A.M., Certified Nurse Aide (CNA) #2 said staffing was horrible on the COVID Unit, and said at one point in January 2021, there was only one CNA during the 3:00 P.M. to 11:00 P.M. shift and the 11:00 P.M. to 7:00 A.M CNA #2 said there was not enough staff to meet resident care needs and to also provided adequate supervision for safety to prevent falls. During an interview on 2/5/21 at 1:55 P.M., CNA #1 said on 1/11/21 and 1/12/21 during the 3:00 P.M. to 11:00 P.M. shift there was only one CNA to care for approximately 53 residents, and residents were not taken care of properly. CNA #1 said some residents needed supervision to prevent falls, and said there just was not enough staff to provide supervision. CNA #1 said one resident did fall on his/her shift because of the lack of required supervision Review of Resident #3's Hospital Orthopedic Report, dated 1/19/21, indicated he/she had a history of non-union of a right periprosthetic distal femur fracture. The Report indicated Resident #3 presented with an abrasion to the right knee status post fall, was non-ambulatory at baseline, complained of back and right shoulder pain, and will be treated with conservative management.

Based on records reviewed and interviews for 1 of 3 sampled residents, (Resident #1), the Facility failed to ensure Resident #1 had a bed/chair alarm (an alarm pad under the resident's buttocks) on his/her wheelchair in accordance with the plan of care. Resident #1 did not have a chair alarm on the wheelchair, and sustained a fall with an acute left hip fracture which required surgical repair. Resident #1 died on [DATE] as a result of complications following surgery. Findings include: Resident #1's [DIAGNOSES REDACTED]. The Facility's Policy, titled Fall Prevention and Program, dated [DATE], indicated that each resident has an individualized plan of care designed with the goal of preventing falls and minimizing injury. Alarm devices will be utilized only if deemed essential as a prevention strategy. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 was moderately cognitively impaired, and required extensive assistance of one person for transfers and ambulation. A Fall Care Plan, initiated [DATE], indicated Resident #1 was to have a chair and bed alarm The Certified Nursing Aide Care Card, dated [DATE] indicated for Safety, Resident #1 was to have a bed and chair alarm. A Nurse's note, dated [DATE], indicated Resident #1 was found in his/her room on the floor at 3:15 P.M. in between a recliner chair and a wheelchair, and on assessment complained of left leg pain. The Physician was notified, an order was obtained to send the Resident to the Emergency Department. The Hospital Report, dated [DATE] indicated Resident #1 was complaining of leg pain and is anticoagulated on Coumadin. Resident #1 sustained an acute displaced left hip fracture which required surgical repair. An Incident/Accident Investigation, dated [DATE], indicated: Resident #1 fell from his/her wheelchair and was found on the floor at 3:15 P.M., CNA #1 placed a tab alarm on Resident #1 when he/she was transferred to the wheelchair before breakfast, CNA #2 had her assignment changed and assumed care of Resident #1 after breakfast CNA #2 toileted Resident #1 at 1:45 P.M., and said there was no alarm on the Resident, CNA #2 found Resident #1 at 3:15 P.M. on the floor, there was no alarm sounding and there was no alarm on or near him/her. CNA #2's witness statement, dated [DATE] at 12:15 P.M., provided as part of the Facility's Internal Investigation, indicated Resident #1 was care planned to have a pad alarm, but it was not in place at the time of the fall. The Safety Positioning Device Check list (an Alarm Lists), dated [DATE] indicated the bed/chair alarm (a pad alarm the resident sits on in a chair or lays on in a bed) was left blank at 7:00 A.M. on [DATE]. The Surveyor interviewed CNA #1 at 10:50 A.M. on [DATE]. CNA #1 said she did not put a chair alarm on Resident #1 when she transferred him/her out off bed to the wheelchair during morning care, on [DATE]. CNA #1 said she transferred Resident #1 up from his/her bed to the wheelchair applied a clip tab alarm (an alligator clip attaches to the Resident's garment with connecting cord with a magnet end attaches to the to the wheelchair), which she found in Resident #1's room. The Surveyor interviewed CNA #2 at 10:00 A.M. on [DATE]. CNA #2 said she thought Resident #1 no longer had a clip tab alarm on because in the past he/she kept taking it off and she thought the alarms were discontinued. CNA #2 said when she toileted Resident #1 at 1:45 P.M. on [DATE], Resident #1 did not have a clip or a chair alarm on his/her wheelchair. CNA #2 said that some time after the change of shift, around 3:00 P.M. on [DATE], she found Resident #1 on the floor in his/her room when she was delivering linen. CNA #2 did not hear, did not see or turn off an alarm, and said she did not see or hear an alarm sound near Resident #1. The Surveyor interviewed the Director of Nurses (DON) at 11:10 A.M. on [DATE]. The DON said that the fall care plan for having the chair alarm on Resident #1's wheelchair was not followed.

