Every finding on record at The Blossoms at Berryville Rehab & Nursing Center

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure significant medication errors did not occur for two (Resident #1 and Resident #5) of five residents reviewed for medication administration. The findings include: Resident #1 Review of Resident #1's admission Record, indicated the facility admitted Resident #1 on 03/09/2026 with diagnoses that included pneumonia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, congestive heart failure, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis. Review of Resident #1's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2026, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #1 was on medications that included a hypnotic, anticoagulant, antibiotic, diuretic, and antiplatelet. Review of the March 2026 Medication Administration Record (MAR), revealed Resident #1 was administered a scheduled cholesterol lower medication, four diuretic medications, two prostate medications, an anticoagulant, a medication to lower blood sugar, potassium electrolyte replacement, a medication to reduce heart rate, antihypertensive, magnesium electrolyte replacement, a medication to treat a nervous system disorder, antibiotic, a sleeping pill, and was on two liters (L) of oxygen on 03/23/2026. Review of a Medication Error Report dated 03/23/2026 at 4:00 PM stated Resident #1 was mistakenly given another resident's medication at approximately 4:02 PM which was discovered between 45 minutes to one hour later. The four incorrect medications given were for blood sugar lowering, an antidepressant, a medication to lower uric acid levels, and an antihypertensive with side effects of low blood sugar and increased levels of potassium. The antihypertensive medication has label warnings for diabetic medications. Monitoring of vitals at 8:00 PM and 10:00 PM revealed minimal hypotension. At 12:00 AM on 03/24/2026, Resident #1's blood pressure was 60/40 and blood sugar was 46. The provider on call was contacted and notified of the earlier medication error; new order was received to send the resident to the emergency room. Review of the Hospital Records revealed Resident #1 was treated for diagnoses of a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury. Blood pressure on arrival was 64/38 and stated that Resident #1 reported, I feel like I am dying. Documentation stated the facility staff reported the resident had been hypotensive for two hours. The electrocardiogram (EKG) revealed no acute Myocardial Infarct (MI), lab results showed elevated heart enzymes and fluid levels consistent with stress on the heart, and a normal white cell count. Resident #1 was subsequently airlifted to another hospital for a higher level of care. Review of Resident #1's vital sign revealed a blood pressure of 98/78 at 8:28 PM and 93/56 at 9:59 PM, then 60/40 at 12:00AM prior to hospitalization. No other hypotensive blood pressure had been recorded since the resident's admission. During an interview on 04/21/2026 at 2:43 PM, Licensed Practical Nurse (LPN) #1 stated, 03/23/2026 was her very first day on the job and she had never worked in a long-term care facility before. LPN #1 stated she had Registered Nurse (RN) #2 training her from 6am-10am prior to RN #2 clocking out for the day and was trained on how the residents took their medications and who had swallowing issues. LPN #1 stated she was trying to help and give medications when she pulled and gave Resident #6's medications to Resident #1. It did not register it was the wrong person; I didn't know the person. The Unit Manager (UM) arrived to help LPN #1. UM instructed me to pull Resident #1's medications, when LPN #1 went to administer them, she realized that the person she gave Resident #6's medications to was actually Resident #1. LPN #1 immediately reported her mistake to the UM. The Director of Nursing (DON) and Nurse Practitioner (NP) were notified. LPN #1 was given one on one education by the Assistant Director of Nursing (ADON) on the five rights of medication administration. LPN #1 stated she had been a nurse for 24 years and was upset. Resident #1 was put on blood pressure monitoring every two hours. LPN #1 stated, I didn't even know how to put orders into the computer at that time. It was a new computer program for me. LPN #1 stated, the residents had pictures loaded in the computer system, but they were so small on the screen and being new people, unless you knew the residents, they look like each other. LPN #1 was told to verify with an aide or someone more familiar with the resident or administration if the aide did not know. LPN #1 stated, I was over stimulated, I could have slowed down. I was trying to do something on my own. During an interview on 04/22/2026 at 2:23 PM, the UM stated, on 03/23/2026 she worked performing wound care, and also worked as the UM and serving as preceptor at the same time. The UM reported that LPN #1 stated she thought she had it and was ok prior to the UM leaving her alone to administer medication. LPN #1 was on her own for about 30 minutes when the UM went to check on her and LPN #1 reported there was a lot going on. So, I asked where she was at, she said [Resident #6], then she looked at the cards, pulled the meds, and went in the room. The UM indicated that LPN #1 reported I made a mistake I gave [Resident #6's] medications to [Resident #1]. The UM and LPN #1 went back down to the cart and went over the photo on the computer chart and had an in-service on five rights to ensure you were giving the right meds to the right person. LPN #1 did not have any long-term care experience. The UM stated, I don't know when the competency checklist should be completed. Somebody should not complete a task alone before they have been checked off. The UM stated the nursing part of the competency check list was checked off that day by RN #2 and then she (UM) worked on a couple as well. I did not do the medication portion I did not look at it. The UM stated she left LPN #1 as she had been through morning medication pass and said she felt comfortable. The UM stated RN #2 did not pass off or give a report to her and she did not see LPN #1 pass any medications before leaving her alone. During an interview on 04/23/2026 at 10:40 AM, RN #2 stated it was LPN #1's first day and LPN #1 had observed RN #2 that morning. RN #2 stated, I don't like them to go hands on when they don't know my residents. [LPN #1] just watched me. RN #2 reported LPN #1 had not performed any task on her own before RN #2 clocked out. I had not checked her off to administer medications by herself. She was not ready to work by herself on the cart. RN #4 stated there was no training provided to her by the facility before she started training new employees. During an interview on 04/22/2026 at 12:36 PM, the Pharmacist stated after reviewing Resident #1's scheduled medications and the medications given in error, she would have monitored for low blood pressure, low blood sugar and over sedation. She stated there were five different medications that would have contributed to the effects but no drug-to-drug interactions and no specific allergic reactions to consider. During an interview on 04/23/2026 at 9:00 AM, the NP stated she received an afterhours call from the ADON reporting Resident #1 had received their roommate's medications by error. She ordered all of Resident #1's medication to be held until the next morning until she could assess Resident #1, blood pressure to be checked every 2 hours, and blood sugar to be checked twice a day. The NP reported she had seen Resident #1 the day before and completed an assessment including the resident's lungs. There had been no change in the Care Plan at that time. Resident #1 had a lot going on with pneumonia and kidney function. The NP stated, It is hard to say if the medication error caused the event or not, it could have gone either way. During an interview on 04/23/2026 at 12:10 PM, the ADON stated LPN #1 misidentified Resident #1 and administered the wrong medications. The NP was notified and Resident #1 was monitored. Resident #1 was later sent out to the emergency room for treatment. The expectations for nurses were to have the right resident and the right medications. LPN #1 was provided one on one education. The UM was assigned to LPN #1 on the cart after RN #2 left but there was a moment LPN #1 wanted to pass medications and the UM stepped away and the incident occurred. During an interview on 04/23/2026 at 12:39 PM, the Administrator stated, it was an unfortunate medication error and no policy, procedure, or training lead up to the error. It was human error. The Administrator was unsure how much training LPN #1 had before she was allowed to complete medication administration alone. The Administrator stated that the UM also did wound care and he was unaware if she was doing both jobs while she was assigned to precept LPN #1. The Administrator stated, The med error is a med error, but [Resident #1] was very sick when [they] got here. Because of the med error [Resident #1] was monitored more and so they caught the change more quickly and sent [Resident #1] out, seven hours after the meds were given. \ During an interview on 04/22/2026 at 10:38 AM, Resident #1's representative stated the facility called at 2:30 AM to report they were life flighting [Resident #1] to a larger hospital because the resident's blood pressure dropped to nothing. The Representative stated, Resident #1 was sent to the emergency room then spent two days in critical care because [Resident] was given someone else's medications. The representative stated he had been at the facility before when medications were passed, and staff never identified Resident #1 by name when they gave medications. Resident #1's Representative stated the doctor stated, if I was you, I would seek legal advice. Resident #5 Review of Resident #5's admission Record revealed, the facility admitted Resident #5 on 02/04/2026 with diagnoses that included critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease. Review of Resident #5's admission MDS, with an ARD of 02/08/2026, revealed Resident #5 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS also revealed Resident #5 was on medications that included an antipsychotic, antidepressant, anticoagulant, antibiotic, diuretic, opioid, and hypoglycemic. Review of the March 2026 MAR revealed, Resident #5 was administered a scheduled antihistamine, a vitamin supplement, a sleeping pill, two antidepressants, antipsychotic, potassium electrolyte replacement, a medication for gastric reflux, steroids, a cholesterol reducing medication, two stool softeners, two diuretics, anticoagulant, magnesium electrolyte replacement, antihypertensive which also lowers heart rate, narcotic pain medication, and supplemental oxygen three L on 03/26/2026. Review of a Medication Error Report dated 03/27/2026 at 5:30 AM, revealed Resident #5 was accidentally given two sleeping pills instead of two pain pills. The on call NP was notified and ordered staff to monitor Resident #5. Other information noted was, resident had no predisposing situations involved. During an interview on 04/22/2026 at 3:18 PM, LPN #3 stated she was in training and both she and her preceptor LPN #4 were both pulling medications from the same cart. LPN #3 stated she was pulling the non-controlled medications and LPN #4 was pulling the narcotics. LPN #3 took the pills in and administered them to Resident #5. The nurses found out later that Resident #5 was administered the wrong pills. LPN #3 stated she believed the mistake was discovered later when they were counting the controlled medications. Resident #5 had asked for a pain pill and was given sleeping pills instead. We called the on-call NP and she said to just monitor the resident. There were no adverse reactions, we just kept an eye on [Resident #5]. The sleeping pill was a controlled medication, and it was in the narcotic box along with all the other controlled medications. LPN #3 stated, LPN #4 punched it from the wrong card. They are both small white pills and she did not pay attention; we were trying to hurry of course. LPN #3 stated she didn't remember any particular competency check offs at all, they just checked her license. I don't know if the preceptor checked off anything or not. It was just that we were both in the cart and that is how the error happened. This Surveyor attempted to contact LPN #4 multiple times and LPN #4 did not return calls for an interview. During an interview on 04/21/2026 at 11:11 AM, Resident #5 stated they had knowledge of a medication error with their pain medication or sleeping medication, but did not remember details of the event. During an interview on 04/22/2026 at 12:36 PM, the Pharmacist stated, the dose of the sleeping medication Resident #5 received was above the recommended daily dose and would definitely increase sedation. The medication specifically could cause amnesia and central nervous system depression. If Resident #5 did not wear a pressurized mask while sleeping it could cause a break in breathing. The medication could also cause episodes of sleep walking. During an interview on 04/23/2026 at 9:00 AM, the NP stated, she saw Resident #5 after the medication error and there were no adverse side effects. During an interview on 04/23/2026 at 12:10 PM, the ADON indicated that LPN #3 stated the wrong medication card was pulled, and two sleeping pills were pulled instead of two pain pills. The expectation for nurses was to have the right resident and the right medications. During an interview on 04/23/2026 at 12:39 PM, the Administrator stated that the medication error with Resident #5 was caught pretty quickly. It was not a medical emergency. [Resident #5] had a good sleep, but it wasn't as critical, not a massive change in condition. Review of a facility policy titled, Medication Administration dated 11/25/2022 revealed, Medication must be administered in accordance with orders. The individual administering medications must verify the resident's identity before giving the resident his/her medication. Methods of identifying the resident include checking photographs attached to the medical record or verifying resident identification with other facility personnel. The individual administering the medication must check the label three times to verify the right resident, right medication, right dose, and right method (route) of administration before giving the medication. The individual administering the medication must initial the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing (DON) Services. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned.

Based on interviews, record review and facility policy review, it was determined that the facility failed to implement effective nurse training to ensure education of new nursing staff for two (LPN #1 and LPN #3) of two nurses reviewed. The findings include: Review of a facility undated New Trainee Folder provided by the Assistant Director of Nursing (ADON) contained the following: -Licensed Nurse Competency Skills Check-off-Gait Belt Technique, Mechanical Lift Technique-Nurse Report Sheet blank-24-Hour Report Sheet-Standing Orders-Incontinent & Catheter Care Observation Checklist-Fluid Restriction Instruction Sheet-Med-Pass Best Practices MAR (Medication Administration Record) Marker-Med-Pass Quick References-Fall Intervention Strategies-Shift Trade Agreement-On-call Process & Contact Information-Physician Order Sheet blank-Falling Leave Fall Prevention-Welcome letter -Policy and Procedures including: Resident Rights, Abuse/Neglect/Exploitation, and Elopements. Review of the undated Licensed Nurse Competency Skills Check-off revealed the preceptor should initial and signify the trainee had met the training requirements for unit safety, professional communication, infection control, provided nursing care, emergency procedures, units rounds & documentation, equipment, medication administration, pain management, discharge process, resident advocacy, professional accountability, quality improvement/risk management, abuse, dementia, effective communication, Quality Assurance and Performance Improvement (QAPI), resident rights, person centered care, cultural competency, and Health Insurance Portability and Accountability Act (HIPPA). Review of the Director of Nursing (DON) Job Description revealed the DON had authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff. The DON ensures that a sufficient number of qualified supervisory and supportive nursing personnel were assigned for each unit to meet the residents' needs. Participation as assigned in the orientation of new staff. Review of the Assistant Director of Nursing (ADON) Job Description revealed the ADON was to assist the DON with the management and training of the nursing services staff. The ADON was responsible for ensuring that Nursing staff were aware of their job duties and the facility's expectation of resident care. Participation as assigned in the orientation of new staff. Review of the Licensed Practical Nurse (LPN) Job Description, revealed responsibilities to participate in developing, conducting, and in-service training classes that provide instruction on 'how to do the job,' and ensures a well-educated nursing services department. Implement and maintain an effective orientation program that orients the new employee to their shift, its policies & procedures, and to the job position and duties. Review of a facility policy titled, Medication Administration dated 11/25/2022, revealed New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned. During an interview on 04/22/2026 at 12:08 PM, the Human Resources (HR) personnel stated that when a new LPN started, she printed off the competency check-off list and placed it in the front of the staffing binder kept at the front nurses' station. HR stated the preceptor should complete it with the new hire over their first three days. When it was completed, it went in a basket in the DON's office so the Unit Manager (UM), DON, or ADON could sign off on it. LPN #1 During an interview on 04/22/206 at 12:20 PM the UM stated, the facility competency checklist created for LPN #1 was put in folder created for her, but the LPN quit before it was completed and took it with her. Review of a Medication Error Report dated 03/23/2026 at 4:00 PM, stated Resident #1 was mistakenly given another resident's medication at approximately 4:02 PM which was discovered between 45 minutes to one hour later. The four incorrect medications given were for lowering blood sugar, an antidepressant, a medication to lower uric acid levels, and an antihypertensive with side effects of low blood sugar and increased levels of potassium. During an interview on 04/21/2026 at 2:43 PM, Licensed Practical Nurse (LPN) #1 stated, 03/23/2026 was her very first day on the job and she had never worked in a long-term care facility before. LPN #1 stated she had Registered Nurse (RN) #2 training her from 6 AM-10 AM prior to RN #2 clocking out for the day and was trained on how the residents took their medications and who had swallowing issues. LPN #1 stated she was trying to help and give medications when she pulled and gave Resident #6's medications to Resident #1. It did not register it was the wrong person; I didn't know the person. The Unit Manager (UM) arrived to help LPN #1. The UM instructed LPN #1 to pull Resident #1's medications, when LPN #1 went to administer them, she realized that the person she gave Resident #6's medications to was actually Resident #1. LPN #1 immediately reported her mistake to the UM. The DON and Nurse Practitioner (NP) were notified. LPN #1 was given one on one education by the ADON on the five rights of medication administration. LPN #1 stated she had been a nurse for 24 years and was upset. LPN #1 stated, I didn't even know how to put orders into the computer at that time. It was a new computer program for me. I was over stimulated, I could have slowed down, I was trying to do something on my own. During an interview on 04/22/2026 at 12:31 PM, LPN #1 stated that the competency checklist was given to her, but it was not completed. RN #2 talked to me about the checklist that morning, but she said we were going to complete the med pass first and look at it later. LPN #1 worked at the facility for three weeks. During an interview on 04/23/2026 at 10:40 AM, RN #2 stated, it was LPN #1's first day and LPN #1 had observed RN #2 that morning. RN #2 stated, I don't like them to go hands on when they don't know my residents. [LPN #1] just watched me. RN #2 reported LPN #1 had not performed any task on her own before RN #2 clocked out. I had not checked her off to administer medications by herself. She was not ready to work by herself on the cart. RN #4 stated there was no training provided for her by the facility before she started training new employees. During an interview on 04/22/2026 at 2:23 PM, the UM stated, on 03/23/2026 she worked performing wound care and worked as the UM at the same time. The UM reported that LPN #1 stated she thought she had it and was ok prior to the UM leaving her alone to administer medication. LPN #1 was on her own for about 30 minutes when the UM went to check on her and LPN #1 reported there was a lot going on. So, I asked where she was at, she said [Resident #6] she looked at the cards and pulled the meds and went in the room. The UM indicated that LPN #1 reported I made a mistake I gave [Resident #6's] medications to [Resident #1]. The UM stated that LPN #1 did not have any long-term care experience. The UM stated, I don't know when the competency checklist should be completed. Somebody should not complete a task alone before they have been checked off. The UM stated the nursing part of the competency check list was checked off that day by RN #2 and then she worked on a couple as well. The UM stated, I did not do the medication portion, I did not look at it. The UM stated she left LPN #1 as she had been through morning medication pass and said she felt comfortable. The UM stated RN #2 did not pass off or give a report to her and she did not see LPN #1 pass any medications before leaving her alone. Review of LPN #1's Employee File revealed an on boarding date of 03/01/2026. Disciplinary action was given on 03/26/2026 for the 03/23/2026 medication error incident, part of the action was LPN #1 was given oversite on the cart for the rest of that day to ensure the nurse understood the five rights of medication administration. The disciplinary action was signed by the UM and ADON. No Licensed Nurse Competency Skills Check-off was completed as of 04/23/2026. LPN #3 Review of a Medication Error Report dated 03/27/2026 at 5:30 AM, revealed Resident #5 was accidentally given two sleeping pills instead of two pain pills. During an interview on 04/22/2026 at 3:18 PM, LPN #3 stated she was in training and both she and her preceptor LPN #4 were both pulling medications from the same cart. LPN #3 stated she was pulling the non-controlled medications, and LPN #4 was pulling the narcotics. LPN #3 took the pills in and administered them to Resident #5. The nurses found out later that Resident #5 was administered the wrong pills. LPN #3 stated she believed the mistake was discovered later when they were counting the controlled medications. Resident #5 had asked for a pain pill and was given sleeping pills instead. The sleeping pill was a controlled medication, and it was in the narcotic box along with all the other controlled medications. LPN #3 stated, LPN #4 punched it from the wrong card. They are both small white pills and she did not pay attention; we were trying to hurry of course. LPN #3 stated she didn't remember any particular competency check offs being done, they just checked her license. I don't know if the preceptor checked off anything or not. It was just that we were both in the cart and that is how the error happened. This Surveyor attempted to contact LPN #4 multiple times and LPN #4 did not return calls for an interview. During an interview on 04/22/2026 at 2:23 PM, the UM stated that LPN #3 was a new nurse and was in training with LPN #4 as a preceptor. Trainees usually had three days of orientation, if they don't feel confident the orientation would be extended until they do. The UM stated the preceptor should be helping them the way they were taught, the right way with the five rights, getting to know the residents, and the computer system. The way that I teach and the way other people teach is different, I always follow up with nurses to see if they feel like they understand something, sometimes I have them walk me through the process after to confirm they do know it. The UM stated there was no training for the preceptor prior to becoming a preceptor. They are just the nurse on the floor that has been working those shifts. Review of LPN #3's Employee File revealed an onboarding date of 03/18/2026. No Licensed Nurse Competency Skills Check-off was completed as of 04/23/2026. LPN #3 was still currently employed at the facility. During an interview on 04/23/2026 at 9:00 AM, the Nurse Practitioner (NP) stated she would like to see the facility follow up and change. We have all been nurses, we have been there. We deserve our orientation, to have that person there to ask our questions. During an interview on 04/23/2026 at 12:10 PM, the ADON stated LPN #1 had 18 years of experience, but none in Long-Term Care. The ADON stated she did not recall how much training LPN #1 had prior to the medication error and did not know if it was her first day. The ADON stated that the preceptor was just one of the floor nurses. The nurses were promoted to preceptor if they had been at the facility longer and knew the residents well. There is no rule, maybe six months. There was no preceptor training prior to training others. The current training program just started in March 2026 prior to the two medication errors. The ADON stated, all new hires get a folder of information. During an interview on 04/23/2026 at 12:39 PM, the Administrator stated he determined there was no policy, procedure, or training issue which led up to the medication errors, it was human error. For training, the facility typically started with three days of training, if the trainee needed additional time they could get it. Some trainees were not comfortable and they got extra training. I'm not sure how much training [LPN #1] had before she was turned loose, she was mid-way and was starting to turn loose. I don't remember when her start date was to be honest. After the medication error LPN #1 was put back into training with a trainer immediately. LPN #1 had been a nurse for a long time but none in Long-Term Care. The Administrator stated, [UM] is the unit manager; I think she is also wound care. I don't know for a fact if she was both the day she was also precepting. The facility will be discussing the medication errors in depth during the April 2026 QAPI meeting. The Administrator stated he would suggest improving the training process and addressing the five rights of medication administration with all nurses.

