Every finding on record at St. Elizabeth's Place

Based on record review, video surveillance review, facility document review, interview, and facility policy review, it was determined that the facility failed to ensure the facility provided an environment that was free from avoidable accidents and hazards for one (Resident #1) of six residents reviewed. Specifically, the facility staff failed to address a sounding alarm on an exit door that directly opened to an unsecured area and allowed Resident #1, who had an altered mental status, to leave the facility premises and travel to an establishment located 0.1 miles behind the facility without the facility's knowledge.It was determined the facility's past non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to the resident. The Immediate Jeopardy (IJ) was related to the Stated Operations Manual, Appendix PP, 483.25 (Quality of Care) for elopement at a scope and severity level of J. The IJ was identified at 04/01/2026 at 4:45 PM.The Director of Operations and the Registered Nurse Consultant (RNC) were notified of immediate jeopardy (IJ) of Past Non-Compliance (PNC) IJ on 04/02/2026 at 2:29 PM. The facility's action plan was reviewed and accepted by the state agency surveyors on 04/02/2026 at 4:30 PM.The findings include:A review of Resident #1's admission Record indicated the facility admitted the resident on 03/25/2026, with diagnoses which included unspecified dementia, difficulty walking, lack of coordination, muscle wasting and atrophy, cachexia [condition that results in loss of skeletal muscle mass], altered mental status, hypoglycemia, and hypothermia.A review of Resident #1's admission Minimum Data Set (MDS), with an Assessment Reference Date of 03/27/2026, revealed a Brief Interview for Mental Status score of 09, which indicated the resident had moderate cognitive impairment. Resident #1's MDS also revealed the resident had an upper body impairment to one side and used a walker and a wheelchair. Resident #1 required partial to moderate assistance for personal and toileting hygiene, showering and bathing, and lower body dressing. Resident #1 required supervision or touch assistance when putting on and taking off footwear. Resident #1 was dependent on staff when walking 50 feet. Resident #1 required partial to moderate assistance for repositioning, and all transfers. Resident #1's MDS further indicated the resident was dependent on staff for walking 10 feet on uneven surfaces such as sloping surfaces or on turf, and to go up and down curbs or one step.A review of Resident #1's Care Plan initiated on 03/25/2026, revealed the resident required assistance from staff for Activities of Daily Living such as assistance with wheelchair mobility. Resident #1's Care Plan also revealed the resident was at risk for elopement. Care Plan interventions included Resident #1 being placed on a secured unit on 03/29/2026, after the resident returned to the facility following the elopement. Care Plan interventions also included to monitor where abouts, redirection, distraction and to attempt to identify patterns and triggers of wandering.A review of a Resident #1's Pre-admission Screen dated 03/20/2026 at 8:38 AM, indicated Resident #1 used a manual wheelchair and walker for ambulation, had nebulizer therapy, oxygen at two liters per minute by nasal cannula/mask, was cognitively impaired, and had dementia. The document also revealed the resident had risk alerts, which included anticoagulation and falls. The resident was receiving therapy services, which included physical therapy, occupational therapy, and speech therapy. Resident #1 required one person assist. Other notes indicated Resident #1 had been admitted to ICU from home related to hypothermia, bradycardia and hypoglycemia.A review of Resident #1's [Nursing] Nsg Admit/Readmit Assessment and Care Plan dated 03/25/2026 at 11:43 AM, indicated Resident #1's Elopement risk score was 9, which indicated the resident was at risk to wander.A review of Resident #1's Nsg Elopement Risk with Care Plan on 03/27/2026 at 9:12 AM, indicated Resident #1's elopement score was 7, which indicated the resident was a low risk for elopement.A review of video surveillance footage was conducted with the Director of Operations on 04/01/2026 at 4:14 PM, for the incident that occurred on 03/28/2026. The following was observed:Outside camera footage- At 11:16:56 PM, Resident #1 was seen leaving the facility.-At 11:18 PM, Resident #1 fell attempting to step up onto the curb. Resident #1 crawled across the grass and sidewalk to the shed.-At 11:26 PM, Resident #1 used a broom and the shed to stand.Dining Room footage- At 11:25:44 PM, Licensed Practical Nurse (LPN) #2 was observed entering the dining room with her cell phone in hand.- At 11:26:18 PM, LPN #2 pulled the door, turned off the alarm, and was observed leaving the dining room on her cell phone.A review of the Police Report on 03/28/2026 indicated at 11:35 PM, a caller advised law enforcement that an elderly [resident] with a possible altered mental status, was at the hotel establishment at which they were employed. At 11:37 PM, the caller said the [resident] arrived there on foot. The Police Report revealed an officer arrived at the hotel establishment at 11:56 PM, and Emergency Medical Services (EMS) was dispatched at 12:08 AM.A review of Resident #1's EMS Records indicated on 03/29/2026 at 12:13 AM, EMS arrived at patient. The EMS Records revealed Resident #1 was alert and oriented x1 [to self only], the resident's skin was cold and dry, and the police officer called for EMS when it was noted that Resident #1 was severely confused. Resident #1 walked with EMS to the ambulance. The EMS Report further indicated that as EMS was leaving the parking lot, [the ambulance was] waved down by staff of [Facility Name]. They told EMS [Resident #1] was a resident at the NH [nursing home] and had been missing for a few hours.A review of Resident #1's Hospital Records dated 03/29/2026, indicated the resident was found in lobby of a hotel near the nursing home, and Resident #1 was orientated to person only. Resident #1's vital signs on 03/29/2026 at 12:33 AM, included a temperature of 96.4 degrees Fahrenheit, a pulse rate of 66 beats per minute, and a blood pressure of 164/94.A review of a statement titled, Establishments Statement by the clerk who was working the front desk of the hotel on 03/28/2026, indicated at around 11:11 PM, Resident #1 walked into the establishment and asked the clerk to help the resident find someone. The clerk called the police department, who arrived at 11:55 PM, then the police called EMS. The report indicated some ladies from next door came in looking for [the resident] at 12:10 AM. A review of an OLTC [Office of Long-Term Care] Witness Statement Form dated 03/30/2026 at 2:30 PM, signed by LPN #2 who was the charge nurse on night shift of 03/28/2026, indicated Resident #1 was last seen while LPN #2 was giving medication to another resident. LPN #2 had given the last medication [on their medication pass] at approximately 11:00 PM and heard the door alarm go off approximately 20 minutes before finishing. LPN #2 thought the alarm was someone taking out the trash, so she did not check the alarm and continued passing medications. LPN #2 indicated the alarm continued sounding and LPN #2 searched the door by laundry first. LPN #2 then indicated she followed the sound to the dining room, entered the code to turn off the alarm, and fully shut the door. LPN #2 indicated I did peak through the door but saw nothing and concluded such. Wrapping up my cart, I grabbed a beverage, went to the bathroom then sat down in the nurses office. About 20-30 minutes later, an [unidentified] CNA indicated they were unable to locate Resident #1. The 300-hall CNA indicated Resident #1, last seen in their wheelchair in dining room, was gone and the wheelchair was still in the dining room.A review of an OLTC Witness Statement Form dated 03/29/2026 at 12:49 AM, signed by CNA #6, indicated Resident #1 was last seen in the dining room at 6:00 PM.A review of an OLTC Witness Statement Form dated 03/30/2026 at 6:42 AM, signed by CNA #4, revealed she was informed that Resident #1 was not in their room, she then exited the back door toward the hotel, behind the building, and saw a police truck and an ambulance. CNA #4 revealed upon approaching the ambulance that she saw Resident #1 in the back, and the ambulance driver had indicated Resident #1 would be taken to the hospital.A review of an undated and untimed OLTC Witness Statement Form indicated CNA # 7 returned from break and began helping look for Resident #1 by checking the rooms on the 200 and 300-Hall, the shower rooms, and the utility rooms.A review of an undated and untimed OLTC Witness Statement Form filled out by Registered Nurse (RN) #5 indicated the other nurse [LPN #2] and their CNA approached myself, [RN #5] and the 300 hall CNA asking if we'd seen a resident who wasn't in their room. Information was communicated to all staff, and a facility wide search was initiated. RN #5 went to the hotel and observed the ambulance preparing to leave with Resident #1 in the back. Emergency Medical personnel stated Resident #1 was being taken to the hospital due to being very cold. RN #5 spoke with the hotel desk clerk who advised Resident #1 had entered the lobby at approximately 11:00 PM.During an interview on 04/01/2026 at 9:12 AM, CNA #1 indicated the last time she saw Resident #1 was on 03/28/2026 at 10:50 PM, prior to the end of her shift at 11:00 PM. She revealed she worked from 7:00 PM to 11:00 PM, on 03/28/2026. CNA #1 indicated she had reported to LPN #2 that Resident #1 was observed wandering and coming out of Resident #1's room multiple times. She stated she was told during shift change at 7:00 PM, to keep an eye on Resident #1 because the resident was moving fast and getting up often.During an interview on 03/31/2026 at 7:53 PM, CNA #8 revealed they worked on 03/28/2026 from 3:00 PM to 7:00 PM, on the same hall that Resident #1 resided on. CNA #8 indicated Resident #1 would not stay in their bed, and that the resident kept getting up. CNA #8 reported, At one point, [the resident] was really roaming bad and looking for [the resident's spouse]. CNA #8 reported that at certain times, Resident #1, who resided on 600-hall, was going in and out of other resident's rooms and the empty rooms on the 500-Hall. CNA #8 reported she told the oncoming nurse[about the behaviors].During an interview on 04/01/2026 at 11:42 AM, LPN #2 revealed she worked from 7:00 PM on 03/28/2026 until 7:00 AM on 03/29/2026. LPN #2 reported she was covering the 300, 400, and 600 Hall, and that around 11:20 PM, an unidentified aid that was covering the 400-600 Halls came to her and told her she could not find Resident #1. LPN #2 stated the last time she saw Resident #1 was around 9:20 PM. Other staff in the building were notified and a search for Resident #1 began inside and outside of the building. LPN #2 reported that RN #5 and an unidentified CNA had found Resident #1 at the hotel behind the facility. LPN #2 stated she did hear the alarm sounding on the dining room door but was unsure of the time. LPN #2 revealed she did look out the door and had turned the alarm off but did not exit the building. LPN #2 revealed she was trained on the egress-door alarm system in December of 2025, and that she was trained to assess why the alarm was sounding and to exit the facility and see if any residents had gotten out. LPN #2 confirmed they were the nurse responsible for Resident #1, and that Resident #1 resided on the 600-Hall.During an interview on 04/01/2026 at 2:13 PM, CNA #3 revealed she worked on 03/28/2026 from 11:00 PM to 7:00 AM on the 400-600 Halls. CNA #3 confirmed she was responsible for the 600-Hall, which was where Resident #1 resided. CNA #3 reported she made rounds around 11:10-11:12 PM and noticed Resident #1 was not in their room. CNA #3 stated they continued to look for Resident #1 and reported to LPN #2 a few minutes later that she was unable to locate the resident. CNA #3 indicated she searched inside and outside of the building and denied hearing the door alarm. CNA #3 reported by the time she made it to the hotel, Resident #1 was on a stretcher in the back of an ambulance and RN #5 told the ambulance driver Resident #1 was a resident of the facility. During an interview on 04/01/2026 at 8:56 AM, CNA #4 reported that RN #5 told her Resident #1 was missing and she began to search for the resident. CNA #4 indicated she walked out of the dining room door and into the field towards the hotel and ditch behind the facility. CNA #4 revealed she looked in through the closed doors of the ambulance inside the back of the ambulance and Resident #1 was being connected to the equipment in the ambulance by the EMS person. CNA #4 revealed that RN #5 arrived and informed the ambulance driver that Resident #1 was a resident to the facility located behind the hotel.During an interview on 04/01/2026 at 10:39 AM, the Maintenance Director indicated the doors to the facility had two alarm systems. The first was the egress alarm system, which controlled getting in and out of the facility. The Maintenance Director then stated, It is not a fire egress. It is a safety egress. It will open after 15 seconds of the door being held. If that alarm sounds, it means someone exited in an emergency way. The Maintenance Director indicated he covered training with all new staff on how the doors and alarms worked. He further indicated that staff were taught if the alarm sounded, staff were responsible for assessing the situation and going outside to see if a resident exited the facility and do a head count to make sure no resident was missing. The Maintenance Director then indicated this was not a written part of the training but was covered verbally.During an interview on 04/02/2026 at 11:26 AM, the Director of Nursing (DON) indicated if the alarm sounded to a door, her expectations were for the staff to assess why the alarm was sounding. She indicated you should open the door and look outside and make sure no one was outside and do an inventory inside the building for residents. The DON stated the nurse educator trained all staff on the egress system and what to do if a door alarm was sounding. The DON expressed her fear of a resident being able to access the freeway if they were outside unattended or without staff knowledge. The DON indicated the hotel front door was, approximately half a football field to a whole football field's length away from the facility's dining room door which Resident #1 exited from. The DON revealed she had a midnight census printed each night for the CNAs to do a head count on their shift. The surveyor observed the freeway to be approximately 90-120 feet from the dining room exit door.During an interview on 04/01/2026 at 3:00 PM, RN #5 revealed that on 03/28/2026 around 11:00 PM, LPN #2 came to her and told her that Resident #1 was missing. RN #5 stated she started searching for Resident #1 and that a few CNAs found Resident #1 at the hotel behind the facility. RN #5 indicated she advised the ambulance driver the patient was a resident from the facility.During an interview on 04/01/2026 at 4:26 PM, the Nurse Educator stated LPN #2 was trained in a two-day orientation on 12/18/2025, that taught the difference in the door and egress alarms. The Nurse Educator indicated LPN #2 was walked around the facility and told what to do if the door alarm sounded. The Nurse Educator then revealed that LPN #2 was taught to go outside of the facility and assess the premises to make sure no resident had eloped.During an interview on 04/02/206 at 11:39 AM, the Director of Operations (who was standing in as the Administrator) indicated that on 03/28/2026 through video surveillance it was determined, Resident #1 entered the dining room, held down the door, the door opened and alarmed, and Resident #1 exited the facility. The Director of Operations indicated LPN #2 was observed to deactivate the alarm. CNA #3 then noticed Resident #1 was missing and began searching inside and outside of the building. The Director of Operations indicated staff were trained prior to this event, on what to do if an alarm sounded and staff had been in-serviced since the incident.A review of an online Weather Service indicated the temperature for [the facility's City, State] on 03/28/2026 at 11:53 PM, was 43 degrees Fahrenheit, with calm winds.A review of an Online Mapping Service indicated the walking distance from the facility to the hotel was approximately 0.1 miles (200 feet).A review of LPN #2's two-day Orientation class on 12/18/2025, with the Nurse Educator, indicated LPN #2 was current on training for how to respond to alarms for emergencies and weather-related issues.A review of LPN #2's undated Nursing Orientation included elopement training and was signed by LPN #2 and the Long-Term Care Consultant.A review of LPN #2's General Orientation Training dated 12/12/2025, initialed by LPN #2, and signed by various department heads, included Entry/Exit Door Codes under the heading of Maintenance, and Federal and State Regulations concerning reporting under the heading of Social Services.A review of LPN #2's Job Description signed by LPN #2 on 12/12/2025, indicated the purpose of the position was to provide direct nursing care to residents and supervise the day-to-day activities performed by nursing assistants. Supervision must be in accordance with current federal, state and local standards. LPN #2's Duties and Responsibilities included many tasks, such as completing accident and incident reports. The section titled, Charting and Documentation Functions included fill out accident/incident reports and chart all reports of incident/accidents involving patients. The section titled Nursing Care Functions included notifying attending physician and next-of-kin when the patient was involved in an accident or incident, and to ensure patients who were unable to call for help were checked frequently. Lastly, the section titled Patient Rights Functions included report and investigate all allegations of abuse and/or misappropriation of patient property.A review of a facility assignment sheet dated 03/28/2026, for the 11:00 PM to 7:00 AM shift indicated CNA #4 was assigned to the 100-Hall, CNA #3 was assigned to the 400 and 600-Halls, and CNA #6 was assigned to the 300-Hall.A review of a facility Nursing Schedule revealed RN #5 and LPN #2 worked 11:00 PM - 7:00 AM, on 03/28/2026. RN #5 was assigned to the 100 and 200-Halls. LPN #2 was assigned to the 300, 400, and 600-Halls.A review of a facility provided document titled Departmental Orientation Nursing - CNA, RNA undated, indicated a Safety Section - Incident reporting (immediate, within 24 hours, to who).A review of a facility provided document titled Departmental Orientation Nursing - LPNs, RNs undated, indicated Nursing Care & Monitoring, Wandering Patients (elopement risks).A review of a facility provided document titled, Facility Timeline of Elopement, revealed:- At 11:16 PM, Resident #1 exited dining room.- At 11:18 PM, Resident #1 fell to ground adjacent to Maintenance shop.- At 11:26 PM, Resident #1 used push broom to stand, and LPN #2 turned off alarm at dining room door.- At 11:28 PM, Resident #1 was out of camera view and walking toward hotel.- At 11:35 PM, Resident #1 requested hotel desk clerk to call a cab. The desk clerk called the local police department, who then called EMS.- At 11:55 PM, EMS arrived at the hotel.- At 12:05 AM, facility staff member saw Resident #1 in back of ambulance at hotel.- At 12:07 AM, staff returned from hotel.- At 1:14 AM, nurse called local ER to obtain Resident #1's status.-At 2:13 AM, Resident #1 returned to facility and was admitted to the memory care neighborhood.A review of a policy titled Accidents/Incidents Investigating and Reporting, with a revision date of July 2017, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The policy further outlines information to be included in a completed Report of Incident/Accident form and submitted to the DON in 24 hours of incident.A review of a policy titled Elopements, with a revision date of December 2007, indicated Elopement is a resident missing from the facility without staff knowledge. A resident that exits the facility and staff is made aware either by alarms or other notification systems and is returned by staff is not elopement. The section titled Policy Interpretation and Implementation included staff shall promptly report any resident suspected of being missing to the Charge Nurse, the DON, and the Administrator. 4. If an employee discovers that the resident is missing from the facility, he/she shall: initiate search of the building(s) and premises; notify Administrator, DON, resident representative, physician, law enforcement officials, and initiate an extensive search of surrounding area.A review of a policy titled Emergency Procedure - Missing Resident, with a revision date of August 2018, indicated Resident elopement resulting in a missing resident is considered a facility emergency. The section titled Policy Interpretation and Implementation included staff would implement the protocol for missing resident, immediately upon discovering that a resident cannot be located. Document the incident and events in the resident record, including circumstances and precipitating factors and notification of police, family, and physician.A review of a policy titled Exits or Means of Egress, with a revision date of January 2019, did not include information on door alarms or response to door alarms.Review of Facility Action Plan put in place 03/29/2026 after elopement incident included: 1. All facility residents will have elopement assessment at the time of admission, quarterly, and with any change in condition.(completion date 03/29/2026)2. The resident affected was placed on secure unit. (completion date 03/29/2026)3. The resident affected was with a new elopement/assessment care plan completed. (03/29/2026)4. Provider/Family notified of the incident/plan/secure unit placement. (03/29/2026)5. Wander Guard was in place for affected residents and checked for battery/expiration date and functioning with no negative findings. (completion date 03/29/2026)6. All facility residents are with a new elopement assessment/and car plan if applicable. (completion date 03/29/2026)7. Continued monitoring and observation/documentation of weekly expiration dates/battery function/and do functioning weekly/PRN QS observation/documentation to TAR for wander guard placement. (completion date 03/29/2026)8. Any resident assessed at risk for elopement, outside the secure unit will be communicated by the closet care plan. (completion date 03/29/2026)9. All residents at risk for elopement are placed in facility elopement book. (completion date 03/29/2026)10. In servicing completed with all staff on elopement policy/Elopement book. (completion date 03/29/2026)11. NSG management will review 24-hour report/word search every AM at start-up M-F, to ensure new Admit/Re-Admits are with elopement assessment/care plan if indicated and need for further planning/intervention R/T exit seeking behavior. (completion date 03/29/2026)12. All residents will have an elopement assessment upon admission, readmission, at 72 hours, at 30 days, quarterly, change of condition and PRN. (completion date 03/29/2026)13. The facility will ensure Elopement Risk assessment for all residents at risk for elopement, are up to date and with care plan if identified at risk. (completion date 03/29/2026)14. Residents identified at risk or high risk for elopement will be care planned with appropriate interventions. The closet care plan will identify those residents for at risk and high risk to alert frontline staff of potential for exit seeking/elopement. Those identified at high risk will be placed in the designated elopement book. (completion date 03/29/2026)15. Those residents identified at risk or high risk will have an updated care plan with interventions as appropriate. The closet care plan will be updated as will (sic) at this time to reflect the most accurate information to the frontline staff. (completion date 03/29/2026)16. In the event of an actual perceived elopement or missing resident, the facility will immediately implement the missing resident protocol. (completion date 03/29/2026)Onsite Verification:Onsite verification of Action Plan was completed on 04/02/2026 at 4:00 PM.In-service provided on wandering and elopement and reporting missing residents promptly to the charge nurse, DON, and Administrator immediately upon discovery on 03/29/2026.Witness statements obtained from staff involved. Interviews conducted on 04/02/2026 with multiple staff in the facility that confirmed they did receive and understanding the recent in-service regarding elopement and the egress alarms systems on the doors of the facilityResident #1's elopement risk assessment and care plan were updated 03/29/2026. Resident #1 was placed on the secured unit. Every 2-hour visual checks completed as observation of Resident #1 for all shift on 03/29/2026.On 03/29/2026 at 4:30 AM, the Administrator went through out the facility and checked every exit door, held exit bar down for 15 seconds to assure the alarm sounded. No negative findings. Family notified on 03/29/2026 at 1:30 PM

