Every finding on record at The Blossoms at Hot Springs Rehab and Nursing Cent

Based on observations, interviews, and record review, it was determined that the facility failed to provide comfortable water temperatures for 2 (Resident #11 and Resident #40) of 10 sampled residents who reside on A and B Halls. Residents were reviewed for a comfortable and homelike environment. The findings include: 1) Review of Resident #40 ' s quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/24, indicated Resident #40 had diagnoses of dementia, high blood pressure, heart failure, and scored 7 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). 2) Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, indicated Resident #11 had diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, non-Alzheimer's dementia and scored 12 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS). a) During an interview on 12/09/2024 at 11:45 AM, Resident #40's representative complained regarding the lack of hot water to the resident's room. b) During an interview on 12/09/2024 at 2:22 PM, Resident #11 voiced concerns about the lack of hot water to their room. c) During an interview on 12/11/2024 at 3:15 PM, Certified Nursing Assistant (CNA) #1 stated that the water gets warm some for the A hall residents. d) On 12/11/2024 at 3:27 PM, during an observation and interview with the Maintenance Supervisor, the hot water tap was turned on to the sink in room [ROOM NUMBER] on B hall, and the Maintenance Supervisor stated A and B halls are farthest from the water heater, and it takes longer to get the water warm. e) On 12/11/2024 at 3:34 PM, the Maintenance Supervisor stated halls C, D, E, and F were close to the water heaters. In addition, the Maintenance Supervisor stated the water heater temperature tops out at 102-103 degrees Fahrenheit. f) On 12/11/2024 at 3:36 PM, the Maintenance Supervisor utilized a temperature gun to determine the temperature of the hot water in room [ROOM NUMBER] on B hall. The Maintenance Supervisor stated the temperature was 96.7 degrees Fahrenheit. g) On 12/11/2024 at 3:44 PM, the Maintenance Supervisor turned on the hot water tap for the sink in room [ROOM NUMBER] on A hall (Resident #40's room). h) On 12/11/2024 at 3:49 PM, the Maintenance Supervisor utilized a temperature gun to determine the temperature of the hot water in room [ROOM NUMBER] on A Hall. The Maintenance Supervisor stated the temperature was 78.6 degrees Fahrenheit. i) On 12/12/2024 at 9:16 AM, the Maintenance Supervisor was interviewed regarding the process of ensuring water temperatures are acceptable. The process was described and the Maintenance Supervisor explained how the Circulation pump was going out for A, B, and C halls and the facility was getting a new one. Copies were requested from the past four (4) weeks of temperature logs, policy for testing/maintaining water temperature, and a copy of the purchase order for a new Circulation pump. j) On 12/12/2024 at 9:19 AM, the Maintenance Supervisor turned on the hot water tap in room [ROOM NUMBER] on hall B. At 9:23 AM, the water temperature reached 100.0 degrees Fahrenheit according to the Maintenance Supervisor's temperature gun. k) On 12/12/2024 at 9:50 AM, the Maintenance Supervisor turned on the hot water tap in room [ROOM NUMBER] on A Hall (Resident #2's room). At 9:59 AM, the water temperature reached 88.2 degrees Fahrenheit according to the Maintenance Supervisor's temperature gun. l) On 12/12/2024 at 10:05 AM, the Maintenance Supervisor provided the last 4 weeks of temperature logs. On the logs, the process was documented as Inspect and log temp 1 room per hall per week. For the month of November 2024, there were no temperature recordings for B hall and one (1) temperature recording out of four (4) weeks for A Hall. For the first two (2) weeks of December 2024, there were no temperature recordings for A hall. m) On 12/12/2024 at 10:10 AM, the Maintenance Supervisor provided the purchase order for the circulator pump and verified there was no policy for checking water temperatures. The date on the purchase order was December 11, 2024. n) On 12/12/2024 at 10:25 AM, the Administrator was interviewed regarding the concerns with the water temperature coming from the hot water taps on A and B hall. The Administrator reiterated the plan for replacing the circulation pump and had no additional comments. o) On 12/12/2024 at 12:03 PM, it was requested from the Maintenance Supervisor to provide temperature logs for the month of October 2024. p) On 12/12/2024 at 12:11 PM, the Maintenance Supervisor provided the temperature logs for the month of October 2024. The process documented on the October log was Inspect and log temp 1 room per hall per week. For October 2024, there was one (1) temperature recorded for week three (3) for A hall and one (1) temperature recorded for week four (4) for A hall. All other weeks during October 2024 had no temperatures recorded for the A and B hall.

Based on observation, record review and interview, the facility failed to ensure 1 of 2 ice scoop holders was maintained in a clean condition to prevent the potential contamination of residents' food or beverages; food items stored in the refrigerator and freezer were covered or sealed to prevent potential cross contamination or food borne illness, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 73 residents who received meals from the kitchen. The findings are: 1. On 01/22/24 at 09:55 AM, the ice scoop holder on the right side of the wall close to the ice machine in the dining room had wet black residue on it. The ice scoop was resting directly in contact with the black residue. The surveyor asked the Dietary Supervisor to wipe the wet black and the wet black residues easily transferred to the paper towel. The surveyor asked the Dietary Supervisor to describe what was observed in the scoop holder. She stated, It was black dirt and was nasty. The surveyor asked Dietary Supervisor how often the ice scoop holder was cleaned and who uses the ice from the machine. She stated, I don't know. 01/22/24 at 09:57 AM, the surveyor asked Certified Nursing Assistant #1 what the ice was for? She stated, For the residents. We used it to fill the water pitchers in the resident's rooms. At 10:00 AM, the Dietary Surveyor asked Dietary supervisor to describe the contents within the ice scoop holder. She stated, It's black dirt, nasty. She was asked, How often do you clean the scoop holder? She stated, It supposed to be cleaned daily. 2. On 01/22/24 at 10:04 AM, an opened box of biscuits was on a shelf in the freezer. The box was not covered, and the bag was not sealed. 3. On 01/22/24 at 10:20 AM, the following observations were made in the freezer: a. An opened box of pizza was on a shelf in the freezer. The box was not covered, and the bag was not sealed. b. An opened box of chocolate chips cookies. The box was not covered, and the bag was not sealed. c. An opened box of peanut cookies. The box was not covered, and the bag was not sealed. 4. On 01/22/24 at 10:30 AM, Dietary Employee #1 turned on the hand washing sink faucet and washed her hands. She then pulled out tissue papers from the tissue dispenser and dried her hands. She removed gloves from the glove box and placed them on her hands, contaminated the gloves. She picked up tray cards and placed them on the trays. Without washing her hands, she picked up glasses that contained beverages to be served to the residents for lunch meal by their rims and placed them on the tray, then covered the glasses with saran wrap. 5. On 01/22/24 at 10:32 AM, Dietary Employee #2 turned on the hand washing sink faucet and washed his hands. He then pulled out tissue papers from the dispenser and dried her hands. He removed gloves from the glove box and placed them on his hands, contaminated the gloves. Without changing gloves and washing his hands, he picked up clean eating utensils by the end of the utensils that would go into the mouth and wrapped them in individual napkins for the residents to use at their lunch meal. At 12:03 PM, the Surveyor asked Dietary Employee (DE) #2 What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. 6. On 01/22/24 at 11:30 AM Dietary Employee (DE) 1# picked up a bag of bread from the bread in the storage room and placed it on the counter, picked up a container of peanut butter from the cabinet and placed it on the counter. At 11:34 AM, (DE) #3 turned on the hand washing sink faucet and washed her hands. She then pulled out tissue papers from the dispenser and dried her hands. He removed gloves from the glove box and placed them on her hands, which contaminated the gloves. She unwrapped the bread bags and removed the slices of bread from the bag and placed them on a piece of pan liner on the counter. When she was about to spread peanut butter on the bread, the Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, Washed my hands. 7. A facility policy titled, Hand washing . provided by the Dietary supervisor on 01/23/2024 at 09:19 AM documented when to wash hands. a. When entering the kitchen at the start of a shift. b. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. c. After engaging in other activities that contaminate the hands.

Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] evaluation with recommendations to facilitate the ability to plan, coordinate and provide necessary care for 3 (Resident #4, #44, and #53) of 11 sampled (Resident #2, #4, #9, #16, #21, #41, #44, #45, #48, #53,#67) and had the potential to affect 39 residents who had a level II PASRR. The findings are: 1. Resident #4 with a diagnosis of SCHIZOPHRENIA, PSYCHOSIS, and CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Significant Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 04/13/2023 indicates a Brief Interview of Mental Status [BIMS] score of 10 (A score of 8-12 suggest a moderate cognitive impairment). a. A care plan (dated, 06/14/2023) required a level 1 PASARR prescreening due to schizophrenia and depression and did require further level 2 evaluation. No recommended services.Refer to psych as needed . b. On 01/25/24 at 8:20 AM, the Social Worker [SW] was asked if Resident #4 had a level II PASARR, and the SW said Resident #4 does have a level II PASRR. c. On 01/25/24 at 8:21 AM, the SW was asked to check Section A 1500 on the Significant MDS dated [DATE]. The SW said it says no, but SW knows Resident #4 does have a mental health disorder. 2. Resident #44 has diagnoses of HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION, TYPE 2 DIABETES MELLITUS, and SCHIZOAFFECTIVE DISORDER. The Admission Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 06/23/2023 indicates a Brief Interview for Mental Status [BIMS] of 10 (A BIMS score of 8-12 suggest moderate cognitive impairment). a. A care plan (Dated, 06/26/2023) documented . I required a level 1 PASARR prescreening due to schizoaffective bipolar type and major depression and did require further level 2 evaluation. No specialized services recommended .Refer to psych as needed . b. On 01/25/24 at 8:15 AM, the SW was asked if Resident #44 had a level II PASRR, and SW told the Surveyor that Resident #44 has a level II PASARR. c. On 01/25/24 at 8:21 AM, the SW was asked to check Section A1500 on the Admission MDS dated , 06/23/2023. The SW said it says no, but SW knows Resident #44 does have a mental health disorder. 3. Resident #53 has a diagnosis of SCHIZOAFFECTIVE DISORDER, MAJOR DEPRESSIVE DISORDER, and senile degeneration of the brain. The Significant Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 08/05/2023 indicated a Brief Interview for Mental Status [BIMS] score of 2 (0-7 suggest severe cognitive impairment). a. A care plan (dated, 08/10/2022) documented .I required a level 1 PASARR prescreening due to schizoaffective, major neurocognitive disorder, history suicidal ideations and did require further level 2 evaluation. No specialized services .Refer to psych as needed . b. On 01/25/24 at 8:21 AM, the SW was asked to check Section A 1500 on the Significant Change MDS dated [DATE]. The SW told the Surveyor that it says no, but Resident #53 does have a level II PASARR. c. On 01/25/2024 at 8:40 AM, the Surveyor asked the SW what is the purpose for documenting mental health on the Minimum Data Set [MDS]. The SW said because that is what we send to CMS, and we need it to be accurately reflected. The Surveyor asked if section A 1500 for (Resident #4, #44, and #53) should have reflected 0 for no mental illness, and the SW said no, because the Social Worker knows they have a mental health diagnosis. d. On 01/25/24 at 9:10 AM, the Surveyor asked the Director of Nursing [DON] who documents to the MDS, and the DON said the Social Worker, and MDS Nurse does section GG. The Surveyor asked why it is important for staff to document appropriately to the MDS. The DON told the Surveyor said that the MDS reflects clinical reimbursement and assessment needs of the resident. The DON expects the MDS to be documented appropriately. e. On 01/25/24 at 9:47 AM, the Surveyor asked the Administrator for an MDS Policy. f. On 01/25/24 at 10:13 AM, The Administrator said they do not have an MDS policy.