Based on observation, interview, and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and the potential development of foodborne pathogens, specifically, not cleaning the drip pans and fish fryer. The findings include: During an observation on 12/01/2025 at 11:20 AM, during the initial tour of the facility's kitchen, this surveyor observed the drip pans were covered with aluminum foil, approximately two feet long, by two feet wide. The foil was completely covered in a brown and black substance, with visible charred curly noodles. During an observation on 12/01/2025 at 11:23 AM, this surveyor observed the grease in the fish fryer to be mostly covered with a layer of floating brown particles. The grease that was visible through the floating debris was cloudy. During an interview on 12/01/2025 at 11:20 AM, Dietary Manager (DM) #2 confirmed that the drip pans had not been cleaned or checked by her personally, since she started her employment in September. DM #2 then said the kitchen staff used the fish fryer a couple times a week and it was cleaned once every two weeks. During an interview on 12/03/2025 at 11:32 AM, [NAME] #3 was asked to verbalize the tasks involved in keeping the kitchen's food preparation areas clean and sanitary, and referenced cleaning the steam table and dishes as a daily task, but there was no mention of cleaning the stove, drip pans, or fish fryer. During an interview on 12/03/2025 at 11:36 AM, DM #2 stated that staff were in-serviced at least once a month on pureeing foods, tray cards, glove use, safe food handling, and kitchen cleaning. During an interview on 12/03/2025 at 11:40 AM, Regional Dietary Manager #1 confirmed that during random weekly visits, sanitation audits were done, in-service recommendations were made to the DM, and competency check offs were performed with staff. During an interview on 12/03/2025 at 11:45 AM, Dietary Aide (DA) #4 stated that doing dishes, making desserts, and pureeing foods were part of the day-to-day job duties. DA #4 did not mention any cleaning tasks other than dishwashing and could not recall when the last in-service was or what it was on. During an interview on 12/04/2025 at 9:36 AM, the Administrator took responsibility of overseeing the kitchen and stated he made frequent visits in the kitchen every day. Spot checks were conducted, along with sampling food, checking in-service training, and checking temperatures of the walk-in refrigerator and freezer. The Administrator confirmed that the drip pans not being cleaned frequently could create a potential hazard of foodborne pathogens. A review of the facility's Policy and Procedure Kitchen Cleaning stated, The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. A review of the facility's Kitchen Cleaning Schedule indicated that the fish fryer was to be cleaned once per week, and the drip pans every day. According to this cleaning schedule, the drip pans had not been cleaned since 11/28/2025, and the fish fryer had not been cleaned since the week of 11/24/2025-11/30/2025.

Based on observation, interview, record review, and facility document review, the facility failed to ensure adequate staffing levels to meet residents' needs for timely assistance, call-light response, and water pass for one (Resident #3) of one resident reviewed, according to the facility assessment. The findings include: A review of the facility assessment revised 07/11//2025, documented required direct-care staffing levels for an average daily census of 64 residents as follows: Dayshift- 6 Certified Nursing Assistants (CNAs)/3 nursesEvening shift- 4 CNAs/3 nursesNightshift- 4 CNAs/2 nurses. A review of facility daily staffing records from 04/05/2025 through 11/23/2025, revealed multiple dates in which the required staffing levels were not met across day, evening, and night shifts, which included: -04/05/2025 with day shift staffing of 6 CNAs/1 nurse and night shift staffing of 3 CNAs/2 nurses for a census of 64 residents-04/12/2025 with day shift staffing of 4 CNAs/2 nurses for a census of 65 residents-04/19/2025 with day shift staffing of 4 CNAs/3 nurses for a census of 66 residents-05/17/2025 with day shift staffing of 6 CNAs/2 nurses and evening shift staffing of 5.5 CNAs/2 nurses for a census of 64 residents-05/24/2025 with evening shift staffing of 6.5 CNAs/2 nurses and night shift staffing of 3.5 CNAs/1 nurse for a census of 66 residents-06/01/2025 with evening shift staffing of 6.5 CNAs/2 nurses for a census of 66 residents-07/06/2025 with day shift staffing of 4 CNAs/3 nurses for a census of 62 residents-08/23/2025 with census of 57 residents and day shift staffing of 5 CNAs/3 nurses with evening shift staffing of 4 CNAs/3 nurses-09/06/2025 with day shift staffing of 5 CNAs/3 nurses and evening staffing of 4.5 CNAs/3 nurses for a census of 56 residents-10/18/2025 with day shift staffing of 4 CNAs/3 nurses for a census of 56 residents-11/02/2025 with night shift staffing of 2 CNAs/2 nurses for a census of 61 residentsThese and additional dates reflected staffing levels below those required in the facility assessment. A review of the facility grievance logs revealed on the following dates, call lights were not answered by staff in a timely manner: 01/30/2025, 03/27/2025, 04/30/2025, 06/03/2025, 06/11/2025, 07/02/2025, 09/25/2025, 09/26/2025, 10/30/2025, 11/01/2025, 11/10/2025, 11/24/2025, and 12/01/2025. A review of the facility's resident council meeting minutes revealed that residents complained their call lights were not answered in a timely manner on 04/24/2025, 05/27/2025, and 07/31/2025. During an observation on 12/01/2025 at 11:30 AM, while rounding and screening residents, this surveyor observed multiple stripped bare, unmade beds in different rooms throughout the facility. During an observation on 12/01/2025 at 12:27 PM, the Administrator, the Activity Director (AD), and Social Director were observed in the facility dining room passing out resident meal trays, and the Administrator was observed assisting with feeding the residents. During an observation on 12/01/2025 at 1:25 PM, this surveyor observed Resident #3's call light lit and sounding, with several staff members walking by the room in the hallway without stopping. Resident #3 was yelling out, Hey when they saw someone pass by the door, several staff members responded Hey, without stopping to check on the needs of the resident. This occurred while this surveyor was in the resident room with them. Resident #3 was sitting up at beside in a wheelchair, their bed was stripped with folded linen lying in a chair in the room. During an interview on 12/01/2025 at 1:56 PM, Resident #3 reported to this surveyor they wanted their bed made and to be assisted to bed. The resident then reported the facility was always shorthanded. During an interview on 12/04/2025 at 11:15 AM, the Administrator indicated he frequently assisted with passing trays and feeding residents at mealtimes. During an interview on 12/04/2025 at 10:15 AM, the AD revealed that assistance in passing meal trays was provided during periods of short staffing, including a report of assisting on Monday 12/01/2025, to ensure trays were distributed on time. During an interview on 12/04/2025 at 9:32 AM, the Administrator reported no known concerns from residents or families about weekend staffing levels and indicated no awareness of residents waiting extended periods for assistance. The Administrator acknowledged that a grievance regarding call-light response time had occurred and stated it was addressed by the Director of Nursing (DON) and the Assistant Director of Nursing through scheduling and staffing adjustments and follow-up with involved staff.During an interview on 12/04/2025 at 9:23 AM, the Administrator stated facility expectations were for beds to be made by 10:00 AM, water to be passed around at 10:00 AM, and at least twice daily, and call lights were to be answered within five minutes. The Administrator reported tasks were monitored through assignment sheets and periodic spot checks conducted by nurses and unit managers. The Administrator then stated there were sufficient staff in the facility. During an interview on 12/04/2025 at 12:03 PM, CNA #13 reported that staffing was not adequate and identified lunchtime as one of the busiest periods of the day. The CNA stated that the front hall had no hot water for approximately one week, which resulted in some residents being unable to be taken to the back hall for showers, due to not having time to complete. CNA #13 stated there was not always enough time to complete required tasks and that concerns had been reported up the chain of command, without improvement. CNA #13 stated that having no water at the bedside was neglect and indicated call lights should be answered within two to three minutes. CNA #13 also noted that scheduled showers were not completed on weekends, due to insufficient staffing. During an interview on 12/04/2025 at 12:14 PM, CNA #10 stated there was not always enough staff to complete assigned tasks. The CNA reported that back-hall staff were responsible for residents located around a corner that was difficult to observe and that call lights were not always answered timely during busy morning care periods. The CNA stated these concerns had been reported to nursing management and assistance was only sometimes provided. During an interview on 12/04/2025 at 12:03 PM, CNA #13 stated there was frequently not enough staff and that this had been reported to the DON, who indicated attempts were being made to hire more staff. The CNA stated water was sometimes not passed as needed due to workload, and tasks could not always be completed. CNA #13 reported call-light wait times of up to ten minutes. The CNA then stated that during a recent weekend shift, daytime staffing consisted of only three CNAs and that it was not sufficient staff to assist residents with breakfast or lunch on weekends. During an interview on 12/04/2025 at 12:33 PM, CNA #5 reported the shower aide was responsible for 20 to 28 scheduled showers a day, as well as nail care, shaving, lotion, and application of skin protectants for residents. CNA #5 then stated frequent re-assignment of the shower aide from shower duties to floor coverage resulted in an incomplete shower schedule. The CNA also reported that residents became upset when shower services were delayed and that concerns had been verbally reported to the DON and additional supervisory staff. CNA #5 stated there was no designated shower aide on weekends. During an interview on 12/04/2025, the DON confirmed the facility had no policy in regard to resident hygiene of answering call lights.

Based on observations, interviews, facility document review, and facility policy review, the facility failed to ensure the following: foods stored in walk in refrigerator was stored off the ground for 1 of 1 kitchen, that beneath the dishwasher was clean for 1 of 1 kitchen, standing water in front of the refrigerator in kitchen and in walk in refrigerator with towels/sheet in floor absorbing water in 1 of 1 kitchen, drinks in the unit refrigerator was labeled, dated and covered for 1 of 3 dining rooms, foods on the unit was dated and used by expiration/best by date 1 of 3 dining rooms, resident's and employee foods not stored in the same refrigerator in 1 of 3 dining rooms and the refrigerator was clean and in sanitary condition for 1 of 3 dining rooms in order to prevent cross contamination and foodborne illnesses. These failed practices have the potential to affect 72 residents who received meals from 1 of 1 kitchen and potential to affect 72 residents who reside in facility and potential to have food in unit refrigerator. Findings included: 1. The Surveyor observed on [DATE] at 10:35 AM, the walk-in refrigerator had water on the floor with towels on top of the refrigerator. There was also water standing without covering of towel on the floor. 2. The Surveyor observed on [DATE] at 10:37 AM, a box of uncovered potatoes sitting on the floor in the pantry room. 3. The Surveyor observed on [DATE] at 10:42 AM, the Surveyor observed underneath the dishwasher to be damp with dark brown areas observed in numerous places on the floor. It also had dark brown areas on the sheetrock. Dietary Manager (DM) #10 stated that the dishwasher was leaking, and the maintenance man fixed it the day before on [DATE]. 4. The surveyor observed a refrigerator in the small dining room on 300 Hall on [DATE] at 7:30 AM. The refrigerator had a brown sticky substance at the bottom underneath crisper drawers. The following were observed in refrigerator: Two cups with fluid without lids. No name or dates observed. 16-ounce (oz) hazelnut creamer- no open date and expired ,d+[DATE] 28 oz of barbeque sauce with no open date 24 oz sweet relish expired [DATE] with no open date. 20 oz mustard with no open date. 22 oz strawberry syrup with no open date 20 oz jar of cowboy candy with open date of [DATE] 20 oz salad dressing with no open date and expired [DATE]. 20 oz salad dressing with no open date and expired [DATE]. 13 oz whipped topping with no lid and no open date 8 oz mustard with no open date and expired [DATE]. 24 oz salad dressing with no open date and expired [DATE]. 16 oz salad dressing with no open date expired [DATE]. 9 oz green cookie icing with no open date, unable to find expiration date. No lid on the bottle. 10 oz dill relish no open date. 18 oz barbeque sauce no open date no expiration date seen on bottle. 8.4 oz sesame dipping sauce no open date expiration date unreadable ink rubbed off. 9 oz red cooking icing bottle with no lid. no open date no expiration date seen. 15 oz soy sauce with no open date and no expiration date seen. 32 oz jar of jalapeno slices no open dates, expired [DATE]. 1 package of mozzarella cheese no open date. 9 oz package of turkey with open date of [DATE] with sell by date of [DATE]. 22 oz bottle of mayonnaise no open date and expired on [DATE]. 1 package of cheese no open date and unable to locate expiration date. 16 oz potato salad with no open date. Half of cantaloupe with no date. Package of croutons package open and no sealed with no open date. 64 oz of cranberry grape bottle with no open date. 1 apple with white fuzz on one side not bagged. 24 oz container of sour cream no open date and expired [DATE]. Container pasta salad container sealed- expired [DATE]. 12 count container of eggs with no open date with best by date [DATE]. 6 count container of eggs with no open date with best by date of [DATE]. 6 count container of eggs with no open date with best by date [DATE]. 18 count container of eggs with no open date with best by date of [DATE]. 24 count container of eggs with no open date with best by date of [DATE]. 1 bottle of 64 oz of hummingbird nectar. 1 cup of dark brown fluid with saran wrap on it with no date. 1 turquoise fabric lunch bag. 16 oz of hazelnut creamer with no open date expired ,d+[DATE]. 28 oz of barbeque sauce with no open date. 24 oz sweet relish with no open date expired [DATE]. 20 oz container of mustard no open date. 22 oz container of strawberry syrup with no open date. 20 oz jar of cowboy candy with date on lid [DATE]. 20 oz bottle of salad dressing with no open date and expiration date of [DATE]. 20 oz bottle of salad dressing with no open date and expiration date of [DATE]. Container of potato salad with no open date. Bag of mozzarella cheese with no open date. Container of salad no open date. Half of cantaloupe with no date. Container of sour cream with no open date and expired on [DATE]. The freezer contained: A box of frozen waffles with no open date. 2 boxes of popsicles with no open date. 2 containers of ice cream with no open date. 1 bag of min ice cups with no open date. 1 cup of dark purple frozen fluid with saran wrap on top with no label or open date. 5. On [DATE] at 10:55 AM, the surveyor observed a sheet/thin blanket lying on the floor in the walk in refrigerator. 6. During an interview on [DATE] at 10:35 AM, DM #10 informed the surveyor the water on the floor in front of the refrigerator in kitchen and the one in walk in refrigerator, was from a leak and the maintenance man had not fixed it yet, and it had been that way since she started, which was ninety days. Also reported that the Maintenance Director was aware of it. Also stated the dishwasher was leaking, and the Maintenance Director had just fixed it the day before. 7. During an interview on [DATE] at 10:55 AM, DM #10 revealed the sheet/thin blanket in the walk-in refrigerator was there to absorb the water that leaks from the top of the refrigerator and reported that Maintenance Director #9 came in on [DATE] and stated that the water is from condensation leaks. DM #10 stated the floor underneath and on the wall beneath the dishwasher was not good and was old, stained, and rusted. DM #10 stated they mop every day, but the floor remains that color. DM #10 stated that it needed to be retiled. Below the dishwasher clean table needs new tiles and it was brown in color. Reported no food should be placed on the floor and it should have been put in the container bins instead. 8. During an interview on [DATE] at 11:10 AM, Maintenance Director #9 revealed the floor beneath the dishwasher was concrete, plain, and dark in color, and that the wall underneath was dirty. Maintenance Director #9 reported there were no missing tiles and the floor was made that way it was just the floor exposed from being dug up over eight years ago when there was a problem there before. Reported that in the walk-in refrigerator the water was coming from the re-circulation fan. It blows the water at times and lands on the floor and is the reason the water is on the floor. Maintenance Director #9 stated they go outside every day and turns it off for about five minutes and it stops it. Maintenance Director #9 reported not being sure if this is done on the weekends and that's why it probably was like that Monday because it had not been done yet. Maintenance Director #9 stated that in the refrigerator there is a tray in the back that fills up, and that it does it more when it is humid. Reported that it is drained every two days to keep it from leaking. On [DATE] at 7:42 AM, the Director of Nursing (DON) stated that the refrigerator in the small dining room on the 300 Hall was used by the residents and staff. The staff is not supposed to use it, but they do. The DON observed the food in the refrigerator and reported the foods did not have open dates on them and were not labeled. The DON observed the turkey lunch meat at bottom of the refrigerator and acknowledged it was expired, and no open date was on it; observed the two cups with no lids on them and stated they had no coverings and was not labeled or have open date on them. The DON reported that the housekeeping department was responsible for cleaning it every day, that the bottom of the refrigerator had spilled brown fluid and appeared sticky, and she was uncertain whose food was whose. At 10:20 AM, was shown the hummingbird nectar in the refrigerator and DON stated she was unsure what it was for, it was a non-food item and should not be in that refrigerator. During an interview with Housekeeping Supervisor (HSKSP) #11 on [DATE] at 9:00 AM, HSKSP #11 reported that as a housekeeper on that hall and had never cleaned the refrigerator in the small dining room. At 10:32 AM, observed the hummingbird nectar bottle in the refrigerator and stated that they do not know why it was in the refrigerator or what it is for, but it should not be in that refrigerator. The bottle was removed by HSKSP #11. A review of a facility document titled, Housekeeping List, undated but received by Administrator dated [DATE], did not indicate any cleaning duty of the refrigerator in the small dining room on the 300 Hall. A review of facility document titled Daytime Dishwasher Duties, undated but received on [DATE] at 11:43 AM, indicated that dishwasher employees are to clean door walls and floor.