Based on record review, observation and interviews, the Facility failed to provide adequate supervision and assistive devices to prevent falls for 2 (#14 and Non-sampled (NS) #1) out of 11 residents with falls, in a total sample of 22 and 1 non-sampled resident. Findings include: The Facility's policy for "Gait Belt (Transfer Belt)" stated: "C. Gait belts will be used for: 1. All transfers of residents who require the assistance of 1 or 2 people. 2. Ambulation of residents who need an escort of 1 or 2 people who are unsteady." 1. For Resident #14, the Facility failed to ensure effective devices were in place during a transfer resulting in a fall with multiple fractures. Resident #14 was admitted to the Facility in 10/2013 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 10/29/13 indicated the resident scored 15 out of 15 (indicating intact cognitive status) on the Brief Interview for Mental Status (BIMS), had no mood or behavior indicators, was an extensive assist of 2 for transfers and toileting, an extensive assist of 1 for ambulation, had balance deficits, not steady, only able to stabilize with staff assistance, used a walker and wheelchair and had no falls. The care plan (initiated 11/2013) for activities of daily living (ADL), self care performance deficit related to activity intolerance, limited mobility, impaired balance and weakness included the following interventions: Requires assistance of 2 staff to reposition and turn in bed. Requires assistive devices such as a walker when transferring and assist of 1. Review of the Fall Risk Assessment of 4/16/14 indicated a score of 10, placing the resident at a moderate risk for falls. The Quarterly MDS, with the ARD of 4/23/14, indicated the resident scored 14 out of 15 (intact cognitive status) on the BIMS, was an extensive assist of 2 for transfers, an extensive assist of 1 for ambulation and toileting, had balance deficits, not steady, only able to stabilize with staff assistance, used a walker and wheelchair and had no falls. A Physical Therapy Certification form with a start of care date of 6/24/14 indicated the resident had a complex medical history with a recent admission to the hospital, and presented with generalized weakness, decreased balance, decreased activity tolerance and an increased fall risk. Review of the nurse's note dated 7/6/14 indicated at 7:15 A.M., the resident was responding to bladder urgency and fell while transferring from the bed to the commode. The resident complained of lower back pain and was transferred to the emergency room . The resident returned to the Facility at 4:00 P.M., with [DIAGNOSES REDACTED]. A review of the post fall investigation dated 7/6/14, indicated the resident requested to use the commode at 7:15 A.M., and was assisted by a Certified Nursing Assistant (CNA). The over bed table was interfering with the transfer and the CNA turned to move it, after assuring the resident was supported by hand placement on the side rail of the bed and the arm of the commode (and not utilizing a walker as care planned). The resident lost balance and fell backwards to the floor. The performance improvement plan included disciplinary action towards the CNA for failure to follow the resident's care plan and failure to utilize a gait belt during an assisted transfer. On 7/16/14 at 11:00 A.M., the resident was observed lying in a low bed with bedside mats on both sides of the bed. A motion sensor was in place and functioning and a floor alarm was in place. The resident said that he/she had recently fallen and felt dizzy after the fall, but was less dizzy now. The resident said he/she did not have too much pain as long as he/she did not move. During an interview on 7/16/14 at 2:37 P.M., Unit Manager #1 said that a gait belt is supposed to be used for any resident who is not independent for transfers. Unit Manager #1 said that Resident #14 also required 1 assist and the use of a walker for transfers. On 7/16/14 at 3:00 P.M., the resident was lying in bed receiving therapy services. The resident said the therapy was painful. On 7/16/14 at 3:06 P.M., the Director of Nursing said that the CNA made an error in judgement and did not follow the plan of care for the use of a walker for transfers and failed to use a gait belt for transfers/ambulation, as per Facility policy. 2. For NS #1, the Facility failed to utilize a gait belt during transfers and ambulation. NS #1 was admitted to the Facility in 5/2014 with [DIAGNOSES REDACTED]. The Fall Risk Assessment of 5/26/14 indicated the resident was at moderate risk for falls. The plan of care for high fall risk of 5/27/14 included the following interventions: Assist with ambulation and transfers as needed. Assure proper footwear is being worn. Fall assessment quarterly and as needed. Physical and occupational therapy evaluation and treatment as indicated. The Resident Care Card indicated on 5/29/14: transfers with rolling walker and assist of 2. The admission MDS assessment with an ARD of 6/1/14 indicated that the resident's short and long term memory was intact. The resident required extensive assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The resident walked in his/her room and the corridor once or twice with assist of 2. The resident had a fall in the last month and in the last 2 to 6 months prior to admission. The Care Area Assessment Worksheet of 6/4/14 indicated that the resident required Hoyer lift transfers on admission, but now stands and walks with 2 assists. He/she remains very weak and is working with physical therapy to increase strength and endurance. Staff will ensure that the call bell is in reach and answered in a timely manner, and the resident has 2 staff to stand and transfer until physical therapy or physician orders [REDACTED]. The Physical Therapy Progress Note of 6/20/14 indicated that the resident's current status was: caregiver assist to stand by assist for transfers and ambulates 50 feet with rolling walker and caregiver assist. Review of Progress Notes of 7/6/14 indicated that at 7:45 A.M., the resident was walking with a walker and CNA assistance in the bathroom. The resident stated that he/she was dizzy and weak. The resident fell backwards and hit his/her head on the wall. The resident sustained [REDACTED]. The resident was sent to the Emergency Department for evaluation. The resident was admitted to the Intensive Care Unit for observation. Review of the Computerized Tomography Scan report of 7/6/14 indicated: suspect a small subdural hematoma (0.3 centimeters in greatest perpendicular dimension). A subdural hematoma refers to an accumulation of blood on the brain's surface beneath the skull. Review of the Fall Investigation of 7/6/14 indicated that the Resident was standing with the walker as the CNA assisted him/her with dressing. The CNA was holding the resident's back with her hand. Then, the CNA bent down to pick up the dirty laundry and garbage bags. The resident said, "Wow" and the CNA looked back and saw the resident fall backwards. The CNA did not use a gait belt per policy. The Performance Improvement Plan of 7/8/14 included: *Description of issue - resident was assisted with ambulation without use of gait belt. Injury of resident occurred with fall. *Immediate and continued change needed for improvement - gait belt worn as part of uniform and used for all resident transfers. Review of Progress Notes of 7/11/14 indicated that the resident was readmitted to the Facility at 5:00 P.M. Observation on 7/17/14 at 9:50 A.M., found NS #1 sitting in a wheelchair near his/her bed. The call bell was in reach. During an interview on 7/17/14 at 1:30 P.M., Unit Manager #1 said that the CNA should have used a gait belt per policy during transfer and ambulation for NS #1, and NS #1 sustained a fall and subdural hematoma.