Based on observation, record review and interview, the facility failed to ensure activities were regularly provided to residents on the weekends. The failed practice had the potential to affect 73 residents that reside in the facility. The findings are: On 01/22/24 at 11:26 AM, Resident #2 stated, No activities happen on the weekend. On 01/22/24 at 12:54 PM, Resident# 48 was asked about activities and if she attends? Resident #48 stated; I love to go to activities, but they have no activities on the weekend. 01/23/24 at 2:00 PM, Resident #48 indicated that she enjoyed playing bingo and having her nails done. Resident indicated she just wished they did stuff on the weekends. On 01/25/24 at 2:15 PM, the Surveyor Interviewed the Activity Director [AD], regarding activities on the weekend. This surveyor asked the AD, how are activities done on the weekend? The AD stated, The weekend Nurse Supervisor does them. The Surveyor asked the AD, if she communicates with the weekend Nurse Supervisor regarding the weekend activities. The AD stated, No, but maybe I should. The Surveyor asked the AD if she had documentation that the weekend Nurse Supervisor does activities on the weekend? The AD stated: no. On 01/25/24 at 3:00 PM, the Surveyor spoke with the Administrator regarding activities on the weekend. The Administrator said the weekend Nurse Supervisor is to do the activities on the weekend. The Administrator also stated the weekend Nurse Supervisor should have a sign in sheet of who all attend each activity. On 01/25/24 at 2:55 PM, the Surveyor spoke with the AD and asked for her records of how she keeps up with who attends activities. The AD provided a binder that had pages in it for each activity and the AD had written the activity, date and a list of the Residents that participated. On 01/25/24 at 3:30 PM, Record review of the activity log for the dates from 12-22-2023 to 01-22-2024. The following dates did not have any activities recorded in the activity logbook: 12-23-23, 12-24-23, 12-25-23, 12-30-23, 12-31-23, 01-06-24, 01-07-24, 01-13-24, 01-14-24, 01-16-24, 01-20-24, and 01-21-24. On 01/25/24 at 3:00 PM, this Surveyor requested an Activities Policy from the Administrator. On 01/26/24 at 9:00 AM, the Administrator came to the Surveyors and stated, They do not have a policy for activities.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. The failed practices had the potential to affect 14 residents who received regular diets and 2 residents who required pureed diets from the kitchen. The findings are: 1. On 01/22/2024, the menu for lunch documented the residents on mechanical soft diets were to receive 3 ounces (oz) of pork roast. a. On 01/22/24 at 12:22 PM, during the noon meal service, Dietary Employee (DE) #2 used a #12 scoop to serve half less portion of ground meat to the residents on pureed diets, instead of full serving of # 12 scoop (3 ounce) per the written menu. b. On 01/23/24 at 8:12 AM, the surveyor asked Dietary Employee (DE) #3 how many servings of pork loin you prepared for the residents on mechanical soft diets. DE #3 stated, I did 6 servings, and I should have done 14 servings. We gave them small portions. 2. On 01/22/2024, the menu for breakfast meal documented the residents on regular diets, and mechanical soft diets were to receive 6 ounces (oz) of oatmeal and residents who required pureed diets were to receive 6 ounces (oz) of pureed oatmeal and 2 to 3 pureed homestyle pancakes. a. On 01/22/24 at 7:40 AM, during the breakfast meal service, Dietary Employee (DE) #2 used a #8 scoop (4 ounce) to serve regular oatmeal to the residents on pureed diets, instead of 6 ounces (2/3 cup) of pureed oatmeal per the written menu. b. On 01/23/24 at 8:03 AM, the kitchen ran out of oatmeal. Six residents were served dry cereal, instead of oatmeal as per the written menu. c. On 01/23/24 08:12 AM, the surveyor asked Dietary Employee (DE) #3 the reason some residents did not receive oatmeal. DE #3 stated, I taught that I had made enough. I had about 6 residents that did not get it. I gave them dry cereal The surveyor asked Dietary Employee (DE) #3 the reason residents on pureed diets were served regular oatmeal. What scoop size she used to serve oatmeal to the residents on pureed diets, and how many servings she gave to each resident. DE #3 stated, I forget to puree it. I used the gray scoop (#8) and I gave a serving each. The surveyor asked Dietary Employee (DE) #3 the reason the reason residents who required pureed diets did not receive pureed pancake. DE #3 stated, I forgot.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who receive meal trays in their rooms on the C- Hall, 11 residents who receive meal trays on the D- hall, 13 residents who receive meal trays in their room on the E- hall, 8 residents who receive meal trays in their room on A- Hall, 5 residents who receive meal trays in their room on the B- hall, and 5 residents who receive meal trays in their room on the F- hall. as documented on a list provided by the Dietary Supervisor #1 on 01/23/2024 at 09:03 AM. The findings are: 1. Resident #56 had a diagnosis of orthopedic aftercare surgical amputation of the right Leg. Minimum Data Set with an assessment reference date of 12/27/23 documented the resident scored 15 indicates cognitively intact on a Brief Interview of Mental Status. a. The physician order dated 12/23/23 documented, General diet, Regular texture, Thin Liquids consistency. b. On 01/22/24 at 10:37 AM, resident #56 stated, that hot food is not hot. I can't eat food that is supposed to be hot when it's cold. c. On 1/23/24 at 08:10AM resident stated, I didn't eat my eggs, they were cold. I did eat my cereal. 2. Resident #48 has a Diagnosis of TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA, CHRONIC VIRAL HEPATITIS, MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION, ANXIETY DISORDER, UNSPECIFIED, ESSENTIAL (PRIMARY) HYPERTENSION, INSOMNIA, HYPERLIPIDEMIA, PAIN, DIFFICULTY IN WALKING, MAJOR DEPRESSIVE DISORDER, CEREBRAL INFARCTION, HISTORY OF FALLING, TOBACCO USE, MUSCLE WASTING AND ATROPHY, ABNORMALITIES OF GAIT AND MOBILITY, MUSCLE WEAKNESS (GENERALIZED), and CONSTIPATION. The Medicare 5 Day Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 12/24/23 documented the resident scored 14 (13 to 15 cognitively intact) on a brief Interview of Mental Status. a. The Resident #48's 12/2/2023 physician orders documented, General Diet: Regular texture, thin liquids consistency. b. On 01/22/24 at 12:15 PM, Resident #48 stated, that when the food arrives in her room it is cold. They do not offer to go heat it up or offer to get her another tray. Resident stated, She has to find a staff person that will go heat the cold tray up for her. 3. On 01/22/24 12:35 PM, an unheated food cart that contained 8 trays for breakfast was delivered to C- hall by the Certified Nursing Assistant #1. 01/22/24 12:53 PM, immediately after the last resident was served in their room on C- hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with the following results: a. Mashed potatoes with gravy 108 degrees Fahrenheit. b. Pork loin 98 degrees Fahrenheit. c. Cauliflower 115 degrees Fahrenheit. 2. On 01/22/24 at 07:42 AM, an unheated food cart that contained 13 trays for breakfast was delivered to E-hall by Certified Nursing Assistant #2. 01/23/24 08:01 AM immediately after the last resident was served in their room on E- hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor were with the following results: a. Milk 55 degrees Fahrenheit. b. Sausage 84 degrees Fahrenheit. c. Scrambled eggs 95 degrees Fahrenheit. 3. On 01/22/24 07:43 AM, an unheated food cart that contained 11 trays for breakfast was delivered to D-hall by Certified Nursing Assistant #3. 01/23/24 07:54 AM, immediately after the last resident was served in their room on E- hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor were with the following results: a. Milk 50 degrees Fahrenheit. b. Oatmeal 108 degrees Fahrenheit. c. Ground sausage 96 degrees Fahrenheit. d. Scrambled eggs 115 degrees Fahrenheit. e. Sausage 86 degrees Fahrenheit.

Based on observation, interview and record review, the facility failed to ensure residents clean laundry was transported in a safe and sanitary manner to protect clean clothing from soil and dust to prevent cross contamination. This failed practice had the potential to affect 18 sampled (Residents R#2, R#9, R#11, R#16, R#18, R#21, R#24, R#29, R#41, R#44, R#45, R#48, R#53, R#55, R#56, R#58, R#67,and R#224) that have their laundry washed by the facility. The findings are: a. On 01/22/24 at 01:42 PM, the Surveyor observed an uncovered rack of laundry resting against the right side of the wall on A hall. b. On 01/22/24 at 01:43 PM, Laundry Worker #1 was observed walking down the hall to the laundry rack. The Surveyor asked what was on the rack, and what procedure is used to return clean laundry to the residents. Laundry Worker #1 said it is a rack of clean clothes, and they have a sheet to cover clean linens on the clothing rack, but it was removed when they got to the hall to distribute clothing. Laundry Worker #1 said they should have covered all the clean clothes back up before walking away for sanitary reasons, and to prevent cross contamination. c. On 01/22/24 at 01:50 PM, The Surveyor walked down B hall and observed the clean laundry rack was unattended and resting against the left side of the hallway with the sheet pulled aside. d. On 01/24/24 at 03:36 PM, during an interview with the Director of Nursing [DON] the Surveyor asked what procedure staff was expected to use when returning clean laundry to residents. The DON said clean clothes should be kept covered while being transported down the hallways. The Surveyor asked the DON why laundry is expected to be covered and the DON said it is for infection control, and to prevent cross contamination. e. On 01/25/24 at 09:30 AM, the Surveyor asked the Administrator for a laundry and infection control policy. 6. On 01/25/24 at 10:26 AM, the Administrator said they do not have a laundry policy. An infection control policy was not provided. f. On 01/25/24 at 10:30 AM, the Administrator provided a document titled Linen Operations and Management documenting, .Transporting linen - clean .Clean linen carts, when delivered, should be covered at all times to help prevent spread of infection . g. On 01/26/2024 at 09:30 AM, the Surveyor asked the Director of Nursing [DON] for the infection control policy. h. On 01/26/2024 at 09:40 AM, the DON provided a policy titled Infection Prevention & Control Program documenting, .Policy Statement 1. The infection prevention and control programs are a facility-wide effort involving all disciplines and individuals and are an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety .

Based on observation, record review and interview, the facility failed to ensure oxygen was administered according to Physician ' s orders and oxygen ordered for whenever necessary was monitored or documented as being provided to reduce the potential for respiratory complications for 2 (Resident #55 and #29) sampled residents that had orders for oxygen therapy. This failed practice had the potential to affect 6 residents that had physician orders for oxygen therapy. The findings are: 1. On 01/22/24 at 10:27 AM, Resident #55 was lying in the bed with oxygen being administered via nasal cannula (NC) at 1 liter per minute (LPM). On 01/22/24 at 3:16 PM, Resident #55 was lying in the bed with oxygen (O2) being received at 1 LPM via NC. On 01/23/24 at 8:14 AM, Resident #55 was lying in the bed with oxygen being received at 1 LPM. a. A physician's order dated 10/14/23 O2 documented oxygen at 3L/min via nasal cannula prn to keep O2 sat (saturation) > (greater than) 92% every 8 hours as needed related to Acute Respiratory Failure. b. A Care plan initiated on 07/19/2023, documented oxygen settings: O2 at 3L (liter) via nasal cannula as needed for shortness of breath humidified. c. On 1/24/24 at 2:15 PM, Licensed Practical Nurse (LPN) #1 was asked to accompany Surveyor to resident # 55's room. LPN # 1 was asked to check the liter flow rate. LPN stated, It's on a 1. LPN #1 was asked what should the flow rate be set on. LPN #1 stated, 2 (two) and reached down and corrected the meter flow rate to a 2. LPN # 1 was asked to explain the reasoning of following Physicians orders. LPN #1 stated, If it is not on the correct amount ordered then they won't get as much oxygen as they need and they will become short of breath and things start to happen. LPN # 1 confirmed that the oxygen flow rate was not correct and stated, It probably got bumped today. 2. Resident #29 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure with Hypoxia (below normal oxygen lever), and Acute Respiratory Failure with Hypercapnia (high levels than normal carbon dioxide). a. Physicians Orders dated 11/08/2023 . Oxygen (O2) at 2.0 Liters/minute via nasal cannula as needed for to keep oxygen saturation >92%. every 8 hours as needed related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), Medication Administration Records (MARs) does not have documentation of dates showing O2 has been administered or O2 checked daily. The Vital Flow Sheet shows Resident #29 has been on oxygen every day since November 2, 2023. b. Care plan dated 11/23/2023 for Resident #29 showed documentation . OXYGEN SETTINGS: O2 at 2L via nasal cannula. Humidified. Date Initiated: 08/03/2023 . The surveyor reviewed physician's notes from 11-2023 to 12-2024 with no documentation of doctor being notified of resident changing oxygen level. c. On 01/22/24 at 11:43 AM, the Surveyor observed. Resident #29 with a nasal cannula with the Oxygen Concentrator set on 3.0 Liters/minute. The Physician Order was for 2.0 Liters/minute. The tubing was dated 01/22/2024. d. On 1/24/2024 at 8:50 AM, the Surveyor observed Resident #29 with nasal cannula set at 3.0 Liters/minute. Resident #29 was coherent, able to respond to questions verbally and appropriately. e. On 1/24/2024 at 9:08 AM, the Surveyor asked Licensed Practical Nurse [LPN] LPN #2 what was Resident #29 ' s oxygen level on the concentrator set at? LPN #2 confirmed O2 is set at 3.0 Liters/minute. It is to be set at 2.0 Liters/minute. LPN #2 asked Resident #29 if she changed the oxygen level. Resident #29 commented yes. f. On 01/24/24 at 9:42 AM, Resident #29 has been observed to be on O2 every day. Medication Administration Record [MAR]'S (page 23) does not show documentation that Resident #29 had been using oxygen. g. On 1/24/2024 at 3:19 PM, the surveyor asked LPN #2 where on MARs do you document Resident is wearing her O2? LPN #2 commented Resident#2 is continuous O2; Some have continuous and as needed O2 orders. Resident #29 O2 is 2.0 Liters/minute as needed. She wears it all the time. She wears it every day, it makes her feel more comfortable. The surveyor asked LPN #2 where is the does documentation on the MARs that a resident received O2? The Surveyor asked LPN #2 to pull up MARs to show documentation LPN#2 confirmed there was no documentation. LPN #2 confirmed MARs do not have O2 given. h. On 1/24/2024 at 3:31 PM, the Surveyor asked the Director of Nursing (DON) is it important for staff to watch the O2 level of a resident? The DON confirmed yes to monitor respiratory status. The Surveyor asked the DON if you have a resident changing their O2 level what procedure do you expect staff to follow? The DON confirmed if adjusting against doctors order I expect them to adjust oxygen back to order level, assess the resident, and then call the doctor to inform that the resident was refusing to leave the O2 at prescription level. The Surveyor asked the DON do you expect staff to document as needed O2 on the MAR? DON confirmed yes, to reflect condition and how often they are using it. This allows the doctor to know that treatment is effective. The Surveyor asked the DON who is responsible for documenting the as needed O2? The DON confirmed the charge nurse. i. On 1/25/2024 at 9:46 AM, the Administrator provided a policy titled Oxygen Administration - Resident documented, Purpose .The purpose of this procedure is to provide guidelines for safe oxygen administration ., Preparation . Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident ., Evaluation .While the resident is receiving oxygen therapy, the following may be evaluated: Signs or symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes), signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion), vital signs prn, lung sounds prn ., Documentation After completing the oxygen setup or adjustment, record the use of the oxygen therapy in the resident's medical record and/or MAR or TAR . and, Reporting .Report other pertinent information in residents medical record as needed .