Based on observations, interviews, and record review, the facility failed to ensure residents were treated with dignity during meal service for 3 (Resident #15, #34, and #55) residents of 13 residents observed during meal service. Findings include: A review of a facility policy titled, Resident Assistance with Meals, with an effective date of April 2021, indicated residents would be assisted with dignity and without staff standing over them while providing dining assistance. A review of a document titled, The Blossoms Employee Handbook, indicated the care of facility residents was guided by respect and dignity of human life. A review of the Admission Record indicated the facility admitted Resident #15 with diagnoses that included difficulty swallowing, muscle weakness, and lack of coordination. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had sever cognitive impairment and required assistance with eating. A review of Resident #15's Care Plan, dated 06/13/2024, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to weakness and cognitive impairment related to dementia. Interventions included set up and supervision during meals, providing orientation focusing on abilities, and promoting meaningful interaction. A review of the Admission Record indicated the facility admitted Resident #34 with a central nervous system disorder affecting movement. The signification change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2024, revealed Resident #34 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment and required assistance with eating. A review of Resident #34's Care Plan, initiated 07/17/2024, revealed the resident had central nervous system disorder affecting movement. Interventions included monitoring for ADLs, signs and symptoms of choking, and difficulty swallowing. A review of the Admission Record, indicated the facility admitted Resident #55 with diagnoses that included movement disorder and progressive disease-causing impairment of memory and mental functions. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2024, revealed Resident #55 had a BIMs score of 0, which indicated the resident had severe cognitive impairment and was dependent on staff for eating. A review of Resident #55's Care Plan, initiated 06/11/2024, revealed the resident was at risk for altered nutritional and hydration and required extensive assistance with eating. Interventions included assisting the resident with meals. During an observation on 08/05/2024 at 1:01 PM, Resident #55 was sitting in a reclining wheelchair, on the far-right side of the first half round table, in the assisted dining room. LPN #4 was standing on the right side of Resident #55, spoon feeding the resident pureed chicken and dumplings. LPN #4 then walked to Resident #34, sitting at the second table on the right side of the dining room, stood on the right side of the resident and spoon fed Resident #34 chicken and dumplings. LPN # 4 then walked to the center dining room table where Resident # 15 was sitting in a wheelchair. LPN #4 stood on the right of Resident #15 and spoon fed resident one bite of chicken and dumplings. LPN # 4 returned to the right side of Resident #55 and spoon fed the resident another bite of food. During an interview on 08/05/2024 at 1:15 PM, Certified Nursing Assistant (CNA) #3 stated staff should be at the same level as residents, not standing when assisting with meals, to prevent intimidating residents. During an interview on 08/05/2024 at 1:30 PM, LPN #4 stated aides sit to assist residents, but the nurse is not required to sit due to the need to move from table to table to assist residents. During an interview on 08/07/2024 at 1:00 PM, the Director of Nursing (DON) stated all staff should be sitting at eye level with residents while providing assistance. There is no exception for nurses, they must provide dignity, so the residents do not feel someone is hovering or intimidating them.

Based on observations, interviews, record review, and policy review, it was determined the facility failed to ensure a bath or shower for 1 (Resident #65) of 1 resident reviewed for activities of daily living. Findings include: A review of a facility policy titled, Showering Residents, dated April 2021, indicated the purpose was to promote resident cleanliness and included a procedure only and did not address missed bathing or showers. A review of the Admission Record, indicated the facility admitted Resident #65 with diagnoses that included a disorder that affected a person's ability to think, a mood disorder, anxiety disorder, pain, and dizziness. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #65 had Brief Interview for Mental Status (BIMS) a score of 10 which indicated the resident had moderate cognitive impairment and an assessment to determine resident's ability to shower/bathe themselves was not attempted. The accompanying Care Area Assessment (CAA) Worksheet indicated the resident may have care needs or problems with cognitive loss, mood disorder impacting loss of cognition, pain, and functional abilities. The Admission Nursing Evaluation, dated 07/12/2024, indicated Resident #65's functional status for ability to transfer required 1 person to assist, a bathing preference of a shower, and required bathing assistance of 1 person. A review of Resident #65's Care Plan, initiated 07/22/2024, revealed the resident had an activity of daily living (ADL) self-care deficit related to fatigue, impaired balance, limited mobility and pain; a cognitive function or impaired thought process related to making decisions. Interventions included using simple instructions to promote independence, cue, reorient and supervise, keep the resident's routine consistent to decrease confusion. The Care Plan did not indicate Resident #65's preferences or number of staff required for assistance. A review of Order Summary, revealed Resident #65 had a disorder that affected a person's ability to think, a mood disorder, anxiety disorder, pain, and dizziness. During an interview on 08/05/2024 at 10:50 AM, Resident #65 stated it had been over a week since their last shower. During an interview on 08/05/2024 at 11:09 AM, Licensed Practical Nurse (LPN) #14, stated the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the floor nurse were responsible to ensure residents receive showers. The ADON was on maternity leave, they were running at a bare minimum and care was being provided. A review of Medication Administration Record, for July and August 2024 revealed Resident #54 had behavior monitoring, that included refusal of care every shift. There was no documentation of Resident #65 refusing care. A review of an Activity of Daily living (ADL) task titled, Shower/Bathe Self, revealed Resident #65 had a shower on 07/20/2024 at 12:55 PM and a shower on 07/30/2024 at 2:29 PM in the last 30 days. A shower sheet provided with the ADL sheet titled, Daily Shower Sheet, documented Resident #65 received a shower on 07/15/2024. Instructions at the bottom of the Daily Shower Sheet indicated the shower aides were to notify the nurse if the resident refused and all showers on the roster were to be accounted for. The Nurse on Duty was to ensure nurse assistants were completing the assigned showers. If a resident refused, the nurse was to encourage the resident and if the resident continued to refuse, staff were to initial the page as a refusal and place a note in the electronic health record as a 'Behavior Note'. The Daily Shower Sheet was provided by the Director of Nursing (DON) on 08/07/2024 at 10:05 AM. The DON stated the Daily Shower Sheet was provided to the shower aides daily and listed residents who were to receive showers on that date and was used to document who received showers and who refused. Initials on the left of the name was the nurse acknowledging a resident refused and initials on the right indicated the aide who provided the care. An R on the right indicated a resident refused. A review of the Tub/Shower Transfer tasks from 07/12/2024 through 08/06/2024, indicated Resident #65 was independent with transfer on 08/02/2024. Not Applicable was documented daily on all other dates during this time. A review of Progress Notes revealed Resident #65 refused a shower on 08/05/2024. No follow-up documentation was found. On 08/06/2024 at 3:34 PM, Resident #65 agreed to be shaved and refused a shower. Follow up documentation at 3:44 PM, the resident agreed to and received a shower. During an interview on 08/07/2024 at 12:57 PM, the DON stated Not Applicable indicated the resident refused a bath or shower and did not know why CNAs would mark Not Applicable when they can mark refused. During an interview on 08/08/2024 at 8:05 AM, CNA #15 stated when aides arrived for their shift, they receive a list of residents who are to receive showers. If a resident refused, the nurse was notified and would go speak with the resident. If the resident still refused it was documented in the electronic health record for bath/shower as refused. Not Applicable was used if staff did not get to the shower for that resident. The nurse was notified if the showers were not done. Residents' usual schedule is twice a week on days chosen by the resident. During an interview on 08/08/2024 at 8:17 AM, CNA #16 stated a list of residents was received at the beginning of the shift. Residents were asked if they wanted their shower or bath and if they refused, the nurse was notified. The nurse would then speak with the resident and if the resident refused, it was documented as a refusal in the computer. Not applicable was used if the CNA did not speak with the resident and the resident did not receive a bath or shower. The nurse received the list of residents for showers.

50924 Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene while serving meals and providing assistance to 6 (Resident #11, #15, #25, #28, #34, and #55) of 13 residents observed, specifically, staff moved from one resident to the next while feeding the residents, and touching other high contact areas, without performing hand hygiene; and failed to ensure that enhanced barrier precautions (EBP) were worn while performing indwelling catheter care to 1(Resident #31) of 3 sampled residents who had orders for indwelling catheter. Findings include: 1. A review of a facility policy titled, Hand Hygiene, dated April 2021, indicated hand hygiene was considered the primary means in preventing the spread of infections and staff should follow handwashing and hand hygiene procedures to prevent the spread of infections to residents. a. A review of a facility policy titled, Resident Assistance with Meals, dated April 2021, indicated residents who were unable to feed themselves would be fed with attention to safety. b. During an observation on 8/05/2024 at 12:52 PM, Certified Nursing Assistant (CNA) #3 used a spoon and placed food in Resident #28's mouth. CNA #3 moved hands below the table, rubbed hands on thighs, and folded their hands on their lap. CNA #3 moved hands above the table, picked up resident's spoon and placed food in resident's mouth. No hand hygiene was performed during this observation. c. During an observation on 08/05/2024 at 12:54 PM, CNA #3 used their hand and wiped the right side of their face, scratched side of their nose, picked up a spoon and placed food in Resident # 25's mouth. CNA #3 then placed the spoon on the table, raised their hands and adjusted their glasses, and picked up the spoon and placed food in Resident # 28's mouth. This observation occurred twice. After placing food in Resident #25's mouth, CNA #3 touched their face, picked up a cup and provided Resident #55 with a drink. No hand hygiene was performed. CNA #3 wiped their fingers on Resident # 28's napkin, picked up a spoon and placed food in Resident #28's mouth. No hand hygiene was performed during the entire observation. d. During an observation on 08/05/2024 at 12:56 PM, Nursing Assistant (NA) #5 and spoon fed Resident #11 chicken and dumplings, laid spoon down, and placed their hands below the table and resided them on their lap, palms down. NA raised their hands above the table, picked up the spoon and fed Resident #11 chicken and dumplings. No hand hygiene was performed during the observation. e. During an observation on 08/05/2024 at 1:01 PM, Licensed Practical Nurse (LPN) LPN #4 was standing on the right side of Resident #55, spoon feeding the resident. LPN #4 then walked to Resident #34, and spoon fed Resident #34. LPN # 4 then walked to the center dining room table where Resident # 15 was sitting in a wheelchair, and spoon fed the resident. LPN # 4 returned to Resident #55 and spoon fed the resident. No hand hygiene was performed between feeding each resident. f. During an interview on 08/05/2024 at 1:15 PM, CNA #3 stated hand hygiene should be done when moving between residents, and after touching clothing, their face, or nose to ensure germs were not spread to the residents. CNA #3 did not sanitize because no sanitizer was available. Sanitizer was observed on the top shelf of the resident's meal cart, brought into the dining room at 12:23 PM. g. During an interview on 08/05/2024 at 1:17 PM, NA #5 stated hands should be sanitized before assisting the resident, after touching their uniform, because residents' immune systems are not like mine so they could get my germs and be ill. h. During an interview on 08/05/2024 at 1:30 PM, LPN #4 stated hand hygiene should probably be done but constantly assisting residents prohibits it. i. During an interview on 08/07/2024 at 1:00 PM, the Director of Nursing (DON) stated staff should sanitize or wash their hands between each resident when passing trays or when feeding residents, to prevent the spread of germs or bacteria that are on their hands, which could result in infection to residents. 2. A review of the Admission Record, dated 12/27/2023, indicated the facility admitted Resident #31 with diagnoses that included infection and inflammatory reaction due to indwelling urethral catheter and neuromuscular disfunction of the bladder. a. During an observation of Resident #31 on 08/05/24 at 3:42 PM, Licensed Practical Nurse (LPN) #8 removed a urinary catheter and inserted a new urinary catheter without putting on a gown for EBP. b. During a subsequential interview on 08/05/24 at 4:02 PM, LPN #8 confirmed Resident #31 was on EBP, but they did not utilize a gown during the urinary catheter insertion and care per policy. c. A review of a facility policy titled, Enhanced Barrier Precautions, dated 09/21/2022, indicated, For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities. Activities listed as devise care or use including urinary catheter.

Based on observations, document review and interviews the facility failed to ensure bleach wipes and disinfectant wipes were not left at bedside for 1 (Resident #42) of 1 sampled resident. The findings are: A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/2024 showed Resident #42 had a Brief Interview of Mental Status (BIMS) score of 12, which suggests moderate cognitive impairment. On 08/05/2024 at 1:24 PM, the surveyor observed a container of bleach wet wipes and disinfectant wipes sitting on Resident #42's table next to bed. On 08/05/2024 at 3:26 the surveyor observed a container of bleach wet wipes and a container of disinfectant wet wipes on Resident #42's table next to bed. On 08/06/2024 at 10:17 AM, the surveyor observed a container of bleach wet wipes and a container of disinfectant wet wipes on Resident #42's table next to bed. On 08/07/2024 at 2:09 PM, the surveyor observed a container of bleach wipes and a container of disinfectant wet wipes on Resident #42's table next to bed. On 08/07/2024 at 2:09 PM, an interview with Certified Nursing Assistant (CNA) #13 was conducted. CNA #13 opened the bleach wipe container and verified that there were wipes in the container, then opened the disinfectant wipe container and verified that there were wipes in that container as well. When asked what type of wipes these containers were, CNA #13 reported they were bleach wipes and sanitizer wipes, and that neither of the wipes should have been left in Resident #42's room. CNA #13 revealed the wipes are hazardous, and the housekeepers store them in their carts. On 08/07/2024 at 2:15 PM, an interview with Registered Nurse (RN) # 12 was conducted. RN #12 revealed that the two containers in the room were bleach wipes and disinfectant wipes and should not be in the resident's room, because they could get mixed up and used as personal wipes or mixed up and used with food. RN #12 reported they should be locked up in cabinets so residents cannot get to them. On 08/08/2024 at 2:20 PM, an interview with Director of Nurses (DON) was conducted. The DON revealed that the wipe containers in Resident #42's room were bleach wipes and disinfectant wipes, and indicated the wipes are a hazard and should not be left where a resident has access to them. They should be stored where a resident cannot have access to them such as the med cart or locked up somewhere else.

Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter drainage bag was concealed in a privacy bag to promote dignity and privacy for 1 (Resident #40) of 2 (Residents #40 and #46) sample mix residents who had an indwelling urinary catheter. The findings included: The following observations were made concerning Resident #40: a. On 09/11/2023 at 3:44 PM, the urinary catheter drainage bag was hooked to the side of the bed touching the floor with no privacy cover. b. On 09/12/2023 at 9:26 AM, no privacy cover was covering the catheter drainage bag. c. On 09/13/2023 at 9:42 AM, no privacy cover was covering the catheter drainage bag. During interview on 09/12/2023 at 9:26 AM, the Surveyor asked Resident #40, how do you feel about people being able to see your catheter bag that is hanging on the side of your bed? Resident #40 stated, I don't like people being able to see it. It embarrasses me. During interview on 09/14/2023 at 2:28 PM, the Assistant Director of Nursing (ADON), said a resident's catheter bag should be covered. On 09/14/2023 at 2:48 PM the Director of Nursing (DON) said, a resident's urinary catheter drainage bag should be covered to preserve the resident's dignity. Review of the facility's policy titled Resident Rights with an effective date 04/2021 and a revision date of 11/01/2022 provided by the DON on 09/15/2023 at 9:10 AM showed residents have the right to be treated with respect, kindness, and dignity.

Based on observation, interview and record review, the facility failed to ensure enteral feeding was correctly labeled with the date, time, initials, and type of nutrition for 1of 1 (Resident #50) on tube feedings. The findings included: During observation on 09/11/2023 at 3:02 PM, Resident #50 was being administered a nutrition tube feeding with an unlabeled bag. On 09/13/23 at 9:52 AM, the Surveyor observed Resident #50 being administered a nutrition tube feeding with the type of nutrition not noted on the bag, but dated 09/13/2023 0000 with the initials CA. Review of the physician's Order Summary Report with an order start date of 07/19/2023 showed, change feeding administration set daily, and label the formula container and administration set with resident's name, date, time, and nurse's initials. During interview on 09/14/2023 at 2:26 PM, the Assistant Director of Nursing (ADON) confirmed Resident #50's bag was not labeled, and it should include the date, initials, time, and type of feeding. On 09/14/2023 at 2:48 PM, the Director of Nursing (DON), said tube feeding bags should be labeled with the type of feeding formula, staff initials, date, and time. Review of the facility's policy dated 04/2021 provided by the DON on 09/14/2023 at 4:29 PM showed nutritional support through enteral feeding will be provided as ordered.