Based on record review, observation and interviews, the Facility failed to follow the plan of care for 1 (#14) out of 11 residents with falls, in a total sample of 22. Findings include: The Facility's policy for "Gait Belt (Transfer Belt)" stated: "C. Gait belts will be used for: 1. All transfers of residents who require the assistance of 1 or 2 people. 2. Ambulation of residents who need an escort of 1 or 2 people who are unsteady." For Resident #14, the Facility failed to follow the plan of care for utilizing a walker and the "Gait Belt Policy" for use of a gait belt for transfers, during a fall that resulted in multiple fractures. Resident #14 was admitted to the Facility in 10/2013 with [DIAGNOSES REDACTED]. The care plan (initiated 11/2013) for activities of daily living (ADL), self care performance deficit related to activity intolerance, limited mobility, impaired balance and weakness included the following interventions: Requires assistance of 2 staff to reposition and turn in bed. Requires assistive devices such as a walker when transferring and assist of 1. Review of the Fall Risk Assessment of 4/16/14 indicated a score of 10, placing the resident at a moderate risk for falls. Review of the nurse's note dated 7/6/14 indicated at 7:15 A.M., the resident was responding to bladder urgency and fell while transferring from the bed to the commode. The resident complained of lower back pain and was transferred to the emergency room . The resident returned to the Facility at 4:00 P.M., with [DIAGNOSES REDACTED]. X-ray results of 7/6/14 revealed a minimally displaced [MEDICAL CONDITION] right femur, [MEDICAL CONDITION] inferior pubic ramus, [MEDICAL CONDITION] ilium and a subacute [MEDICAL CONDITION] pubic symphysis. A Review of the POS [REDACTED].M., and was assisted by a Certified Nursing Assistant (CNA). The over bed table was interfering with the transfer and the CNA turned to move it, after assuring the resident was supported by hand placement on the side rail of the bed and the arm of the commode (and not utilizing the walker as per plan of care). The resident lost balance and fell backwards to the floor. The performance improvement plan included disciplinary action towards the CNA for failure to follow the plan of care and failure to use a gait belt during an assisted transfer as per Facility policy. On 7/16/14 at 11:00 A.M., the resident was observed lying in a low bed with bed side mats on both sides of the bed. A motion sensor was in place and functioning and a floor alarm was in place. The resident said that he/she had recently fallen and felt dizzy after the fall, but was less dizzy now. The resident said he/she did not have too much pain as long as he/she did not move. During an interview on 7/16/14 at 2:37 P.M., Unit Manager #1 said that a gait belt is supposed to be used for any resident who is not independent for transfers. Unit Manager #1 said that Resident #14 also required 1 assist and the use of a walker for transfers. On 7/16/14 at 3:00 P.M., the resident was observed lying in bed receiving therapy services. The resident said the therapy was painful. During an interview on 7/16/14 at 3:06 P.M., the Director of Nursing said that the CNA made an error in judgement and did not follow the plan of care for the use of a walker for transfers and failed to use a gait belt for transfers/ambulation, as per Facility policy. Please refer to F323.

Based on record review and interview, for one out of five sampled Residents (Resident #1) the Facility failed to ensure that a personal alarm was placed on Resident #1 as care planned, when a new Nurse Aide Orientee toileted Resident #1, then left Resident #1 in a chair at the nurses' station without the personal alarm in place and Resident #1 stood up, attempted to ambulate without assistance, fell and sustained a right subcapital non-displaced hip fracture. Findings include: The facility admitted Resident #1 in February, 2013. A fall risk assessment, dated 8/19/13, indicated Resident #1 was at high risk for falls. A fall risk care plan, updated on 8/31/13, indicated Resident #1 required a Tabs (personal alarm) alarm on the bed and chair, and an undated CNA Care Card also indicated Resident #1 required a Tabs alarm to the bed and chair. A quarterly Minimum Data Set (MDS) assessment, dated 9/4/13, indicated Resident #1 had clear speech, understood others and was usually understood by others. The MDS indicated Resident #1 scored 3 out of 15 possible points on a Brief Interview for Mental Status, which represented severely impaired cognition. The MDS indicated Resident #1's [DIAGNOSES REDACTED]. The MDS indicated Resident #1 required extensive staff assistance with transfers and ambulation, and Resident #1 used a walker or wheelchair for mobility. The MDS indicated Resident #1 was not steady and was only able to stabilize with staff assistance while moving from a seated to a standing position and when walking. The MDS indicated Resident #1 had two falls with injury. A nurse's note, dated 11/9/13, indicated Resident #1 was found on the floor in the hallway and it appeared that Resident #1 attempted to self ambulate. The nurse's note indicated Resident #1's personal alarm was not in place. The nurse's note indicated Resident #1 denied any pain and there was no apparent injury. An Incident/Accident Report, dated 11/9/13, indicated Resident #1 was found on the floor in the hallway at 6:15 P.M. The Surveyor interviewed Certified Nurse Aide (CNA) #1 at 3:15 P.M. on 12/11/13. CNA #1 said she was precepting a new Nurse