Based on interview and record review, the facility failed to ensure staff notified the Administrator immediately after a suspected allegation of abuse and/or neglect to rule out possible abuse/neglect, and possible injury for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents; and failed to ensure an injury of unknown origin for (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents was reported to the State Agency according to regulatory timeframe's to prevent potential delays in reporting abuse/neglect/injury of unknown origin. This failed practice had the potential to affect 62 residents according to the Roster Matrix provided by the Administrator on 12/1/2022 at 1:49 p.m. The findings are: Resident #1 had a diagnosis of Schizophrenia and Dementia. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/8/2022 documented was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and required limited physical assistance for bed mobility, and extensive physical assistance for transfer, dressing, toilet use and personal hygiene, and had a gastronomy tube (G-tube) and received a mechanical soft diet. 1. The Division of Medical Services (DMS) Office of Long Term Care Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS-762) for the October 8, 2022 incident documented, .Date and Time of Discovery: 10/8/2022 at 7:30 p.m.Date Incident Reported to OLTC: 10/09/2022 Time: 2:00 PM .Date and Time of Discovery: 10/8/2022 Time: 7:30 PM . Complete Description of Incident . Complete Description of Incident . On 10/8/2022, the facility obtained a xray of [Resident #1's] right wrist due to swelling. There was no brusing [bruising] or redness to the area. The xray report the facility received indicated [Resident #1] has a oblique minimally displaced fracture of the distal radius. [Resident #1] was sent to the ER [emergency room ] to be treated . The facility did not report Resident #1's injury of unknown source to the State Agency within the two hour period. 2. The DMS-762 Report for the November 14, 2022 incident documented, .Summary of Incident . CNA [Certified Nursing Assistant] reported that a nurse did not administer enteral feeding as ordered throughout the right shift . 3. The DMS-762 OLTC (Office of Long Term Care) Witness Statement Form dated 11/14/2022 at 8:00 a.m. by the Director of Nursing (DON) documented, .[CNA #1] verbalized via telephone that she did not feel as if resident [Resident #1] received enteral feedings as ordered on the 11-7 [11:00 Am to 7:00 AM] shift on the night of 11/11/22 . 4. The DMS-762 OLTC Witness Statement Form by CNA #1 dated 11/15/2022 for the 11/11/2022 incident documented, .The nurse didn't give the resident [Resident #1] her feedings all night. I know, cause I was on D Hall the entire night. She made no attempt to do it. The only time she came down there was to push hydration cart . CNA #1 did not immediately report allegations of neglect upon suspicion to the Administrator. 5. The Employee Disciplinary Action Report for CNA #1 provided by the Administrator on 12/1/2022 at 3:15 p.m. documented, .on 11/14/2022 staff member failed to report an abuse/neglect allegation per facility policy . 6. The Abuse Prevention Program Acknowledgment Form and Abuse/Neglect Policy provided by the DON on 12/2/2022 at 11:18 a.m. documented CNA #1 signed the form upon hire on 3/2/2022. 7. On 12/1/2022 at 2:15 p.m., the Surveyor asked the Director of Nursing (DON), Who notified the facility of [Resident #1] not being fed internal feedings on the 11-7 [11:00 PM - 7:00 AM] shift on 11/11/2022? The DON stated, [CNA #1]. The Surveyor asked, Who did [CNA #1] notify? The DON stated, She notified myself. The Surveyor asked, When did [CNA #1] notify the facility of this incident? The DON stated, On the Monday morning of the day the reportable was submitted. The Surveyor asked, When was this incident reported to OLTC? The DON stated, That morning. The Surveyor asked, Why did it take three days for the staff to report the incident that happened on 11/11/2022? The DON stated, Because she had wrote it on a statement and slid it under my door and I didn't get it until Monday morning and that's when I called her to get her details. The Surveyor asked, When is allegations of abuse supposed to be reported? The DON stated, Immediately. The Surveyor asked, Who is supposed to report allegations of abuse? The DON stated, Any staff member. The Surveyor asked, Who is allegations of abuse supposed to be reported to? The DON stated, The Administrator. The Surveyor asked, When/what is the timeframe OLTC is notified of allegations of abuse? The DON stated, Within two hours. The Surveyor asked, Is [CNA #1] working and available for interview? The DON stated, We reprimanded her, and she has been in-serviced and trained on reporting abuse. CNA #1 was unavailable for interview due to being hospitalized . 8. On 12/1/2022 at 2:22 p.m., the Surveyor asked the DON, [Resident #1's] reportable for the fracture to the right wrist, time and discovery was 10/8/2022 at 7:30 p.m., but OLTC was not notified until 10/9/2022 at 2:00 p.m., why? The Administrator stated, We didn't know it was actually fractured until we got the report back. 9. On 12/1/2022 at 2:27 p.m., the Surveyor asked CNA #2, When are allegations of abuse supposed to be reported? CNA #2 stated, As soon as it happens. The Surveyor asked, Who is allegations of abuse supposed to be reported to? CNA #2 stated, The Administrator. The Surveyor asked, Have you been in-serviced on abuse/neglect training? CNA #2 stated, Yes. The Surveyor asked, How often do you receive abuse/neglect training? CNA #2 stated, Every time it happens and yearly. 10. On 12/1/2022 at 2:31 p.m., the Surveyor asked House Keeper (HK) #1, When are allegations of abuse supposed to be reported? HK #1 stated, Whenever it happens, immediately. The Surveyor, Who is allegations of abuse supposed to be reported to? HK #1 stated, The CEO [Chief Executive Officer], the Administrator. The Surveyor, Have you been in-serviced on abuse/neglect training? HK #1 stated, Yes. The Surveyor, How often do you receive abuse/neglect training? HK #1 stated, Our supervisor updates, the Administrator has in-services, a lot. 11. On 12/1/2022 at 2:35 p.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, When are allegations of abuse supposed to be reported? LPN #1 stated, Immediately. The Surveyor asked, Who is allegations of abuse supposed to be reported to? LPN #1 stated, The CNA tells the Charge Nurse, the Charge Nurse tells the DON, and the DON tells the Administrator. The Surveyor asked, Have you been in-serviced on abuse/neglect training? LPN #1 stated, Yes, The Surveyor asked, How often do you receive abuse/neglect training? LPN #1 stated, Upon hire, then again, twice since October. 12. On 12/2/2022 at 11:00 a.m., the Surveyor asked the Administrator, What day and time was the facility notified of [Resident #1's] x-ray results, fracture to the right wrist? The Administrator stated, The x-ray came in on 10/8/2022 at 6:30 p.m., but I found out around 7:30 p.m. The Surveyor asked, On the DMS-762, it documented date and time of discovery was 10/8/2022 at 7:30 p.m. correct? The Administrator stated, Yes. The Surveyor asked, On the DMS-762, documented the date the incident was reported to OLTC was 10/9/2022 at 2:00 p.m. correct? The Administrator stated, Yes. The Surveyor asked, Why was this incident not reported to OLTC within the two hour time frame? The Administrator stated, It should have been reported. The Surveyor asked, Do you know exactly how [Resident #1] obtained the fracture to the right wrist? The Administrator stated, No we don't know, it had started swelling and we got an x-ray. The Surveyor asked, What kind of injury was this? The Administrator stated, Well it was unknown origin. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and following the CMS [Centers for Medicare and Medicaid Services] guidelines for reporting allegations of abuse? The Administrator stated, That they would report it to me immediately. 13. The facility policy titled, Abuse, Neglect, and Exploitation, provided by the Administrator on 12/1/2022 at 2:29 p.m. documented, .We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from verbal, sexual, physical, or mental and psychosocial abuse, neglect, misappropriation of property, and involuntary seclusion. The facility considers all the above to be abuse and uses the general term abuse to specify all . All complaints, concerns or suspicions of abuse should be immediately reported to the Administrator . All personnel are required to immediately report all suspected cases of abuse to the Administrator. (ln the absence of the Administrator, suspected abuse should be reported to the Director of Nursing (DON) and immediate supervisor) . The facility will report all alleged violations involving mistreatment, neglect or abuse to the Office of Long-Term Care, Family, Police, and Physician (MD) .