Based on observation, interview, and record review, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician for 2 Residents (Resident #13 and #50), O2 tubing, and humidifier bottles were not dated for 2 Residents (Resident #40 and #50). The failed practice had the potential to affect 6 Residents (Resident #6, Resident #13, Resident #30, Resident #40 Resident #50, and Resident #259). Review of Resident #13's physician's Order Summary Report dated 09/11/2023 showed the following: a. A history of Covid-19 and Pneumonia. b. A physician's order dated 06/08/2022 showed administer oxygen at 2 LPM (liters per minute) as needed for shortness of breath. Review of Residnet #13's care plan showed asminister oxygen 2 liters per minute when needed. On 09/11/2023 at 11:58 AM, the Surveyor observed Resident # 13's oxygen setting at 1 1/2 liters per minute via nasal cannula with the tubing dated 9/10/23. On 09/12/2023 at 9:31 AM, the Surveyor observed Resident #13's oxygen setting at 1 1/2 liters per minute via nasal cannula with the tubing dated 9/10/23. On 09/13/2023 at 09:46 AM, the Surveyor observed Resident # 13's oxygen setting at 2 liters per minute via nasal cannula with tubing dated 9/10/23. On 09/13/23 at 09:46 AM, the surveyor observed Resident #13's O2 setting at 2 liters per minute via nasal cannula with tubing dated 9/10/23. During interview on 09/14/2023 at 2:26 PM, the Assistant Director of Nursing (ADON) verified Resident #13's physician's orders for oxygen showed 2 liters per minute. Review of Resident #40's physician Order Summary Report dated 09/11/2023 showed the following: a. Diagnosis of pneumonia. b. A physician's order dated 08/09/2023 showed, change oxygen tubing and humidity bottle on Sunday every week as needed. c. A physician's order dated 08/09/2023 showed oxygen 2 liters continuous via nasal cannula every shift. On 09/11/2023 at 3:53 PM, the Surveyor observed Resident #40 receiving oxygen therapy at 2 liters via nasal cannula with the date of 09/03/2023 on tubing and the humidifier bottle. On 09/12/2023 at 9:27 AM, the Surveyor observed Resident #40 receiving oxygen therapy at 2 liters via nasal cannula with the tubing and humidifier bottle dated 09/03/2023. c. On 09/13/2023 at 9:43 AM, the Surveyor observed Resident #40 receiving oxygen therapy at 2 liters via nasal cannula with tubing and humidifier bottle dated 09/12/2023. During interview on 09/14/2023 at 2:26 PM, the Assistant Director of Nursing (ADON), said oxygen tubing and the humidifier bottle are changed once a week on Sunday, and the oxygen tubing and humidifier bottle are dated at that time. During interview on 09/14/2023 at 2:48 PM, the Director of Nursing (DON), said oxygen tubing and the humidifier bottle are changed every Sunday night when needed, and the oxygen tubing and humidifier bottle are dated at that time. Review of Resident #50's physician Order Summary Report dated 09/11/2023 showed the following: a. Diagnoses of emphysema, malignancy of the esophagus and right lung and chronic obstructive pulmonary disease. b. A physician's order dated 08/09/2023 showed change all trach related tubing weekly and when needed. c. An ordered dated 07/10/2023 showed oxygen at 3L(liters) every shift. On 09/11/2023 at 10:49 AM, the Surveyor observed Resident #50's oxygen being administered at 1 1/2 liters with no date on the oxygen tubing or humidifier bottle. On 09/12/2023 at 9:10 AM, the Surveyor observed Resident #50's oxygen being administered at 2 liters with no date on the oxygen tubing or humidifier bottle. d. On 09/13/23 at 09:52 AM, the Surveyor observed Resident #50's oxygen being administered bled into the ventilator tubing at 3 liters with humidifier bottle dated 9/12, and the tubing undated. During interview on 09/13/2023 at 9:52 AM, Resident # 50 stated, They never change that oxygen tubing. They can't find any long enough to reach so they keep using the same one. During interview on 09/14/2023vat 2:26 PM, the Assistant Director of Nursing (ADON), said oxygen tubing and the humidifier bottle are changed once a week on Sunday, and the oxygen tubing and humidifier bottle are dated at that time. The surveyor asked the ADON, confirmed Resident #50's oxygen tubing was not dated. During interview on 09/14/2023 at 2:48 PM, the Director of Nursing (DON) said oxygen tubing and the humidifier bottle are changed every Sunday night when needed, and the oxygen tubing and humidifier bottle are dated at that time. Review of facility's policy titled Oxygen Administration-Resident dated 4/2023 provided by the DON on 09/14/2023 at 4:29 PM showed the following: Provide safe oxygen administration by verifying the physician's orders, and change oxygen tubing weekly, and label with the date it was changed. Based on observation, interview, and record review the facility failed to ensure the mask on the nebulizer was stored in a plastic bag to minimize the potential for infection of 1 Resident #259 of sampled residents who take breathing treatments. The findings included: Review of Resident #259's physician orders with a start date of 09/01/2023 showed administer albuterol 3 milliliters inhale orally every 4 hours. Record review of Resident #259's care plan dated 09/11/2023 showed diagnoses of emphysema and chronic obstructive pulmonary disease. During observation on 09/11/2023 at 11:07 AM, Resident #259's nebulizer mask was laying on the other bed in the resident's room. During observation on 09/12/2023 at 08:32 AM Resident #259's nebulizer mask was laying on the other bed in the resident's room. During interview on 09/14/2023 at 11:27 AM, LPN #1 confirmed that a nebulizer mask should be stored in a plastic bag between treatments. During interview on 09/14/2023 at 1:09 PM, the Director of Nursing (DON) said the process for storing a nebulizer mask is after the mask is used, it is cleaned, dried, and put in a plastic bag. Review of facility's policy titled Respiratory Therapy Guidelines provided by the DON on 09/14/2023 at 1:33 PM showed the procedure to prevent infection consist of storing the nebulizer mask in a plastic bag marked with the date and resident's name between uses.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the resident for 1 of 1 meal observed. This failed practice had the potential to affect 53 residents who receive meals from 1 of 1 kitchen. The findings included: Review of the facility's lunch menu week 4 showed on Wednesday 09/13/2023 residents were to receive chicken parmesan (1 each - 2 ounces), spaghetti noodles (3/4 cup), squash au gratin (1/2 cup), garlic bread 1 slice, poke cake 1 piece. During observation on 09/13/2023 at 12:31 PM, DE #1 used tongs to remove an unmeasured amount of noodles onto plates during lunch service. The Surveyor asked DE #1 how do you know the noodle portions are the correct proportioned amounts when using tongs? DE #1 said there is no way to measure pasta that she is aware of. During interview on 09/14/2023 at 10:17 AM, the Dietary Manager (DM), said all food placed on the residents' plates should be measured and pasta is measured with a scoop. On 09/14/2023 at 2:58 PM a review of the facility's policy titled Food Preparation and Handling provided by the Dietary Manager on 09/14/23 at 11:17 AM showed, all food items served to residents and clients are prepared according to standardized recipes. On 09/14/2023 at 3:15 PM, a review of the facility's policy titled Standardized Recipes showed cooks/chefs are expected to use and follow the recipes provided.

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands to decrease the potential for foodborne illness and prepared all foods on clean designated food preparation surfaces for residents receiving food from 1 of 1 kitchen. The failed practices had the potential to affect 53 residents who received meals from the kitchen. The findings included: On 09/13/2023 at 9:30 AM during the lunch meal preparation Dietary Employee (DE) #1 with gloved hands, reached for the trash can located at the end of the sink pulled it away from the sink, discarded onion peels and slid it back to the sink. DE #1 removed gloves, placed new gloves on and returned to chopping onions at the cook's prep table. No handwashing was observed. On 09/13/2023 at 9:36 AM, DE #1 retrieved 2 sealed boxes that contained grilled chicken patties from the walk-in cooler. DE #1 placed both boxes on the food prep table, retrieved a folding blade pocketknife from her pocket and cut the tape strip on the top of the box. DE #1 returned the knife to her pocket, donned clean gloves, removed grilled chicken patties from the box, and placed them in a deep metal pan. No hand washing was observed. DE #1 said she keeps her personal knife for opening boxes. On 09/13/2023 at 9:53 AM, DE #1 used a folding blade pocketknife to cut bottom strips of tape from 1 box of grilled chicken patties, flattened the box, placed it to the side, and returned knife to pocket. No hand washing or knife cleaning was observed. On 09/13/2023 at 9:55 AM, DE #1 touched the trash can lid with an ungloved hand while placing soiled gloves in the trash can. DE #1 picked up a partially used box of grilled chicken patties and carried it to the walk-in cooler. No hand washing was observed. On 09/13/2023 at 11:48 AM, DE #1 placed a metal pan containing noodles on the end of the sink closest to the prep table. The pan's edge was touching the side of a bucket containing clear liquid and kitchen towels previously identified by DE #1 as water and sanitizer mixture. On 09/13/2023 at 11:52 AM, no hand washing was observed before DE #1 removed 4 chicken patties and sauce from a deep metal pan containing 60 chicken patties, sauce, and cheese. The 4 patties and sauce were placed into a blender to be pureed. On 09/13/2023 at 11:53 AM, DE #1 touched the lid of the trash can next to the sink located behind the cook's prep table with ungloved hands. DE #1 then touched hair and face. No hand washing was observed. On 09/13/2023 at 12:02 PM, DE #1 placed paper liners in 2 metal baking trays, opened a package of bread, donned clean gloves but did not wash hands, and placed bread slices on the paper lined metal trays. On 09/13/2023 at 12:05 PM, DE #1 placed a plastic measuring cup on the side of the sink closest to the cook's prep table and placed butter in a measuring cup. DE #1 then placed the butter and measuring cup into the microwave. No hand washing was observed. On 09/13/2023 at 12:17 PM, DE #1 moved the trash can located by the sink behind the cook's prep table with ungloved hands. DE #1 then placed oven mitts on hands. No hand washing was observed. On 09/13/2023 at 12:19 PM, DE #1 touched the lid of the trash can located by the sink behind the cook's prep table with oven mitts on hands and continued to be used to move hot pans during lunch meal preparation. On 09/13/2023 at 12:26 PM, DE #1with ungloved hands walked to the steam table area to begin plating lunch meals. No hand washing was observed prior to plating. On 09/13/2023 at 12:30 to 12:38 PM, DE #2 at the food service window during meal service touched her face and hair with ungloved hands and did not perform hand washing. DE #2 continued to place drinks and desserts on trays being served to the residents. On 09/13/2023 at 12:31 PM, DE #1 placed food in 1 tan colored divided plate with a visible crack in the side. The plate was placed on a serving tray and sent out. On 09/14/2023 at 10:17 AM, an interview was conducted with the Dietary Manager (DM). The DM stated her rule regarding handwashing and what she tells her staff is Wash your hands all the time. If you touch something, wash your hands. The DM said if employees are on the food service line during meal service and touch their face or hair, they need to wash their hands. The DM stated wearing gloves never takes the place of hand washing. The DM said employees could wear gloves when mixing things that were too thick for mixers, so they didn't get stuff all over their hands, but other than that they were not to wear them. The DM said no surface of the sink would be considered a clean area or should be used for food preparation. The DM said the kitchen staff have been instructed to throw away plates and trays if they are broken, and if a resident was served on a broken plate he or she could have been cut. On 09/14/2023 at 3:45 PM a review of facility's policy titled Handwashing Procedure showed hands should be washed after touching bare human parts other than clean hands and clean exposed portions of arms. During food preparation, as often as necessary to remove soil and contamination and prevent cross-contamination when changing tasks. Before putting on gloves and after removing gloves.

Based on observation and interview, the facility failed to ensure an indwelling urinary catheter drainage bag did not touch the floor to prevent the risk of infection for 1 (Resident #40) of 2 (Residents #40 and 46) sample mix residents who had an indwelling urinary catheter. The findings included: On 09/11/2023 at 3:44 PM, the Surveyor observed Resident #40's urinary catheter drainage bag was hooked to the side of the bed touching the floor. On 09/12/2023 at 9:26 AM, the Surveyor observed Resident #40's urinary catheter drainage bag hooked to the side of the bed with half of the bag lying on the floor. During interview on 09/14/2023 at 2:28 PM, the Assistant Director of Nursing (ADON) said a resident's urinary catheter drainage bag should not be touching the ground because the urine won't flow correctly into the bag and could cause an infection. During interview on 09/14/2023 at 2:48 PM, the Director of Nursing (DON), said a resident's urinary catheter drainage bag should be below the bladder and not touching the floor because it could cause an infection or possibly an injury if the resident is in a wheelchair.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, palatable consistency to minimize the risk of choking or other complications for those residents who require pureed diets for 1 of 1 meal observed. The failed practice had the ability to affect 4 residents who received pureed diets. The findings included: 09/13/2023 at 12:26 PM a pan that contained pureed bread was observed on the steam table being served to residents receiving pureed meals. The consistency of the pureed bread was soupy and very watery. On 09/14/2023 at 10:17 AM, an interview was conducted with the Dietary Manager (DM). The DM confirmed there were 4 residents in the facility currently receiving a pureed diet, and the consistency of pureed food should be a pudding like consistency.

Based on observation, record review and interview, the facility failed to ensure sufficient staff were available at all times to provide nursing and related services to meet the residents' needs safely. This failed practice had the potential to affect all 51 residents as documented on the Resident Census and Conditions of Residents provided by the Director of Nursing (DON) on 6/13/22 at 9:20 AM. The findings are: 1. On 06/12/2022 at 1:03 PM, Certified Nursing Assistant (CNA) #3 was setting up a resident's lunch tray at the feeding assistance table and left the tray uncovered with no aide to feed the resident. 2. On 06/12/2022 at 1:04 PM, CNA #3 was setting up another resident's lunch tray at the feeding assistance table with no aide to feed resident. 3. On 06/12/2022 at 1:06 PM, the Administrator delivered another resident's lunch tray at the feeding assistance table with no aide to feed resident. 4. On 06/12/2022 at 1:07 PM, the DON set down in front of one of the residents and offered one bite and left the Dining Toom with no one at feeding assistance table to feed the 5 residents who were at the feeding assistance table. 5. On 06/12/2022 at 1:15 PM, the Administrator returned to the feeding assistance table, sat down on a stool, and began feeding 2 of the 5 residents at the feeding assistance table. 6. On 06/12/2022 at 1:27 PM, the DON returned to the Dining Room and began feeding the resident she was offering the one bite to before leaving. 7. On 06/12/22 at 10:41 AM, CNA #4 was standing by [Resident 19's] bed. Resident #19 stated, I've gone to the bathroom. CNA #4 stated, Okay, I will go get some help and be right back. 8. On 6/12/22 at 11:08 AM, the resident was asked, Did they come in to help you change your brief yet? She stated, No, not yet. They've been busy . 9. On 06/12/22 at 11:41 AM, CNA #3 entered Resident #19's room and stated, Do you need to be changed? He removed her blankets and her pants and stated, You've soaked through. We are going to have to change it all. CNA #3 changed his gloves and removed her brief. He stated that he had been very busy today and had been working twelve and sixteen hour shifts. 10. On 06/12/22 at 4:15 PM, Resident #9 was sitting in her room in a wheelchair. She asked this Surveyor to assist her to the bathroom. The Surveyor asked her what she normally does when she needs assistance and she stated, I have already pushed it and they came in and turned it off, said they were coming back, but never did. Surveyor instructed the resident to push her call light again and the resident pushed her call light. This Surveyor stepped into Hallway 500 and observe there were no staff in the hallway. This Surveyor stood in the hall and at 4:18 PM, CNA #3 entered Resident #9's room and stated, I am still looking for someone to help me. Then the light above her door went off. CNA#3 was asked. What was [Resident #9] wanting? He stated, She needs to go to the bathroom, but she is a two person assist and I've got to find somebody to help me. 11. On 06/12/22 at 4:25 PM, Resident #9, CNA #3 and CNA #4 entered the resident's room and shut the door. 12. On 6/14/22 at 2:44 PM, the DON was asked, Why do you think it took so long to assist the residents totally dependent on staff to eat on Sunday, and why do you think it takes so long for residents to receive peri care and staff not turn call lights off when they request help while waiting on another staff to help or get bed pan? She stated, Because we are so short staffed, especially on the weekends.

Based on observation, record review and interview, the facility failed to ensure infection control measures were consistently followed to prevent the spread of infection by failure to ensure staff disinfected hands between each resident while serving meal trays; and failure to ensure staff and visitors wore face mask correctly while in the facility. This failed practice had the potential to affect all 51 residents according to the Resident Census and Condition of Residents provided by the Director of Nursing on 6/13/22 at 9:20 AM. The findings are: 1. On 6/12/22 at 10:01 AM, a sign on the facility's front door documented, All visitors Must be screened upon entry & [and] all visitors Must wear a mask. 2. On 06/12/22 at 10:29 AM, entered the kitchen for initial tour, Dietary Employee #1 (DE) walked out of the dish washing area with a blue surgical mask under her chin. DE #1 adjusted the mask as soon as she saw the surveyor. DE #2 was setting up the food processor for puree and had a blue surgical mask under the nose. 3. On 6/12/2022 at 10:22 AM, Certified Nursing Assistant (CNA) #6 was at the front Nurses Station leaning forward and talking directly to two residents (approximately 6 inches from their face who were not wearing mask) with her face mask down under her chin. The Director of Nursing (DON) was standing by this CNA and did not instruct her to pull up her facemask to cover her nose and mouth. 4. On 6/12/2022 at 10:55 AM, CNA #6 was asked, How have you been instructed to wear your face mask? She stated, Covering my nose and mouth. She was asked, Were you wearing your facemask correctly when you were talking to the two residents sitting in front of the Nurses Station when we entered? She said, No, but I'm tired and upset. I had a wreck last night. 5. On 6/12/22 at 11:11 AM, the Dietary Manager (DM) arrived and entered through the back door near the walk-in refrigerator/freezer. She introduced herself to the Surveyor. She set her purse down. The DM asked the surveyor, Where do you need me to start? The DM was asked Do you need to do your screening? The DM stated, Yes, I will finish that now. At 11:16 AM, the DM exited through the dish washing area, into dining area, walking within six feet of 3 residents sitting in the Dining Room who were not wearing a mask, down hall to the screening area. 6. On 6/12/2022 at 11:51 AM, the DON was asked, How have you instructed staff to wear their face mask? She stated, Over their nose and face. 7. On 6/12/2022 at 11:55 AM, a visitor was standing in the hallway at the doorway of Resident room [ROOM NUMBER] with her face mask down under her chin talking to a surveyor. No residents were in the hallway in front of Resident room [ROOM NUMBER]. 8. On 06/12/2022 at 12:10 PM, the above visitor was inside Resident room [ROOM NUMBER] visiting with the resident, who was not wearing a mask and the resident's family who was not wearing mask for approximately 10 minutes with her face mask under her chin. 9. On 06/12/2022 between 12:28 PM and 12:50 PM, the above visitor with her facemask below her chin visited with residents at three different tables and none of the residents at all three tables were wearing mask. The visitor was approximately two to three feet from the resident's faces while visiting with them. 10. On 6/12/22 at 3:19 PM, CNA#1 and CNA#3 were standing by the 500 Hall common area with their mask pulled below their chin. They were within 6 feet of three residents who were sitting in wheelchairs. All of them pulled their mask over their nose and mouth when they saw this surveyor and walked away. 11. On 6/12/22 at 3:20 PM, a female visitor with her mask below her chin was in the 500 Hall. She was asked, Who are you? She stated, I am a church member with [Resident #17.] The visitor continued to talk to the residents with her mask pulled down below her mouth. 12. On 06/13/22 at 11:25 AM, DE #4 entered the kitchen through the back door near the walk-in refrigerator/freezer with her mask under her nose and did not raise it until she was at the hand washing sink. 13. On 06/13/22 at 11:27 AM, DE #5's mask was under her chin when she walked back from the area near the bread rack by the walk-in refrigerator. She did not raise her mask up until she was in the area with the dish washer. 14. On 06/13/22 at 11:50 AM, DE #5 entered through the back door near the walk-in refrigerator and did not have a mask on until she was at the hand washing sink. 15. On 06/13/22 at 11:58 AM, the DM was asked, Should kitchen staff have their masks covering their nose and mouth? The DM stated, Yes and No. If they are around food and dishes, they need to have it on. The Administrator had an in-service in December and told kitchen staff that in other areas of the kitchen it can be down. 16. On 06/14/22 at 9:36 AM, the surveyor and the DON were walking down the 400 Hall. Occupational Therapist #1 was in the therapy room standing over a female resident in a wheelchair with his masked pulled down below his chin. The DON was asked if she had seen the therapist with his mask down and she stated, Not till you said something. 17. On 06/13/2022 at 11:51 AM, the DON was asked, What are visitors instructed to do while in the facility? She stated, They are instructed to wear a face mask over their nose and mouth while in the facility. She was asked, What could happen if visitors and staff didn't wear face mask properly while in the facility? She stated, Could cause a spread of infection. 18. On 6/14/22 at 11:02 AM, the Administrator was asked, What is your current practice for the visitors being screened? He stated, They have to sign this form [Core Principles of COVID-19 Infection Prevention for Visitors] on their first visit and we keep them on file . 19. On 06/15/22 at 1:07 PM, Regional Nurse Consultant (RNC) was interviewed via telephone and was asked, Are you aware of a policy or in-service stating that kitchen staff do not have to wear masks at certain times? She stated, No, kitchen does not have a different policy. They handle food items. They can, just as others, remove their mask to eat or take a drink. She was asked, What about while handling clean dishes? She stated, They are no different than CNAs wearing masks in the halls without residents or laundry wearing a mask while transporting linens. She was asked, Who is responsible for IC [Infection Control] training? She stated, ICP [Infection Control Preventionist], DON, and Admin [Administration] are, but as I say to everyone, everyone in the building is responsible to ensure each other are wearing their masks appropriately. She was asked, Who is responsible for ensuring visitors are wearing theirs appropriately? She stated, That one is tricky because we do not have eyes on them at all times, but all staff are responsible for saying something to them if they see it. 20. On 06/15/22 at 2:23 PM, CNA #7 was in the hallway foyer where the 200 and 300 Halls meet conversing with 4 other staff with his face mask pulled below his bottom lip. None of the staff present instructed him to wear his mask correctly. 21. On 06/15/2022 between 4:15 and 4:25PM, the visitor who was at the facility on Sunday wearing her mask below her chin was visiting in Resident room [ROOM NUMBER] with the resident with her face mask below her chin. She was sitting in a chair next to the resident not wearing a mask. The visitor was approximately 2 to 2 1/2 feet from her face. 22. The Inservice titled, Mask Wearing & Handwashing 101, dated 4/4/22 provided by the Administrator on 06/14/22 at 10:20 AM documented, .Masks are to be worn at all times unless eating & drinking. Must cover nose & mouth completely. Masks need to be worn while performing tasks that affect Residents. If alone in office or room away from residents not performing anything that affects residents ok to take mask down .