Based on observation, record review, interviews, and facility policy review, it was determined that the facility failed to ensure staff performed hand hygiene and utilized necessary personal protective equipment (PPE) for 1 (Resident #27) of 1 resident reviewed for isolation precautions. The findings are: 1. A review of the Admission Record noted Resident #27 was initially admitted to the facility on [DATE], with diagnoses which included severe intellectual disability and autistic disorder. 2. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #27 was unable to complete a Brief Interview for Mental Status (BIMS), with a score of 00. 3. A review of the Physician Order Summary revealed Resident #27 was on enhanced barrier precautions (EBP), due to the wound to their left knee. 4. During an observation on 05/20/2025 at 5:30 AM, CNA #2 and CNA #3 were observed transferring Resident #27 using a mechanical lift and changing Resident #27's clothing. Both CNAs failed to utilize a gown while providing care. The CNAs also failed to perform hand hygiene after removing their gloves following the care and before exiting the room. 5. During an interview on 05/20/2025 at 5:30 AM, CNA #3 confirmed Resident #27 was on EBP and that she and CNA #2 should have worn gowns while providing high-contact care to Resident #27. CNA #3 confirmed neither she nor CNA #2 performed hand hygiene after removing their gloves. 6. During an interview on 05/20/2025 at 5:35 AM, CNA #2 confirmed Resident #27 was on EBP, which required a gown and gloves to be worn during close contact care. When asked why it was important to adhere to EBP while providing care, she stated to protect the residents. CNA #2 confirmed she did not perform hand hygiene after removing her gloves and before leaving the room. 7. A review of the Enhanced Barrier Precaution policy, last revised 08/2022, indicated: EBPs employ targeted gown and glove used during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, and providing hygiene. 8. A review of the Hand Hygiene policy, with a revision date of October 2023, revealed Hand hygiene is indicated immediately before touching a resident, after touching a resident, after contact with blood, body fluids, or contaminated surfaces, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after a glove removal. 9. During an interview on 05/22/2025 at 10:53 AM, Lead CNA #4 confirmed that hand hygiene before and after care was provided was an important part of infection control practices and this was how the facility trained staff to perform tasks. Lead CNA #4 also confirmed EBP and utilizing proper PPE was an important step in maintaining proper infection control. 10. During an interview on 05/19/2025 at 11:48 PM, the Director of Nursing (DON) confirmed all staff, including CNAs and nurses, received training on hand hygiene and EBP and a check-off list, in which staff were to demonstrate/teach back to the trainer, was completed once they were trained, to confirm knowledge.