Based on observation, interview, and record review the facility failed to ensure fingernails were clean and groomed to promote good personal hygiene and grooming for 1 (Resident #5) of 21 (Resident #3, #5, #8, #16, #17, #23, #25, #26, ,#27, #34, #37, #40, #42, #43, #47, #50, #56, #61,#62, #63 and #65) sampled residents who required assistance with nail care. This failed practice had the potential to affect 62 residents that lived in the facility and required assistance with nail care according to a list provided by Administrator on 11/10/22 at 10:30 AM. The findings are: 1. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons with personal hygiene and one person's physical help in the part of bathing activity. a. The Care Plan with an initiated date of 6/26/20 documented, .Focus: I have an ADL [activities of daily living] self-care performance deficit r/t [related to] weakness and confusion . Intervention: .BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 11/07/22 at 1:21 PM, Residents #5 was lying in bed watching television. His fingernails extended approximately 1/8th of an inch past the end of the nail bed and had a black substance under some of the nails on each hand. c. On 11/08/22 at 9:46 AM, Resident #5 was lying in bed watching television. His fingernails were approximately 1/8th of an inch past the nail bed with some jagged edges. There was a black substance under some of the nails. The Surveyor asked Resident #5, Do the staff help you clean and trim your nails? Resident #5 stated, They cleaned and clipped them about 2 weeks ago. d. On 11/09/22 at 8:15 AM, Resident #5 was sitting up in bed eating cereal for breakfast. His fingernails were approximately 1/8th of an inch past the end of the nail bed with some jagged edges. There was a black substance under some of the nails. Resident #5 scratched his left arm with his right hand and stated, I wish I would stop itching. The Surveyor asked, Have you told the staff you are itching? Resident #5 stated, Yes I have told them, and they have been putting some lotion on, that has helped a little. e. On 11/09/22 at 1:30 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 to accompany her to Resident #5's room and asked LPN #2, Can you describe [Resident #5's] fingernails? LPN #2 looked at Resident #5's fingernails and stated, They are short but a couple of them need to be cleaned. The Surveyor asked, How much assistance does [Resident #5] need with Activities of Daily Living? LPN #2 stated, I am an agency nurse, but what I have observed in the days that I have worked here is that he needs full assistance. As far as feeding goes, you set up his food and he can feed himself. The Surveyor asked, Who is responsible for fingernail care? LPN #2 stated, The CNA [Certified Nursing Assistant] staff are. The Surveyor asked, How often should nail care be done? LPN #2 stated, Each place has its own protocol, but I think it should be done as needed. The Surveyor asked, Does [Resident #5] refuse nail care? LPN #2 stated, I am not sure about that. Sometimes he refuses his medications, but I was able to coax him to take his medication by explaining why he needed to take them. The Surveyor asked, Why is it important that residents nails are kept clean and groomed? LPN #2 stated, It could lead to infection if he scratches himself and it does not look good if nails are dirty and not groomed. f. On 11/09/22 at 1:39 PM, the Surveyor asked CNA #1, How long have you worked for the facility? CNA #1 stated, I came back about a month ago, but I had worked here for 3 years prior to that. The Surveyor asked, How much assistance does [Resident #5] need with Activities of Daily Living? CNA #1 stated, He requires extensive assistance. Sometimes he does okay, but he has a lot of shaking which makes it more difficult for him and causes him to be frustrated when he tries to do things for himself. The Surveyor asked, Who is responsible for fingernail care? CNA #1 stated, The CNA staff are responsible. The Surveyor asked, How often should nail care be done? CNA #1 stated, We normally do it on shower days. The Surveyor asked, Does [Resident #5] refuse nail care? CNA #1 stated, He has been in a really good mood today, but sometimes he does refuse care. He did not want help with eating this morning, but at lunch he was shaking so much he let us help him. The Surveyor asked, Why is it important that residents nails are kept clean and groomed? CNA #1 stated, If they are not clean and groomed it can cause scratches and infection. A lot of residents like to scratch and skin tears can be horrible. I am going to try and see if he will let me clean his nails. I don't think he would let the other aide clean them this morning. It depends on his mood and who is trying to care for him, but sometimes I can convince to let me do the care. If his [CONDITION(S)] is really playing up, he wants to be left alone. He does like to do things for himself. He has been scratching and I have been putting lotion on to try and help with that. g. On 11/09/22 at 1:55 PM, CNA #1 came to the Surveyor and stated, I just wanted to let you know [Resident #5] let me clean his nails. h. On 11/10/22 at 8:38 AM, the Surveyor asked the Director of Nursing (DON), Who is responsible for fingernail care? The DON stated, The CNA if they are not diabetic and if they are diabetic the nurses do nail care. The Surveyor asked, How often should nail care be done? The DON stated, As needed. Usually during bath days, the aides do the nails and the nurses do the diabetic patients nails weekly. The Surveyor asked, Why is it important that residents nails are kept clean and groomed? The DON stated, To promote good personal hygiene and for infection control purposes. i. The facility policy titled, Care of Fingernails/Toenails, provided by the Administrator on 11/10/22 at 10:30AM documented, .Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines: .2. Proper nail care can aid in the prevention of skin problems around the nail bed . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore gloves during the administration of an insulin injection to 1 (Resident #38) of 4 residents observed during medication administration to prevent potential infection or transmission of blood borne pathogens. Findings included: 1. Review of a Centers for Disease Control and Prevention (CDC) article titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, last reviewed 03/02/2011, revealed, Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration. The following are infection control recommendations that anyone who performs or assists with blood glucose monitoring and/or insulin administration should review to assure they are not placing themselves or persons in their care at risk. The policy also indicated, Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. 2. A review of an undated facility policy titled, Subcutaneous Medication Administration Procedures, provided by the Administrator on 11/09/2022 at 8:00 AM, revealed the policy did not address the use of gloves during administration of injections. 3. Review of an Admission Record revealed Resident #38 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Review of Resident #38's electronic medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. During an observation of the medication administration pass on 11/07/2022 at 3:38 PM, Licensed Practical Nurse (LPN) #1 entered the room of Resident #38 and administered a [MEDICATION(S)] R injection into the resident's left arm. The LPN was not wearing gloves during administration of the injection. 6. During an interview on 11/07/2022 at 3:49 PM, LPN #1 stated she had never worn gloves while injecting insulin, only while cleaning the glucometer. 7. During an interview on 11/07/2022 at 4:17 PM, the Director of Nursing (DON) stated it was her expectation that the nurses wear gloves when administering insulin. 8. During an interview on 11/09/2022 at 11:21 PM, LPN #3, the Infection Control Preventionist, revealed it was expected that gloves be worn during insulin administration due to the possibility of contact with bodily fluids. 9. During an interview on 11/10/2022 at 8:04 AM, the Administrator revealed it was her expectation that the nursing staff wear gloves while using the glucometer to check a resident's blood sugar, but she would not expect the nurse to wear gloves while injecting insulin because wiping the site of the injection with an alcohol wipe would be the barrier. 10. During an interview on 11/10/2022 at 9:10 AM, LPN #4 stated she wore gloves to check blood sugar levels, to administer insulin, and to clean the glucometers, because there was always a risk of contact with bodily fluids. 11. During an interview on 11/10/2022 at 9:13 AM, LPN #5 stated she would wear gloves when checking blood sugar, pricking the resident's skin when giving insulin, and cleaning the glucometer. 12. During a follow-up interview on 11/10/2022 at 10:24 AM, the DON revealed the facility did not have a universal precautions policy; however, the facility followed CDC guidelines.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; failed to ensure leftover food items were used by its use-by date to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 2 of 2 ice machines and 1 of 2 ice scoop holders were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 67 residents who received meals from the kitchen (total census: 67), as documented on a list provided by Administrator on [DATE] at p.m. The findings are: 1. On [DATE] at 10:16 a.m., the following observations were made during the initial tour of the kitchen: a. A zip lock bag that contained leftover sausage was stored on a shelf in the refrigerator. Dietary Employee #1 was asked what was in the bag. She stated, There was leftover sausage from breakfast. We will use them for pureed meat for breakfast tomorrow. b. A container of leftover tomato soup dated [DATE] was stored on a shelf in the refrigerator in the kitchen. c. An open zip lock bag that contained shelled boiled eggs was stored on a shelf in the refrigerator. The bag was not sealed. d. One open box of salt was stored on a shelf above the food preparation counter. The box was not covered. e. An open bag of hamburger buns was stored in a basket on top of the food preparation. The bag was not sealed. There was no date on the bag to identity when it was opened. 2. On [DATE] at 10:42 am., there was a box that contained 15 bottles of chocolate milk in the refrigerator in the storage room, another box had 5 bottles of chocolate milk. A milk crate had 5 bottles of chocolate milk in it. All the bottles of milk had an expiration date of [DATE]. 3. On [DATE] at 10:44 a.m., the following observations were made in the storage area: a. An open box of garlic bread was stored on a shelf in the freezer. The box was not covered or sealed. b. There was a bag of corn chips on a shelf in the storage room with an expiration date of [DATE]. 4. On [DATE] at 10:58 a.m., there was dried on brown residue above the panel of the ice machine in the kitchen. Dietary Employee #2 was asked to wipe the brown residue on the panel of the ice machine. He did so, and the brown residue easily transferred to the tissue. He was asked to describe what was wiped off and who uses ice from the ice machine and how often do you clean it. He stated, We clean it 2 times a month. We use it in the kitchen to fill beverages served to the residents at meals. 5. On [DATE] at 11:01 a.m., the ice scoop holder on the wall by the ice machine in the dining room had pink residue inside the scoop holder. Dietary Employee #2 was asked to wipe the pink residue in the scoop holder. He did so, and the pink residue easily transferred to the tissue. He was asked, how often do you clean the ice scoop holder. He stated, Once a week. 6. On [DATE] at 11:02 a.m., there was a wet black residue underneath the ice machine panel in the dining room. Dietary Employee #2 was asked to wipe wet black residue under the panel. He did so, and the black residue easily transferred to the tissue. He was asked, How often do you clean the ice machine and who uses the ice from the machine? He stated, We clean it once a month. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. 7. On [DATE] at 11:14 a.m., Dietary Employee #3 was wearing gloves on her hands She picked up a pan of cake and placed it on the counter. She removed spice containers, a container of peanut butter and a bag of brown sugar, contaminating the gloves. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets for lunch. At 11:16 a.m., she picked up slices of cake and placed them in a blender to be pureed and served to the residents who received pureed diets for the lunch meal. 8. On [DATE] at 11:25 a.m., Dietary Employee #1 used a rag to wipe off particles of food items that spilled on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for the lunch meal. 9. On [DATE] at 1:16 p.m., a box that contained loaves of bread and a box that contained hamburger buns were on a rack in the storage room. The manufacture instruction on each box documented: keep frozen at 0 degrees Fahrenheit or below. 10. A Leftovers policy received from Regional Director on [DATE] at 11:43 a.m. documented, .Leftovers cannot be used as alternates unless requested by patients / residents. They may be used as an extra or incorporated into a different menu item as an alternate . 11. A Hand Washing policy documented, .When to wash your hands: After engaging in any other activities that contaminates the hands .

Based on observation, record review and interview, the facility failed to ensure call lights were in reach and accessible for 2 (Residents #17 and #60) of 30 (Residents #5, #57, #18, #27, #48, #65, #17, #50, #51, #28, #9, #40, #64, #52, #29, #12, #38, #14, #21, #22, #63, #33, #35, #60, #52, #23, #11, #20, #40 and #6) sampled residents who were dependent on staff for assistance and able to use the call light. This failed practice had the potential to affect 67 residents who were dependent on staff for assistance and able to use the call light as documented on a list provided by the Administrator on 08/05/21. The findings are: 1. Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/21 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status, required extensive assistance with most Activities of Daily Living and had a fall with injury. a. The Comprehensive Care Plan with an initiated date of 11/19/20 documented, .I have an ADL self-care performance deficit r/t [related to] Aggressive Behavior, Dementia and generalized weakness . Encourage me to use bell to call for assistance . Everyone is at risk for falls, but I am a high risk for falls r/t severe cognitive impairment with poor safety awareness, not easily redirected, wandering, incontinent, behaviors and I take daily [CONDITION(S)] medications r/t my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 08/02/21 at 11:31 A.M., Resident #60 was lying in bed with eyes closed, the call light was draped around the call light connector to the wall approximately 3 feet out of reach of the resident. 2. Resident #17 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 05/14/21 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and required extensive assistance of one staff member for all activities of daily living. a. A Care Plan dated 11/28/2020, documented, . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 08/02/21 at 10:38 A.M., Resident # 17 was asleep on a low bed. There was no furniture in the room other than the bed. Two call lights were draped over an overbed light and out of the resident's reach. c. On 08/03/21 at 8:55 A.M., Resident #17 was lying in bed. Two call lights were draped over the overbed light out of the resident's reach. d. On 08/04/21 at 2:00 P.M., Resident #17 was sitting on his bed. There was no furniture in the room. Two call lights were draped over an overbed light and out of the resident's reach. e. On 08/04/21 at 11:30 A.M., CNA #3 was asked, Why does [Resident #17] not have any furniture? She answered, He might trip and fall because he's blind. She was asked, Why doesn't he have a call light? She pointed to the 2 call lights draped over the overbed light and out of his reach and answered, He does have one. She was asked, Why does he not have one he can reach? She answered, He fell on ce, and it was wrapped around him. f. On 08/05/21 at 9:25 A.M., the MDS Coordinator was asked, Why does [Resident #17] not have a call light that he can reach? She answered, That one I couldn't tell you. She was asked, Is it documented on the care plan that he is not to have furniture or a call light? She answered, No. She was asked, Should these interventions be documented on the care plan? She answered, Yes. 3. On 08/05/21 at 10:47 A.M., the Director of Nursing (DON) was asked, Should a resident ' s call light be in reach and accessible at all times? The DON stated, Yes. 4. On 08/05/21 at 4:45 P.M., the Director of Nursing was asked, If a resident has an intervention of no furniture in the room, should that be on the care plan? She answered, Yes. She was asked, If a resident has an intervention of No Call Light, should that be on the care plan? She answered, Yes. But all of our residents are care planned to have a call light. She was asked, Should residents' call lights be in reach? She answered, Yes. 5. A Call Lights policy received from the Administrator on 08/05/21 documented, It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance .9. Always place the call light in an accessible location to where the resident is located in their room .