Based on observation, interview and record review, the facility failed to ensure proper documentation of COVID-19 vaccination status for all staff; failed to ensure accuracy of data entered into National Health Care Safety Network (NHSN); failed to ensure accuracy of COVID-19 vaccination status of staff was given to surveyors; and failed to ensure facility chosen contingency plan for unvaccinated staff was followed. The findings are: 1. On 06/14/22 at 8:00 AM, the Administrator stated, We follow the CDC [Centers for Disease Control and Prevention] guidelines for testing and all COVID-19 guidelines. 2. On 06/14/22 at 7:14 PM, Staff Vaccination Data Received and the NHSN documented the following: a. All percentage columns in NHSN site were blank. b. Data submitted shows - Y [Yes] c. Passed Quality Assurance check shows - N [No] d. COVID-19 Vaccination Status for providers list had duplications of 3 staff listed in two different categories. 3. On 06/15/22 at 9:30 AM, The Administrator was asked, Who is responsible for entering data into NHSN? The Administrator stated, I am. I enter it every Friday. 4. On 06/15/22 at 11:19 AM, the Administrator was shown the COVID Staff Vaccination for providers completed form and was asked, Is this information you entered into NHSN? The Administrator stated, It is. The surveyor stated, Staff are duplicated on the list. The Administrator stated, I wasn't sure how to list them. They have one vaccination but then got a religious exemption. The Administrator was asked, Have you received any notification that NHSN has not accepted your data? The Administrator stated, No, I have not received a call or anything by email. The surveyor informed the Administrator, There is no data in NHSN, and the Passed Quality Assurance check shows No. The Administrator stated, If I put something in wrong it flags me, and I correct it. When I am done, I get an 'it's saved'. I get other notifications from NHSN regarding their webinars. I am not sure why there is no data. The Administrator was asked, I wanted to confirm that you stated at 8:00 am yesterday when we received the entrance conference documentation that your facility follows all CDC guidelines for COVID-19 regarding, testing and COVID outbreak management. The Administrator stated, Yes we are. The Administrator was asked, Is the facility following CDC guidelines listed in the Outbreak Management that you provided us for non-vaccinated staff with exemptions, the contingency plan? The Administrator stated, Yes, we follow CDC. The Administrator was shown page 2 of the Outbreak Management (OM) received and was asked, Should staff be following the testing, N95 mask and entry screening listed here? The Administrator looked at OM and stated, We should be, but we are not doing that. They are only wearing regular masks. I guess we have not followed that part to the letter. I was just happy to get them to wear a mask. 5. On 06/15/22 at 12:58 PM, received statements from Regional Nurse Consultant and Administrator regarding receipt of NHSN alerts in incorrect email. 6. The Outbreak Management document received from the Administrator on 6/12/2022 at 5:31 p.m. documented, .Unvaccinated Staff Special Precautions and Contingency Staffing Plan . Use of NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent for source control regardless whether they are providing direct care or otherwise interacting with residents . a. The COVID 19 Staff Vaccination Status for Providers documented Dietary Employee #5, Housekeeper #1, CNA #7 were exempted from receiving the COVID 19 Vaccine. 1) On 06/15/22 at 2:31 PM, Dietary Employee (DE) #5 was wearing a blue surgical mask and was asked, Are you aware that the facility follows the CDC guidelines for a contingency plan or additional precautions for unvaccinated staff, which includes an N95 mask? DE #5 stated, No. 2) On 06/16/22 at 10:53 AM, Housekeeper #1 was asked, Are you aware that the facility follows the CDC guidelines for a contingency plan or additional precautions for unvaccinated staff, which includes an N95 mask? Housekeeper #1 stated, No. 3) On 06/16/22 at 11:20 AM, Certified Nursing Assistant (CNA) #7 was asked, Are you aware that the facility follows the CDC guidelines for a contingency plan or additional precautions for unvaccinated staff, which includes an N95 mask? CNA #7 stated, No. (CNA raised surgical mask due to it falling below nose 4 times in 2 minutes during interview.)

Based on observation, record review and interview, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage area were dated and labeled of when received, opened and/or prepared; failed to ensure foods stored in the refrigerator were sealed/closed completely to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen and failed to ensure dietary staff had their hair completely covered in a hair net. These failed practices had the potential to affect all residents 51 (resident census: 51) who received meals from the kitchen as documented on a list provided by the Director of Nursing (DON) on 6/13/22. The findings are: 1. On 06/12/22 at 10:29 AM, entered the kitchen for initial tour, Dietary Employee #1 (DE) walked out of the dish washing area with no hairnet over her ponytail. DE #1 adjusted the hairnet as soon as she saw the surveyor. 2. On 06/12/22 at 10:34 AM, the following observations were made in the Dry Storage Room: a. A container with ground pepper was not dated, and the lid was open. b. On the left side of Dry Storage Room, on the second shelf was a small green bowl of cereal covered by saran wrap with the name [NAME] on it and not dated. DE #2 was asked to accompany the surveyor to the Dry Storage Room. DE #2 was asked whose bowl of cereal it was on shelf. DE #2 stated it was made for a resident that went to the hospital. DE #2 was asked if it should be dated. DE #2 stated, It will be thrown away because she went to the hospital. DE #2 was asked again if it should be dated and DE #2 stated, Probably so. c. Near the entrance to the Dry Storage Room, there were potatoes in a plastic storage bin under sweet potatoes in a plastic bin, not dated. DE #2 was asked when the potatoes were received. DE #2 stated, I do not remember. DE #2 was asked if she could find a date on the bin and DE #2 stated, There is not a date. 3. On 06/12/22 at 10:54 AM, there were two half loaves of bread sitting on the prep counter to the right of the stove, they were not dated. DE #2 was asked to find a date on them. DE #2 stated there is not a reason to because they dated the bread storage bin. (The storage was located next to walk-in refrigerator/freezer). 4. On 06/12/22 at 11:03 AM, the following observations were made in the standing refrigerator next to DM office. a. A ziploc bag with 10 slices of smoked ham was not sealed/closed b. A two pound sealed package of smoked ham slices was not dated. DE #3 was asked if it should be dated and if the ziploc bag should be sealed. DE #3 stated Yes. c. In the bottom of the standing refrigerator was a sealed bag of noncooked liquid eggs in a silver rectangular pan, not dated. DE #2 was asked if she could find a date on the bag. DE #2 stated, I know there is not one. DE #2 was asked if there should be a date. DE #2 stated, I don't know. 5. On 6/12/22 at 11:11 AM, the Dietary Manager (DM) arrived and entered through the back door near the walk-in refrigerator/freezer. She introduced herself to the Surveyor. She set her purse down and put on a hairnet. Two inches of her hair was hanging out the back of the hairnet. 6. On 06/12/22 at 11:25 AM, the following observations were made in the walk-in refrigerator with the Dietary Manager: a. An open five pound bag of shredded Swiss cheese with green and white spots and patches throughout dated 3/1/22. The DM was asked how much was left in the bag. The DM stated, About 3 pounds and took the bag to throw it out. b. A metal pan of Jell-O dated 5/30 was covered in aluminum foil with a hole in foil and a whiteish film on top of the reddish colored Jell-O. The DM was asked how much she thought was in the pan. The DM stated, About 4 cups. The DM stated they had made it for one resident, and she didn't like it. c. Two one gallon jugs of milk with an expiration date of 6/4/22 where on the bottom shelf of the refrigerator near other milk. 7. On 06/12/2022 at 12:53 PM, 12:55 PM, 1:00 PM and 1:02 PM, during the lunch meal service, CNA #3 was serving meal trays to residents, he did not disinfect his hands between meal trays. 8. On 06/12/2022 during lunch meal service, the Administrator did not disinfect his hands prior to serving resident meal trays. 9. On 06/13/2022 at 11:51 AM, the DON was asked, When should staff disinfect their hands during meal service? She stated, They should disinfect their hands between each residents tray served. She was asked, What could happen if staff didn't disinfect their hands between serving each resident meals? She stated, Could cause a spread of infection. 10. On 06/13/22 at 12:15 PM, the following observations were made with the DM. The DM was asked to check the standing refrigerator to see if the smoked ham was still in the refrigerator. The DM stated the ziploc was thrown out but stated, I forgot to date the ham. The DM was asked, Should it be dated or discarded? The DM stated, It should now be discarded since I forgot to date it yesterday. 11. On 06/15/22 at 1:07 PM, Regional Nurse Consultant (RNC) was interviewed via telephone and was asked, Who is responsible for monitoring staff hand washing between giving residents trays, etc. [etcetera]? She stated, I mean charge nurses and DON but again and staff that sees them not sanitizing or washing between residents should say something to them. 12. The facility policy and procedure titled, General Food Preparation & Handling, provided by the DON on 06/16/22 at 8:45 AM documented, . Leftovers must be dated, labeled, covered . Dating, labeling, or sealing foods in storage was not addressed. 13. The facility policy and procedure titled, Kitchen Policies & Operating Procedures provided by the DON on 06/16/22 at 8:45 AM documented, .Date dry goods . Safety & Sanitation: .Cleanliness: .Restrain hair: Wear a hat (or net) and tuck hair into it. Dating, labeling, or sealing foods in storage was not addressed.

Based on observation, record review, and interview the facility failed to ensure a resident, who was at high risk for elopement and wore a Wander Guard transmitter, was adequately monitored and failed to ensure Wander guard alarms were audible or loud enough for staff to hear and respond in a prompt manner to prevent the potential for elopement, accident, and or injury for 1 (Resident #1) of 4 (Residents #1, #2, #3, and #4) sampled residents who were at high risk for elopement and wore Wander Guard transmitters. 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 wandered from the facility and was found lying in the grass outside of the facility, and had the potential to cause more than minimal harm to 5 residents who were at risk for elopement and wore Wander Guard transmitters, according to a list provided by the Director of Nursing (DON) on 04/22/2021. The facility removed the Immediate Jeopardy and corrected the failed practice on 04/16/2021 prior to the survey. The administrator was notified of the Past Immediate Jeopardy on 04/28/2021. The findings are: 1. Resident #1 had diagnoses of Alzheimer's Disease, [CONDITION(S)], and [CONDITION(S)] Disorder. The Significant Change in Status Minimum Data Set with an Assessment Reference Date of 2/28/2021 documented the resident scored 7 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status and required 2 persons assistance with transfers and toileting needs. a. The Plan of Care documented, .I am an elopement risk/wanderer r/t [related to] impaired safety awareness and I have a wanderguard on my wheelchair .Date Initiated: 03/30/2021 .Revision on: 03/30/2021 . On 4/16/21 I eloped from building into parking lot; Intervention: started neuros, one on one while awake and Q [every]15 min [minutes] while asleep . A wanderguard has been placed on my wheelchair, ensure it is in place and working . b. The Nursing Progress Note documented, . 3/31/2021 14:07 [2:07 p.m.] .resident continues to be emotional crying and wandering up and down the halls looking for her way out. Wander guard remains in place. Will continue to monitor . c. The Wandering Risk Scale dated 4/6/2021 documented, .has wandered aimlessly within the home or off the grounds . has wandered in the past month . Resident is able to self-propel herself when in wheelchair around the building. She often does so, trying to find the way out to go home to her mom . Score 16 . Scores of 11 - above High Risk to Wander . d. Nursing Progress Note documented, .4/8/2021 21:14 [9:14 p.m.] .Resident was tearful and exit seeking the first part of this shift. Redirection away from exit doors to common areas only briefly successful . e. Nursing Progress Note documented 4/16/2021 23:00 [11:00 p.m.] . this nurse called to front door by staff that resident was out of the building. Front door alarm going off, CNA [Certified Nursing Assistant] was bringing resident back to front door, stated resident was on ground in front of her w/c [wheelchair] and she was assisted back into w/c to bring her back into the building. Resident taken to her room and head to toe assessment performed. Resident changed into bed clothes and placed in bed. Found bruise to right elbow area and no other injuries. Resident alert to self, rom [range of motion] wnl [within normal limits] for resident vs [vital signs] wnl, foley cath [catheter] patent and draining. [Medical Director], DON [Director of Nursing], admin [Administrator] and family notified. Will continue to monitor . f. Nursing Progress Note documented, .4/17/2021 02:55 [2:55 a.m.] Incident Note Text: Continues to be monitored post elopement/unwitnessed fall. Vital signs and neuros WNL. ROM as before. No voiced c/o [complaints of] to note. Respirations even and unlabored. No s/s [signs or symptoms] pain/discomfort to note. Has rested with eyes closed thus far this shift. Will continue care . g. Nursing Progress Note documented, .4/17/2021 10:31 [10:31 a.m.] Discharge Summary Note Text: Resident transferred via EMS [Emergency Medical System] to [Hospital] for eval [evaluation] into Memory mood [and] Thought . h. The facility's direct care staffing form was reviewed for the evening of 4/16/2021. The facility had two nurses and two Certified Nursing Aides that worked the entire evening shift. The census was 47 residents. The facility was below minimum staffing guidelines for the state of Arkansas. i. On 4/22/2021 at 2:00 p.m., Registered Nurse (RN #1) was asked, Does [Resident #1] actively go to the exit doors? RN #1 stated, Yes, [Resident #1] will go to the front door and the 300 Hall door. The wanderguard alarm will go off and somebody will have to go to the door and reset the wanderguard alarm to shut it off. [Resident #1] is always saying it is time for me to go home or I need to go home to see my mom. She doesn't usually push on the doors. [Resident #1] pushes herself in her wheelchair. RN #1 was asked, How did she get out of the facility on 4/16/2021? RN #1 stated, I don't really know for sure. I cannot see how she could get out the front door by herself. We did have a visitor at that time. He usually will ask for someone to let him out. I know we were short staffed that night. I was taking some of the resident's out to smoke. I didn't hear anything. The other nurse came and got me and said that the front door was alarming and that a resident might of got out. We close the double doors by the dining room after dinner. All you have to do is push on them and they will open. When I got to the front door both alarms were sounding. The front door was alarming, and the strip alarm was going off. [Nursing Assistant #1] had went out to get [Resident #1]. It was raining. [Resident #1] did get out of her wheelchair. A person who worked at [Hospital] found her on the ground and called 911. You cannot hear the strip alarm (wanderguard alarm) from the nurses' station with the double doors closed. j. On 4/22/2021 at 2:23 p.m., Certified Nursing Assistant (CNA #1) was asked, Does [Resident #1] actively go to the exit doors? CNA #1 stated, [Resident #1] has been exit seeking for weeks. I seen her pushing on the fire doors by the Dining Area. She always says she wants to go home. She is usually redirectable. She will try to stand up with her catheter. Her pressure alarm in her wheelchair will go off. She has been trying to escape for days. You will have to run down there and reset the alarm. The alarm seems to kind of stop her. CNA #1 was asked, How did she get out of the facility on 4/16/2021? CNA #1 stated, I don't really know. I was never outside. I never heard any alarm because I was in a resident's room. Nobody on the back hall would of been able to hear the alarm. I heard that a person in the kitchen texted one of the nurses that the front door alarms were going off. I know we didn't have enough staff that night. It was raining. When they got her back in the facility, she was wet and scared. CNA #1 was asked, When was the last time you saw [Resident #1] on 4/16/2021 prior to her getting out of the building? CNA #1 stated, She was in the Dining Room. I was delivering hall trays. That was the last time I seen her. k. On 4/28/2021 at 12:54 p.m., Laundry staff #1 was asked, Did you hear the front door alarms sounding when [Resident #1] got out of the building on 4/16/2021? Laundry staff #1 stated, I was working in laundry. I didn't hear any alarm. I heard a lady from the hospital found her outside. Laundry staff #1 was asked, Have you seen [Resident #] actively go to the exit doors on 4/16/2021? Laundry staff #1 stated, She always goes to the exit doors. She gets agitated about wanting to go home. Every once and awhile she will push on the doors. Her wanderguard will go off. She will go to the 300 Hall door and then to the front door. She is pretty quick. She doesn't do that all day. At times she will get aggravated. I have gotten her away from the 300 Hall door several times. I work second shift. She was agitated that day. She was not pushing at the door that day. I just redirected her. I shut the alarm off. At least seven to eight times that night. She will usually run right back up front. l. On 4/28/2021 at 2:05 p.m., Nursing Assistant (NA #1) was asked, How did you know a resident had gotten out the front door on 4/16/2021? NA #1 stated, I was walking up front to see if I could find another CNA to help me. I think it was around 6:50-7:00 p.m. I thought I heard a slight noise like an alarm but I wasn't sure because the fire doors were closed. I went to the front door and a gentleman was knocking on the door. He said I believe you have a resident down by the dumpsters. I did hear the alarm when I was up front. I believe they were both alarming. The door one seemed to be ringing. I think I might of heard the 300 Hall door alarming. I don't know which direction she went. The blank bar (wanderguard alarm) connected to the front door was still ringing. You have to put a magnet on it to make it stop. That side alarm was going off. I know that. I had to do the keypad to the front door to talk with that guy. A [Hospital] employee was with [Resident #1] when I found her. The employee had put a jacket over her. I didn't really catch what was going on. I pushed her back to the building in her wheelchair. NA #1 was asked, When was the last time you saw [Resident #1]? NA #1 stated, I saw her going to the Dining Area. I was trying to have a conversation with her. Before that she said I'm going home, I'm going home. She would get frustrated. Those double doors are always closed. I never really saw her make it to the double doors. m. On 4/28/2021 from 2:35 p.m. to 2:40 p.m.; the wanderguard alarm was activated at the front door with the Maintenance Director present. The double doors were closed by the Dining Area and the alarm was faintly audible or detected at the nursing station. 2. The facility initiated corrective action immediately after the incident on 04/16/2021 by implementing the following: a.the facility did a head count of residents to ensure all other residents were accounted for with no negative findings. b. All fire and elopement door alarms were checked for functionality and were verified to be in working order. c. During the facility's investigation, it was discovered that the lobby door, where administrative offices are, was too far from the resident hallways to hear the Wanderguard alarm, explaining why it was not heard until staff went to the dining room, which is near the lobby. The maintenance director ensured that all door alarms were set to sound as loudly as possible. A very loud secondary alarm was installed on the fire doors between the dining room and the lobby to alert staff when anyone opens the door to allow for more response time in the absence of administrative staff before a resident could make it to the lobby entrance. d. In addition to these measures, the facility is seeking installment of an enunciator for the Wanderguard system at the front nurses' station, making the alarm audible to all staff. e. All residents were assessed for changes to their risk for elopement and everyone who is at risk for elopement was verified to have a functioning wanderguard in place. f.In-service on the facility's elopement policy, elopement drills are in place for each shift to ensure continued rapid and appropriate response.