Based on observation, interview, and record review, the facility to ensure food preparation equipment was free of debris to prevent potential for cross contamination; spices stored in the cabinet or on a shelf in the storage room were dated for first-in-first out spice rotation; 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition; and dietary staff washed their hands before handling clean equipment to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 89 residents who received meals from the kitchen (total census 89). The findings are. 1. On 03/04/24 at 10:51 AM, the deep fryer had an accumulation of crumbs floating on the top of the oil. The Surveyor asked the Dietary Supervisor (DS) when they last used the deep fryer and how often they cleaned it. The DS stated, They used it on Friday, and we clean it once a week. The surveyor asked the DS if the crumbs should still be on the oil. The DS stated, They should have been strained on Friday. 2. On 03/04/24 at 10:54 AM, the following observations were made around the area where ice scoop holder and ice machine were located: a. The ice scoop holder on the wall by the ice machine had a black spot at the bottom of it. The ice scoop was sitting directly on the residue. The surveyor asked the DS to wipe the area. The DS did and the wet black residue easily transferred to the tissue. When asked to describe the residue, the DS stated, It was dirt, and black residue. b. The ice machine located in the kitchen had black/pink residue on the panel where ice empties into the reservoir. The surveyor asked the DS to wipe the area. The DS did and the wet black/pink residue easily transferred to the tissue. When asked to describe the residue, the DS stated, It was dirt, black and pink residue. The Surveyor asked the DS, Who uses the ice from the ice machine and how often do you clean it? The DS stated, We use it to fill beverages served to the residents at mealtimes. 3. On 03/04/24 at 10:55 AM, the following observations were made in the spice cabinet above the food preparation counter: a. An opened container of pumpkin spice and a container of cinnamon were in the cabinet, and there were no dates on the containers to indicate when they had been received. b. A container of chicken seasoning was in the cabinet and there was no date on the container to indicate when it had been opened. c. An opened container of beef base was in the cabinet and had no opened date to allow for first in, first out storage rotation. 4. On 03/04/24 at 10:59 AM, Dietary Employee (DE) #1 was wearing gloves when opening a box that contained ham logs. DE #1 removed 2 logs of ham from the box and placed them in a pan. DE #1 unwrapped the seals from the ham logs. Without changing gloves and washing her hands, DE #1 sliced the ham and placed them in a pan. DE#1 covered the pan with foil and placed it in the oven to be heated up and served to the residents for lunch. 5. On 03/04/24 at 11:26 AM, DE #2 was wearing gloves when DE #2 pushed a utility cart out of the way. Without changing gloves and washing hands, DE #2 picked up glasses from the clean dish rack by their rims and placed them on the trays to be used serving drinks to the residents for lunch meal. At 12:20 PM, the surveyor asked DE #2, What should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have taken the gloves off and washed my hands. 6. On 03/04 /24 at 11:27 AM, DE #1 removed a pan that contained cooked ham from the oven and placed it on the counter. DE #1 then contaminated their hands by picking up pans from underneath the preparation counter and placed them on the counter with the fingers touching the inside of the pans. DE #1 picked up a spray bottle from the counter and sprayed inside the pans. Without washing hands, a bare hand was used to attach a clean blade at the base of the blender to be used in grounding and pureeing meat to be served to the residents on mechanical soft and pureed diets for lunch. 7. On 03/04/24 at 11:34 AM, DE #1 opened the oven door and placed a pan that contained ground ham into the oven. Without washing hands, DE#1 picked up a blade and attached it to the base of the blender to be used in pureeing meat to be served to the residents who required pureed diets for lunch meal. 8. On 03/04/24 at 11:42 AM, the following observations were made in the storage room. a. There was a container of garlic powder on a shelf in the storage room but had no opening date. b. There was an opened bag of hash brown in an opened plastic resealable bag on a shelf in the storage room. Neither bag was sealed. 9. On 03/04/24 at 12:03 PM, DE #3 who was filling glasses with beverages to be served to the residents for lunch meal was observed touching beverage dispenser with a bare hand. Without washing hands, DE #3 picked up glasses that contained ice by the rims and placed them on the tray. At 12:18 PM, the surveyor asked DE #3, What should you have done after touching dirty objects and before handling clean equipment? DE #3 stated, I should have washed my hands. 10. On 03/05/24 at 11:36, DE #5 turned on the food preparation sink faucet with a bare hand. With the contaminated hand, DE #5 picked up glasses by their rims and obtained water in them to be served to the residents for lunch. The Surveyor asked DE #5, What should you have done after touching the dirty objects and before handling clean equipment? DE #5 stated, Washed my hands. 11. A facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices documented, .Employees must wash their hands .During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and or after engaging in other activities that contaminate the hands . 49596

Based on observation, interview, and record review, the facility to ensure a call light was within reach for 2 (Resident #6 and R#387) of 17 sample mix residents who could use a call light. The findings are: 1. Resident #6 had diagnoses of Dementia, Muscle wasting and atrophy, Epilepsy, Difficulty in walking, and Abnormalities of gait and mobility. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/25/24 showed a Brief Interview for Mental Status (BIMS) of 13 (13 to 15 indicates cognitive intactness). 1a. The care plan showed .staff are to encourage the resident to .utilize the call light for assistance, if needed . 1b. On 03/04/24 at 01:25 PM, the Surveyor observed Resident # 6 call light lying on the floor. 1c. On 03/04/24 at 03:09 PM, the Surveyor observed the resident's call light lying on the floor. 1d. On 03/04/24 at 03:13 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, Where should a call light be placed while a resident is in bed? CNA #6 stated, Within reach. The Surveyor asked, Where is Resident #6 call light? CNA #6 stated, Attached to the wall. The Surveyor reiterated, Where is the residents call light? CNA #6 stated, Attached to the wall. The Surveyor asked, Is the end with the call button on the wall? CNA #6 stated, No. The Surveyor asked, Where is the end with the call button? CNA #6 stated, On the wall. 1e. On 03/04/24 at 03:18 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Where should a call light be placed while a resident is in bed? LPN #2 stated, Within reach. The Surveyor asked, Can you tell me where Resident #6 call light is located? LPN #2 stated, In the floor. 1f. On 03/05/24 at 02:23 PM, the Surveyor asked the Director of Nursing (DON), Can you tell me where the call light is? The DON confirmed the call light was on the floor. 49866 2. Resident #387 had diagnoses of Type 2 diabetes mellitus without complications, Other atherosclerosis of native arteries of extremities, other extremity, and Mixed hyperlipidemia. Resident #387 admitted on [DATE]. The findings are: 2a. On 03/06/24 at 01:29 PM, the Care Plan for Resident #387 did not show any addressed areas for call lights or Activities of Daily Living (ADL) at this time. 2b. On 03/04/24 at 02:13 PM, the surveyor observed Resident #387 ' s call light in floor next to the bed, underneath the bedside table, and not in the resident's reach. 2c. On 03/05/24 at 09:37 AM, the surveyor observed the call light sitting on the dresser not in the resident's reach. 2d. On 03/05/24 at 09:43 AM, the surveyor asked Nurse Assistant (NA) #1, Where is a call light supposed to be? He/she stated, In reach of the patient. The Surveyor asked NA #1, Can you tell me where this call light is located? NA #1 stated On the dresser, not in reach. NA #1 then moved the call light into reach of resident at that time. 2e. On 03/05/24 at 10:16 AM, the Surveyor asked LPN #1, Can you tell me where this call light is located? LPN #1 stated, On the bed next to [the resident]. The Surveyor asked, Where is a call light supposed to be? LPN #1 stated, Within reach, and I will get a clip put on there for the resident, so it can be clipped to bed. A document provided by DON on 3/7/24 at 9:34 AM titled CNA Job Description showed, .Keep the nurses' call system within easy reach of the patient .

Based on observation and interview the facility failed to ensure residents meals were removed from the serving trays in the dining room to de-emphasize the institutional character of the setting to promote dignity and respect. This failed practice had the potential to affect 3 (Residents #20, #30, and #73) sampled residents who eat in the dining room. The findings are: On 03/04/24 at 12:54 PM, the Surveyor observed the Director of Nursing (DON) delivering meals to 3 separate residents, leaving the plate of food and drinks on the serving tray. On 03/04/24 at 01:02 PM, the DON confirmed leaving the meals on a serving tray was not homelike. A document titled Resident Rights provided by the Nurse Consultant on 3/5/24 at 2:45 pm showed, .Federal and state laws guarantee certain basic rights to all residents .The rights include .be treated with respect, kindness, and dignity .

Based on observation and interview, the facility failed to ensure call lights were answered in a timely manner. This failed practice had the potential to affect 2 (Resident #43 and #82) of 17 sample mix residents who can use a call light. The findings are: 1. On 03/04/24 at 02:24 PM, the Surveyor observed Resident #43 push the call light after indicating to the Surveyor they were wet. The call light sounded and then stopped. No light came on outside of the door. 1a. On 03/04/24 at 02:36 PM, a Certified Nursing Assistant (CNA) answered the call light then left the room. 1b. On 03/04/24 at 02:39 PM, the CNA returned to the room with Nursing Assistant (NA) #2. 1c. On 03/04/24 at 02:44 PM, the Surveyor asked NA #2, Do the lights come on outside the door when a resident presses their call light? CNA #7 stated, The lights do not turn on outside the door or make an alarm. The room number and time shows up on the hall clock and on the screen at the nurse's desk. The Surveyor asked, Why did it take so long to answer Resident #43's call light? NA #2 stated, There are 2 NA's and 1 CNA. We each have a section and help each other. 49071 2. On 3/4/24 at 2:14 pm, Resident #82 stated a medication was needed, and the call light had been pushed. The Surveyor stayed in the room with resident for some time before leaving and approaching the nurse station. The screen that alerted staff when a call light is on displayed Resident #82's call light had been on for 32 minutes. 2a. On 3/4/24 at 2:43pm, Licensed Practical Nurse (LPN) #2 confirmed they were assigned to the hall on which Resident #82 resided and were responsible for answering call lights. LPN #2 confirmed Resident #82's call light had been on for 32 minutes and the resident could be hurt and require immediate attention. 2b. On 3/6/24 at 1:15 pm, the Assistant Director of Nursing (ADON) was asked, How is your staff alerted to a call light when it is pushed by a resident? The ADON stated, There are blinking boards at the end of each hall to let the staff know, as well as a board at each nursing station. The ADON was asked, Can a nurse answer a call light? The ADON confirmed they could. The ADON was asked, If a nurse is sitting at desk at the nursing station and the call light is going off and showing on the screen what should the nurse do? The ADON stated, Get up and answer the call light and take care of the resident, then go find out where your certified nursing assistant is and where they have been. The ADON was asked, What negative outcome could occur if a call light isn't answered in a timely manner? The ADON stated, Anything could happen I mean, a fall, death or any number of accidents could occur. 2.c. On 3/7/24 at 9:34 am, the Director of Nursing (DON) provided a document titled Job Description Certified Nursing Assistant that documented, .Answer patient calls and call lights or other notifications promptly .

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 03/04/24 at 11:35 AM, Dietary Employee (DE) #1 placed 6 servings of sliced ham into a blender, added juice from the cooked ham, used #10 scoop to add a serving of thickener and pureed. At 11:37 AM, DE #1 poured the pureed ham into a pan to be served to the residents on pureed diets for lunch. The mixture did not have a smooth consistency and had particles of thickener that were not completely pureed, and there were pieces of intact ham visible in the mixture. 2. On 03/04/24 11:44 AM, DE #1 placed 6 servings of cornbread into a blender, added 2 cartons of warm whole milk and pureed. At 11:47 AM, DE #1 poured the pureed cornbread into a pan and placed it in the oven. The consistency of the pureed cornbread was lumpy and was not smooth. 3. On 03/04/24 at 12:02 PM, DE #2 placed 8 servings of brownies into a blender, added a carton of whole milk and poured. DE #2 used a #8 scoop to portion pureed brownies into 6 bowls. The consistency of the pureed brownies was runny and was not formed. 4. On 3/04/2024 at 12:06 PM, a pan of pureed spinach was on the steam table. The consistency of the pureed spinach was running and was not formed. 5. On 03/04/24 at 12:27 PM, the Surveyor asked DE #4 to describe the consistency of the pureed food items served to the residents on pureed diets. DE #4 stated, Pureed ham was not smooth, it was thick and gritty. It should be pureed a little longer. Pureed macaroni and cheese were thick, not smooth and was lumpy. Needed to be pureed a little longer. Pureed cornbread was lumpy and not smooth. Pureed spinach was runny, it needed to be thickened. At 12:58 PM, the Surveyor asked DE #1 to describe the consistency of the pureed. DE #1 stated, I consider flavor, color, texture of nectar. The Surveyor asked DE #1 to look at the pureed ham that was still on the tray line. DE #1 stated, It was thick and there were lumps of ham in the pureed meat. The Surveyor asked DE #1 to look at the pureed cornbread, macaroni and cheese and the turnip greens and describe their consistency. DE #1 stated, Spinach was too runny, the cornbread and macaroni and cheese were not a smooth texture. The cornbread, macaroni and cheese and ham all appeared thick, grainy, and lumpy. They were not pureed enough, and they should have been smoothie, thick and free of lumps. 6. On 03/05/24 at 08:10 AM, the following observations were made in the dining room. a. The pureed biscuit served to the residents who required pureed food items at the breakfast meal was not thick enough and lumpy. b. The puree meat served to the residents on pureed diets was gritty and thick. c. On 03/05/24 at 08:12 AM, the surveyor asked the DE #4 to describe the consistency of the pureed food items served to the residents on pureed diets for breakfast meal. DE #4 stated, Pureed biscuit was thick and lumpy. Pureed meat was lumpy and not smooth. 49596

Based on observation and interview, the facility failed to ensure that staff were wearing PPE (Personal Protection Equipment) correctly in the facility when residents had been diagnosed with Covid-19. The failed practice had the ability to affect 89 residents in the facility. The findings are: 1. On 3/4/2024 at 12:08 PM, Certified Nursing Assistant (CNA) #1 was passing trays in the main dining area with mask pulled down under their nose. 2. On 3/5/24 at 08:36 AM, CNA #2 was in the weight room where residents were present with their mask pulled down under their chin. 3. On 3/4/24 at 12:11 PM, CNA #1 was asked how a mask is intended be worn. CNA#1 stated, Over my nose and mouth. CNA #1 was asked, Why should you wear it over your nose and mouth? CNA #1 stated, To protect ourselves and the residents. 4. On 3/5/24 at 08:37 AM, CNA #2 was asked, Should staff be wearing a mask when they are around residents? CNA #2 confirmed, Yes, we should be. CNA #2 was asked, How is the proper way to wear your mask? CNA #2 stated, Over my nose and mouth. 5. On 3/6/24 at 10:47 AM, the Director of Nursing (DON) was asked, How should the proper way of PPE to be worn? The DON stated, Wear your mask over your nose and mouth and your gloves and gown when indicated. 6. On 3/6/24 at 2:45 PM, a policy titled Personal Protective Equipment, was received from the Nurse Consultant which documented, Policy Interpretation and Implementation . 5. Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals .

Based on interview and record review, the facility failed to ensure Dementia in-service training was provided in the past year. The findings are: On 03/07/24 at 11:20 AM, The Surveyor reviewed in-services and competency training for the past year and did not locate a Dementia in-service. The Surveyor requested the Dementia In-Service. On 03/07/24 at 11:29 AM, the Administrator stated, We looked through all the in-services and could not find one for Dementia. The Surveyor asked, Do you have a Dementia in-service for the past year? The Administrator confirmed there has been no Dementia in-service training for the last year.

Based on observation, interview, and record review, the facility failed to ensure fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming. This failed practice had the potential to affect 2 (Resident #31 and R#44) residents of 21 sampled residents; and the facility failed to ensure 1 (Resident #72) of 11 sampled residents received a shave. The findings are: 1. Resident (R) #44 diagnoses included Alzheimer's disease, Dementia with agitation, and Bell's palsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/24 showed a Brief Interview for Mental Status (BIMS) of 01 (0 to 7 points indicates severe cognitive impairment). R #44 required maximum/substantial assistance with personal hygiene. 1a. The care plan for R #44 showed the resident required assistance with activities of daily living (ADL) related to weakness and cognitive loss. Staff are to provide assistance to the extent necessary with ADL (hygiene, etc.) and the resident requires minimal assistance x1 with ADL tasks. 1b. On 03/04/24 at 01:46 PM, R #44 ' s fingernails were 1/4 inch long with jagged edges and brown matter underneath. 1c. On 03/04/24 03:08 PM, R #44's fingernails were 1/4 inch long past the nailbed with jagged edges and brown matter underneath. 1d. On 03/04/24 at 03:15 PM, the Surveyor asked Certified Nursing Assistant (CNA) #6, How often are nails trimmed and cleaned? CNA #6 stated, Shower days. The Surveyor asked, Who is responsible for trimming and cleaning nails? CNA #6 stated, The CNA that does the shower. The Surveyor asked, Can you describe Resident # 44 nails? CNA #6 stated, They look fine. The Surveyor asked, Are they long, jagged, or dirty? CNA #6 stated, Yes Ma'am, they are. 1e. On 03/04/24 at 03:19 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Who is responsible for trimming and cleaning nails? LPN # 2 stated, [R # 44] is diabetic, so the nurses are responsible for trimming. On shower days the CNA typically cleans them and notifies the nurse if they need a trim. The Surveyor asked, Will you describe the resident's fingernails for me? LPN #2 stated, They are dirty and could use a trim. 1f. On 03/05/24 at 02:19 PM, the Director of Nursing (DON) confirmed the resident's fingernails need to be cleaned and trimmed. 37634 2. Resident #31 had diagnoses of Need for assistance with personal care and Squamous cell carcinoma of anal skin. The Discharge MDS with an ARD of 2/27/24 documented the resident required modified independence for cognitive skills for daily decision making and required substantial/maximal assistance with personal hygiene. A care initiated 8/30/23 documented, .Attempt to keep hands/nails clean . On 3/04/24 at 3:25 PM, R #31's nails were 1/2 inch long, jagged with a brown substance underneath them. On 3/04/24 at 3:27 PM, CNA #7 was asked, How often are [R #31's] nails trimmed and cleaned? CNA #7 stated, Whenever they get long enough to cut. On 3/04/24 at 3:37 PM, R #31 asked this Surveyor, Can you cut my nails? R #31 was asked, Did [CNA #7] cut your nails when [CNA #3] was in your room? R #31 stated, No [CNA #3] didn't. R #31 was asked, Is there a reason [CNA #3] didn't cut your nails? R #31 stated, I don't know. R #31's nails were 1/2 inch long, jagged with a brown substance underneath them. On 3/04/24 at 3:28 PM, CNA #7 was asked, Can you tell me why you didn't cut [R #31's] nails when you were in the room a few minutes ago? CNA #7 stated, I cut the corner off one of [R #31's] nails. That's all [R #31's] asked me to do. On 3/05/24 at 2:45 PM, Nurse Consultant #1 provided a policy titled, Fingernails/Toenails, Care of. It documented, .The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming . Proper nail care aid in the prevention of skin problems around the nail bed . 3. Resident #72 had diagnoses of Need for assistance with personal care and Wedge compression fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing The Modification of Admission /Medicare - 5 Day MDS with an ARD of 2/04/24 documented the resident scored 10 (8-12 indicates moderately impaired) on a BIMS and required substantial/maximal assistance with personal hygiene. A care initiated 2/06/24 documented, .Shaved by staff . On 3/04/24 at 11:17 AM, R #72 ' s beard was 1/2 inch long. On 3/04/24 at 2:12 PM, R #72 ' s beard was 1/2 inch long. On 3/04/24 at 2:13 PM, R #72 was asked, How often do you get a shave? and stated, It's been a long time. I would love to have a shave now. On 3/04/24 at 2:45 PM, CNA #4 was asked, How often does [R #72] get a shave? CNA #4stated, [R #72] should get one every shower day. CNA #4 was asked, What's [R #72's] shower day? CNA #4 stated, Every Monday, Wednesday, and Friday on the second shift. CNA #4 was asked, Can you tell me why [R #72] hasn't been shaved? CNA #4 stated, I don't know. On 3/05/24 at 2:45 PM, Nurse Consultant #1 provided a policy titled, An Activities of Daily Living (ADL) . which documented, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on observation, interview, and record review, the facility failed to assure that 1 (Resident #56) of 1 sampled got to go to their smoke breaks. The findings are: On 3/04/24 at 1:47 pm, Resident (R) #56 reported not having gotten to go out to smoke for 3 days, and that when a certified nursing assistant (CNA) was asked they say they don't have time or enough staff to take resident to smoke. On 3/05/24 at 10:45 am, the Director of Nurses (DON) was asked, Does [R #56] smoke? The DON confirmed, Yes, this resident does go out sometimes to smoke. The DON was asked, If a resident asks to be gotten up to smoke what should the staff do, and stated, The staff should get the resident up and take them. The DON was asked, If a resident refuses to get up to go smoke after asking staff to come and get them, up what should the staff do? The DON confirmed, Document that they didn't want to get up. On 3/05/24 at 10:45 am, the Nurse Consultant (NC) was asked, Should [R #56] be on the smoking list if a resident smokes, and is care planned for smoking? The NC confirmed, Yes, we will get them added to the list. On 3/05/24 at 3:21pm, CNA #3 was asked, If a resident asks to get up to go smoke what should the staff do? CNA #3) stated, Get them up to go smoke. CNA #3 was asked, If a resident is getting low on cigarettes what should the staff do? CNA #3 stated, Notify the social worker so they can purchase them or contact the family to bring some. CNA #3 was asked, Is it a resident right to go smoke if they desire to? CNA #3 confirmed, Yes, it is. CNA #3 was asked, If a resident asks staff to get them up to smoke and then changes their mind and doesn't want to get up, what should the staff do? CNA #3 confirmed, Document that they refused to get up. On 3/6/24 at 10:45 am, the NC provided a policy titled, Smoking Policy-Residents which documented, .Policy Statement . The facility has established and maintains safe resident smoking practices . Policy Interpretation and Implementation 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences .

Based on observation, interview, and record review, the facility failed to ensure catheter securement devices were utilized for 1 (Resident #69) of 3 sampled residents (#27, #69, #82) who had an indwelling catheter in place. The findings are: On 03/04/24 at 1:32 pm, Resident #69 did not have any securement device in place to hold catheter tubing in place to avoid trauma to the urethra by preventing pulling and tension. On 3/5/24 at 10:05 am, Resident #69 did not have a securement device to hold catheter tubing in place. On 3/5/24 at 3:25 pm, Certified Nursing Assistant (CNA) #5 was asked, How should a foley catheter be secured? CNA #5 stated, By a leg strap or [named brand of catheter securement device]. CNA #5 was asked, Who is responsible for making sure an indwelling foley security device is on the resident? CNA #5 stated, The nurse usually puts them on. On 3/5/24 at 3:33 pm, the Director of Nurses (DON) was asked, How should a foley catheter be secured? The DON stated, By using a [named brand of catheter securement device]. The DON was asked, Who is responsible for making sure a resident with an indwelling foley has this in place? The DON stated, The nursing staff or the CNA. On 3/6/24 at 2:13 pm, a policy titled, Foley Catheter Insertion Female Resident, was provided by the Nurse Consultant which documented, .Steps in the Procedure . 25. Attach catheter to drainage tubing. Tape catheter to inner thigh or secure with leg band .

Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident #32) of 1 sampled resident received a thorough head to toe skin assessment. This had the ability to affect 89 residents. The findings are: On 3/4/24 at 11:29 am, Resident (R) #32 reported they had a sore on the top of the head that was draining. The Surveyor observed a sore with a scab and open area with drainage on the top of the resident's head. The Surveyor asked if the Resident had informed anyone. R #32 stated, I have been telling my nurse on every shift for 2 or 3 weeks that I need to see my doctor, and no one has done anything. I really need to see my doctor. On 3/5/24 at 11:30 am, Skin assessments documenting no sore to R #32 had been completed for the past two weeks. On 3/7/24 at 8:20 am, Licensed Practical Nurse (LPN) #3 was asked, When a skin audit is performed how should this be done? LPN #3 stated, Start with the head and move down over the entire body. LPN #3 was asked, If a Resident complains to the nurse that they have a draining sore what should the nurse do? LPN #3 stated, I would first assess it to make sure it was there, then I would contact the APRN [Advanced Practice Registered Nurse] to see the resident when he was here next, then I would contact the wound care nurse to start treatment on it. LPN #3 was asked, What negative outcome can occur from an oozing sore that is not treated? LPN#3 stated, They could become septic. On 3/5/24 at 3:30 pm, the Director of Nursing (DON) was asked, When a skin audit is performed can, you explain how this is done. The DON stated, The nurse does a complete head to toe assessment. The DON was asked, If a resident complains of having a draining wound to the nurse what should happen. The DON stated, The nurse should go assess to see if there is a wound, then if there is one they need to call APRN to see what they want done and so the APRN can see them as soon as they are in the building next. The DON was asked, If a wound is not addressed by anyone, what negative outcome could occur? The DON stated, The resident could develop an infection. 5. On 3/6/24 at 3:52pm, the Administrator informed the Surveyor the facility did not have a policy regarding skin audits.

Based on interview, observation, and record review, the facility failed to preform nail care on two (Resident #2 and #3) of six (Resident #2, #3, #4, #5, #6 and #7) sampled residents who were dependent on the staff for nailcare according to a list supplied by the Nursing Consultant on 08/22/2023 at 3:59 PM. The findings included: On 08/21/2023 at 11:39 AM Resident #2 was observed sitting in a Geri Chair with contractures to both hands. The nails on both hands were long and jagged. On 08/22/2023 at 9:40 AM Resident #2 observed in room sitting in a Geri Chair. Fingernails on both hands and toenails on both feet were 1/4 inch past the tips of the fingers and toes. Review of Resident #2's Care Plan with a revision date of 04/26/2021 showed, Provide assistance to extent necessary with ADLs (bathing, dressing, grooming, toileting, hygiene, etc.) Requires extensive assistance with ADL tasks. Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident required extensive assistance of 2 people for personal hygiene and bathing. On 08/21/2023 at 11:25 AM Resident #3 was observed in in bed with toenails 1/4 inch past the end of the toes and jagged. On 08/22/2023 at 2:50 PM Resident #3 was asked Would you like your nails trimmed and filed? Resident #3 stated, I do my own fingernails, but yes, it would be nice to have my toenails trimmed, they are long. Resident #3's care plan with a revision date of 01/25/2022 showed, on bath day, check nail length trim as necessary and report any changes to the nurse. Resident #3's Quarterly MDS dated [DATE] showed Resident #3 required extensive assistance of one staff member with personal hygiene and bathing. On 08/22/2023 at 1:35 PM Assistant Director of Nursing (ADON) #2 confirmed Resident #3's toenails on both feet were thick, jagged and 1/4 to a 1/2 inch past the tips of the toes. The Surveyor asked ADON #2 when are resident's nails trimmed? she stated, On bath days. On 08/22/2023 at 2:52 PM the Surveyor asked ADON #2 who is responsible for nail care? ADON #2 said the nurse perfoms nail care if the resident is a diabetic. If the resident is not a diabetic, the Certified Nursing Assistant (CNA) performs the nail care. On 08/22/2023 at 2:45 PM review of the task sheets for Resident #2 and #3, received from the Administrator showed no specific tasks listed for nail care. Review of the facility's policy titled Care of Fingernail/Toenails with a revision date of 02/2018 showed, nail care includes daily cleaning regular trimming.