Based on observation, interview and record review, the facility failed to ensure allegation of abuse was immediately reported to the Administrator so an investigation could be promptly imitated and protection from further abuse implemented for 1 (Resident #22) of 1 sampled resident. The findings are: Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 05/21/21, documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status; required limited assistance for transfer, dressing, and personal hygiene; and supervision to walk in room and corridor. a. On 08/02/21 at 10:53 A.M., Resident # 22 had a large purple and black area to the left forearm approximately 2 centimeters in diameter. Resident #22 was asked, What happened? Resident #22 stated, A nurse squeezed it on Saturday. Resident #22 was asked, Did you tell anybody? Resident #22 stated, Yes, the nurse. Resident #22 was asked, Did they do anything about it. Resident #22 stated, No. b. On 08/02/21 at 12:00 P.M., the Director of Nursing (DON) was overheard asking Resident #22 what happened to his arm. Resident #22 told the DON, He squeezed my arm, that male nurse on Saturday. The DON asked Resident #22, Did you tell anyone? Resident #22 stated, Yeah, the other nurse. c. On 08/04/21 at 1:49 P.M., Licensed Practical Nurse (LPN) #3 was asked, When did [Resident #22] say how the incident to his arm happened? LPN #3 stated, He told me it was over the weekend, but not a specific day. LPN #3 was asked, Do you know why [Resident #22's] area to his arm was not reported? LPN #3 stated, No, I don't know who he told. He said he told a nurse. d. On 08/04/21 at 2:00 P.M., the DON was asked, When did [Resident #22] say how the incident to his arm happened? The DON stated, When I heard about it is when [LPN #3] came to me after y'all went on the medication pass. e. On 08/04/21 at 4:03 P.M., the Assistant Director of Nursing (ADON) was asked, Were you on duty this past weekend? The ADON stated, Yes. The ADON was asked, Did anyone report to you about a male staff member squeezing [Resident #22's] left arm? The ADON stated, No. The ADON was asked, When did you become aware of the bruised area to [Resident #22's] left forearm? The ADON stated, Monday morning, after the nurse found out about it. The ADON was asked, What time was that? The ADON stated, Around 10 or 11 A.M. The ADON was asked, Was that after the surveyor found it. The ADON stated, Yes. f. On 08/05/21 at 3:58 P.M., The Administrator was asked, Should unknown bruises be reported? The Administrator stated, Yes. The Administrator was asked, Who is responsible for ensuring bruising on residents is reported? The Administrator stated, Whoever would see it. The Administrator was asked, Who should it be reported to? The Administrator stated, To me. The Administrator was asked, Have your staff been trained on reporting new bruising or bruises of unknown origin? The Administrator stated, Yes. The Administrator was asked, Do you expect your staff to follow policy and procedures? The Administrator stated, Yes. g. An Abuse Prevention policy provided by the Administrator on 08/02/21 at 11:00 A.M. documented, .We believe that the resident has the right to be free from verbal, sexual, physical or mental abuse . the facility will utilize an abuse prevention program . the following procedures have been developed and implemented to properly screen, report, protect, investigate and correct issues relating to abuse . staff is trained upon orientation and annually on the abuse prevention program . the training will include types of abuse . and the recognition of signs and symptoms of abuse which may include . bruises, skin tear, welts, etc., of unknown origin . h. An Abuse Prevention Program policy provided by the Administrator on 08/02/21 at 12:30 P.M. documented, . It is the policy of this facility to prevent resident abuse . Reporting .employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .the nursing staff is additionally responsible for reporting the appearance of bruises .

Based on observation, record review and interview, the facility failed to ensure resident care plans were reviewed and revised to meet the resident needs for 2 (Resident #17and #66) sampled residents. This failed practice had the potential to affect all 67 residents as documented on the Resident Census and Conditions of Residents form provided by the Administrator on 08/02/21 at 12:05 P.M. The findings are: 1. Resident #17 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/21 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive assistance of one staff member for all activities of daily living. a. A Care Plan dated 11/28/2020, documented, . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 08/02/21 at 10:38 A.M., Resident # 17 was asleep on a low bed. There was no furniture in the room other than the bed. Two call lights were draped over an overbed light and out of the resident's reach. c. On 08/03/21 at 8:55 A.M., Resident #17 was lying in bed. Two call lights were draped over the overbed light out of the resident's reach. d. On 08/04/21 at 2:00 P.M., Resident #17 was sitting on his bed. There was no furniture in the room. Two call lights were draped over an overbed light and out of the resident's reach. e. As of 08/04/2021, Resident #17's Care Plan did not contain documentation that all furniture was to be removed from the room. f. On 08/04/21 at 11:30 A.M., CNA #3 was asked, Why does [Resident #17] not have any furniture? She answered, He might trip and fall because he's blind. She was asked, Why doesn't he have a call light? She pointed to the 2 call lights draped over the overbed light and out of his reach and answered, He does have one. She was asked, Why does he not have one he can reach? She answered, He fell on ce, and it was wrapped around him. g. On 08/05/21 at 9:25 A.M., the MDS Coordinator was asked, Why does [Resident #17] not have any furniture in his room? She answered, Because he's blind. He was tripping. She was asked, Why does he not have a call light that he can reach? She answered, That one I couldn't tell you. She was asked, Is it documented on the Care Plan that he is not to have furniture or a call light? She answered, No. She was asked, Should these interventions be documented on the Care Plan? She answered, Yes. h. On 08/05/21 at 4:45 P.M., the Director of Nursing was asked, If a resident has an intervention of No Furniture in the room, should that be on the Care Plan? She answered, Yes. She was asked, If a resident has an intervention of No Call Light, should that be on the Care Plan? She answered, Yes. But all of our residents are care planned to have a call light. 2. Resident #66 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 07/15/21 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a BIMS and received Anticoagulant Medication 7 days during the lookback period. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. As of 08/04/2021 Resident #66's Care Plan did not contain documentation of the use of Anticoagulant Medications. c. On 08/05/21 at 9:25 A.M., the MDS Coordinator was asked, Does [Resident #66] have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She answered, Yes. [MEDICATION(S)]. She was asked, Is the use of anticoagulants documented on the Care Plan? She answered, No. She was asked, Should the use of anticoagulants be documented on the Care Plan? She answered, Yes. d. On 08/05/21 at 4:45 P.M., the Director of Nursing was asked, If a resident takes anticoagulant medications, should this be documented on the Care Plan? She answered, Yes.

Based on observation, interview and record review, the facility failed to ensure fingernails were trimmed and cleaned to promote good personal hygiene for 2 (Residents #20 and #6) of 20 (Residents #18, #48, #65, #66, #17, #50, #51, #28, #40, #64, #267, #29, #12, #38, #14, #21, #22, #35, #60, #20, and 6) sample mix residents. This failed practice had the potential to affect 44 residents who were dependent on staff for nail care according to a list provided by the Administrator on 08/04/21. The findings are: 1. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/21 documented the resident was moderately impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS) and required limited assistance with bed mobility, transfers, toilet use and personal hygiene and extensive assistance with bathing. a. The Comprehensive Care Plan with an initiated date of 11/04/19 documented, .Focus I currently require assist [assistance] with all adls [Activities of Daily Living] x [times] one staff due to increased weakness and decreased endurance . check my fingernails and toe nails and trim as needed unless I am diabetic then please notify my nurse . I require limited to extensive assist x 1 staff with bed mobility, transfer, dressing, toileting, personal hygiene, bathing, eating and locomotion . Please check my fingernail and toenail length and trim as needed . b. On 08/02/21 at 12:58 P.M., Resident #20 was sitting on the edge of the bed with long fingernails that extended over the tip of the fingers approximately 0.5 centimeter with a brown and black substance underneath the nails. c. On 08/03/21 at 12:06 P.M., Resident #20 was sitting on the bed with long fingernails that extended over the tip of the fingers approximately 0.5 centimeters with a brown and black substance underneath the nails. Resident #20 was asked, When was the last time your fingernails were cleaned and trimmed? Resident #20 stated, It has been a while, they need to be cut. d. On 08/04/21 at 10:14 A.M., the Director of Nursing (DON) was asked, Is [Resident #20] dependent on staff for nail care? The DON stated, Yes. The DON was asked, Should a resident have long fingernails with black and brown substances located underneath the nails? The DON stated, No. e. On 08/04/21 at 10:36 A.M., the Administrator was asked, Is [Resident #20] dependent on staff nail care? The Administrator stated, Yes. The Administrator was asked, Should a resident have long fingernails with black and brown substances located underneath the nails? The Administrator stated, No. 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan documented, . Focus: I require extensive assist x 1 staff with bed mobility, transfer, dressing, toileting, personal hygiene, bathing, eating and locomotion. Date Initiated: 11/21/2020 Observe for my hygiene needs and render as needed each shift and prn. Date Initiated: 11/21/2020 . Please check my fingernail and toenail length and trim as needed unless I am diabetic. Date Initiated: 11/21/2020 . Focus I have the potential to experience skin alterations r/t [related to] fragile skin d/t [due to] the aging process, incontinence . Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 04/23/2019 . b. On 08/04/21 10:45 A.M., Resident #6's fingernails were approximately 1/2 inch long with jagged edges and a brown substance under them. Certified Nursing Assistant (CNA) #2 was asked, What is that brown substance under her fingernails? She said, Looks like food. c. On 08/04/21 at 11:10 A.M., Resident #6 was lying in bed. Her fingernails were approximately ½ inch long with jagged edges and a brown substance under them. d. On 08/05/21 at 10:15 A.M., Resident #6 was lying in bed. She had a brown substance under her fingernails. 3. A Nail Care policy provided by the Administrator on 08/04/21 documented, Policy: It is the policy of the facility to provide personal hygiene needs and to promote health, safety and the prevention of infection. This includes clean, smooth nails at a well-groomed safe length acceptable to the resident .