Complaint # (AR 836) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure care and services were provided in accordance with professional standards of practice, by failing to thoroughly assess for injury and check range of motion to the lower extremities after a resident with a recent [MEDICAL CONDITION] was found on the floor, which potentially resulted in a delay in identifying a second [MEDICAL CONDITION] hip, and failure to document the incident in the clinical record and inform administration and the oncoming shift regarding the incident, to ensure staff were aware of the need to closely monitor the resident for any signs / symptoms of injury for 1 (Resident #1) of 2 (Residents #1 and #5) case mix residents who experienced falls in the past 30 days. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused of could have caused serious harm, injury or death to Resident #1, who was found on the floor and was subsequently diagnosed with [REDACTED]. The Administrator was notified of the past immediate jeopardy on 4/25/19 at 2:36 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 3/28/19 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required 1 person assistance with transfers and toileting and had a history of [REDACTED]. a. The Plan of Care dated 4/19/19 documented, .He has had an actual fall before admission and is at risk for additional falls with potential for injury due to his unsteady gait and problems with balance . Offer assistance for ambulation, observe for and report any increased weakness, problems with balance or unsteadiness . PT (Physical Therapy) consult for strength and mobility . b. The Radiology Results Report documented, Examination Date: 4/17/2019 13:06 (1:06 p.m.) .Exam: Hip X-ray Unilateral 2-3 Views Left .Impression .1. Age-indeterminate oblique proximal femoral fracture. This may represent the initial fracture requiring hardware placement. This may represent a new acute perihardware fracture. Indeterminate given the lack of prior studies. Recommend correlation with preoperative imaging to confirm. 2. Intact-appearing THA (Total Hip Arthroplasty) hardware . The hospital Emergency Record dated 4/18/19 at 9:07 p.m. documented, . brought in by EMS (Emergency Medical Center) complaining of left leg pain. Patient recently had a left [MEDICAL CONDITION] repaired by (Orthopedist) on (MONTH) 7 and was sent back to the nursing home the day after surgery . The patient now returns to the ED (Emergency Department) after experiencing acute LEFT hip pain and internal rotation of the LEFT leg . Plain films performed last night confirmed presence of a LEFT proximal femur peri-prosthetic fracture. He is now admitted for surgical fixation of same. No other reported injury . c. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 4/18/19 documented, Date and Time of Discovery: 04/18/2019. Time 8:30 PM . Date and Time of Incident (if known): (blank) . Date Incident Reported to OLTC (Office of Long Term Care): 04/18/2019 Time: 10:21 PM . At approx (approximately) 1930 (7:30 p.m.) (Resident #1's sister) came to the nurse on shift to report an incident the resident had told her about, (Resident #1's sister) states that the mean nurse threw him in bed and very rough the other night. When asked which nurse he stated, the one who pulled off my bandage the other night to count my staples. After further investigation it was found to be (Licensed Practical Nurse (LPN) #1). He states that his hip/leg was hurting him and he could not put any weight on it ever since this incident . The section of the form designated for, Findings and Actions Taken documented, .Police, Physician, Director of Nurses and Administrator notified. Witness statements gathered from employees. None indicated seeing (LPN #1) be physically rough with (Resident #1) or any other resident. Resident's with a BIMS score of 8 or higher were interviewed that (LPN #1) would have been assigned too (sic), none indicated any form of abuse . During the investigation, two Certified Nursing Assistants (CNA's), (CNA #1) and (CNA #2), indicated that (Resident #1) fell and was on the floor the evening of 4/16/2019. Review of medical record did not indicate a progress note, assessment or Incident and Accident report. (CNA #1) stated that she answered (Resident #1's) call light and found him on the floor. She asked the nurse to assist her. (CNA #2) confirmed that (CNA #1) asked for assistance getting (Resident #1) out of the floor. (LPN #1) denies (Resident #1) ever falling or being asked by (CNA #1) for assistance to get him out of the floor. (LPN #1) stated that while passing his room she saw him standing and starting to fall. She attests that she helped him back into bed and he was never on the floor . Due the conflicting stories of between the two CNAs and (LPN #1) it is believed that (Resident #1) had an unreported fall on the evening of 04/16/2019. Due to (LPN #1) failure to assess and report the fall, the facility is substantiating neglect . 1.) The OLTC Witness Statement Form dated 4/19/19 at 6:35 p.m. documented, .Witness Full Name (LPN #1) . On the evening of 4/16/19 (I) was walking by Resident room (and) he was standing up out of his WC (wheelchair), holding onto bed side table, when I got into room he started to fall (and) assisted to side of bed. He then started to slide out of the bed (and) assisted Resident into bed with (cradle) lift. No complaint of pain voiced. Resident lifted his own leg (and) placed on pillows to float heel . 2.) The OLTC Witness Statement Form dated 4/19/19 at 2:16 p.m. documented, .Witness Full Name (CNA #1) . (Resident #1) call light was going off I went down to answer the call light and he was in the floor. So I went and got (LPN #1) told her (Resident #1) was in the floor she checked his arms and stuff then said let pick him up we got him up and on the bed. (LPN #1) then walked out and told (CNA #2) to come in and help me change him. So then we got all of that done and went back to the nurse station and she never asked to get vitals on anything . d. On 4/24/19 at 3:07 p.m., CNA #1 was asked when Resident #1 was found on the floor. CNA #1 stated, It was on Thursday night (4/16/19) around 6:30 p.m. to 8:30 p.m. CNA #1 was asked what she did when she found Resident #1 on the floor and stated, I went and got (LPN #1). He was sitting on his butt with his legs straight out. She (LPN #1) kind of moved his arms around. She didn't do anything with his legs. She didn't ask me to do vital signs. (LPN #1) helped me get him out of the floor . She never asked me to do a witness statement. She never has asked me to do a witness statement when a resident has fallen. I have reported her just because she has a bad attitude. He (resident) didn't seem like he was in a lot of pain. (LPN #1) told me she didn't need anything else done. (CNA #2) came in and helped me change (Resident #1). (CNA #2) did not see (Resident #1) on the floor. At 4:03 p.m., CNA #3 was asked when he assisted Resident #1 and stated, The only time I assisted (Resident #1) was when I assisted him back to bed on 4/17/19. It was in the evening. CNA #3 was asked what happened when he saw Resident #1 in his room and stated, He was a one person assist with a gait belt. (LPN #1) told me to go check on him. When I saw him, he was starting to stand up. He was trying to get into bed. He did not appear to be in any pain. I assisted him in bed and when I went to pick up his feet, he said his leg was broken and hurting. I went straight to (LPN #1) and told her. I never seen (sic) her get up. e. On 4/25/29 at 8:30 a.m., the Director of Rehabilitation (DOR) was asked about Resident #1's rehabilitation stay at the facility. The DOR stated, He had two rounds of therapy here. I saw him at the hospital before he came here. He was working with therapy at the hospital. He had no difficulty bearing weight. He had some sequencing issues when using his walker. I just figured it was related to his stroke. He never said he had any pain. On 4/17/18, it was like night and day. I walked with him outside the day before. The (Physical Therapist) said he was completely different. He wasn't bearing any weight on his left side. The biggest red flag was that he wasn't putting any weight on that left side. We immediately reported it to the nurse. He did say that he was in pain. His transfer was not good either. We physically had to help him with turning without him twisting that left leg. He never said anything about a nurse or CNA being rough with him. He told me that he thought it happened during a transfer the evening before. He had sequencing issues with the walker. Stopping and starting but he did that from the beginning. I didn't notice his feet turned in. When he stepped with his left foot he would not pass his right foot without cues. I just figured it was from weakness due to his stroke. f. On 4/25/19 at 8:55 a.m., LPN #2 was asked about Resident #1's status on the morning of 4/18/19. LPN #2 stated, I remember I asked him myself if he was doing better. I went ahead and gave him a pain pill. It was 9:04 a.m. Therapy had went in there and he could hardly stand and they put him back to bed. I didn't give him another pain pill that day. (LPN #3) came on shift around 3:15 p.m. The MAR (Medication Administration Record) doesn't say that she gave any pain medications, but maybe she just failed to sign out on the MAR. g. On 4/25/19 at 12:50 p.m., the Director of Nursing (DON) was asked if LPN #1 had received any disciplinary actions prior to this incident. The DON stated, No. The DON was asked if the CNAs were required to write a witness statement after any accident or fall and stated, They know they are supposed to, but with the charting on the computer, sometimes the nurses will just put in their statements. They now know that they need to write up any witness statement with any accident or fall and, of course, with any abuse allegation. The DON was asked if LPN #1 ever worked after the incident was reported on 4/18/19. The DON stated, She came up front to the Administrator's office and filled out a witness statement but, she was never working as an LPN after 4/18/19. h. The facility removed the Immediate Jeopardy and corrected the failed practices on 4/19/19 prior to the survey, as evidenced by the following: 1.) The facility thoroughly investigated the cause of the fracture and terminated LPN #1 as a result: The DMS form 762 dated 4/18/19 documented, .Employee (LPN #1) termination effective 04/24/2019 . The facility completed body audits on every resident assigned to (LPN #1), interviewed staff, In-serviced all staff on abuse and neglect, fall prevention and reporting procedures for falls. Monitoring began on 04/19/2019 and will be on-going 5 times a week for a minimum of 8 weeks. QAPI (Quality Assurance Performance Improvement) committee following incident and will continue to monitor . The facility's investigation, submitted to OLTC on 4/18/19, included witness statements from multiple staff and other residents. The facility also provided their in-service documentation and sign-in sheet - topics covered included, What to Report, When to Report and Who to Report Incidents to and, Fall Prevention 2.) On 4/25/19 at 1:28 p.m., the DON provided a typed form that documented, I (DON), assessed every Resident on the Back Hall (400 hall, 500hall and the last 4 rooms on 200 Hall). There were no s/s (signs or symptoms) of unaccounted bruises, scratches or evidence of a fall at that time. When I assessed the residents, I asked them if they had any falls recently, if they felt safe and if any staff member had been verbally or physically abusive or rough. All residents denied . The facility provided written witness statements and body audit forms dated 4/18/19 and 4/19/19 to demonstrate these actions were completed. 3.) On 4/25/19 at 1:40 p.m., the Administrator provided a Fall Monitoring Form that documented, .Beginning 04/19/2019 Staff will be interviewed 5x (times) a week for minimum of 8 weeks to ensure any falls that happened on their shift were reported and an Incident and Accident Report was completed and notification to the family and Director of Nurses . No further negative findings had been identified between 4/19/19 ant 4/25/19.

Complaint # (AR 836) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure a resident was free from neglect, as evidenced by failure to thoroughly assess for injury and check range of motion to the lower extremities after a resident with a recent [MEDICAL CONDITION] was found on the floor, which potentially resulted in a delay in identifying a second [MEDICAL CONDITION] hip, and failure to document the incident in the clinical record and inform administration and the oncoming shift regarding the incident, to ensure staff were aware of the need to closely monitor the resident for any signs / symptoms of injury for 1 (Resident #1) of 2 (Residents #1 and #5) case mix residents who experienced falls in the past 30 days. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused of could have caused serious harm, injury or death to Resident #1, who was found on the floor and was subsequently diagnosed with [REDACTED]. The Administrator was notified of the past immediate jeopardy on 4/25/19 at 2:36 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 3/28/19 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required 1person assistance with transfers and toileting and had a history of [REDACTED]. a. The Plan of Care dated 4/19/19 documented, .He has had an actual fall before admission and is at risk for additional falls with potential for injury due to his unsteady gait and problems with balance . Offer assistance for ambulation, observe for and report any increased weakness, problems with balance or unsteadiness . PT (Physical Therapy) consult for strength and mobility . b. The Radiology Results Report documented, Examination Date: 4/17/2019 13:06 (1:06 p.m.) .Exam: Hip X-ray Unilateral 2-3 Views Left .Impression .1. Age-indeterminate oblique proximal femoral fracture. This may represent the initial fracture requiring hardware placement. This may represent a new acute peri hardware fracture. Indeterminate given the lack of prior studies. Recommend correlation with preoperative imaging to confirm. 2. Intact-appearing THA (Total Hip Arthroplasty) hardware . The hospital Emergency Record dated 4/18/19 at 9:07 p.m. documented, . brought in by EMS (Emergency Medical Center) complaining of left leg pain. Patient recently had a left [MEDICAL CONDITION] repaired by (Orthopedist) on (MONTH) 7 and was sent back to the nursing home the day after surgery . The patient now returns to the ED (Emergency Department) after experiencing acute LEFT hip pain and internal rotation of the LEFT leg . Plain films performed last night confirmed presence of a LEFT proximal femur peri-prosthetic fracture. He is now admitted for surgical fixation of same. No other reported injury . c. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 4/18/19 documented, Date and Time of Discovery: 04/18/2019. Time 8:30 PM . Date and Time of Incident (if known): (blank) . Date Incident Reported to OLTC (Office of Long Term Care): 04/18/2019 Time: 10:21 PM . At approx (approximately) 1930 (7:30 p.m.) (Resident #1's sister) came to the nurse on shift to report an incident the resident had told her about, (Resident #1's sister) states that the mean nurse threw him in bed and very rough the other night. When asked which nurse he stated, the one who pulled off my bandage the other night to count my staples. After further investigation it was found to be (Licensed Practical Nurse (LPN) #1). He states that his hip/leg was hurting him and he could not put any weight on it ever since this incident . The section of the form designated for, Findings and Actions Taken documented, .Police, Physician, Director of Nurses and Administrator notified. Witness statements gathered from employees. None indicated seeing (LPN #1) be physically rough with (Resident #1) or any other resident. Resident's with a BIMS score of 8 or higher were interviewed that (LPN #1) would have been assigned too (sic), none indicated any form of abuse . During the investigation, two Certified Nursing Assistants (CNA's), (CNA #1) and (CNA #2), indicated that (Resident #1) fell and was on the floor the evening of 4/16/2019. Review of medical record did not indicate a progress note, assessment or Incident and Accident report. (CNA #1) stated that she answered (Resident #1's) call light and found him on the floor. She asked the nurse to assist her. (CNA #2) confirmed that (CNA #1) asked for assistance getting (Resident #1) out of the floor. (LPN #1) denies (Resident #1) ever falling or being asked by (CNA #1) for assistance to get him out of the floor. (LPN #1) stated that while passing his room she saw him standing and starting to fall. She attests that she helped him back into bed and he was never on the floor . Due the conflicting stories of between the two CNAs and (LPN #1) it is believed that (Resident #1) had an unreported fall on the evening of 04/16/2019. Due to (LPN #1) failure to assess and report the fall, the facility is substantiating neglect . 1.) The OLTC Witness Statement Form dated 4/19/19 at 6:35 p.m. documented, .Witness Full Name (LPN #1) . On the evening of 4/16/19 (I) was walking by Resident room (and) he was standing up out of his WC (wheelchair), holding onto bed side table, when I got into room he started to fall (and) assisted to side of bed. He then started to slide out of the bed (and) assisted Resident into bed with (cradle) lift. No complaint of pain voiced. Resident lifted his own leg (and) placed on pillows to float heel . 2.) The OLTC Witness Statement Form dated 4/19/19 at 2:16 p.m. documented, .Witness Full Name (CNA #1) . (Resident #1) call light was going off I went down to answer the call light and he was in the floor. So I went and got (LPN #1) told her (Resident #1) was in the floor she checked his arms and stuff then said let pick him up we got him up and on the bed. (LPN #1) then walked out and told (CNA #2) to come in and help me change him. So then we got all of that done and went back to the nurse station and she never asked to get vitals on anything . d. On 4/24/19 at 3:07 p.m., CNA #1 was asked when Resident #1 was found on the floor. CNA #1 stated, It was on Thursday night (4/16/19) around 6:30 p.m. to 8:30 p.m. CNA #1 was asked what she did when she found Resident #1 on the floor and stated, I went and got (LPN #1). He was sitting on his butt with his legs straight out. She (LPN #1) kind of moved his arms around. She didn't do anything with his legs. She didn't ask me to do vital signs. (LPN #1) helped me get him out of the floor . She never asked me to do a witness statement. She never has asked me to do a witness statement when a resident has fallen. I have reported her just because she has a bad attitude. He (resident) didn't seem like he was in a lot of pain. (LPN #1) told me she didn't need anything else done. (CNA #2) came in and helped me change (Resident #1). (CNA #2) did not see (Resident #1) on the floor. At 4:03 p.m., CNA #3 was asked when he assisted Resident #1 and stated, The only time I assisted (Resident #1) was when I assisted him back to bed on 4/17/19. It was in the evening. CNA #3 was asked what happened when he saw Resident #1 in his room and stated, He was a one person assist with a gait belt. (LPN #1) told me to go check on him. When I saw him, he was starting to stand up. He was trying to get into bed. He did not appear to be in any pain. I assisted him in bed and when I went to pick up his feet, he said his leg was broken and hurting. I went straight to (LPN #1) and told her. I never seen (sic) her get up. e. On 4/25/29 at 8:30 a.m., the Director of Rehabilitation (DOR) was asked about Resident #1's rehabilitation stay at the facility. The DOR stated, He had two rounds of therapy here. I saw him at the hospital before he came here. He was working with therapy at the hospital. He had no difficulty bearing weight. He had some sequencing issues when using his walker. I just figured it was related to his stroke. He never said he had any pain. On 4/17/18, it was like night and day. I walked with him outside the day before. The (Physical Therapist) said he was completely different. He wasn't bearing any weight on his left side. The biggest red flag was that he wasn't putting any weight on that left side. We immediately reported it to the nurse. He did say that he was in pain. His transfer was not good either. We physically had to help him with turning without him twisting that left leg. He never said anything about a nurse or CNA being rough with him. He told me that he thought it happened during a transfer the evening before. He had sequencing issues with the walker. Stopping and starting but he did that from the beginning. I didn't notice his feet turned in. When he stepped with his left foot he would not pass his right foot without cues. I just figured it was from weakness due to his stroke. f. On 4/25/19 at 8:55 a.m., LPN #2 was asked about Resident #1's status on the morning of 4/18/19. LPN #2 stated, I remember I asked him myself if he was doing better. I went ahead and gave him a pain pill. It was 9:04 a.m. Therapy had went in there and he could hardly stand and they put him back to bed. I didn't give him another pain pill that day. (LPN #3) came on shift around 3:15 p.m. The MAR (Medication Administration Record) doesn't say that she gave any pain medications, but maybe she just failed to sign out on the MAR. g. On 4/25/19 at 12:50 p.m., the Director of Nursing (DON) was asked if LPN #1 had received any disciplinary actions prior to this incident. The DON stated, No. The DON was asked if the CNAs were required to write a witness statement after any accident or fall and stated, They know they are supposed to, but with the charting on the computer, sometimes the nurses will just put in their statements. They now know that they need to write up any witness statement with any accident or fall and, of course, with any abuse allegation. The DON was asked if LPN #1 ever worked after the incident was reported on 4/18/19. The DON stated, She came up front to the Administrator's office and filled out a witness statement but, she was never working as an LPN after 4/18/19. h. The facility removed the Immediate Jeopardy and corrected the failed practices on 4/19/19 prior to the survey, as evidenced by the following: 1.) The facility thoroughly investigated the cause of the fracture and terminated LPN #1 as a result: The DMS form 762 dated 4/18/19 documented, .Employee (LPN #1) termination effective 04/24/2019 . The facility completed body audits on every resident assigned to (LPN #1), interviewed staff, In-serviced all staff on abuse and neglect, fall prevention and reporting procedures for falls. Monitoring began on 04/19/2019 and will be on-going 5 times a week for a minimum of 8 weeks. QAPI (Quality Assurance Performance Improvement) committee following incident and will continue to monitor . The facility's investigation, submitted to OLTC on 4/18/19, included witness statements from multiple staff and other residents. The facility also provided their in-service documentation and sign-in sheet - topics covered included, What to Report, When to Report and Who to Report Incidents to and, Fall Prevention 2.) On 4/25/19 at 1:28 p.m., the DON provided a typed form that documented, I (DON), assessed every Resident on the Back Hall (400 hall, 500hall and the last 4 rooms on 200 Hall). There were no s/s (signs or symptoms) of unaccounted bruises, scratches or evidence of a fall at that time. When I assessed the residents, I asked them if they had any falls recently, if they felt safe and if any staff member had been verbally or physically abusive or rough. All residents denied . The facility provided written witness statements and body audit forms dated 4/18/19 and 4/19/19 to demonstrate these actions were completed. 3.) On 4/25/19 at 1:40 p.m., the Administrator provided a Fall Monitoring Form that documented, .Beginning 04/19/2019 Staff will be interviewed 5x (times) a week for minimum of 8 weeks to ensure any falls that happened on their shift were reported and an Incident and Accident Report was completed and notification to the family and Director of Nurses . No further negative findings had been identified between 4/19/19 ant 4/25/19.