Aide Orientee and it was the new Nurse Aide Orientee's second day of orientation. CNA #1 said nurse aide orientees were required to remain with the preceptor during all care, but she had not told the Nurse Aide Orientee that she needed to remain with the preceptor during all care. CNA #1 said she had discussed care plans and care cards with the Nurse Aide Orientee on the previous evening (however, the Nursing Assistant Orientation Program Checklist indicated the Nurse Aide Orientee signed off with the preceptor on care plans and location of care plans on 11/12/13 and on alarms on 11/13/13). CNA #1 said she was with another resident and was unaware that the Nurse Aide Orientee had toileted Resident #1. The Surveyor interviewed CNA #2 at 3:38 P.M. on 12/11/13. CNA #2 said they were getting ready for supper in the dining room and the Nurse Aide Orientee brought a resident into the dining room. CNA #2 said Resident #1 had already stood up and she had removed Resident #1's alarm and placed the alarm on Resident #1's walker. CNA #2 said she was walking Resident #1 to the toilet and another resident required assistance, so she asked the Nurse Aide Orientee to toilet Resident #1. CNA #2 said she did not tell the Nurse Aide Orientee that Resident #1 required a personal alarm, but the alarm was on Resident #1's walker, so she believed the Nurse Aide Orientee would see the alarm. CNA #2 said she was aware that the Nurse Aide Orientee was new, but was not aware that the Nurse Aide Orientee was not supposed to provide any care without the preceptor present. The Surveyor interviewed the Nurse Aide Orientee at 3:57 P.M. on 12/11/13. The Nurse Aide Orientee said she had transported a resident to the dining room and Resident #1 was being assisted to the doorway by CNA #2, who asked her to toilet Resident #1. The Nurse Aide Orientee said she toileted Resident #1 without any problem, but when she returned to the dining room with Resident #1, Nurse #1 told her to take Resident #1 out to the nurses' station and that Resident #1 would eat supper at the nurses' station. The Nurse Aide Orientee said she took Resident #1 out to the nurses' station and seated Resident #1 in a straight back chair. The Nurse Aide Orientee said CNA #2 never told her that Resident #1 required an alarm and she did not see the alarm on the walker. The Nurse Aide Orientee said she did not know Resident #1 or that Resident #1 required an alarm, so she never placed the personal alarm on Resident #1. The Nurse Aide Orientee said she did not check Resident #1's care card. The Nurse Aide Orientee said she was not told that she could not provide care to residents without the preceptor present, but after Resident #1 fell the preceptor told her that she could not provide care without the preceptor. The Surveyor interviewed the Unit Manager at 1:18 P.M. on 12/11/13. The Unit Manager said the Nurse Aide Orientee should not have provided care to Resident #1 without the preceptor present. The Unit Manager said after the Nurse Aide Orientee toileted Resident #1, she placed Resident #1 in a chair at the nurses' station, but failed to place the Tabs alarm on Resident #1 as per the plan of care. The Surveyor interviewed Nurse #1 at 4:40 P.M. on 12/11/13. Nurse #1 said when the Nurse Aide Orientee brought Resident #1 back to the dining room, she told her to take Resident #1 out to the nurses' station for supper. Nurse #1 said she worked 7:00 A.M. to 7:00 P.M. and Resident #1 had not eaten much breakfast or lunch that day, so she decided to move Resident #1 out to the nurses' station for supper and see if less distraction helped with Resident #1's appetite. Nurse #1 said after supper she had just finished a dressing change and when she came out of the room, someone said Resident #1 was on the floor. Nurse #1 said Resident #1 was lying on the floor in the hallway, not far from where he/she had been sitting. Nurse #1 said she assessed Resident #1 and Resident #1 had no complaint of pain and was able to move both legs. Nurse #1 said both legs were also in good alignment. Nurse #1 said Resident #1's alarm was not in place at the time of the fall. Nurse #1 said for the remainder of her shift, Resident #1 had no complaint of pain. A nurse's note, dated 11/10/13, indicated that Resident #1 experienced a fall at about 6:15 P.M. on 11/9/13 and at 8:45 P.M., Resident #1 pointed to his/her upper right thigh and complained of pain while being toileted. The nurse's note indicated there was no apparent deformity, no bruising, no redness and Resident #1's right leg was in complete normal alignment. The nurse's note indicated Resident #1 was placed in bed, medicated for pain and the Physician was notified. The nurse's note indicated Resident #1 had moderate relief with the pain medication, but the pain continued with movement and the Physician ordered Resident #1 transferred to the Hospital for evaluation and treatment. A Hospital Discharge Summary, dated 11/10/13, indicated Resident #1 was brought to the Hospital related to a complaint of leg pain after an unwitnessed fall. The Hospital Discharge Summary indicated Resident #1 was diagnosed with [REDACTED]. The Hospital Discharge Summary indicated Resident #1's family (a Health Care Proxy was invoked) opted to treat Resident #1 conservatively and not operate at this time, so Resident #1 was returned to the nursing Facility. A nurse's note, dated 12/6/13, indicated Resident #1 was placed on Hospice care and a nurse's note, dated 12/7/13 indicated Resident #1 passed away at 4:40 P.M. on 12/7/13.