Based on interview and record review, the facility failed to ensure Physicians Orders were followed for daily weights for 1 (Resident #20) of 2 (Residents #20 and #33) sample mix residents. The findings are: 1. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/21 documented the resident was moderately impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS) and required limited assistance with bed mobility, transfers, toilet use and personal hygiene and extensive assistance with bathing. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 05/21/2021 . b. The Comprehensive Care Plan documented, .daily weights Date Initiated: 05/24/2021 . c. The May 2021 Medication Administration Record (MAR) and/or medical record does not contain documentation of a daily weight for 05/23/21. d. The June 2021 MAR and/or medical record does not contain documentation of daily weights for 06/05/21, 06/26/21 and 06/27/21. e. The July 2021 MAR and/or medical record does not contain documentation of daily weights for 07/04/21, 07/18/21 and 07/27/21. f. On 08/05/21 10:50 A.M., the Director of Nursing (DON) was asked, Should Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, Yes. The DON was asked, Does [Resident #20] have an order to be weighed daily? The DON stated, Yes. g. On 08/05/21 10: 51 A.M., the DON was asked for a policy on following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review and interview, the facility failed to ensure medications were not left at the bedside to prevent accidental ingestion by others for 1 (Resident #33) of 6 (Residents #48, #17, #38, #39, #52 and #20) sampled residents. This failed practice had the potential to affect 14 residents who had cognitive impairment and ambulated by any means according to a list provided by the Administrator on 08/05/21 and The facility failed to ensure a fall intervention was appropriately implemented to prevent further falls and potential injury or harm for 1 (Resident #60) of 11 (Residents #50, #48, #20, #18, #35, #33, #38, #5, #17, #6, and #60 ) sampled residents who had falls in the last 90 days. This failed practice had the potential to affect 18 residents who had falls over the last 90 days according to a list provided by the Administrator on 08/05/21 and The facility failed to ensure medications were not left unsecured in the resident's room for 1 (Resident #51) of 4 (Residents #5, #18, #51 and #63) sample mix residents who had orders for [MEDICATION(S)] Ointment. This failed practice had the potential to affect 4 residents who had orders for [MEDICATION(S)] Ointment according to a list provided by the Administrator on 08/05/21 and The facility failed to ensure 2 of 2 clothes dryers remained free of lint build up to decrease the potential for fire and loss of laundry services for one of one laundry room located off the dining room and connected to hall D. This failed practice had the potential to affect 67 residents according to the Resident Census and Conditions of Residents form provided by the Administrator on 08/02/21. The findings are: 1. Resident #33 had diagnoses of [CONDITION(S)] and [CONDITION(S)] with Behavioral Disturbances. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/22/21 documented the resident scored 14 (13 -15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required limited assistance with bed mobility, transfers, eating and toilet use. a. On 08/02/21 at 12:10 P.M., Resident #33 was sitting in a wheelchair in his room. There was a clear medicine cup that contained a red unknown liquid substance sitting on a dresser. Resident #33 was asked, What is that in the medicine cup? Resident #33 stated, It is cough medicine, they gave it to me this morning when I was coughing. b. On 08/03/21 at 9:25 A.M., Resident #33 was not in his room, there was a clear medicine cup that contained a red unknown liquid substance sitting on a dresser. c. On 08/05/21 at 10:48 A.M., the Director of Nursing (DON) was asked, Do you know what was in the medicine cup in [Resident 33's] room? The DON stated, I believe they said it was cough syrup. The DON was asked, Should medications be left at the bedside? The DON stated, No. The DON was asked, Does [Resident 33] have an order to self-administer medications? The DON stated, No. d. A Medication Administration-General policy received by the Administrator on 08/05/21 at 11:35 A.M. documented, .Medications and biological are stored safely, securely, and properly . 2. Resident #60 had diagnoses of Non Alzheimer's Dementia and [CONDITION(S)]. The Quarterly MDS with an ARD of 07/07/21 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status, required extensive assistance with most Activities of Daily Living and had fall with injury. a. The Comprehensive Care Plan with an initiated date of 11/19/20 documented, .Everyone is at risk for falls, but I am a high risk for falls r/t [related to] severe cognitive impairment with poor safety awareness, not easily redirected, wandering, incontinent, behaviors and I take daily [CONDITION(S)] medications r/t my diagnosis of Dementia with Behaviors. I have impaired vision and do not wear glasses 2/26/19 Fall: Fall mat on the floor beside the bed . b. On 08/02/21 at 11:31 A.M., Resident #60 was lying in bed with eyes closed with no fall mat beside the bed. c. On 08/03/21 9:28 A.M., Resident #60 was lying in bed with eyes closed with no fall mat beside the bed. d. On 08/04/21 at 10:16 A.M., DON was asked, Is [Resident #60] care planned to have a fall mat at the bedside? The DON stated, Yes. The DON was asked, Has [Resident #60] had falls and one of the interventions was a fall mat at the bedside? The DON stated, Yes. e. On 08/04/21 at 10:37 A.M., the Administrator was asked, Is [Resident #60] care planned to have a fall mat at the bedside? The Administrator stated, I will have to look. The Administrator was asked, Has [Resident #60] had falls and one of the interventions was a fall mat at the bedside? The Administrator stated, Apparently so. f. An Incidents/Accidents/Falls policy received from the Administrator on 08/04/21 documented, .15 .the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place . 3. Resident #51 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), [CONDITION(S)] Disease, and Hypertension. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. a. A physician order with a start date of 06/23/21 documented .[MEDICATION(S)] Ointment 20% [percent] .apply to coccyx topically every shift for blanchable redness to coccyx . b. On 08/03/21 at 1:07 P.M., Resident #51 was sitting in his wheelchair in his room. A container of [MEDICATION(S)] was on the bedside table. c. On 08/03/21 at 1:18 P.M., Registered Nurse (RN) #1 was asked, Does [Resident #51] have an order for [MEDICATION(S)]? RN #1 stated, No. RN #1 was asked, Should [MEDICATION(S)] be left in the resident rooms? RN #1 stated, No. RN #1 was asked, Is [MEDICATION(S)] considered a medication? RN #1 stated, Yes. d. On 08/05/21 at 10:58 A.M., Licensed Practical Nurse (LPN) #3 was asked, How should containers of [MEDICATION(S)] be stored? LPN #3 stated, In the treatment closet or the wound closet. e. On 08/05/21 at 11:05 A.M., LPN #4 was asked, How should containers of [MEDICATION(S)] be stored? LPN #4 stated, I think in the treatment cart. f. On 08/05/21 at 11:08 A.M., the Director of Nursing (DON) was asked, How should containers of [MEDICATION(S)] be stored. The DON stated, In a locked cart or the treatment cart. g. A Medication Administration - General policy provided by the Administrator on 08/04/21 at 9:54 A.M. documented, Medication Storage In The Facility .Medications and biologicals are stored safely securely, and properly following manufacturer's recommendations or those of the supplier . the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or designated administrative personnel . h. A Material Safety Data Sheet provided by the Assistant Director of Nursing on 08/04/21 at 9:56 A.M. documented, .[MEDICATION(S)] Ointment .Hazard Identification .the chief health hazard associated with exposure during normal use and handling is the potential for mild irritation of contaminated skin . this product is combustible . when involved in a fire, this material may decompose and produce irritating vapors and toxic compounds . including carbon oxides and [MEDICATION(S)] compounds . employees must be trained to properly use this product . use of this product should be performed in a designated area for working with drugs . store this product away from incompatible materials . 4. On 08/05/21 at 2:11 P.M., Dryer #1 had approximately 5 inches by 5 inches of lint in the floor of the dryer and approximately a half inch thick by 4 foot of lint around the electrical wires. The Administrator was asked, What do you see? She said, Lint. The Administrator was asked, Should it be there? She replied, No. Laundry Aid (LA#2) was asked, Tell me what do you see? She said Lint. LA#2 was asked, Should it be there? She said, No. LA#2 was asked, What could happen with the lint around the electrical wires? She said, A fire. Dryer #2 had approximately 1/2 inch thick by 4 inches of lint on the top of the screen where all the electrical wires were. LA#2 was asked, Tell me what do you see? She said, Lint. The Surveyor asked, Should it be there? She said, No. The surveyor asked, What could happen with the lint around the electrical wires? She said, A fire. LA #2 stated, That the dryers are blown out every Friday, and documented on a blowout log by the Maintenance Man. a. A Laundry Policy and Procedures for Laundry Personnel and a Laundry Daily Lint Screening Cleaning form provided by the Administrator on 08/05/21 at 2:36 P.M. documented, .All dryer lint screens must be cleaned by laundry staff after every 2 loads and documented on the Laundry Daily Lint Screen Cleaning Form . b. The Laundry Daily Lint Screening Cleaning form provided by the Administrator on 08/05/21 at 2:36 P.M. documented, 8-5 [2021] was signed off as being cleaned at 7:00 A.M., 9:00 A.M., 11:00 A.M. It was not signed for 1:00 P.M. c. On 08/05/21 at 3:10 P.M., the Administrator was asked, Did you find the log from the maintenance man where he blows out the dryer? She said, No he does not have one.

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 residents for 2 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets, 16 resident who received mechanical soft diets and 44 residents who received regular diets from 1 of 1 kitchen (total census: 67), according to a list provided by the Regional Director on 8/3/2021. The findings are: 1. On 8/2/2021, the menu for the lunch meal documented residents who received regular diets were to receive 4 oz (ounces) of ham, residents who received pureed diets were to receive #8 scoop of pureed baked glazed ham, #8 scoop of mashed sweet potatoes (1/2 cup) and #16 scoop (¼ Cup) of pureed dinner roll. 2. On 8/2/2020 at 12:30 p.m., the following observations were made during the lunch meal service: a. Dietary Employee #1 served a small piece of baked glazed ham to the residents on regular diets as specified on the menu. b. Dietary Employee #1 and #4 used a #16 scoop to serve pureed ham to the residents on pureed diets and the residents on mechanical soft diets. The menu specified a #8 scoop (4 ounces) for each resident who received a pureed diet and mechanical soft diets. She used a #16 scoop to serve a single portion of pureed ham and mechanical soft ham, which was equivalent to 2 ounces, instead of #8 as specified on the menu. c. The residents on pureed diets and the residents on mechanical soft diets were served mashed potatoes, instead of sweet potatoes, as specified on the menu. d. There was no pureed dinner roll or pureed bread served to the residents on pureed diets. The menu specified for the residents on pureed diets to receive a #16 pureed dinner roll which was equivalent to ¼ cup. e. On 8/2/2021 at 12:49 p.m., Dietary Employee #2 was asked to weigh the same amount of ham served to the residents at the meal. He did so, and it weighed 1.9 oz, instead of 4 ounces as specified on the menu. f. On 8/2/2021 at 12:56 p.m., Dietary Employee #1 was asked the reason residents on pureed diets did not receive pureed bread. She stated, I forgot to serve it. She was asked, How much meat did each resident on a pureed diet and each resident on mechanical soft diet receive? She stated, I gave a single serving of pureed meat to each resident using the blue scoop. Same as the residents on mechanical soft diets. g. On 8/2/2021 at 12:57 p.m., Dietary Employee #4 was asked, What scoop size did you use to serve the pureed ham and the mechanical soft meat? She stated, I used the blue scoop and I gave a single serving of pureed meat and a single serving of mechanical meat each. h. On 8/2/2021 at 1:00 p.m., all the residents were served 1.9 ounces of ham. There were no sweet potatoes served to the residents on pureed diets. All residents on double portions were served single portion of meat. i. On 8/3/2021 at 7:28 a.m., residents on pureed diets were served a single serving of pureed sausage, pureed scrambled eggs and either grits or oatmeal. There was no pureed biscuit and gravy served to the residents on pureed diets. At 7:41 a.m., Dietary Employee #5 who prepared the breakfast meal was asked, What was the reason residents on pureed diets did not receive a pureed biscuit? She stated, I forgot to do it.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 7 residents who received pureed diets as documented on the Diet List provided by the Administrator on 8/3/2021. The findings are: 1. On 8/2/2021 at 11:04 a.m., Dietary Employee #1 prepared mashed potatoes with salt, pepper and melted margarine and milk. She covered the pan with a piece of foil and placed it in a warmer. The consistency of the mashed potatoes was too thick. 2. On 8/02/2021 at 11:48 a.m., Dietary Employee #1 placed 4 servings of sliced ham into a blender, added glaze and pureed. At 11:50 a.m., she added 2 more servings of ham into a blender and pureed. At 11:56 p.m., she poured the pureed ham into a pan, covered the pan with a piece of foil and placed on the steam table. The consistency of the pureed ham was lumpy and not smooth. 3. On 8/03/2021 at 7:28 a.m., the pureed sausage served to the residents on pureed diets was lumpy and was not smooth. There were pieces of meat visible in the mixture. At 7:34 a.m., Certified Nursing Assistant #1 was asked to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It has chunks of meat in it. 4. On 8/03/21 at 7:41 a.m., Dietary Employee #5 who prepared breakfast meal was asked to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It was lumpy. I should have pureed it a little longer. She was asked what the reason was the residents on pureed diets did not receive pureed biscuit. She stated, I forgot to do it.