Based on record review and interview, the facility failed to ensure that Resident #2, who had poor food consumption and additional energy and protein needs due to the presence of pressure sores and a fracture, maintained acceptable parameters of nutritional status, such as body weight and protein levels. The facility failed to develop and implement interventions to monitor nutritional parameters to promptly identify any significant weight loss and the need for further interventions for 1 (Resident #2) of 4 (Residents #1, #2, #3 and #6) case mix residents who had weight loss. The failed practice likely resulted in a pattern of harm for Resident #2, who experienced a severe weight loss in a 6 month period, and only had the potential to affect this 1 resident that was not receiving monthly weights, according to a list provided by the Director of Nursing (DON) on [DATE]. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 6 (,[DATE] indicates severe impairment) on a brief interview for mental status, was independent for eating with only set up help, required extensive assistance with all other activities of daily living, was 64-inches tall, weighed 163 pounds, had no significant weight loss, received a mechanically altered diet, was edentulous and had 3 Stage II pressure ulcers. a. The Dietary Progress Notes dated [DATE] and signed by the registered dietitian documented: "St (stage II) on L (left) buttock - 8 # (pound) wt (weight) (down) over past month since admit - current wt (equals) 170 - Recent diet (change) to puree - eating better, per staff, but does refuse some meals - Diab (diabetic) shake (at) HS (hour of sleep) plus unjury QD (every day) (order expired ,[DATE]) - Rec (recommend) this be re-orderd - monitor- may need to (increase) unjury to BID (twice daily) (and) add supplement." b. The Dietary Progress Notes dated [DATE] and signed by the Registered Dietitian documented: "Decubs (Decubiti) noted. Wt stable. MVI (multivitamin) noted. Unjury BID noted. [MEDICATION NAME] 2.6 (low) ([DATE]) noted could be (secondary) to decub. Diet Order: Regular pureed, LCS (low concentrated sweets), and NAS (no added salt) with fair intakes ,[DATE]% recorded. Recommend continue SF (sugar free) health shakes at HS, Unjury BID and (increase) protein in diet. Will continue to monitor." c. Adocument provided on [DATE] by the facility was titled "Weight Change History" and documented: "..XXX[DATE] weight 170.00, [DATE] weight 172.00, [DATE] weight 165.00, [DATE] weight 163.00..." d. The physician progress notes [REDACTED]. A facility document titled "Weekly Weight Log" documented, "..XXX[DATE] ...using a 6 point lift until she is ready (healed) enough to go into a chair, weight is to be held off on..." e. The Dietary Progress Notes and the "Weekly Weight Log" did not document any weights for the resident in [DATE]. f. The Dietary Progress Notes dated [DATE] and [DATE] and signed by the Registered Dietician (RD) documented [DATE] and [DATE] weights were unavailable. The RD documented the resident was consuming an average of 30% of the [DATE] meals and an average of 45% of the [DATE] meals. The RD documented labs were reviewed and she recommended continuation of the current plan of care. The only labwork available for review in the resident's clinical record after the resident's inability to be weighed was dated [DATE]. The lab work documented the resident's hemoglobin level was 10.6 (normals ,[DATE]) and her hematocrit level was 34 (normals ,[DATE]). There was no [MEDICATION NAME] level obtained. There was no intervention documented to ensure the resident maintained acceptable parameters of nutrition during the time the facility could not weigh the resident. g. On [DATE] at 9:40 a.m., the Minimum Data Set (MDS) Coordinator was asked, "How does the facility monitor the resident's (Resident #2) weight?" She stated, "We don't." h. On [DATE] at 10:45 a.m., the Medical Records nurse stated to the surveyor, "Her (Resident #2) weight is 139 pounds." The surveyor asked, "Was she weighed this morning?" She stated, "Yes." The resident experienced an 18.235% weight loss in 6 months (31 pound weight loss, from a [DATE] weight of 170 pounds to a [DATE] weight of 139 pounds). i. On [DATE], "Dietary Progress Notes" were reveiwed and no interventions were added to ensure the residents nutritional parameters were monitored since weight monitoring had stopped in [DATE]. On [DATE], "physician's orders [REDACTED].

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure that Residents #1 and #2, who had pressure sores, received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure treatment orders were obtained and performed to thoroughly assess skin at least weekly and document wound characteristics in order to promptly identify skin breakdown and wound healing or deterioration to ensure prompt effective treatment for 1 (Resident #1) and failed to ensure urine was cleansed from skin to prevent skin breakdown for 1 (Resident #2) of 3 case mix residents (Residents #1, #2 and #12) who had pressure sores. The failed practice likely resulted in a pattern of harm for Resident #1 who developed a Stage III pressure sore to the right heel that was not treated from 4/17/11 until 5/8/11, and was likely to cause more than minimal harm for 4 residents who had pressure sores, according to a list received from the Director of Nursing (DON) on 7/1/11 at 12:50 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/18/11 documented the resident scored 4 (0-7 severe impairment) on a brief interview for mental status (BIMS), required extensive assistance of one person for bed mobility and personal hygiene, did not walk in the room or in the corridor, used a wheelchair for mobility, was frequently incontinent of bowel and bladder and had one Stage II pressure sore. a. The April 2011 Medication and Treatment Administration Record Report from 4/1/11 through 4/14/11 documented a treatment order for pressure sore to the right buttocks, but did not document any physician's orders [REDACTED]. The Wound/Skin Record dated 4/14/11 documented the resident's skin was clear. b. Nurses Notes dated 4/14/11 at 3:30 a.m. documented, "Temp (temperature) 101.3. (Physician) and (Power of Attorney) notified..." The physician's orders [REDACTED]." c. The hospital Skin Care Progress Record dated 4/14/11 documented, "...R (right) heel c (with) 2 cm (centimeter) round hardened white tissue surrounded by 1-1/2 cm non-blanchable reddened tissue, no drainage or tunneling noted. Tegafoam applied on admit..." The hospital Skin Care Progress Record dated 4/17/11 documented, "...Dressing changed to R (right) heel, Appearance unchanged since Admit..." d. The Admission Nursing Assessment (readmission to facility) dated 4/17/11 at 3:00 p.m. documented, "...L (left) heel Stage III... Special Treatments and Procedures: ...R (right) heel drsg (dressing) (changes)..." The anatomical drawing documented an 'X' on the right heel. The nurses notes dated 4/17/11 at 3:00 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "Res (Resident) arrived to facility... Admit DX (diagnoses) Pneumonia, (hypokalemia), CKD ([MEDICAL CONDITION]) ...Recurrent UTI (urinary tract infection) ...wound to right heel ...per nurse at hosp (hospital) wounds cleaned et (and) dressed today..." On 7/1/11 at 9:07 a.m., LPN # 1 stated, "A verbal report from the ER said it (the right heel wound) was a Stage III. No, I did not see the wound on 4/17/11. We were doing treatments on that heel before she went to the ER. I assumed the treatment was still there before she went in. I assumed the treatments were still in the IMAR (computerized system the facility uses). It did have the OpSite on the dressing on 4/17/11." Nurses Notes from 4/18/11 through 5/7/11 documented a pressure sore to the right buttocks but did not document anything regarding the pressure sore to the right heel. On 6/30/11 at 1:35 p.m., the DON said she could not find any documentation regarding the pressure sore to the right heel between 4/17/11 and 5/8/11. e. The Wound/Skin Record dated 4/21/11 documented skin clear. The Wound/Skin Record dated 4/28/11 documented skin clear. The Wound/Skin Record dated 5/5/11 documented S/T (skin tear) to L (left) knee. f. The April 2011 Medication and Treatment Administration Record Report from 4/17/11 through 4/30/11 documented a treatment order for pressure sore to the right buttocks, but did not document any physician's orders [REDACTED]. g. The nurses notes dated 5/8/11 at 1:00 p.m. and signed by LPN #1 documented, "Res c/o (complained of) R (right) foot pain (at) 11:53. Res rec'd (received) PRN (as needed) Tylenol 650 mg (milligram) p (after) lunch. Res cont (continued) to complain of R foot pain. Pulled sock off of R (right) foot noticed drsg (dressing)covered c (with) OpSite to R (right) heel. Pulled dressing off et (and) noticed Stage 3 wound to R (right) heel. Notified RN (Registered Nurse) supervisor. Tx (treatment) done to R (right) heel et (and) order put in comp.(computer) Will do standing order Tx see TO (telephone order)..." On 6/30/11 at 3:15 p.m., the wound nurse stated the wound to the resident's right heel on 5/8/11 was "Pretty nasty, her whole heel was black, the sides of her heel was black. The dressing had been on there so long there was drainage on there... " On 7/1/11 at 9:07 a.m., LPN # 1 stated, "It (right heel) did have a dressing under the OpSite on 5/8/11. (On 5/8/11), I started to peel the dressing off, it was red, it looked fresh, it was not black at all. It had a little bit of serosangous drainage. It did not have an odor. I did not call the physician. I usually fax over the wounds and notify him that way. I don't remember if I did that." h. The Physicians Orders dated 5/8/11 documented, "Cleanse Stage III wound treatment right heel with wound cleanser, apply Iodosorb oint (ointment) cover with occlusive drsg (dressing) daily and PRN." i. The Care Plan dated 5/19/11 for actual skin breakdown associated with chronic debilitation documented, "...Stage III right heel... reassess pressure ulcers at least weekly during body audit/or as needed/as ordered... nurse to do weekly skin audit, chart and notify MD as needed for treatments... staff to observe for skin changes during routine care, report to charge nurse..." On 6/29/11 at 3:55 p.m., Certified Nursing Assistant (CNA) #1 stated she would report any new pressure areas to the nurse. On 6/29/11 at 4:12 p.m., the wound nurse stated the nurses do the skin audits once a week. j. The Skin/Wound QI (Quality Improvement) Log dated 5/12/11, 5/19/11 and 5/25/11 documented the resident had a Stage III wound to the right heel with measurements of 3x2x2 cm (centimeters, length by width by depth). The documentation did not include wound characteristics. k. The Skin/Wound QI Log dated 6/2/11, 6/9/11, 6/15/11, and 6/24/11 documented the resident had a Stage III wound to the right heel measures at 1x1x1 cm. The documentation did not include wound characteristics. On 6/29/11 at 4:15 p.m., during an interview with the DON and the Facility Nurse Consultant, the DON stated documentation of a wound should include the size, depth, any drainages, what the edges look like, any odor, and what the wound bed looks like. She stated the documentation would be done by the wound nurse on the skin log that is used for skin quality improvement every week. The skin audits/body audits are to be done by the charge nurse, as well, and it should be documented on there. The Nurse Consultant said there is nothing established at this time to monitor the accuracy of the wound documentation. The DON stated she could not say if the wound nurse had any formal wound training or not. l. On 6/28/11 at 9:01 a.m., after the resident was transferred to the bed, the big toe on the left (L) foot had an open, dry area on the knuckle of the toe and a dressing covering the 4th and 5th toes. m. The physician's orders [REDACTED]." o. On 6/29/11 at 9:55 a.m., the Director of Nursing (DON) observed the resident's pressure sore to the right heel. She described the pressure sore as 2 cm round with .2 cm depth, dry, a little crusty and had yellow slough. On 6/30/11 at 3:15 p.m., the wound nurse stated, "When I started with the Iodosorb, the black peeled off. It was pink skin, just pink healthy looking tissue, not granulation, after three or four days. I'd put that on and just scrub." She stated, "Now a lot of that color is from the Iodosorb. It looks granulated to me cause it's filling in." The wound nurse stated she did not know what the cream/yellow colored tissue was on the wound now. She stated when the wound was black, "I called it a St (stage) III, the creamy stuff more a II." The wound nurse stated she had not had any specific wound training and was not wound certified. 2. Resident #2 had [DIAGNOSES REDACTED]. The Significant Change in Status MDS with an ARD of 3/28/11 documented the resident scored 6 (0-7 indicating severe impairment) on a BIMS, required extensive assistance with toilet use and personal hygiene and had 3 Stage II pressure ulcers. a. On 6/28/11 at 2:04 p.m., the Wound Nurse performed a treatment to the resident's left buttock. The resident had 2 open areas (Stage II) to the left buttocks; the top one measured 3 cm (centimeters) by 1 cm and the bottom one measured 1 cm by 1 cm by 0.1 cm. When the wound nurse completed the treatment, Certified Nursing Assistant (CNA) #2 and CNA #3 had removed the soiled brief. The resident's right buttock, perineum, labia and mons pubis were not cleansed of urine prior to applying a clean incontinent brief. b. On 6/28/11 at 2:27 p.m., CNA #3 was asked, "When should peri care be provided?" and she stated, "Every time go to bathroom, every time they're laid down and when you change a soiled brief." The surveyor asked, "Was the resident's brief soiled?" The CNA stated, "Yes." The surveyor then asked, "Did you provide peri-care?" The CNA stated, "No." At 2:30 p.m., CNA #2 was asked, "When should peri-care be provided?" The CNA stated, "Every time you change a brief." The surveyor asked, "Did you provide peri-care when you changed the resident's brief?" The CNA stated, "No."