Based on record review, witness statements, and interviews the facility failed to provide adequate assistance with transfers for 1 (Resident #3) resident who required a two person assist for transfers and had a documented history of falls. The failed practice resulted in past non-compliance. The findings are: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/27/23 documented resident required 2-person assistance with transfer. a. The Care Plan initiated on 12/13/22 documented, .Falls: Increased risk for falls related to cognitive loss, history of falls, very poor safety awareness, and potential med side effects. Resident is unable to use call light to call for assistance due to cognitive impairments. 3/21/2021 Fall, 5/22/2021 Fall, 5/25/2021 Fall, 8/19/2021 Fall, Unavoidable falls 11/2/2021, Fall 4/8/2022, Fall 6/29/2023, Fall .Transfers x2 [times two] assist Wheelchair for general mobility-Mobile via staff push .ADL [Activities of Daily Living] status/Pain: Requires extensive to total assistance with ADL's related to cognitive loss. Dx. [Diagnosis] Dementia and Alzheimer's. Resident is edentulous 9/14/2021 Decline in ADL function noted related to weakness associated with pneumonia .Provide assistance to extent necessary with ADLs (Bathing, dressing, grooming, toileting needs/pericare, hygiene, etc.) Requires extensive to total assistance x2 with ADL tasks .Resident has a current diagnosis of Dementia and Alzheimer's Disease . b. Closet Care Plan in Resident #3's room with a print date of 06/26/23 documented, .Transfer, Extensive assistance, two persons physical assist . c. A Nursing I & A (Incident and Accident) Note dated 06/29/23 at 1804 (6:04 PM) showed, called to room by CNA [Certified Nursing Assistant), resident lying on floor on left side, no s/s [signs/symptoms] of pain noted, no injuries noted. ROM [Range of Motion] WNL [Within Normal Limits] for resident no injuries noted, resident assisted back to bed by staff x2. d. A timeline of documentation provided by the facility for 07/18/23 showed: 12:00 PM - CNA transferred resident from bed to wheelchair X 1 assist 1:30 PM - CNA transferred resident from wheelchair to bed x 1 assist 3:00 to 3:30 PM - CNA changed resident and provided peri care X 1 assist 3:40 PM - the ADON (Assistant Director of Nursing) assessed resident and ROM WNL 6:25 PM - LPN (Licensed Practical Nurse) assessed leg and did not document and findings and reported her findings to oncoming nurse 6:45 PM - CNA x 2 assist provided care and notified LPN of swelling of leg and bruising, and looked broken 7:20 PM - LPN observed right leg turned out while patella and upper thigh turned inward. Notified APRN (Advanced Practice Registered Nurse) via Telemed. Orders received to send to ER (emergency room ). e. On 7/18/23 Physician ordered, Send to ER [emergency room ] for eval [evaluation] and tx [treatment] pain in R [Right] leg. f. 07/18/23 ER documentation, .Comminuted, Angulated, and impacted distal femoral metaphyseal .She is non ambulatory and her bone quality is not good. Because of these 2 factors I think it is unwise to consider internal fixation. I am not sure the screws would hold for 1 and the other is that she is non ambulatory and has a flexion contracture . g. The following Witness statements were obtained regarding the events that occurred with Resident #3: -Witness statement dated 07/19/23 completed by Certified Nursing Assistant (CNA) #9 documented, During Monday 7/17/23, I [employee name] gave [Resident name] a shower and all that was noticed was an old yellow bruise on her right lower thigh. I then informed the charge nurse on the hall. -Witness statement dated 07/19/23 completed by CNA #5 documented, As of Monday, when we transferred [Resident #3] back to bed, we asked charge nurse please take a look at her knee and inner knee cause of bruising. The color of bruising was yellowish for I know this past weekend we worked which was Sat [Saturday], Sun [Sunday], and Mon [Monday] she would guard her knee and would favor it not putting any weight on it. When transferring [Resident #3], we use 2 [two] people transfer and a gait belt. She doesn't pivot or turn or stand by herself or with help. -Witness statement dated 07/19/23 completed by CNA #6 documented, I, [employee name] worked the 400 hall on 7/17/23. At that point [Resident #3] had a light-colored bruise on the inside of her leg and slight swelling of her knee. I noticed when she was rolled to be changed, she would grab her right knee and seemed to be in pain. My sister, [CNA #5] and I informed the nurse. When we transfer [Resident #3] we use a gait belt and two people. -Witness statement dated 07/19/23 completed by Licensed Practical Nurse (LPN) #1 documented, 7/17/23 CNA's brought to my attention resident had bruising to her R [right] thigh and they thought her knee was hurting her. I told CNA's I would assess it after her shower and if it needed to by x-rayed I would get one. After shower complete and resident was put to bed this nurse went down an assessed residents leg. Bruising noted to inner R [right] thigh. Bruise appeared to be a few days old. I did ROM [Range of Motion] on leg. Full ROM R knee and foot. Resident showed no signs of discomfort with ROM. R knee was slightly longer than the left. I did not order x-ray because resident ROM was WNL [Within Normal Limits]. I also was aware resident had a recent fall which possibly caused the bruising. -Witness statement dated 07/19/23 completed by LPN #3 documented, I came on shift on 7/18/23 at 7am and Resident was up in chair in the common area in Med A station. Resident had no distress noted during that time. Resident showed no signs of pain or discomfort. I gave report and ended my shift at 1400 [2:00pm] to ADON (Assistant Director of Nursing). Nothing reported to me from staff during my shift. -Witness statement dated 07/19/23 completed by Certified Nursing Assistant (CNA) #1 documented, I went and got [Resident name] up at around noon yesterday for lunch. I did transfer by myself from her bed to her wheelchair. I have worked with her before, but I didn't look at her care plan before providing care. -Witness statement dated 07/19/23 completed by CNA #2 documented, Tuesday the 19th approximately 1:30pm I put [Resident name] to bed. I pulled her wheelchair as close to the bed as possible and I proceeded to place my arms around her in a bear hug position and set her on the bed and I performed peri care on her and put a clean brief on her and position her bed and put floor mat down. -Witness statement dated July completed by CNA #7 documented, I came in around 3:00pm and started around 3:30pm to change 400 hall. I started in [Resident #3] room. When I removed the covers off her I saw that she had a purple/blackish and yellow bruise on her thigh (right thigh). That her right leg was bent as well. I reported to the charge nurse which was the DON [Director of Nursing] and ADON [Assistant Director of nursing] [name]. I let them know about the bruise and her leg looking bent in bed. I continued to change her. She didn't try to push my hands away or showed any movement like she didn't want to be changed. I went in there again around 5:45pm to feed [Resident #3] dinner. I later did another round about 7:00pm [Resident #3] needed to be changed again so I had another CNA go in the room with me to get her changed. When I went to change her the last time I saw her leg still looking deformed and the bruise, so I let [nurse name] know. She was the next nurse who came in. -Witness statement dated 07/19/23 completed by ADON (Assistant Director of Nursing) Documented, This nurse was approached by a CNA stating resident has a bruise and asked nurse to assess. Upon entering the room, resident was lying in bed with eyes closed, respirations even and unlabored. Nurse assessed area reported. Brusing noted to inner thigh, yellow in color. Area cool to touch, no edema noted, ROM completed an WNL. No signs of pain or discomfort noted with ambulation. Results reported to DON. This nurse was notified by CNA at approximately 1530 [3:30pm] and resident was assessed at approximately 1540 [3:40pm]. -Witness statement dated 07/18/23 completed by DON (Director of Nursing) documented, CNA notified this nurse and ADON that resident had a bruise to her R [right] upper thigh, indicating area by rubbing her own R thigh. ADON immediately called the tx [treatment] nurse asking if she had noticed any bruising. She informed him that she was not aware of any bruising, but resident did have a fall on 6/29/23. ADON assessed the resident at this time and reported back to me that she had a yellowing old bruise to R upper thigh. He stated he performed ROM and resident did not express/indicate pain or discomfort. He also reported no noted edema, redness, or warmth. -Witness statement dated 07/18/23 completed by CNA #8 documented, On July 18th, 2023, at 6:45pm I went and help with care on [resident name] with [CNA #7]. When I went in, she was in a fetal position. After care, I went to my nurse [LPN#2 name] and ask did she get report about [Resident #3] and that her leg looks broke. When we were doing cares, I saw swelling and a bruise on inner thigh. After reporting it to the nurse she came to look, and she was not informed about [Resident #3] leg. Looking at the bruise one part was yellow and the other part was dark purple. -Witness statement dated 07/19/23 completed by LPN #2 documented, As I was passing medicine to my residents the CNA asked me if I could come look at another resident because her leg looked weird. I finished my med pass and went to the resident's room at 1525 [6:25pm]. When I arrived to the resident's room, I noticed a bruise on the resident's leg. The bruise on the resident's leg was red and fingerprint marks were implanted in her leg. The aide told me that she couldn't straighten her leg and tried to show me. I told her to not try to straighten her leg I did not report the incident because the CNA's told me that it was already reported to the ADON and DON before they left for the day. When I took the keys for 400/600 hall nothing was reported to me about the resident's leg. I reported the incident to the oncoming nurse when she arrived. I did not document what I seen in the resident log. -Witness statement dated 07/19/23 completed by LPN #4 documented, This nurse clocked into work on 7/18/23 at 1839 [6:39pm]. This nurse reported to assigned halls to take report and count cart with day shift nurse. Day shift nurse was called by this nurse at 1843 [6:43pm]. She stated she was in a room with a resident. While waiting for day shift nurse, CNA reported [Resident#3]: her right leg looked really weird and I think it could be hurting her. CNA also reported a bruise to the right inner thigh. Upon inquiring CNA about falls or injuries, CNA denied knowledge and stated she reported findings to DON and ADON prior to night shift. In the middle of CNA report day shift nurse arrived and reported abnormality and bruise to leg and asked that I follow up on it. This nurse proceeds to count and get report from day shift nurse. I tended to a different resident to administer comfort care meds then proceeded to 400 hall with med cart. CNA reminded me to check on [Resident #3], Upon inspection, a blue/black/purplish bruise was noted to inside of right thigh. Right leg was noted to be visibly abnormally placed and positioned. Right foot was noted to be turned outward while patella and upper thigh noted to be turned inward. Upon assessment, I was unable to abduct or adduct RLE [Right Lower Extremity] nor was I able to assess ROM in any direction of the leg, hip, knee, or ankle. Upon attempt, the resident cried out in pain. Assessment stopped and APN [Advanced Practice Nurse] notified as I saw no new orders or interventions for this resident and was told the incident had been reported. APN denied knowledge. Telemed visit conducted, new orders received to send to ER [emergency room ] for eval and treat r/t [related to] pain and decreased mobility of right leg. APN notification at 1920 [7:20pm]. DON notified of findings and orders at 1927 [7:27pm]. DON stated it had been reported to her and ADON. DON stated ADON assessed resident and there were no abnormal findings. Medic One called for transport at 1928 [7:28pm]. Once Medic One arrived, I was questioned about the origin of possible injury and bruise. I denied knowledge of origin. Medic stated, I have to call this in. She has a broken leg and finger tip bruising to her thigh, without unknown cause. I voiced understanding and attempted to notify DON at 1959 [7:59pm] with no answer. I then notified Admin per chain of command at 2000 [8:00pm]. DON returned my call at 2002 [8:02pm] and was notified of transport and Medic One's Observations/statement. Resident left the facility with Medic One at 1958 [7:58pm]. Son [name] notified at 1942 [7:42pm]. h. On 07/21/23 at 1:32 pm, the Surveyor asked CNA #3, Where is the residents transfer assistance level documented so that you know how the resident is transferred? CNA #3 stated, In the closet care plan. The surveyor asked CNA #3, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? CNA #3 stated, No. They surveyor asked CNA #3, Why? CNA #3 stated, Because there is a risk for falls and there is a reason the resident is a two person assist. Mostly for safety reasons. i. On 07/21/23 at 1:35 pm, the Surveyor asked CNA #4, Where is the residents transfer assistance level documented so that you know how the resident is transferred? CNA #4 stated, In their closet care plan. The surveyor asked CNA #4, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? CNA #4 stated, No. Not at all The surveyor asked CNA #4, Why? CNA #4 stated, Because you can drop them, hurt them and it's not practical at all. j. On 07/21/23 at 1:42 pm, the Surveyor asked Director of Nursing (DON), Where is the residents transfer assistance level documented so that you know how the resident is transferred? DON stated, In their closet care plan and care plan. The surveyor asked DON, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? DON stated, No. They surveyor asked DON, Why? DON stated, It is unsafe, and it is against their plan of care. k. On 07/21/23 at 1:38 pm, the Nurse Consultant provided a copy of the DMS-762. The DMS 762 documented, .Facility has determined per investigation and witness statements that yellow/green bruising to right thigh is R/T [related to] fall on 6/29/23. Based on hospital findings of resident's bone density we can prove that the leg was not broken from the inappropriate transfer vs [versus] the previous injury of the fall that worsened over time. We do not know that the transfer broke her leg. We do know we had an inappropriate transfer x2 [times two] but cannot confirm the fracture was due to the inappropriate transfer . l. On 07/21/23 at 12:23 pm, the Nurse Consultant provided a policy labeled, Safe Lifting and Movement of Residents. The policy documented, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency) . The facility submitted an action plan that was completed prior to the survey entrance to include, staff providing return demonstration of resident transfers, closet care plans reviewed, updated and transfer status highlighted for quick view, and transfers will be monitored.