Complaints # (AR 408) and # (AR 379) were substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure treatment and care were provided in accordance with accepted standards of nursing practice after a newly admitted resident experienced falls, as evidenced by failure to ensure thorough post-fall assessments and monitoring for pain or injury were provided; failure to ensure neurological (neuro) checks were conducted after unwitnessed falls to rule out potential head injury; failure to ensure information about the resident's falls was promptly documented on the baseline care plan and communicated to oncoming shifts to facilitate appropriate ongoing monitoring; and failure to ensure increased pain after a fall was promptly evaluated and the physician consulted, which resulted in the delay in [DIAGNOSES REDACTED].#1) of 4 (Residents #1, #3, #5, and #6) case mix resident who fell in the last 6 months. The failed practices resulted in a pattern of actual harm to Resident #1, who experienced falls and subsequent pain and bruising, but was not thoroughly evaluated for injury, resulting in a delayed [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. a. Hospital records dated 5/10/19 and 7/16/19 documented the resident was evaluated for post-fall injury on 5/10/19 after a fall at home and was evaluated for mental status changes on 7/16/19. b. A Progress Note dated 8/9/19 at 8:37 p.m. and signed by Licensed Practical Nurse (LPN) #4 documented, .Admit in facility in wheelchair around 1830 (6:30 p.m.) via facility transportation and accompanied by a staff member. Alert and oriented x (times) 2 with confusion episode . Body (audit) completed with some discolorations noted to lower extremities bilaterally, RUQ (right upper quadrant), left thigh. +1 (plus 1) [MEDICAL CONDITION] noted to left foot. Resident is legally blind. Voices needs with clear speech. Can answer Yes / No questions . No distress noted at this time . c. An Admission Nursing Evaluation dated 8/9/19 and signed by LPN #4 documented, .I. Cardiovascular . 3. [MEDICAL CONDITION] Yes . Location / grading . +1 pitting to both feet . Skin Assessment . General Condition of Skin . dry . warm . with skin discoloration . Indicate on diagram below all the marks such as rashes, old or recent scars, bruises or discoloration (regardless of how slight), lacerations, decubitus ulcers and other ulcerations or questionable markings considered other than normal . Site: 23 Coccyx . Description . discoloration . 24) Site: Groin . Description . discoloration . 36) Site: Left thigh (rear) . Description . Discoloration . 37) Site: Right knee (front) . Description . discoloration . Site: Other (specify) . Description: Top of both feet swollen . +1 [MEDICAL CONDITION] noted . Swollen eyes bilaterally with redness noted . d. The Baseline Care Plan dated 8/9/19 documented, .E. Safety Goals and Interventions . Safety / Fall History . 1. History of Falls . Unknown . [MI] Medications . Pain Management . 6a. Pharmacological Pain Regimen . None . Q. Completion Date of the Baseline Care Plan 1a. Completion Date of the Baseline (Due within 48 Hours of Admission / Updates ongoing until completion of full Comprehensive Care Plan): 8/12/19 . 1b. Name of the Employee Signing that the Baseline Care Plan is Complete (Due within 48 hours of Admission and left open for revisions to the plan of care until the full Comprehensive Care Plan is finalized).: (Registered Nurse #1) . The completion date of the Baseline Care Plan was 3 days after the resident's admission to the facility. e. An Incident and Accident Report dated 8/9/19 at 9:00 p.m. documented, .Incident Location . Resident's Room . Person Preparing Report . (LPN #4) . Nursing Description . When entering resident room, resident noted to be sitting on floor with back against wheelchair, feet in front and right arm propped onto wheelchair . Wheelchair noted to be locked . When this nurse asked resident what happened, resident stated she was looking for her husband . She then began yelling 'honey' repeatedly . This nurse asked resident if she hit her head, and she stated 'no' . Resident assessed for pain with none noted at this time . Resident then transferred to wheelchair using gait belt by this nurse and CNA (Certified Nursing Assistant) . Resident then transferred to bed . Resident body audit completed . Agencies / People notified (None documented) . There was no documentation to indicate neurological checks were initiated after this unwitnessed fall. 1.) A Weekly Body Audit form, attached to the Incident and Accident Report dated 8/9/19, documented the resident had discoloration to the left shoulder, right lower quadrant (RLQ) of the abdomen, left outer thigh, buttocks, and the left elbow. It also documented swelling and redness of the eyes and head, discoloration and [MEDICAL CONDITION] (+1) to the tops of both feet. 2.) A Progress Note dated 8/9/19 at 9:00 p.m. documented, .Late Entry . Situation . The Change in Conditions reported on this CIC (Change in Condition) Evaluation are / were . Falls . Outcomes of Physical Assessment . Positive findings reported on the resident / patient . C. New Intervention Orders . Other . No . The electronic health record documented this note was created by LPN #4 on 8/14/19 at 12:54 p.m., 5 days after the resident's first fall in the facility. 3.) A Progress Note dated 8/9/19 at 9:50 p.m. by LPN #4 documented, .Late Entry . Note Text . When entering resident room, resident noted to be sitting on floor with back against wheelchair, feet in front and right arm propped onto wheelchair. Wheelchair noted to be locked. When this nurse asked resident what happened, resident stated that she was looking for her husband. She then began yelling honey repeatedly. This nurse asked resident if she hit her head, and she stated 'no'. Resident assessed for pain with none noted at this time. Resident then transferred to wheelchair using gait belt by this nurse and CN[NAME] Resident then transferred to bed. Resident body audit completed . The electronical health record documented this note was created by LPN #4 on 8/14/19 at 12:41 p.m., 5 days after the resident's first fall in the facility. 4.) A Fall Risk Evaluation dated 8/9/19 by LPN #4 documented, .2a. Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or scheduled PPS), whichever is more recent? (Not assessed / No information) . C. Determination . Total Score of 10 or Above represents HIGH RISK . Total Score: 8 . This evaluation was signed by LPN #4 on 8/14/19, 5 days after the resident's first fall in the facility. There was no documentation on 8/9/19 regarding any ongoing post-fall monitoring, such as pain assessments, skin checks to determine if bruising or swelling was present, and neuro checks to rule out head injury. f. A Skilled Documentation Note dated 8/10/19 at 2:20 p.m. and signed by LPN #5 documented, .VII. Skin . [NAME] Skin (Pick all that apply): (Nothing marked) . XI. Summary . Awake, alert . No concerns noted . Continue poc (plan of care) . The note did not document any ongoing post-fall monitoring, such as neuro checks or evaluation for injury, nor indicate the nurse was aware of the resident's fall on 8/9/19. The additional notes that were dated 8/10/19 were not created until 8/14/19, according to the EHR time stamps: 1.) A Skilled Documentation Note dated 8/10/19 at 5:32 p.m. by LPN #5 documented, .Basics . 4. Most Recent Pain Level . 5 .VII. Skin . [NAME] Skin . e. Bruise . XI. Summary . Resident lying quietly with no distress noted . One person assist with ADLS (activities of daily living) . Left shoulder with mild [MEDICAL CONDITION] and light bruising noted . Resident stated she had fallen over a chair at home . No concerns noted . Continue P[NAME] (Plan of Care) . The electronic health record documented this note was completed by LPN #5 on 8/14/19, 5 days after the resident's first fall in the facility. 2.) A Progress Note dated 8/10/19 at 5:32 p.m. by LPN #5 documented, .Late Entry . Note Text . Resident lying quietly with no distress noted . Left shoulder with mild [MEDICAL CONDITION] and light bruising noted. Resident stated she had fallen over a chair at home. No concerns noted. Continue poc (Plan of Care) . The electronic health record documented this note was created by LPN #5 on 8/14/19 at 1:39 p.m., 5 days after the resident's first fall in the facility. 3.) A Skilled Documentation Note dated 8/10/19 at 11:15 p.m. by LPN #1 documented, .I. Basics . 4. Most Recent Pain Level . 5 .VII. Skin . [NAME] Skin . e. Bruise . (No documentation of description / location of bruise) . XI. Summary . Resident lying quietly with no distress noted . Left shoulder with mild [MEDICAL CONDITION] and light bruising noted. Resident stated she had fallen over a chair at home . No concerns noted . Continue P[NAME] . The electronic health record documented this note was completed by LPN #1 on 8/14/19, 5 days after the resident's first fall in the facility. On 8/28/19, 8/29/19, 8/30/19, and 9/3/19, multiple attempts were made to contact LPN #1 via telephone for an interview regarding the delay in documentation and pain levels. The LPN did not return the surveyor's calls. g. A Skilled Documentation Note dated 8/11/19 at 10:39 a.m. by LPN #5 documented, .I. Basics . 4. Most Recent Pain Level . 0 .VII. Skin . [NAME] Skin . h. Other . See below . XI. Summary . Resident lying quietly with eyes closed. Resp even and unlabored. No distress noted. No complaints of pain at this time. Continues to have [MEDICAL CONDITION] and discoloration to left shoulder. Bilateral lower extremities with discoloration and dry scaly skin noted. One person assist with ADLS. No concerns noted. Continue P[NAME] . The electronic health record documented this note was created by LPN #5 on 8/14/19, 5 days after the resident's first fall in the facility. 1.) A Skilled Documentation Note dated 8/11/19 at 5:46 p.m. by LPN #5 documented the most recent vitals were completed on 8/14/19 and, .I. Basics . 4. Most Recent Pain Level . 0 .VII. Skin .[NAME] Skin . (No documentation) . XI. Summary . Resident awake, alert. Resp. even and unlabored. No distress noted. No complaints of pain. Continues to have [MEDICAL CONDITION] and discoloration noted to left shoulder. One person assist with ADLS. Incontinent of b/b with peri care given. No concerns noted. Continue P[NAME] . The electronic health record documented this note was created by LPN #5 on 8/14/19, 5 days after the resident's first fall in the facility. 2.) A Progress Note dated 8/11/19 at 10:39 a.m. by LPN #5 documented, .Late Entry . Note Text . Resident lying quietly with eyes closed. Resp even and unlabored. No distress noted. No complaints of pain at this time. Continues to have [MEDICAL CONDITION] and discoloration to left shoulder. Bilateral lower extremities with discoloration and dry scaly skin noted. One person assist with ADLS. No concerns noted. Continue P[NAME] (Plan of Care) . The electronic health record (EHR) documented this note was created by LPN #5 on 8/14/19 at 1:44 p.m. 3.) A Progress Note dated 8/11/19 at 11:41 a.m. by LPN #5 documented, .Note Text . Resident alert, oriented with some confusion noted. Resp even and unlabored. No distress noted. Makes needs known. Resident is legally blind. One person assist with ADLS. Incontinent of b/b with peri care given. Lower extremities noted (with) discoloration noted bilaterally. cl (Call Light) in reach . 4.) A Progress Note dated 8/11/19 at 5:46 p.m. by LPN #5 documented, .Late Entry . Note Text . Resident awake, alert. Resp. even and unlabored. No distress noted. No complaints of pain. Continues to have [MEDICAL CONDITION] and discoloration noted to left shoulder. One person assist with ADLS. Incontinent of b/b with peri care given. No concerns noted. Continue P[NAME] (Plan of Care) . The EHR documented this note was created by LPN #5 on 8/14/19 at 1:54 p.m. h. An Incident and Accident (I&A) Report dated 8/11/19 at 6:50 p.m. documented, .Incident Location . Resident's Room . Person Preparing Report . (LPN #5) . Nursing Description . It was reported that resident was noted to be sitting in front of bed with back against bed and feet pointing straight forward . Resident noted to have bilateral arms propped up on bed behind resident. Resident denied pain or discomfort. Resident noted to have discoloration upon admission, no new discoloration or injury present at this time. Resident stated she did not hit her head . Immediate Action Taken . Head to toe completed . Pain assessment with no negative findings Agencies / People notified . (None documented) . There was no documentation to indicate neuro checks and ongoing monitoring for pain or signs / symptoms of injury were initiated after this unwitnessed fall. 1.) A Fall Risk Evaluation dated 8/11/19 by the Assistant Director of Nursing (ADON) documented, .2a. Has the resident had any falls since admission / entry or reentry or the prior assessment (OBRA or scheduled PPS), whichever is more recent? . No . C. Determination . Total Score of 10 or Above represents HIGH RISK . 1. Total Score . 8 . The electronic health record documented this evaluation was signed by the ADON on 8/19/19. 