Based on record review, interview, and observation, for on of six sampled residents (Resident #1), the Facility failed to ensure that there was a physician's order for a laboratory blood draw on Resident #1 when a laboratory slip was completed without a physician's order for the blood test. The findings included: Resident #1 was admitted to the Facility in June 2010, with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 9/6/10, indicated Resident #1 had intact short term memory, intact long term memory, and Resident #1 had some difficulty with decision making in new situations. The MDS indicated Resident #1 usually understood others and Resident #1's ability to communicate with others was limited to making concrete requests. The MDS indicated Resident #1 had no adverse behaviors. The MDS indicated Resident #1 had a partial loss of voluntary movement of the arm, hand, leg, and foot. According to the MDS, Resident #1 required extensive staff assistance with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene, and bathing; but Resident #1 was able to eat independently. The Facility's Lab Protocols/Guidelines indicated the 11:00 P.M. to 7:00 A.M. nurse was responsible for checking labs (orders for laboratory testing) nightly for those labs due the next day, completing the lab slips, up-keep of all resident lab sheets, verification of labs done, and carry over of all open (not completed) labs to new sheets. The Facility's Lab Protocols/Guidelines indicated the 11:00 P.M. to 7:00 A.M. nurse would enter the resident's name and test to be done on the Lab Tracking Log and place the lab slip in the tracking log book for pick-up by the lab. A review of the Facility's staffing indicated Nurse #1 was on duty on the 11:00 P.M. to 7:00 A.M. shift on 10/6/10 into 10/7/10. Nurse #1 was interviewed at 9:00 A.M. on 10/22/10. Nurse #1 said Nurse #1 usually worked 3:00 P.M. to 11:00 P.M., but worked 11:00 P.M. to 7:00 A.M. that night. Nurse #1 said Nurse #1 checked Resident #1's lab kardex and Resident #1 was listed for a blood draw the next morning. Nurse #1 said Nurse #1 had worked at the Facility for 3 years and knew all the residents who were receiving [MEDICATION NAME] (anticoagulant) and Resident #1 was listed for a PT/INR ([MEDICATION NAME] time/International Normalized Ratio - blood test to monitor anticoagulant therapy), but Resident #1 was not on [MEDICATION NAME], so Nurse #1 wondered why the test was ordered. Nurse #1 said Nurse #1 then checked Resident #1's chart, but could not find a physician's order for the PT/INR. Nurse #1 said there was no order in Resident #1's chart, but the PT/INR was listed on Resident #1's lab kardex. Nurse #1 wondered if a nurse had taken the order and forgotten to write the order, so Nurse #1 filled out the lab slip and because this was not a scheduled blood draw, Nurse #1 called the lab to come and do the blood draw. Nurse #1 said the Unit Manager arrived at about 6:30 to 7:00 A.M. and Nurse #1 asked the Unit Manager about the lab order. Nurse #1 said Nurse #1 asked the Unit Manager if Nurse #1 should remove Resident #1 from the Lab Tracking Log since there was no physician's order for the PT/INR, but the Unit Manager said to keep Resident #1 on the Lab Tracking Log and the Unit Manager would find out who wrote the order on the kardex. Nurse #1 said Resident #1 was left on the Lab Tracking Log, because the Unit Manager said to do so. Unit Manager #1 was interviewed at 12:55 P.M. on 10/12/10 and again at 9:45 A.M. on 10/22/10. Unit Manager #1 said it was the responsibility of the 11:00 P.M. to 7:00 A.M. nurse to transcribe lab orders onto the Lab Tracking Log. Initially, Unit Manager #1 told the Surveyor that Unit Manager #1 had not spoken to Nurse #1 regarding the incident, but after the Surveyor spoke with Nurse #1, the Surveyor interviewed Unit Manager #1 a second time. Unit Manager #1 said Unit Manager #1 was sorry that Unit Manager #1 had not mentioned speaking to Nurse #1, but the Surveyor did not specifically ask about Unit Manager #1's conversation with Nurse #1 on that specific morning. Unit Manager #1 said Nurse #1 questioned the order for Resident #1's PT/INR, because Nurse #1 could not find a physician's order. Unit Manager #1 said Unit Manager #1 told Nurse #1, no order, no lab draw. Unit Manager #1 said while Unit Manager #1 was speaking with Nurse #1, Nurse #2 pulled out Resident #1's lab kardex and showed Unit Manager #1 the documentation that Resident #1 was to have a PT/INR on 10/7/10 and the documentation was dated 10/5/10. Unit Manager #1 said they did not know who wrote the alleged order on the lad kardex. Unit Manager #1 said Unit Manager #1 was unaware that Nurse #1 had completed a lab slip and would never have told Nurse #1 to leave the lab slip in the Lab Tracking Log. Unit Manager #1 said Unit Manager #1 would never have told Nurse #1 that Unit Manager #1 would follow-up on it, because Unit Manager #1 had morning meeting to attend and would not have been back on the unit before the Phlebotomist was in to draw blood. A review of a Lab Tracking Log, dated 10/7/10, indicated Resident #1 had a PT/INR ordered. The Lab Tracking Log indicated that the Phlebotomist initialed that the blood had been drawn from Resident #1's right antecubital. A review of Resident #1's medical record indicated no physician's order for a PT/INR on 10/7/10. The Director of Nursing was interviewed at 11:06 A.M. on 10/12/10. The Director of Nursing said there was no physician's order for Resident #1's PT/INR blood draw on 10/7/10. Resident #1 was interviewed at 9:00 A.M. on 10/12/10. Resident #1 said the Phlebotomist entered Resident #1's room and told Resident #1 that the Phlebotomist was going to draw some blood. Resident #1 said Resident #1 asked the Phlebotomist why the blood was being drawn, but the Phlebotomist did not tell Resident #1. Resident #1 said when the Phlebotomist inserted the needle it really hurt and Resident #1 asked the Phlebotomist to stop, but the Phlebotomist just kept pushing the needle in. Resident #1 said Resident #1 asked the Phlebotomist twice to stop and let go of Resident #1's arm. Resident #1 said at that point Resident #1 tried to pull the arm away from the Phlebotomist, but the Phlebotomist pulled Resident #1's arm back and then held the arm down. Resident #1 said the Phlebotomist seemed to be in a bad mood right from the start and would not even tell Resident #1 why the blood was being drawn. Resident #1 said the Phlebotomist held Resident #1's arm so tight that there was a bruise. The Surveyor observed Resident #1's right antecubital area on 10/12/10 and no bruising was present; however, the Surveyor observed bruising on Resident #1's right inner wrist in a pattern that was consistent with the way in which Resident #1 told the Surveyor that the Phlebotomist held Resident #1's right wrist. Refer to F 221.