Based on record review and interview, the facility failed to ensure staff followed the care plan for resident transfer for 1 (Resident #3) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents. The failed practice resulted in findings of past non-compliance. The findings are: 1. Resident #3's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/27/23 documented the resident required extensive physical assistance requiring 2 plus persons with transfers. a. A Care Plan initiated on 02/05/22 with a revision date of 07/05/23 documented, Falls: Increased risk for falls related to cognitive loss, history of falls, very poor safety awareness, and potential med [medication] side effects. Resident is unable to use call light to call for assistance due to cognitive impairments. 03/21/2021 Fall, 05/22/2021-Fall, 05/25/2021 Fall, 08/19/2021 Fall, Unavoidable falls, 11/02/2021 Fall, 04/08/2022 Fall, 06/29/2023 Fall . Transfers x2 [times two] assist . Resident is impulsive and transfers self independently. Staff to monitor and attempt to assist prn [as needed] . b. A Closet Care Plan (MDS Kardex Report) in Resident #3's room with a print date of 06/26/23 documented, Transfer, Extensive assistance, Two plus persons physical assist . c. An Office of Long-Term Care (OLTC) Witness Statement dated 07/19/23 completed by Certified Nursing Assistant (CNA) #1 documented, I went and got [Resident #3] up at around noon yesterday for lunch. I did transfer by myself from her bed to her wheelchair. I have worked with her before, but I didn't look at her care plan before providing care. d. An (OLTC) Witness Statement dated 07/19/23 completed by CNA #2 documented, Tuesday the 19th approximately 1:30 p.m. I put [Resident #3] to bed. I pulled her wheelchair as close to the bed as possible and I proceeded to place my arms around her in a bear hug position and set her on the bed and I performed prairie [peri] care on her and put a clean brief on her and position her bed and put floor mat down. e. On 07/21/23 at 1:32 p.m., the Surveyor asked CNA #3, Where is the residents transfer assistance level documented so that you know how the resident is transferred? CNA #3 stated, In the closet care plan. The Surveyor asked, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? CNA #3 stated, No. The Surveyor asked, Why? CNA #3 stated, Because there is a risk for falls and there is a reason the resident is a two person assist. Mostly for safety reasons. f. On 07/21/23 at 1:35 p.m., the Surveyor asked CNA #4, Where is the residents transfer assistance level documented so that you know how the resident is transferred? CNA #4 stated, In their closet care plan. The Surveyor asked, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? CNA #4 stated, No. Not at all The Surveyor asked, Why? CNA #4 stated, Because you can drop them, hurt them and it's not practical at all. g. On 07/21/23 at 1:42 p.m., the Surveyor asked the Director of Nursing (DON), Where is the residents transfer assistance level documented so that you know how the resident is transferred? The DON stated, In their closet care plan and care plan. The Surveyor asked, If a resident is a two person assist for transfers is it ok for one CNA to transfer that resident? The DON stated, No. The Surveyor asked, Why? The DON stated, It is unsafe, and it is against their plan of care. h. On 07/21/23 at 1:38 p.m., the Nurse Consultant provided a copy of the DMS (Division of Medical Services) -762 Investigation Report dated 07/18/23 documented, .Facility has determined per investigation and witness statements that yellow/green bruising to right thigh is R/T [related to] fall on 6/29/23. Based on hospital findings of [Resident #3's] bone density we can prove that the leg was not broken from the inappropriate transfer vs [versus] the previous injury of the fall that worsened with time. We do not know that the transfer broke her leg. We do know we had an inappropriate transfer x2 [times two] but cannot confirm the fracture was due to the inappropriate transfer . i. A policy titled Safe Lifting and Movement of Residents, provided by the Nurse Consultant on 07/21/23 at 12:23 p.m. documented, Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency) . The facility submitted an action plan that was completed prior to the survey entrance to include, staff providing return demonstration of resident transfers, closet care plans reviewed, updated and transfer status highlighted for quick view, and transfers will be monitored.

Based on record review and interview, the facility failed to ensure the Resident, Resident Representatives and Families were notified by 5:00 PM the next calendar day following the occurrence/s of a confirmed positive COVID 19. The failed practice had the potential to affect 86 residents according to the Resident Census and Conditions of Residents provided by the Administrator on 12/13/22. The findings are: 1. The Staff and Resident COVID-19 Positive Log for the last four weeks provided by the Administrator documented: Four residents tested positive for COVID-19 on 11/14/22, one resident tested positive on 11/16/22 and 11/19/22, one staff member and four residents tested positive on 11/21/22, five staff members tested positive on 11/23/22, one staff member on 11/25/22 and a resident tested positive for on 12/1/22. 2. The facility's [Communication Software] messages for Residents #42, #57 and #76 was completed on 12/14/22, there were no messages sent out of confirmed cases of COVID-19 on 11/14/22, 11/16/22, 11/19/22, 11/23/22, 11/25/22 and 12/1/22. 3. Resident #134 tested positive for COVID-19 on 11/21/22. A review of Resident #134's Progress Notes from 11/21/22 to 11/23/22 did not contain documentation the resident's representative or family were notified of Resident's #134's positive COVID -19 test. 4. Resident #64 tested positive for COVID-19 on 12/1/22. A review of Resident #64's Progress Notes from 12/1/22 to 12/3/22 did not contain documentation the resident's representative or family were notified of Resident's #64 positive COVID-9 test. 5. On 12/15/22 at 8:29 AM, the Surveyor asked Licensed Practical Nurse (LPN) #7, When a resident's representative and/or family member are notified that the resident tested positive for COVID, where is it documented that they were notified? LPN #7 stated, In the progress notes. The Surveyor asked, On 11/21/22, [Resident #134] tested positive for COVID, is there a progress note that the resident's representative or family was notified? LPN #7 stated, No. The Surveyor asked, On 12/1/22, [Resident #64] tested positive for COVID, is there a progress note that the resident's representative or family was notified? LPN #7 stated, No. 6. On 12/15/22 at 8:41 AM, the Surveyor asked the Administrator, Who receives the COVID-19 results? The Administrator stated, The Infection Preventionist (IP) performs the rapid test on the residents and staff, and she informs me of the results. The Surveyor asked, What is the facility's mechanism that is used to inform the residents, their representative, and families of confirmed or suspected COVID-19? The Administrator stated, [Communication Software]. The Surveyor asked, Who is responsible for informing the residents, resident representatives, and family of a confirmed COVID-19 infection? The Administrator stated, Me, the IP notifies the COVID positive resident's family or representative. The Surveyor asked, When do you notify the residents, resident representatives, and families, of a confirmed or suspected COVID-19 infection? The Administrator stated, That day. The Surveyor asked, According to your [Communication Software] log, in the last 4 weeks, on what dates were messages sent out to the resident's representative and or family to notify them of a positive resident and or staff? The Administrator stated, I sent out a message on 11/7/22, 11/11/22 and 11/21/22. The Surveyor asked, On 11/14/22, 11/16/22, 11/19/22, 11/23/22, 11/25/22 and 12/1/22, either a staff and or a resident tested positive for COVID -19, were [Communication Software] messages sent out to the resident representatives and families? The Administrator stated, No.

Based on observation, record review, and interview, the facility failed to ensure humidity bottles and storage bags were changed weekly as ordered by the physician to prevent the potential for cross contamination that could result in a respiratory infection for 2 (Residents #74 and #134); failed to ensure there was a physician order for oxygen therapy for 1 (Resident #34) and failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complicationsfor 1 (Resident #74) of 3 (Residents #34, #74, and #134) sampled residents who had physician orders for oxygen therapy. The findings are: 1. Resident #74 had diagnoses of Acute and Chronic Respiratory Failure, Shortness of Breath (SOB) and Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The Physicians Order dated 6/13/22 documented, .O2 [Oxygen] 2L [Liter] via NC [Nasal Cannula] every shift for SOB . b. The Care Plan with a revision date of 12/06/22 does not address oxygen therapy. c. On 12/12/22 at 9:17 AM, Resident #74, was lying in bed with oxygen in place at 3.5 liters via nasal cannula. The humidity bottle was dated 12/2/22 and the storage bag was dated 11/28/22. d. On 12/13/22 at 9:55 AM, the Surveyor asked Licensed Practical Nurse (LPN) #4, When are the resident's humidity bottle and storage bag ordered to be changed? LPN #4 stated, Every Sunday. The Surveyor asked, What is the date on the humidity bottle and storage bag? LPN #4 stated, The humidity bottle is dated 12/2, and the storage bag is dated 11/28. The Surveyor asked, Are the humidity bottle and storage bag being changed every Sunday as ordered? LPN #4 stated, No. 2. Resident #134 had diagnoses of Dementia, Ischemic Cardiomyopathy, Cerebrovascular Accident, Pneumonia and Septicemia. The Modified Admission MDS with an ARD 11/2/22 documented the resident scored 3 (0 -7 indicates severely cognitively impaired) on a BIMS and received oxygen therapy. a. The December 2022 Physicians Order documented, .O2 @ 4 L via NC . Order Date 10/31/22 . Change and date O2 tubing and water bottle q [every] week . Order Date 11/7/22 . b. The Care Plan with a revision date of 11/25/22 documented, .Cardiac/Respiratory: Risk for altered cardiac output and respiratory complications. Oxygen in use . Oxygen per orders . Observe for any S/S [signs/symptoms] of respiratory distress or signs of infection . Monitor for signs of decreased cardiac output or signs of respiratory complications . c. On 12/12/22 at 10:20 AM, Resident #134 was resting in bed with oxygen in place at 4 liters via nasal cannula, a storage bag was lying on the bed side dresser and was dated 11/28. d. On 12/13/22 at 9:55 AM, LPN #4 accompanied the Surveyor to Resident #134's room. Resident #134 was resting in bed with oxygen in place at 4 liters. The Surveyor asked LPN #4, What is the date on his oxygen storage bag? LPN #4 stated, 11/28. The Surveyor asked, Is the storage bag being changed as ordered? LPN #4 stated, No. e. The facility policy titled, Oxygen Administration, provided by the Administrator on 12/14/22 at 9:50 AM documented, .The purpose of this procedure is to provide guidelines for safe oxygen administration . Verify that there is a physician's order . Review the physician's order . Review the resident's care plan . Assemble the equipment and supplies as needed . 44524 A review of a facility policy titled, Oxygen Administration, revised 10/2010, revealed in preparation for the administration of oxygen, staff must, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A review of an Admission Record revealed Resident #34 had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (low level of oxygen in body tissue), sleep apnea (interrupted breathing during sleep), anoxic brain damage (deprivation of oxygen to the brain), and a history of pneumonia. A review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #34 scored 3 on a Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS indicated the resident received oxygen therapy while a resident. A review of a care plan, initiated 11/09/2022, revealed Resident #34 was at risk for respiratory complications and had oxygen in use. The facility included an intervention to provide Oxygen per orders. A review of an Order Summary Report of active physician orders for Resident #34, as of 12/12/2022, revealed no evidence of an order for oxygen therapy. A review of the Medication Administration Record for December 2022 revealed there were no physician's orders for oxygen for Resident #34. A review of Progress Notes for Resident #34 revealed that on 11/01/2022 at 10:55 AM, the resident was on 2 liters per minute (LPM) of oxygen per nasal canula (PNC), and the oxygen saturation percentage dropped to 84%. The resident's oxygen rate was increased to 3 LPM PNC, which increased the oxygen saturation level to 89%. The resident's oxygen rate was increased again to 4 LPM via oxygen mask, and the resident's oxygen saturation level increased to 95%. A review of Progress Notes for Resident #34 revealed that on 11/05/2022 at 11:15 PM, Resident #34 was administered oxygen at 4 LPM PNC. A review of Progress Notes for Resident #34 revealed that on 11/09/2022 at 12:43 AM, Resident #34 was administered oxygen As ordered. A review of Progress Notes for Resident #34 revealed that on 11/16/2022 at 6:52 PM, Resident #34 was administered oxygen at 2 LPM PNC. A review of Progress Notes for Resident #34 revealed that on 11/21/2022 at 6:52 PM, Resident #34 was administered oxygen at 4 LPM PNC. A review of Progress Notes for Resident #34 revealed that on 11/24/2022 at 6:43 PM, Resident #34 was administered oxygen at 4 LPM PNC. During an observation on 12/12/2022 at 10:14 AM, Resident #34 was lying in bed with the head of the bed elevated approximately 30 degrees. Oxygen was being administered at 3.5 LPM PNC. During an observation on 12/13/2022 at 12:09 PM, Resident #34 was lying in bed with the head of the bed elevated approximately 30 degrees. Oxygen was being administered at 2 LPM PNC. During an interview on 12/13/2022 at 12:01 PM, Certified Nursing Assistant (CNA) #1 stated Resident #34 was on oxygen but was not sure of what the rate was. During an interview on 12/13/2022 at 12:30 PM, Licensed Practical Nurse (LPN) #2 stated the resident received oxygen at 2 LPM PNC. She stated she was aware of the flow rate because it was on the resident's physician's orders. LPN #2 pulled up the resident's electronic health record (EHR) and showed the surveyor a physician's order for oxygen at 2 LPM PNC, with a start date of 12/02/2022. LPN #2 audited the physician's order, which showed the order was created on 12/13/2022 and back dated to start on 12/02/2022. When asked how the LPN knew what the oxygen order was prior to it being ordered on 12/13/2022, the LPN did not respond. LPN #2 stated if the resident was receiving oxygen, there should be a physician's order for it. A review of an Order Audit Report revealed a physician order was created on 12/13/2022 at 10:16 AM for Oxygen as needed for shortness of breath 2 liters/min [minute] per nasal cannula PRN [as needed], by the Director of Nursing (DON). The Order Date was listed as 12/02/2022. During an interview on 12/13/2022 at 12:48 PM, the DON stated Resident #34 received oxygen at 2 LPM PNC. She stated staff should know the flow rate of the oxygen based on the physician's orders, and if a resident was receiving oxygen, there should be a physician's order. The DON stated staff approached her on 12/13/2022 and stated Resident #34 was receiving oxygen and the DON realized the resident did not have a physician's order for it, so she put one in. She stated she probably clicked the wrong date, when asked about back dating the order to indicate a start date of 12/02/2022. During an interview on 12/13/2022 at 1:34 PM, LPN #4 stated if a resident received oxygen, there should be a physician's order for it. During an interview on 12/14/2022 at 9:35 AM, LPN #11 stated the resident received oxygen at 2 to 4 LPM. She stated the staff monitored the resident's oxygen saturation level and adjusted the flow of the oxygen as needed. She stated she knew what the flow rate was from the order that the doctor gave me. She reviewed the order in the resident's EHR and was shown the order date for the oxygen was created on 12/13/2022, and she stated the order should have been written before then. She stated she thought she had seen a physician's order for 2 to 4 LPM but she may have Resident #34 confused with the resident's roommate. She stated Resident #34 was always on 2 LPM because the resident would come out to the day room and use the portable oxygen, which was set at 2 LPM. During an interview on 12/15/2022 at 2:28 PM, the Administrator stated if a resident was receiving oxygen, staff should verify the flow rate on the physician's orders.