Complaint # was substantiated (all or in part) in these findings. Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure Resident #5 received the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure appropriate positioning was provided that applied minimal pressure on the extremities to reduce the risk of injury during the insertion of an indwelling catheter for a resident with lower extremity contractures; to ensure the left lower extremity was assessed following trauma; to ensure probable pain of the affected site was questioned and validated; to ensure x-ray results that documented a [MEDICAL CONDITION] femur post positioning trauma were promptly obtained; and the plan of care for transfer and bed mobility was updated for 1 (Resident #5) of 2 (Residents #1 and #5) case mix residents who required the placement of an indwelling catheter. The failed practice resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death to Resident #5, who presented with a a new [MEDICAL CONDITION] femur after the insertion of a foley catheter, and had the potential to affect 2 residents who had an indwelling catheter, as documented on a list provided by the Director of Nursing (DON) on 3/23/11 at 1:05 p.m. The facility was informed of the Immediate Jeopardy on 3/22/11 at 4:37 p.m. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 2/15/11 documented the resident had a score of 5 (severe cognitive impairment) per brief interview for mental status, required total physical assistance of 2 staff persons for bed positioning and transfer, had functional limitation in range of motion with impairment of both lower extremities, had frequent pain and had pain that was very severe, horrible, as described by the resident. a. On 3/12/11 at 10:15 a.m., the Nurse's Notes documented "(Certified Nursing Assistant (CNA) #1) stated that R's (Resident's) Foley collection bag was near empty and bed was wet from urine. Upon inspection Foley was occluded, replaced (with) 18 FR (French) using sterile technique and inflating H2O (water) bulb with 10 cc (centimeter) fluid. Drainage tube began flowing immediately. (Resident) leg hip bilaterally contractures. (Resident) c/o (complained of) pain esp -(especially) in (left) knee area. Gave (two) Tylenol 325 mg (milligram) for pain. Will continue to monitor. (Resident) tol (tolerated) procedure o.k. Foley, which was present, was removed intact with sediment present on distal end of tube." 1) On 3/22/11 at 2:30 p.m., CNA #1 stated, "On 3/12/11 around or before noon, I helped (CNA #2) and (Licensed Practical Nurse (LPN) #1) as (LPN #1) was putting in a catheter. I held her (resident's) left leg and (CNA #2) had the right leg. We tried to get her legs as far apart so he (LPN #1) could see. He told me and (CNA #2) to keep pulling apart. I got to a point where I didn't want to pull any farther. I didn't want to hurt her and he pushed her left leg with his arm. Then her leg cracked. I heard it. It sounded like bones crunching on bones. He went ahead and put the catheter in. When it was over, I went and talked to (Registered Nurse (RN) #1) and told her what had happened. (RN #1) went and looked at the leg. Later, they sent her for x-rays." 2) On 3/23/11 at 3:32 p.m., RN #1 stated "No one reported to me that (LPN #1) pushed on the left leg and it popped. The only staff that told me of the 3/12/11 incident was (LPN #1). He said it was a difficult cath (catheter) because you can't get her legs apart because they are contracted together and he heard a pop at the left knee. I did not interview the aides. I told (LPN #1) to fill out and I & A (Incident and Accident Report). (Resident #5's) legs are contracted." 3) On 3/22/11 at 4:10 p.m., LPN #1 stated, "I assisted (CNA #1) with the left leg to give me better visualization. I used my shoulder and that's when I heard the pop." b. On 3/12/11 at 1:15 p.m., the Nurse's Notes documented "(Resident) c/o throbbing knee pain (left) side. Stated 'the pain is throbbing'. (Physician on call) called the facility and said to send (Resident) to (local hospital's) x-ray department to eval (evaluate). Family, DON (Director of Nursing) were notified. (Resident) taken by C.N.A., awaiting results." c. The Radiology Report documented, "admitted : 03/12/11... discharge date : 03/12/11... Complete 03/12/11... Procedure: Left Knee Two Views... Description: AP (anteroposterior) and lateral views of the left knee show evidence of ununited or malunion of the metaphyseal level [MEDICAL CONDITION] left femur. There is exuberant callus formation noted on the lateral view. There appears to be [MEDICAL CONDITION] of the proximal and distal fragments suggesting motion at the pseudoarticulation." "The knee joint shows [MEDICAL CONDITION] change as well though no acute fracture line is identified at this time. There is vague suggestion of increased fluid density around the joint suggesting joint effusion though swelling of the suprapatellar bursa is not apparent. Demineralization suggests [MEDICAL CONDITION] or possible disuse [MEDICAL CONDITION]" Impression: "1. post traumatic changes as noted with probable malunion of an old distal femoral fracture. 2. Probable joint effusion. 3. arthritic changes of the knee joint as noted... 03/14/11 11:30 (a.m.) Date/Time Signed... Copy for (attending physician) via modem." d. The attending Physician's Progress Note dated 3/14/11 (no time noted) documented, "(Resident #5) is a 56 y.o (year old) female who was a new admission the nursing home several months ago. She was hospitalized for [REDACTED]. She is reasonably stable and voices no complaints today. She has not had any vomiting or diarrhea. She remains very unwilling to do much for herself. She wants to be left alone. She just lays in bed. She remains depressed in spite of medications. She has also had significant bedsores which are progressing and slowly healing. She has had some problems with a leaking Foley catheter and this is much better now, however, when the nurses were trying to change her catheter last Saturday, there was pain from a popping sensation in her pelvis. She was sent to the emergency room , evaluated and was determined not to have any kind of fracture." e. Nurses Notes from 3/13/11 - 3/17/11 were reviewed with findings as follows: 1) The Nurse's Notes dated 3/13/11 at 2:00 a.m., 10:45 a.m. and 4:05 p.m. (All Nurse's Notes for 3/13/11) did not document an assessment of the resident's left leg, nor did the notes document complaints of pain or any interview of the resident regarding pain. 2) The Nurse's Notes dated 3/14/11 at 2:30 p.m. (all Nurse's Notes for 3/14/11) did not document an assessment of the resident's left leg, nor document any complaints of pain by the resident or any interview of the resident regarding pain. 3) The Nurse's Notes dated 3/15/11 at 1:00 a.m. documented, "No s/s (signs or symptoms) of pain or discomfort to left knee." There was no documented assessment of the left leg. 4) The Nurse's Notes dated 3/15/11 at 9:40 a.m., documented, "...(No) (signs or symptoms) pain or discomfort to (left) knee. f/u for x-ray done. (no) pain voiced..." There was no documented assessment of the left leg. 5) The Nurse's Notes dated 3/15/11 at 6:00 p.m., did not document an assessment of the left leg, nor document complaints of pain or an interview with the resident regarding pain of the left leg. 6) The Nurse's Notes dated 3/16/11 at 9:45 a.m. documented, "...No c/o pain or s/s (signs or symptoms) of discomfort." There was no documented assessment of the resident's left leg. 7) The Nurse's Notes dated 3/16/11 at 3:00 p.m. documented, "...No c/o pain or discomfort." There was no documented assessment of the resident's left leg. 8) The Nurse's Notes dated 3/17/11 at 1:10 a.m. did not document an assessment of the resident's left leg, nor document complaints of pain or an interview with the resident regarding pain. 9) The Nurse's Notes dated 3/17/11 at 9:30 a.m. documented, "...no c/o pain or s/s of discomfort." There was no documented assessment of the resident's left leg. f. The Incident and Accident Report dated 3/17/11 at 12:30 p.m. documented "(Certified Nursing Assistant (CNA) #1) and (CNA #2) report to this nurse R (resident) L (left) leg doesn't look right. Assessment revealed L leg from hip to knee turned outward, significant [MEDICAL CONDITION] and c/o (complaint of) pain. Notified DON (Director of Nursing). R's (attending physician) in building. Assessed R. Ordered to send to ER (emergency room ) via ambulance. R was transported via ambulance. Report given to ambulance and ER staff. Notified husband." 1) On 3/22/11 at 1:55 p.m., CNA #1 stated, "On 3/17/11 (CNA #2) and I got (Resident #5) up about 7:15 a.m. to 7:30 a.m. for breakfast. Her left hip was swollen the same as it was the day before. We got her up using the Vanderlift using the leg straps as a cradle instead of crossing the straps between her legs. After transfer, we took her to the Activity Dining Room in her Geri-chair. She is very stoic. She did not complain of pain. After breakfast, we took her back to her room and put her back to bed. She was happy to get back to bed. We turned her to the right side and positioned her with a wedge and pillows. A pillow was placed between her legs by me. Around 10:00 a.m., we turned her to the left side and placed a wedge to her back. Her legs are contracted so we left the pillow between her knees. She did not complain of pain. Between 12 noon and 12:30 p.m., we went in to get her up for lunch. Her left leg was more swollen and it looked like she had a big bump to the outside of the thigh near the hip. I went to (LPN #2) and said there is something wrong with her leg. She came and looked at the leg. She said she was going to get the doctor. I know that her leg was swelling before noon. (Registered Nurse (RN) #1) told me on (3/16/11) that (Resident #5) had [MEDICAL CONDITION] from fluid retention." 2) On 3/22/11 at 1:25 p.m., RN #1 stated, "On 3/17/11 at 7:15 a.m. to 7:30 a.m., I checked the Foley leg strap on (Resident #5). It was on her left leg. Her left leg was swollen from the hip to the foot. There was no discoloration. It was in good alignment. She had no complaints of pain. I asked her about pain. She denied any pain. On 3/12/11 and 3/13/11, as well as, 3/16/11 and 3/17/11 I looked at her leg. On 3/10/11 her left leg in its entirety was swollen. On 3/11/11, 3/12/11 and 3/13/11, it was no more swollen than on 3/10/11. On 3/16/11 it was more swollen, about 10% more and it was the same on 3/17/11 at 7:15 a.m. to 7:30 a.m. On 3/17/11 about 1:00 p.m., the left leg was 30-40 percent more swollen, discoloration that was reddish purple of the left inner thigh and her left knee was rotated outward. I called and asked for the x-ray report of 3/12/11 for (attending physician who was in the building). I gave it to the Director of Nursing who gave it to him in my presence. He said 'Oh, No', then went and looked at (Resident #5). I don't think (attending physician) knew about the x-ray report until the Director of Nursing gave it to him. On 3/16/11 I asked about the x-ray report (of 3/12/11) but did not follow up." g. On 3/22/11 at 5:28 p.m., the Attending Physician stated in regard to the x-ray report of 3/12/11, "It is an old fracture to me with a malunion. Motion at the site indicates malunion. In 2008 there was an injury with malunion. The old malunion is probably the pop that they heard (on 3/12/11). It did not heal properly. She has a broken leg that the x-ray now showing what happened in 2008. It tried to heal, it didn't work, it's not a good repair, it's not a solid repair. With a little bit of pressure it can break. The body tried to heal it. The body didn't do a good job of healing." In response to questions posed about his Physician's Progress Note of 3/14/11, the attending physician stated, "I had not viewed the x-ray report on the 14th (3/14/11). I was led to believe this lady went to the ER, had an x-ray and everything was fine. When I saw her that day, I didn't look at her legs, only saw her foot. She had no pain. She was covered. I brought all the notes (physician progress notes [REDACTED]. The facility received my report on the 17th. The facility did not have my Progress Report until the 17th. I thought I knew there was no fracture. On the 17th I got the x-ray report." The attending physician was asked if the facility reported on 3/16/11 that there was an increase of 20 percent [MEDICAL CONDITION] in the left leg. The attending physician stated, "Not that I recall." When asked if he would have made any alterations in the plan of care if he had known of the fracture of 3/12/11 he stated, "She has an old fracture, it came lose. It's all going to depend on her pain. Of course, we would need to support that area when giving care." h. The emergency room 's physician progress notes [REDACTED]. Will transfer to (metropolitan hospital)." 1) The Radiology Report dated 3/17/11 documented, "...AP view of the left femur shows a comminuted shaft [MEDICAL CONDITION] with evidence of old [MEDICAL CONDITION] femur in the subtrochanteric region with exuberant callus formation and evidence of old [MEDICAL CONDITION] femur above the condyles also with callus formation. There is demineralization suggesting marked [MEDICAL CONDITION]." The impression was documented as "Comminuted shaft [MEDICAL CONDITION] femur seen in one projection only." 2) The (metropolitan hospital's) Physician's Progress Notes dated 3/18/11 documented an assessment of: "Left comminuted femur fracture, Dementia, buttock decubitus ulcers bilaterally and severe osteoporotic bone." i. On 3/23/11 at 3:16 p.m., the Assistant Director of Nursing (ADON) interviewed the resident in the presence of the surveyor. The resident stated during an approximate 5 minute interview, "They pulled my legs apart, that's when my leg got hurt. I would say that someone had a hold of both legs. My legs won't open that much." The ADON and surveyor assessed the left leg. The ADON described the alignment of the left leg as the "left leg swollen, the left knee turned inward and the left foot and lower leg turned outward." j. On 3/22/11 at 9:25 a.m., a copy of the DMS-762 Form entitled "Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, And Exploitation of Residents in Long-Term Care Facilities" dated 02/18/2011 (date should have been 03/18/2011) was received from the Director of Nursing. Section III - Findings and Actions Taken, documented the following: "Resident has an indwelling Foley catheter in place; on 3/12/2011 charge nurse replaced the Foley due to leaking. When he moved the residents legs to facilitate placement there was a pop in the residents knee. The resident at that time complained of pain, charge nurse notified the physician on call and was given an order to transport to (hospital) for an x-ray of her left knee. Resident was transported to (hospital) radiology and then returned back to the facility. Radiology report was faxed to resident's doctor from (hospital) and was again reviewed on 3/17/2011 when the resident was complaining of pain. Facility obtained copy of radiology report by request on 3/17/2011. Radiology findings reviewed by radiologist on 03/14/2011. Resident is totally dependent of staff to meet all her needs, all transfers are with a Vanderlift as patient is unable to bear weight. Resident was transferred to geri-chair in the AM (morning) for breakfast and transferred back to bed following breakfast using the Vanderlift. Resident has [DIAGNOSES REDACTED]. The resident did not complain of any increased pain until 3/17/2011 when the C.N.A.'s were going to get her up for lunch at which point they noticed the swelling and rotation of the leg. Witness statements were obtained and charts reviewed. There were no incident reports on the resident for falls during this period. Resident's husband states via telephone conversation that the resident's bones are brittle, and that she had sustained a fracture at home in 2008. Resident returned from (hospital) on 3/21/2011. Resident will continue to have all needs met by the staff. Ongoing staff in-services on proper turning and transferring techniques will be conducted by RNA (Restorative Nursing Aide) with oversight from therapy department. At the completion of staff interviews and chart review, it is the belief of administration that no abuse occurred to this resident. Due to medical [DIAGNOSES REDACTED].N.A.'s were inquiring if the resident was ready to get up for lunch at which point the resident was complaining of pain." k. The Immediate Jeopardy was removed and the deficient practice reduced to the Scope and Severity of an "H" l on 3/23/11 at 10:45 a.m. when the following Plan of Removal was implemented: 1) Plan of Removal: Prompt determination of change in condition with immediate notification of physician and family, and timely action taken. 2) Nursing Services (charge nurses, treatment nurse, MDS coordinator or a licensed designee appointed by the DON on a weekly basis) will conduct thorough rounds on every resident on their units every day to assess every resident for any signs of change in condition. All active charts on every resident currently residing in the facility will be reviewed, noting any change in condition or no change in condition, starting on 03/22/2011. This comprehensive chart review will be completed by Nursing Administration, MDS/Care Plan Coordinator, and Medical Records with documentation of their finding (change of condition found or no change of condition found). Chart review will be completed by 3/24/2011. 3) All licensed nursing staff will be in serviced and trained by the Director of Nursing beginning March 22/2011, in-service for all licensed staff will cover proper technique of insertion of indwelling Foley catheter, proper assessment technique including documentation of assessments, appropriate assessment of any actual suspected injury to residents. Also covered in licensed staff in servicing will be proper assessment of pain to include both verbalized pain and observation for non verbal signs of pain with appropriated documentation of findings based on a scale of 0-10. In conjunction with this in servicing will be notification to all licensed nurses of immediate change in protocol signified by all residents with change in condition will be sent through the emergency room for full evaluation and new orders as deemed appropriate by the hospital physician. No staff member will be permitted to work until he/she has received the in-service training stated above. All new hires for the nursing department, beginning 03/23/2011, will be given the same in-service and training with documentation of this education prior to being allowed to work in the facility. 4) Reporting and Monitoring System: Upon recognition that a change in condition has occurred, the charge nurse will notify the Director of Nursing, the Assistant Director of Nursing as well as the facility Administrator, of the change in condition. The charge nurse, the Director of Nursing or other licensed nurse will complete a thorough nursing assessment of any resident with ANY noted change regardless of how minor it may appear with thorough documentation of same. The charge nurse will contact the attending physician or physician on call Immediately By Telephone, Not Fax. The change in condition, the notification of Nursing Administration, and the notification of the physician and the resident's family/responsible party will be documented thoroughly in the nurses' notes in the clinical record. Any signs or symptoms of change in condition will be monitored and documented in the clinical record every shift for not less than 72 hours and longer, if indicated. 5) If the charge nurse is unable to contact the attending physician by telephone, he/she will then contact the Director of Nursing who will in turn contact the Medical Director for orders and interventions. (In the event of an emergency the charge nurse may transfer the resident to a hospital. He/she will then relate this information to the Director of Nursing who will notify the attending physician or the Medical Director, as appropriate.) 6) The Director of Nursing, the Assistant Director of Nursing or a licensed designee will make rounds every day to assess for any change in condition in any resident. During other shifts and on weekends, as necessary, the Director of Nursing will designate a licensed nurse to perform these quality assurance rounds with request of written verification of the completion and the findings from these rounds. If any resident is found to have a change in condition, the nurse identifying the change will be responsible for notifying the attending physician immediately by telephone, not fax. The Director of Nursing will be advised in person or by telephone of any resident with a change in condition. These quality assurance rounds and follow-up procedures will begin 03/23/2011 and will continue until reviewed in 30 days by the CQI committee or until we are found to be in compliance with state and federal regulations. Any instance requiring a resident to be sent to the emergency room will be followed up by the Director of Nursing or her designee and the Administrator the following the next business day. Requests will be made for any records from the emergency room or hospitalization in order to continue appropriate care. 7) The facility Administrator and Nursing Administrator will have full responsibility for follow-up on any change in condition to ensure that all proper measures and interventions have been taken for the well-being of the resident and a positive outcome. 8) System Check: All changes in condition will be thoroughly documented in the clinical record including the symptoms of the change and the nursing assessment, including vital signs, level of consciousness, changes in physical status, level of pain, etc. The change in condition will also be documented on the 24-Hour Report Form so that the information gets passed on to the other shifts. This notation on the 24-Hour Report Form will be made in red ink to draw attention to it. 9) Systems Check: The Director of Nursing or her designee will review the 24-Hour Report Form daily for any change in condition. Should there be a change of condition listed on the 24-Hour Report Form, the DON or her designee will then review the clinical record for proper notification of the attending physician and the family as well as a full description of the signs and symptoms of the change in condition. He/she will then check the physician's orders [REDACTED]. The DON or her designee will assess the resident, and follow up that all outstanding reports are obtained and rewarded to attending physician, and placed in resident's clinical record. (If he/she has not been transferred to hospital) and document her findings in the clinical record also. 10) The Director of Nursing or her designee will initial the 24-Hour Report Form daily at the bottom of the form indicating that she has reviewed it in its entirety. The 24-Hours Report Form will then be forwarded to the facility Administrator daily for his review. He will also initial the form at the bottom of the page verifying that he has reviewed the information on the form. (The Director of Nursing and facility Administrator will review the 24-Hour Report Forms from Fridays and Saturdays and Sundays on the following Mondays and ensure proper follow up.) Note: Any problems contacting attending physicians or obtaining a reasonable response from an attending physician will be referred to Medical Director.