Based on record review, interview, and observation, for one of six sampled residents (Resident #1), the Facility to ensure that Resident #1 remained free of manual restraint when the Phlebotomist disregarded Resident #1's request to stop the procedure and instead forcefully held Resident #1's right arm down to prevent Resident #1 from pulling the arm away in order to complete the blood draw against Resident #1's wishes. Resident #1 sustained bruises to the right wrist and experienced emotional upset. The findings included: Resident #1 was admitted to the Facility in June 2010, with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 9/6/10, indicated Resident #1 had intact short term memory, intact long term memory, and Resident #1 had some difficulty with decision making in new situations. The MDS indicated Resident #1 usually understood others and Resident #1's ability to communicate with others was limited to making concrete requests. The MDS indicated Resident #1 had no adverse behaviors. The MDS indicated Resident #1 had a partial loss of voluntary movement of the arm, hand, leg, and foot. According to the MDS, Resident #1 required extensive staff assistance with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene, and bathing; but Resident #1 was able to eat independently. A review of a Lab Tracking Log, dated 10/7/10, indicated Resident #1 had a PT/INR ([MEDICATION NAME] time/International normalized ratio - blood test to monitor anticoagulant therapy) ordered. The Lab Tracking Log indicated that the Phlebotomist initialed that the blood had been drawn from Resident #1's right antecubital (at the bend of the elbow). Resident #1 was interviewed at 9:00 A.M. on 10/12/10. Resident #1 said the Phlebotomist entered Resident #1's room and told Resident #1 that the Phlebotomist was going to draw some blood. Resident #1 said Resident #1 asked the Phlebotomist why the blood was being drawn, but the Phlebotomist did not tell Resident #1. Resident #1 said when the Phlebotomist inserted the needle it really hurt and Resident #1 asked the Phlebotomist to stop, but the Phlebotomist just kept pushing the needle in. Resident #1 said Resident #1 asked the Phlebotomist twice to stop and let go of Resident #1's arm. Resident #1 said at that point Resident #1 tried to pull the arm away from the Phlebotomist, but the Phlebotomist pulled Resident #1's arm back and then held the arm down. Resident #1 said the Phlebotomist seemed to be in a bad mood right from the start and would not even tell Resident #1 why the blood was being drawn. Resident #1 said the Phlebotomist held Resident #1's arm so tight that there was a bruise. Although Resident #1 had [DIAGNOSES REDACTED]. The Speech Therapist was interviewed at 10:07 A.M. on 10/12/10. The Speech Therapist said the Speech Therapist was walking down the hallway and heard a voice say, you're hurting me, get away from me. The Speech Therapist then entered Resident #1's room and Resident #1 was seated in a chair and the Phlebotomist had a tourniquet on Resident #1 and the needle was inserted into Resident #1's arm. The Speech Therapist said Resident #1 was trying to move Resident #1's arm away and the Phlebotomist said stop it, you're going to hurt yourself. The Speech Therapist said Resident #1 had tears streaming down Resident #1's face and the Phlebotomist was holding down Resident #1's arm. The Speech Therapist said at one point the Phlebotomist used two hands to hold down Resident #1's arm and the needle was still sticking into Resident #1's arm. The Speech Therapist said Resident #1 told the Phlebotomist to stop and get away from Resident #1 and the Speech Therapist also told the Phlebotomist to stop. The Speech Therapist said the Rehabilitation Program Manager then entered the room and also told the Phlebotomist to stop. The Speech Therapist said Resident #1 kept trying to pull Resident #1's arm away, but the Phlebotomist used two hands to hold Resident #1's arm down. The Speech Therapist said the tourniquet was still on Resident #1's arm after the Phlebotomist took the needle out and the Rehabilitation Program Manager released the tourniquet. The Speech Therapist said the Phlebotomist tried to put a bandage on Resident #1's arm, but Resident #1 did not want anything to do with the Phlebotomist. The Speech Therapist said Nurse #2 had also entered the room and told the Phlebotomist to stop, but the Phlebotomist did not stop. The Speech Therapist said Nurse #2 told the Phlebotomist to stop again and then Nurse #2 got right between Resident #1 and the Phlebotomist. The Speech Therapist said finally the Phlebotomist stopped and left the room and Nurse #2 took over and bandaged the Resident's arm at the site of the needle stick. The Speech Therapist said it seemed like the Phlebotomist was determined to draw the blood whatever. The Rehabilitation Program Manager was interviewed at 4:08 P.M. on 10/8/10. The Program Manager said the Program Manager had just entered the Facility and heard someone yelling you're hurting me stop, don't do that. The Program Manager went to Resident #1's room and observed the Phlebotomist standing over Resident #1 and the Phlebotomist had a needle stuck in Resident #1's right arm. The Program Manager said Resident #1 was trying to swing the arm, so the Program Manager tried to calm Resident #1. The Program Manager said the Phlebotomist asked the Program Manager to release the tourniquet, which the Program Manager did. The Program Manager said the Phlebotomist was holding down Resident #1's arm and the needle was just hanging out of Resident #1's arm. The Program Manager said Resident #1 was really upset and told the Phlebotomist to stop, but the Phlebotomist just held Resident #1's arm down. The Program Manager said the Phlebotomist commented there was blood everywhere and Resident #1 was still trying to pull the arm away, so the Program Manager told the Phlebotomist to let go of Resident #1. The Program Manager said the Program Manager told the Phlebotomist to stop a total of three times and Resident #1 also told the Phlebotomist to stop. The Program Manager said the Phlebotomist was just not listening. The Program Manager said