Based on observation, record review, and interview, the facility failed to ensure the call light was accessible to allow residents to summon for assistance to accommodate their individual needs for 1 (Resident #57) of 15 (Residents #9, #10, #21, #22, #43, #45, #57, #60, #63, #72, #74, #78, #79, #134, and #136) sampled residents who used call light system to summon for assistance. The failed practice had the potential to affect 70 residents who required and used a call light according to the list provided by the Director of Nursing (DON) on 12/15/22. The findings are: Resident #57 had diagnoses of Dementia and History of Falling. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person for bed mobility and transfers, was not steady with moving from seated to standing position, walking and surface to surface transfer, and utilized a wheeled walker and a wheelchair. a. The Care Plan dated 04/26/22 documented, The resident is High risk for falls r/t [related to] Dementia, decreased mobility, generalized weakness . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 12/12/22 at 9:14 AM, Resident #57 was resting in a low bed, the head of bed was up, a fall mat was in place, the resident's walker was close to bed on the fall mat. The resident's call light was looped through the top of the bed frame and dangled close to the floor, not in reach. c. On 12/13/22 at 9:57 AM, Licensed Practical Nurse (LPN) #4 accompanied the Surveyor to Resident #57's room. The resident was lying in bed and the call light remained looped through top of bed and dangled close to the floor, out of reach. The Surveyor asked LPN #4, Is [Resident #57] a fall risk? LPN #57 stated, Yes. The Surveyor asked, Is her call light where she can reach it? LPN #4 stated, No. The Surveyor asked, Should her call light be in reach? LPN #4 stated, Yes. d. The facility policy titled, Answering the Call Light, provided by the DON on 12/15/22 at 12:28 documented, The purpose of this procedure is to respond to the resident's requests and needs . When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on observation, record review, and interview, the facility failed to ensure information regarding a residents' code status was accurately documented to enable staff to quickly ascertain the residents' wishes in the event of a decline in condition for 1 (Resident #134) of 23 (Residents #9, #10, #21, #22, #29, #34, #43, #45, #46, #55, #60, #61, #63, #70, #72, #74, #78, #79, #80, #81, #82, #134 and#136) sampled residents whose code status were reviewed. The findings are: Resident #134 had a diagnosis of Dementia. The Modified Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) [DATE] documented the resident scored 3 (0 -7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Face Sheet documented, .CPR [Cardiopulmonary Resuscitation] FULL CODE - Please see misc.[miscellaneous] documentation . b. The Code Status dated and signed by the resident representative on [DATE] documented, .I want a DNR Code Status (DO NOT RESUSCITATE) . c. The Physician Order dated [DATE] documented, .CPR FULL CODE - Please see misc. documentation . d. The Care Plan dated [DATE] documented, .Full code status in place . Review code status with the resident/responsible party quarterly or as needed . Check to make sure that code status is listed on the resident profile/face sheet . e. On [DATE] at 1:26 PM, the Surveyor asked Licensed Practical Nurse (LPN) #4, How do you know what a resident's code status is? LPN #4 stated, In an emergency situation it's on their closet care plan and it on the resident's face sheet in the computer. LPN #4 accompanied the Surveyor to Resident #134's room and opened the resident's closet door. The Surveyor asked, What is his code status? LPN #4 stated, He's a full code. The Surveyor asked LPN #4 to log into the laptop and look up Resident #134. The Surveyor asked, What is his code status on his face sheet? LPN #4 stated, He's a Full Code. f. On [DATE] at 1:28 PM, the Surveyor asked the Director of Nursing (DON), How do the staff know what the resident's code status is? The DON stated, It's in the resident's closet on the care plan for immediate access. In their EHR [Electronic Health Record] on the resident's face sheet. The Surveyor asked, What is [Resident #134's] code status? The DON stated, According to his face sheet, he's a Full Code. The Surveyor asked, What is his code status under misc. documentation? The DON asked, Advance Directive, where the Resident representative signed his code status? The Surveyor stated, Yes. The DON stated, His Code Status states he's a DNR. g. The facility policy titled, Advance Directives, provided by the Administrator on [DATE] at 9:50 AM documented, .Advance directives will be respected in accordance with state law and facility policy . The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive . In accordance with current OBRA (Omnibus Budget Reconciliation Act) definitions and guidelines governing advance directives, our facility has defined advanced directives as preferences regarding treatment options and include, but are not limited to: .Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident . representative . has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used .

Based on observation, record review and interview, the facility failed to ensure a mechanical lift and 2-staff assistance was provided during transfer of a resident with severe osteoporosis, as per the resident's assessed and care planned needs, to prevent injury for 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who required mechanical lift transfers. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was manually transferred by one staff member and sustained a fracture to the left proximal humerus. This failed practice had the potential to cause more than minimal harm to 9 residents who required a 2-person mechanical lift transfer, according to a list provided by the Administrator on 9/27/17. The Administrator was notified of the past noncompliance at the level of immediate jeopardy on 9/13/17 at 6:30 p.m. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 8/5/17 documented the resident scored 10 (8-12 indicates moderately impaired on a Brief Interview for Mental Status (BIMS), was totally dependent on the assistance of two plus people for transfers, required extensive assistance of two plus people for bed mobility, required extensive assistance of one person for locomotion on and off the unit, used a wheelchair for mobility and had no falls since prior assessment. a. The Fall Risk assessment dated [DATE] documented the resident's total fall risk score was 55, with a score of 45 or higher indicating a high risk for falls. The Fall Risk, post fall assessment dated [DATE] documented a total fall risk score of 50. The Fall Risk assessment dated [DATE] documented a total score of 75. b. The Care Plan dated 8/10/17 documented, The resident is high risk for falls related to CVA (Cerebrovascular Accident) with left hemiparesis, seizure disorder, balance problems, antianxiety and antidepressant medications . The resident requires mechanical lift with total assist by (2) staff for transfers. The resident is non-weight bearing . c. Physician's office notes dated 8/25/17 at 9:45 a.m. documented, (Resident #1's) left arm was bruised and swollen from the shoulder down .left shoulder was swollen and sticking outward. Pt (patient) has deep dark purple bruising to the left arm . (Resident #1) states it is painful to move. (Resident #1) has a history of osteoporosis and CVA causing her left side to be paralyzed . (Resident #1) presents with complaints of shoulder pain. d. The Office of Long Term Care Incident and Accident Report (I & A), Division of Medical Services (DMS) form 7734 dated 8/25/17 documented, On 8/25/17 at approximately 10:00 a.m., I was notified by the Assistant Director of Nursing (ADON) #1 that (Resident #1) had some discolorations to her upper left arm. The Nurse Practitioner was in the building at the time and assessed (Resident #1)'s condition . stated that we should send her (Resident #1) to the ER (emergency room ) at this time for further assessment. We received a call from the ER at approximately (2:00 p.m.) stating that (Resident #1) had a fracture to her humerus . Based on my observations I do believe that the injury occurred when (Certified Nursing Assistant (CNA) #1) transferred (Resident #1) without using the patient lift. The visible distress and discomfort was a clear indicator that she was hurting. The arm was positioned in a way that could easily cause a fracture to a patient with bone density like (Resident #1) has. Based on my observation of the contorted arm position, it appeared that (Resident #1) had her left arm out in front of her with her wrist by her waist when (CNA #1) had her in an upright position. When (CNA #1) put her in motion to a seated position in her wheelchair, the arm remained out in front of her body. When (Resident #1) sat down in her wheelchair her left arm got jammed into her upper leg. It was clear that there was pressure put on her arm when in that position. (CNA #1) was suspended immediately when cause of injury was discovered and was later terminated for failure to follow resident's care plan which lead to injury. e. A Nurse's Note dated 8/25/17 at 3:08 p.m. documented, Resident was laying (sic) in bed when the aides called me to her room. I noticed her left upper arm had a deep purple bruise all the way around her arm and it was swollen and warm to the touch. Looked at video footage and found that CNA on third shift had transferred resident by herself without lift, per her care plan. f. An Office of Long Term Care (OLTC) Witness Statement form dated 8/25/17 at 3:45 p.m. and signed by the Administrator documented, On 8/25/17 at approximately 9:00 a.m., I was notified that (Resident #1) had some discoloration on her left arm. I observed the discoloration and it appeared to be fairly significant. The APN (Advanced Practice Nurse) was currently in the building so we had her to look at (Resident #1) arm. She stated that we should send her to the ER to get a Doppler and X-ray. While (Resident #1) was at the ER I began watching facility surveillance footage to see if I could identify the discoloration on her arm and build a timeline to see if I could disclose the cause of the discoloration. The video footage showed: On 8/24/17 at 5:39 a.m., I witnessed (CNA #1) exit (Resident #1's) room with (Resident #1) in a wheelchair. (Resident #1) was visibly in discomfort and it appeared she was crying. (CNA #1) left (Resident #1) in the common area and returned to the hall. She returned to (Resident #1) within a few seconds and noticed that (Resident #1) arm (left) was in a contorted position. (CNA #1) attempted to adjust her arm to make her more comfortable .I contacted (CNA #1) via telephone, after watching her enter and exit (Resident #1's) room. She stated that she couldn't come in to work immediately, but she would give a statement over the phone. She stated that she did transfer (Resident #1) from bed to wheelchair by herself without using a mechanical lift. She states she put her hands under (Resident #1) arms, pulled her up in bed, and helped her stand and pivot to sit in her wheelchair. I asked why she didn't use the lift and she stated she didn't know to. I asked her if she looked at the care plan and she stated, 'No'. g. An OLTC Witness Statement form dated 8/25/17 and signed by CNA #2 documented . When I left the nursing station to start getting the residents up I notice (Resident #1) was already up by the nursing station. When I (walked) up to her she was crying and I asked her what was wrong and she didn't tell me, but then I (noticed) her left hand position incorrectly so I put it back in the right position. I (informed) the nurse about the situation. (CNA #1) did not tell me nor ask for help getting her up. h. An OLTC Witness Statement form dated 8/27/17 at 10:06 a.m., and signed by CNA #1 documented, Wednesday night I was scheduled to work 200/300 (halls). I got (Resident #1) up by myself Thursday morning around 6 (6:00 a.m.). It wasn't until after I got her in chair that I realized she was a lift. Yes, I should have told my charge nurse, but I didn't. Thing is, I was extremely careful and transferred her slowly. Not once did she say or her body language told me she was in pain. i. The Physician's History of Present Illness Notes dated 8/28/17 at 9:45 a.m. documented, (Resident #1) . sent from the nursing home for apparent left upper arm injury. She was found this morning with intrusions to the left upper arm. This patient has severe dementia. She is unable to tell me when or if she fell . She does report that her hip is hurting her. But will not elaborate as to which hip is hurting her. Her arm is splinted in a triangular swath .Severe Osteoporosis .Frontal and lateral views of the humerus were obtained. Moderately displaced transverse fracture of the proximal humeral metaphysis with medial displacement of fracture fragment . (Resident #1) has a left proximal humerus fracture. She will need to keep this arm in the sling . General inspection of the skin showed [DIAGNOSES REDACTED]. Clinical impression: Left upper extremity bruising all over, edematous .Plan, left arm in sling, follow-up with (Orthopedic Physician) in 2-3 weeks . j. An OLTC Witness Statement form dated 8/30/17 and signed by Assistant Director of Nursing (ADON) #2 documented, .This nurse watched video playback of CNA (CNA #1) bring resident .from resident's room to lobby area on 8/24/17 a.m. (morning). Resident was tearful and had left arm twisted/contorted in lap. CNA left resident in lobby and went back to Hall 200. k. Nursing Notes and I & A follow-up dated 8/31/17 documented, 8/25/17 CNA reported to nurse that (Resident #1) had purple discoloration, swelling, and warmth to left arm. Resident unable to explain what happened. Upon review of video footage, 11:00 p.m. - 7:00 a.m. shift (CNA #1) was witnessed bringing resident out of her room via 1 person transfer. Resident was in obvious distress in video and left arm twisted/contorted in resident's lap. CNA admitted to transferring resident via 1 person pivot transfer from bed to wheelchair. l. On 9/13/17 at 2:50 p.m., the Administrator was asked, What type of monitoring do you have for the CNAs? He stated, The DON started right after the incident happened and I don't know if she started any check-offs. That was her first check-off. He was asked, When did you first hear about the incident? He stated, The day after is when they first noticed the bruising to her arm. I reviewed the camera for about 4 hours after I was informed of the incident. He was asked, How did you prevent this incident from happening again? He stated, Explain to them to follow the closet care plan, and I got the occupational therapy to do a training with them. They are checked off during orientation and in-serviced on care plans every couple of months. He was asked, How long did (CNA #1) work here? He stated, Two to three weeks. He was asked, What type of training did (CNA #1) have prior to the incident with (Resident #1) on 8/24/17? He provided a copy of the Resident Lifting/Transfer policy that was signed by CNA #1 on 8/8/17, which documented, .At no time may only one employee LIFT a resident . Prior to the lifting/transfer of ANY resident, staff members are required to: 1. Check and follow the resident's care plan/assessment for lifting/transfer level of assistance/devices/equipment . All lifting and transferring of non-weight bearing residents requires 2 or more persons AND the use of a mechanical lift; non-weight bearing residents may not be lifted or transferred without the use of a mechanical lift and at least 2 persons.1 person alone, may not, at any time, operate a mechanical lift in order to lift or transfer a non-weight bearing resident, nor attempt to manually lift/transfer a non-weight bearing resident . The Administrator also provided a form signed by CNA #1 on 8/8/17, which documented, I verify that I have been instructed to refer to individual residents' closet care plan located inside the resident's closet door for assist needs of the residents. I will refer to the care plan to ensure best quality of care and safety of the residents are met. I understand that failure to follow resident care plan may result in termination of employment and subject to loss of my certification and/or license at the discretion of the Office of Long Term Care. 2. The facility removed the immediate jeopardy and corrected the failed practices on 8/25/17 prior to the survey, by initiating a corrective action plan, as follows: a. A typed list titled, Actions Taken to Date by the facility Administrator documented the following: 1.) Reported incident to OLTC on 8/25/17. 2.) Suspended the CNA that didn't follow the care plan. 3.) Interviewed residents and staff members to determine any other information about the injury. 4.) Performed body audits on the other residents that are a 2 person assist with a mechanical lift to ensure they were not affected. No negative findings. 5.) Started inservice on 8/25/17 with staff on neglect. 6.) Started inservice on 8/25/17 on following the resident's care plan. 7.) Started inservice on 8/25/17 that failure to follow a resident's care plan can be considered neglect. 8.) Terminated the CNA that didn't follow the resident's care plan on 8/25/17. 9.) Had the contracted Occupational Therapist complete an in-service on 9/8/17 regarding safe transfers. 10.) Re-inserviced staff on abuse and neglect on 9/8/17. 11.) Re-inserviced staff on following the care plan on 9/8/17. 12.) Facility continues to make daily action rounds ensuring closet care plans are in the patients' room. No negative findings. 13.) Checked employee files for their statement that they have been educated to the resident's closet care plan. No negative findings. b. The written plan also documented, Daily through walking rounds all department heads inspect each room to determine if there is a care plan available. If there is no care plan in the room they report the negative finding at 0900 (9:00 a.m.) in the morning stand-up meeting. Also, daily during nurse management observation rounds, we are observing for proper transfers . c. An Inservice Education Report dated 8/25/17 documented, Attention All Staff: Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Did you know that failing to follow a resident's plan of care is considered neglect? It only takes one time that you decide to transfer a patient by yourself that is care planned to be transferred by 2 people to be considered neglect. If you accidentally cause injury to a patient by failing to follow a plan of care then you could end up losing your certification . d. An Inservice Education Report dated 9/8/17 documented, Safe Transferring and fall preventions - rehab and restorative . Location of a residents (sic) closet care plan . Following the closet care plan for ADLs . Not following the closet care plan can be considered neglect . Charge nurses it is your responsibility to observe each day that the aides are following the care plans. You must monitor that each ADL is carried out according to the care plan . e. A Witness Statement dated 9/14/17 at 8:30 a.m. and signed by the MDS Coordinator documented, .I worked on 8/25, 8/28, 8/29, 8/30, 8/31, 9/1, 9/5, 9/6, 9/7, 9/8, 9/11, 9/12, 9/13, 9/14 (2017) . During these days I rounded at least once every day and observed CNAs during resident care and transfers multiple times, no negative findings witnessed . f. An In-service Education Report with a date of 8/25/17, titled Neglect documented . Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Twenty five staff signed the in-service form. g. An in-service education report dated 9/8/17 documented the topics: 1.) Safe transferring and fall preventions-rehab and restorative 2.) Abuse and Neglect 3.) Location of residents' closet care plan 4.) Following the closet care plan for ADLs (activities of daily living) 5.) Not following the closet care plan can be considered neglect. 6.) Charge nurses it is your responsibility to observe each day that the aides are following the care plans. You must monitor that each ADL is carried out according to the care plan. Seventy six employees signed the in-service form. 3. On 9/13/17 at 12:02 p.m., CNA #3 and CNA #4 transferred the resident from the bed to a chair, via a mechanical lift. The transfer was completed successfully.