the Program Manager told a nursing assistant to get the nurse. The Program Manager said the Phlebotomist held Resident #1's right wrist and Resident #1 tried to pull the arm away and the Phlebotomist just pushed down harder on Resident #1's wrist. The Program Manager said Nurse #2 had heard the commotion and came to the room. The Program Manager said Nurse #2 told the Phlebotomist to get away from Resident #1. Nurse #2 was interviewed at 3:30 P.M. on 10/8/10. Nurse #2 said about 9:45 A.M. Nurse #2 heard yelling and went to Resident #1's room. Nurse #2 said the Speech Therapist, the Rehabilitation Program Manager and the Phlebotomist were in the room. Nurse #2 said the Phlebotomist was holding Resident #1's right arm and the blood had already been drawn. Nurse #2 said Resident #1 told the Phlebotomist to let go and the Phlebotomist did not let go of Resident #1's arm, so Nurse #2 told the Phlebotomist to let go. Nurse #2 said the Phlebotomist told Nurse #2 that there would be blood everywhere. Nurse #2 said the Phlebotomist held Resident #1's arm pretty tightly and Resident #1 was physically pulling the arm away. Nurse #2 said Resident #1 was visibly upset and crying, so at that point, Nurse #2 approached the Phlebotomist and told the Phlebotomist to let go of Resident #1 and leave the room. Nurse #2 said the Phlebotomist finally let go of Resident #1 and on the way out of the room, the Phlebotomist commented that was a pretty good stick and the Phlebotomist did not know why you're upset. Nurse #2 said the Phlebotomist appeared agitated or annoyed. Nurse #2 said after the Phlebotomist left, Resident #1 told Nurse #2 that the needle stick hurt more than usual and Resident #1 asked the Phlebotomist to stop, but the Phlebotomist did not stop. Nurse #2 said Resident #1 had very little movement of the left arm due to a stroke, so was only able to move the right arm. Nurse #2 said Nurse #2 assessed Resident #1 and Resident #1 had redness around the antecubital area from the stick, but there was no bruising at that time. Nurse #2 said Nurse #2 checked Resident #1 the next day and there were bruises on Resident #1's wrist that looked like finger marks where the Phlebotomist held Resident #1's right wrist. The Phlebotomist was interviewed at 10:15 A.M. on 11/3/10. The Phlebotomist said the Phlebotomist entered Resident #1's room and introduced self to Resident #1 and said the Phlebotomist was there to draw blood. The Phlebotomist said Resident #1 asked why and the Phlebotomist replied that the Physician had ordered blood work. The Phlebotomist said the Phlebotomist prepared equipment and then applied the tourniquet on Resident #1's right arm. The Phlebotomist said as soon as the needle was inserted, Resident #1 looked at the needle and said it hurt. The Phlebotomist said if Resident #1 complained that the needle hurt, the Phlebotomist had no problem removing the needle. The Phlebotomist said the needle was placed well and there was blood return. The Phlebotomist said Resident #1 said stop and a phlebotomist should always stop if a resident said to stop. The Phlebotomist said the Phlebotomist was reaching for some gauze to use when the needle was removed, but Resident #1 started moving the arm. The Phlebotomist said two staff that were unknown to the Phlebotomist entered the room and watched, but never offered to help. The Phlebotomist said finally one of the two staff members removed the tourniquet when asked, but neither of the two told the Phlebotomist to stop. The Phlebotomist said Resident #1 really started flailing Resident #1's arms around and the Phlebotomist had to hold down Resident #1's arm. The Phlebotomist said the needle was still in Resident #1's arm, so the Phlebotomist had to hold the needle in place. The Phlebotomist said the Phlebotomist asked the other two staff to help hold Resident #1, but nobody helped hold Resident #1. The Phlebotomist said the Phlebotomist held Resident #1's arm down with one hand and held the needle in place with the other hand. The Phlebotomist said the Phlebotomist never let go of the needle in Resident #1's arm. The Phlebotomist said the Phlebotomist had to hold down Resident #1's arm with quite a lot of force, because Resident #1 could have gotten very hurt with the needle and the Phlebotomist had to stabilize Resident #1's arm. The Phlebotomist said after the fact the nurse entered the room and the Phlebotomist just let go of Resident #1's arm. The Phlebotomist said this was a horrible incident and the Phlebotomist had never come across anything like this in 7 years. Although the Phlebotomist told the Surveyor that Resident #1 said stop right after the needle was inserted and that a Phlebotomist should stop if a resident said stop, the Phlebotomist continued the blood draw until a specimen was obtained, because: A Laboratory Report, dated 10/7/10, indicated a specimen collected at 9:45 A.M. on 10/7/10 showed that Resident #1's PT was 10.6 and Resident #1's INR was 1.0. A nurse's note, dated 10/7/10 at 10:00 A.M., indicated Resident #1 was alert and oriented to person, place, and time. The nurse's note indicated Resident #1 complained of pain in the right antecubital area and there was a small lesion site on the right antecubital area due to a needle stick. A review of a 72 hour skin assessment, dated 10/7/10, indicated at 4:00 P.M. Resident #1 had 2.6 centimeter x 2.5 centimeter bruise on the inner right wrist. The 72 hour skin assessment indicated at 6:25 P.M. on 10/7/10 Resident #1 had a 3.5 centimeter x 2.5 centimeter bruise on the right inner wrist and a 1 centimeter x 0.3 centimeter pink area in the right antecubital area. The 72 hour skin assessment indicated on 10/8/10 Resident #1 had a 2.4 centimeter x 2.5 centimeter bruise on the inner right wrist and a 1.4 centimeter x 2.1 centimeter bruise in the right antecubital area. The Surveyor observed Resident #1's right antecubital area on 10/12/10 and no bruising was present; however, the Surveyor observed bruising on Resident #1's right inner wrist in a pattern that was consistent with the way in which Resident #1 told the Surveyor that the Phlebotomist held Resident #1's right wrist. Refer to F 504.

Based on observation, interview, and record review, for one of three sampled Residents (Resident #1), the Facility failed to measure the temperature of the tea water to ensure the tea was served at a safe temperature when Resident #1 was served hot tea in a styrofoam cup that was three quarters full and Resident #1 spilled the tea and sustained a second degree burn to the right thigh. The findings included: Resident #1 was admitted to the Facility in April 2009, with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/11/10, indicated Resident #1 had impaired short term memory, impaired long term memory, and moderately impaired decision making ability. The MDS indicated Resident #1 required staff supervision when eating. An ADL (Activities of Daily Living) care plan, updated on 8/19/10, indicated Resident #1 required supervision/cues at meals and the Resident Care Card for Resident #1 also indicated that Resident #1 required supervision/cueing with meals. A nurse's note, dated 8/24/10 at 10:45 P.M., indicated Resident #1 was at the nurses' station drinking tea and dropped the cup on Resident #1's lap. The nurse's note indicated the tea spilled on Resident #1's right upper thigh and a red area was noted to the right thigh. The nurse's note indicated Resident #1 was taken to the bathroom to change clothes, cold water compresses were applied, and the physician was notified. The nurse's note indicated the physician ordered the area monitored until resolved and and ice pack applied for 10 minutes. The nurse's note indicated Resident #1 denied pain to the right thigh, the skin was intact, and the red area decreased within 15 minutes. Nurse #1 was interviewed at 12:08 P.M. on 9/3/10. Nurse #1 said Resident #1's usual routine was to have a snack at bedtime and Resident #1 favored either tea or hot chocolate and toast. Nurse #1 said Nurse #1 made tea and toast for Resident #1 and used the microwave in the kitchenette to warm the tea water. Nurse #1 said Nurse #1 had no way to determine the temperature of the tea water, but Nurse #1 was able to comfortably hold the cup of tea. Nurse #1 said the tea was made in a large styrofoam cup, which was the usual routine at the Facility. Nurse #1 said the cup was 3/4 full and Nurse #1 then set the toast and tea on a tray table in front of Resident #1 and went back to the medication cart. Observations made by the Surveyor on the day of survey indicated it took approximately 18 ounces of water to fill the large styrofoam cup to 3/4 full. Nurse #1 said Resident #1 was in Nurse #1's peripheral view and Nurse #1 did not really observe Resident #1 spill the tea, but heard the noise of the cup falling and then heard Resident #1 respond with something like, oh my. Nurse #1 said there was a nursing assistant near Resident #1 and they both responded to Resident #1. Nurse #1 said Resident #1's clothing soaked up most of the liquid, but there was some tea on the floor as well. Nurse #1 said Nurse #1 and the nursing assistant immediately took Resident #1 into the bathroom near the nurses' station and assessed Resident #1. Nurse #1 said Resident #1 had a pink area on the right thigh, but no blisters were observed and they applied cold compresses to Resident #1's right thigh. Nurse #1 said Resident #1's physician was notified and ordered ice packs and the area to be monitored. Nursing Assistant #1 was interviewed at 2:52 P.M. on 9/3/10. Nursing Assistant #1 said Resident #1 returned to the Facility from dialysis and wanted a snack. Nursing Assistant #1 said Nurse #1 made toast and tea for Resident #1 and told Resident #1 to be careful, because it was a little hot. Nursing Assistant #1 said Resident #1's tea was in a large styrofoam cup. Nursing Assistant #1 said Nursing Assistant #1 was seated directly in front of Resident #1 on the other side of the tray table. Nursing Assistant #1 said Resident #1 went to grab the cup of tea, but grabbed the very bottom of the cup and the cup flipped towards Resident #1. Nursing Assistant #1 said it happened so quickly that Nursing Assistant #1 was not able to catch the cup. Nursing Assistant #1 said the tea spilled all over Resident #1's lap, but Resident #1's right leg was the only place that burned. Nursing Assistant #1 said they immediately took Resident #1 into the bathroom and placed a cold washcloth on the burned area. Nursing Assistant #1 said there were no blisters at that time, only a red area. A nurse's note, dated 8/25/10 at 6:15 A.M., indicated Resident #1's right outer thigh was pink in color; however, a nurse's note, dated 8/25/10 at 8:00 P.M. indicated Resident #1 had a pink area on the right outer thigh that was 5 centimeters x 2 centimeters in size and the area contained two blisters. The nurse's note indicated one of the blisters was 1 centimeter x 1 centimeter in size and the other blister was 0.2 centimeter x 0.2 centimeter. A physician's orders [REDACTED].#1 on 8/26/10. A physician's progress note, dated 8/26/10, indicated Resident #1 had a superficial first degree burn on the right thigh related to a spill of hot liquid. The physician's note indicated there was also a small area of second degree burn with clear vesicle not yet open. The physician documented that Silvadene (topical anti-infective medication) would be ordered. The Surveyor, accompanied by Nurse #2, observed Resident #1's burn at 10:40 A.M. on 9/3/10 with permission of Resident #1. The Surveyor observed while Nurse #2 removed the dressing and Silvadene. The Surveyor observed Resident #1's outer right thigh had a healing burn that was a reddened area with opened blisters approximately the size of a half-dollar with no signs or symptoms of infection. Nurse #2 then re-applied Silvadene and covered the area with a dressing. Resident #1 slept through the dressing change. Resident #1 was interviewed at 1:12 P.M. on 9/3/10. Resident #1 was unable to recall the incident.