Complaint # substantiated, all or in part, in these findings. Based on record review and interview the facility failed to ensure the physician was notified of the family giving water by mouth for 1 of 1 (Resident #1) case mix resident who was to receive nothing by mouth (NPO), and of a change in condition and omitted physician ordered water flushes for 1 (Resident #1) of 2 (Residents #1 and #3) case mix residents who had feeding tubes. This failed practice resulted in actual harm to Resident #1 who was hospitalized for [REDACTED]. 1. The Guidelines for Notifying Physicians of Clinical Problems documented, "Overview: These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. 2. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 11/21/12 documented the resident scored 6 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had an indwelling catheter, and a feeding tube. a. The Care Plan dated 11/15/12 documented, "... Administer tube feeding formula and flushes as ordered ... Report to the physician: Complications/side effects of tube feeding; Significant weight changes; ...Notify physician if residual is greater than ordered parameters, and record any new orders in the resident's record..." b. Admission Physician order [REDACTED]. (The feeding tube formula order was clarified on 11/16/12 to 2 Cal HN, 5 cans a day.), and H2O (water) flushes 30cc (cubic centimeters) before and after each use, (check) placement q (every) shift." There were no additional orders for flushes. c. A Dietary Consult Referral dated 11/16/12 documented, "...Reason for Consult: Tube fed/wounds. ... Estimated Caloric Needs: 1945-2334 kcal (kilo calories)/d (per day) ... 75.5-98 g (grams) Protein ... 1945-2334 ml (milliliters) fluid (kg (kilograms) x 25-30 ml (milliliters) or : Comments: New admit 11/16/12 (Friday). Hx (History) [MEDICAL CONDITION]/UTI and currently receiving [MEDICATION NAME] (and) [MEDICATION NAME]. Formula provides 1200 ml., 2400 kcal/d, 828 ml free H20, (and) 100 g pro (protein). Recommendations: 1) Flush 60 ml before (and) after meds (medications) (and) [MEDICATION NAME]. 2) Flush 120 ml q 6 hours = 480 ml. 3) Prostat ... 4) Weekly wts (weights)." The document was signed on 11/17/12 at 9:00 p.m. d. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Flush peg tube (with) 30cc H20 before (and) after each use. ..." The MAR indicated [REDACTED]. There were no other flushes documented from 11/16/12 to 11/20/12. e. A physician order [REDACTED]. Flush (with) 120 ml per tube q 6 hrs (hours)..." f. The MAR indicated Flush peg tube (with) 60 ml before (and) after each use..." The nurses' initials indicated this was started on 11/20/12, however, there were no initials on the 10-6 shift on 11/23/12 and 11/24/12, and on the 2-10 shift on 11/26/12. g. The MAR indicated Flush peg tube (with) 120 ml q 6 hrs." The nurses' initials indicated this was started on 11/20/12, however, there were no initials on the 6:00 p.m. flush time on 11/26/12. h. The nurses notes dated 11/25/12 at 5:30 p.m. documented the resident was more lethargic and complaining of aching all over and was sent to the hospital at 6:05 p.m. i. The emergency room report dated 11/25/12 documented, "... Lethargic ... Appears well nourished/hydrated ... 2015 (8:15 p.m.) Water 150 cc peg tube. ... Condition; improved... Disposition/Outcome", discharged was checked and to nursing home was circled. The Basic Metabolic Panel (BMP) dated 11/25/12 at the emergency room documented abnormal lab values as follows: Chloride 110 with a reference range of 98-107, BUN (Blood Urea Nitrogen) 72 with a reference range of 7-18 and Creatinine 1.8 with a reference range of 0.6-1.3. The nurses notes dated 11/25/12 documented the resident returned at 9:30 p.m. with a physician order [REDACTED]. j. The November 2012 MAR indicated [REDACTED]." There were no initials on the 10-6 shift on 11/25/12, the initials on 11/26/12 on the 6-2 shift were circled to indicate not given. There were no initials on the 2-10 and the 10-6 shift on 11/26/12. The initial was circled on the 6-2 shift on 11/27/12. The back of the MAR indicated held the 150 cc flush, resident started to cough." There was no documentation in the record that the physician was notified that the flush was held. k. On 11/27/12 at 7:00 a.m. the nurses notes documented, "Resident gurgling, tried to suction. Unable to reach phlegm. Temp (temperature) 100.9. Respiratory distress. HR (heart rate) 130. Sats (Pulse Oximetry)..." The resident was sent to the hospital at 8:45 a.m. and admitted . l. The Patient Transfer Form dated 11/27/12 documented, "... 2. Final Diagnosis (es), ... Primary:[MEDICAL CONDITION](Hypertension), UTI, [MEDICAL CONDITION]. All Other Conditions: Aspiration NPO. ... Family giving H2O PO in evenings..." m. The records from the hospital dated 11/27/12 documented, "... (Resident #1) was transferred from NH (Nursing Home) for possible aspiration. ...appears dehydrated. ... moderate distress; ...dry oral mucosa, yellow - fissured tongue. ... decreased air movement with crackles, rhonchi and few scattered wheezes. ... Clinical Impression/Problem: Pneumonia, Dehydration. Condition: Serious. ... History of Present Illness: (Resident #1) is a chronically debilitated elderly [AGE] year-old ... transferred ... with probable aspiration pneumonia. The patient was hospitalized two weeks ago with complicated urinary tract infection. At that time ... had culture [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus) from the tip of the penis and [DIAGNOSES REDACTED] has grown from the urine, as well as pseudomonas. These were treated aggressively with intravenous antibiotics for over one week. ...was transferred to local nursing home. ...has an indwelling Foley catheter. ...Other problems include moderate [MEDICAL CONDITION] and [MEDICATION NAME], a remote [MEDICAL CONDITION] with dysphagia requiring chronic PEG tube feedings, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], and senile [MEDICAL CONDITION]. Past surgery: As mentioned the patient has had PEG tube placement, as well as prostatic aortic valve. ... heart surgery was in 2005. Laboratory: ...His profile shows a creatinine of 1.8, which is about his baseline. His electrolytes are normal. ...His serum [MEDICATION NAME] is 3.5, which is mildly depressed. Patient's white blood count is 9000, hematocrit 37.6%. Urinalysis showed pyuria and hematuria, microscopically, but [MEDICATION NAME] was negative and only a trace of bacterium was noted. A chest x-ray report generated from the emergency room suggested cardiomegaly with central [MEDICAL CONDITION] vascular congestion. No distinct infiltrate was noted. Bilateral pleural effusions were seen. It is possible that the patient will exhibit pneumonitis once hydrated. Assessment: 1. Probable aspiration pneumonia. 2. Multiple medical comorbidities as listed above." n On 12/7/12 at 11:53 a.m. Licensed Practical Nurse (LPN) #2, who cared for the resident, was asked about the resident's hydration. She stated the resident never had symptoms of dehydration. She stated, "A lot of the residents with Peg tubes when they are admitted have an order for [REDACTED]." The LPN did not know why there was a delay from the time the dietitian made her recommendations and when the extra flushes were started. (Resident #1) had residual on the 26th, so I did not give the 150 cc flush. She was asked if she notified the physician of the residual and that the 150 cc flush was not given. The LPN stated, "No." She also stated that the resident had gurgling on the 27th and did notify the physician and sent the resident to the hospital. She stated, "On the 27th, I didn't check his residual he was gurgling. I just got the order to send him out. I didn't think dehydration, I thought aspiration because of the family (giving PO water) and all the extra flushes he was getting." The LPN stated that she had not ever told the physician the family was giving PO water to the resident before 11/27/12. o On 12/7/12 at 1:30 p.m., LPN #3 was asked about no initials on the MAR indicated [REDACTED]. (10-6 a.m. shift). She stated, "I think I did it, but forgot to sign off on it. Any skips I think I just did not document." She did not remember the resident ever having signs of dehydration. The LPN stated she was also aware of the family giving PO water and had not reported this to the physician.