2.) A Progress Note dated 8/11/19 at 7:50 p.m. by the ADON documented, .Late Entry . Situation . The Change In Condition (CIC) reported on this CIC Evaluation are / were . Falls . Functional Status Evaluation . Fall . C. New Intervention Orders . Other. NA (Not Applicable) . The EHR documented this note was created by the ADON on 8/19/19 at 10:06 a.m. 3.) A Skilled Documentation Note dated 8/11/19 at 11:25 p.m. by LPN #1 documented the most recent vitals were not available for review and, .VII. Skin . [NAME] Skin . e. Bruise . (No documentation of description / location of bruise) . Resident in bed resting with eyes closed, bed low and call light within reach. No c/o (complaints of) pain, discomfort, or distress .The electronic health record documented this note was completed by LPN #1 on 8/14/19. i. A Skilled Documentation Note dated 8/12/19 at 2:44 p.m. by LPN #8 documented, .VII. Skin . [NAME] Skin . e. Bruise . XI. Summary . Resident awake, alert, and oriented to self with noted confusion. Blind in both eyes . Noted large bruise on left upper arm. Scattered bruising on BLE (Bilateral Lower Extremities) . Brown spots noted on Bil (Bilateral) feet. No verbal / nonverbal ques (cues) of pain noted . There was no documentation to indicate LPN #8 was aware of the falls on 8/9/19 and 8/11/19 or that the LPN followed up to attempt to determine if the large bruise to the left upper arm had been reported to the DON, physician and / or Administrator and evaluated as to its cause. 1.) A Progress Note dated 8/12/19 at 2:44 p.m. by LPN #8 documented, .Note Text . Resident awake alert and oriented to self with noted confusion. Blind in both eyes . Noted large bruise on left upper arm. Scattered bruising on BLE (Bilateral Lower Extremities), brown spots noted on Bil (bilateral) feet. No verbal / nonverbal ques (complaints of) of pain noted . (Created by LPN #8) . 2.) A New Admit H&P (History and Physical) dated 8/12/19 and completed by the facility's Medical Director documented, .The patient . admitted to the facility from (Hospital #1) where she was treated from 7/15/19 (through) 8/9/19 for a Mental Health Disorder. Pt (patient) is seen today lying in bed. She appears asleep but does awaken to verbal stimuli. When asked for her name, she asked why I needed it. She does respond to her name and states her DOB (date of birth). She is able to report her current city . She keeps her eyes closed throughout this entire visit. She has h/o (history of) [MEDICAL CONDITION]. Information is obtained from pt (Patient). Pt chart, and NH (nursing home) staff given pt confusion and poor historian. Wound Care Nurse reports pt (patient) has dried skin to her LLE (left lower extremity), top of foot. [MEDICAL CONDITION] is reported to LLE (left lower extremity). Pt has a hematoma to left forehead and bridge of nose, but is unable to report how this happened. Pt does report some neck discomfort but no other pain is reported at this time . Pt reports she lives with her daughter but is not sure if she will be returning there. Pt may be staying LTC (Long Term Care) . There was no documentation to indicate the Medical Director was aware of the resident's falls on 8/9/19 and 8/11/19 or of the large bruise to the left upper arm. 3.) A Skilled Documentation Note dated 8/12/19 at 10:39 p.m. by LPN #4 (the nurse who completed the Incident / Accident Report for the 8/9/19 fall) documented, .XI. Summary . Lying in bed with eye close and awake. Alert and oriented to self. No distress noted . Transfer x (times) 2 persons assist and mobile via wheelchair. Assist in feeding and consumed dinner with good appetite . Discolorations noted to upper and lower extremities. Remains on Skilled Nurse Care as indicated with no change noted . A Progress Note dated 8/12/19 at 10:39 p.m. by LPN #4 documented the same findings as the Skilled Documentation Note above. Neither of the notes included a reference to the resident's falls on 8/9/19 and 8/11/19. j. A Progress Note dated 8/13/19 at 12:17 a.m. by LPN #6 documented, .Resting in bed, eyes closed . Skin warm and dry to touch. Noted discoloration to upper, lower extremities . Extensive assist with adls (activities of daily living) x (times) 2 assist with transfers. No s/sx (signs / symptoms) of pain or discomfort noted. Will continue Plan of Care on this shift . 1.) A Skilled Documentation Note dated 8/13/19 at 12:17 a.m. by LPN #6 documented the same findings as the above Progress Note. Neither of the notes included a reference to the resident's falls on 8/9/19 and 8/11/19. 2.) A Progress Note dated 8/13/19 at 8:30 a.m. by LPN #1 documented, .Late Entry . Note Text . On Skilled Care due to [MEDICAL CONDITION]. Resident requires extensive assist x (times) 1 with ADLs (activities of daily living), transfers, and toileting due to being legally blind. Able to take morning medications with ease. Resident lying in bed with no c/o (complaints of) pain, discomfort or distress. HOB (Head of bed) elevated, bed low, and call light within reach. Continues with therapy. See therapy notes for progress. Incontinent with peri-care q (every) 2 h (hours) and PRN (as needed) for comfort and skin integrity. Discolorations remains on resident body before admissions with no improvements yet noted . The EHR documented this note was created by LPN #1 on 8/14/19 at 3:42 p.m. 3.) A Skilled Documentation Note dated 8/13/19 at 8:30 a.m. by LPN #1 documented, .VII. Skin . [NAME] Skin . e. Bruise . (No documentation of description / location of bruise.) . XI. Summary . Resident lying in bed with no c/o (complaints of) pain, discomfort or distress .Discolorations remains on resident body before admissions with no improvements yet noted . The EHR documented this note was completed by LPN #1 on 8/14/19. 4.) A Skilled Documentation Note dated 8/13/19 at 6:43 p.m. (not signed) documented, .VII. Skin .[NAME] Skin . e. Bruise . (No documentation of description / location of bruise) . Skin warm and dry to touch. Noted discoloration to upper, lower extremities .No c/o (complaints of) of pain or discomfort noted. Will continue to monitor . The signature and date fields were blank and the status of the note was, in progress. k. The Admission Minimum Data Set with an Assessment Reference Date of 8/14/19 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status; required limited one person assistance for bed mobility, transfers, dressing, eating, and toilet use; required extensive physical assistance of one person for personal hygiene and bathing; required a wheelchair for mobility; did not receive scheduled or as needed pain medication; exhibited no indicators of pain or possible pain; and had one fall since admission or prior assessment with no injury. l. A Progress Note dated 8/14/19 at 3:30 a.m. by the Assistant Director of Nursing documented, .Situation . The Change In Conditions reported on this CIC Evaluation are / were . Pain (uncontrolled) . Pain Status Evaluation . Does the resident / patient have pain . Yes . Nursing observations, evaluation, and recommendations are . Resident verbalizing pain during ROM (range of motion) to left upper extremity, noted swelling to left shoulder . Primary Care Provider Feedback . Primary Care Provider responded with the following feedback . [NAME] Recommendations . New order for PRN (as needed) Tylenol, STAT (immediate) shoulder x-ray . B. New Testing Orders . X-ray . C. New Intervention Orders . New or Change in Medications Other . Awaiting x-ray, new order prn Tylenol . This note was documented as created by the ADON on 8/14/19 at 11:08 a.m. 1.) A Progress Note dated 8/14/19 at 4:32 a.m. by LPN #6 documented, .Note Text . CNA (Certified Nursing Assistant) reported to this nurse that resident was crying, stating she was in pain. Upon assessment, resident c/o (complained of) left shoulder pain. Rated pain 5/10 (pain rated at a 5 on a scale of 1 to 10). Left shoulder with previously noted discoloration, new onset swelling. Resident verbalized pain when attempting ROM (range of motion). APN (Advanced Practice Nurse) notified. New order for STAT (Immediate) shoulder x-ray, Tylenol 650 prn (as needed) q (every) 6 h (hours) as needed. All responsible parties notified. Tylenol administered at 0330 (3:30 a.m.) . Noted to be effective. Resident resting in bed, eyes closed, resp (respirations) even and non-labored. No s/sx (signs / symptoms) of pain or discomfort at this time . 2.) A Progress Note dated 8/14/19 at 7:15 a.m. by the ADON documented, .Note Text . Received x-ray results that showed acute fracture to left humerus . Spoke with APN (Advanced Practice Nurse) who stated to transfer resident to ER (emergency room ) via (Ambulance Service). (Ambulance service) called and arrived at facility at 0710 (7:10 a.m.) and transferred resident via gurney . 3.) A Progress Note dated 8/14/19 from Hospital #2 documented, .History of Present Illness . (Resident #1) . presents to the ED (Emergency Department) with a Chief Complaint of Fall . presents from (Facility Name) for evaluation of left shoulder pain after suspected fall. The patient has been at this facility for 2 days after a recent admission to (Hospital #1) for unknown medical reasons. They state she showed up with bruising and has since been complaining of left shoulder pain. There has been no known fall at this rehab (rehabilitation) facility. There is bruising to the left shoulder and left chest wall . Left shoulder is deformed there is some bruising to the left chest as well . CT (Computed [NAME]ography) head and cervical spine are negative. She has a left humeral head fracture. Placed in shoulder immobilizer. Orthopedics (medical doctor) consulted. Likely non-operative given her overall ill appearance and medical problems . H&P (history and physical) by (medical doctor . Patient is . present with left shoulder pain from the nursing and rehab center. Patient had been at the nursing home rehab for the last 2 days complaining of her left shoulder hurting after a fall. They sent her to the emergency room today as the complaints were constant. Patient was lethargic on admission but she is more alert now, but she certainly does not give a good history. She tells me that she fell , but she cannot remember when, and by the color of the bruise it appears to be at least for 5 days old as it is bronze color and there is no purple color . This note was dated 5 days after the resident's first fall in the facility (8/9/19). m. A 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 as reported to the Office of Long Term Care (OLTC) on 8/14/19, documented, .Section 1 . Reporting Information . Date Incident Reported to OLTC . 8/14/19 . Time . 7:47 a.m. Date and Time of Incident (if known) . 8/14/19 . Time . 7:47a.m.Date and Time of Discovery . 8/14/19 . Time . 7:47a.m . Type of Incident . (none marked) . Name of involved Resident . (Resident #1) . Section II . Complete Description of Incident . Resident noted to complain of pain to her left arm. MD (Medical Doctor) notified with order obtained for an x-ray to her left arm. Results received with findings of an acute fracture to her left humerus. Resident noted to have fallen on 8/11/19, slid from her wheelchair landing on her bottom in (front) of her chair. No injuries or s/s (signs/symptoms) of pain noted at time of fall . Section III . MD reviewed results and gave order for resident to be sent to ER (emergency room ) for evaluation and treatment as indicated . Resident noted to have been admitted to (Hospital #1) after a fall at home with no reports of shoulder pain during that stay . Resident was admitted to facility on 8/9/19 with discoloration noted to her left chest wall and upper arm . Resident was assessed by the APN (Advanced Practice Nurse) for initial admission visit on 8/12/19 with no complaints or abnormal findings noted . n. A Physician's Progress Note dated 8/20/19 by the Medical Director documented, .Pt (patient) (Resident #1) was seen on 8/12/19 for Initial Admit (Admission) visit. No shoulder pain was reported at this time. Pt was just treated at (Hospital #1) after a fall at home, and no reports of pain in shoulder noted during that stay. Pt was later reported as c/o (complained of) pain in left shoulder on 8/14/19 and X-ray revealed fracture of this shoulder. Suspect this was related to a pathological fracture . o. A Care Plan with a revised date of 8/21/19 documented, .Focus . Resident is a risk for falls R/T (related to) Poor Safety Awareness, Unsteady Gait . Interventions . 8/11/19 Fall . Bolster mattress provided . Date Initiated . 8/12/19 . Encourage resident to ask for assistance when attempting to transfer . Date Initiated . 8/21/19 . Keep call light within reach . Date Initiated . 8/21/19 . Provide a clutter free environment . Date Initiated . 8/21/19 . Provide a well-lit environment . Date Initiated . 8/21/19 . Provide appropriate foot wear . Date Initiated . 8/21/19 . p. The physician's orders [REDACTED]. Pain Monitoring . Non-Verbal (Pain Scale for the Cognitively Impaired) every shift . Pain Monitoring . Verbal (Numerical Scale) every shift . 8/14/19 . [MEDICATION NAME] Tablet 325 MG (milligrams) Give 2 tablets by mouth every 6 hours as needed for pain . 1.) A Weights and Vitals Summary documented a pain level summary on 8/9/19 at 9:53 p.m., on 8/10/19 at 2:42 p.m., on 8/12/19 at 2:46 p.m., on 8/12/19 at 10:38 p.m., on 8/13/19 at 8:33 a.m., on 8/14/19 at 4:32 a.m., and on 8/14/19 at 1:40 p.m. There was no numerical pain scale for any shift on 8/11/19 and pain scales were not completed every shift every day as ordered. 2.) As of 8/27/19 at 2:30 p.m., the Electronic Medication Administration Record (eMAR) dated (MONTH) 2019 contained no nurse signatures or initials for any of the physician-ordered medications. 3.) On 8/28/19 at 8:48 a.m., LPN #2 was asked for a copy of the (MONTH) 2019 Medication Administration Record (MAR). At 9:27 a.m., LPN #2 provided a paper copy of the MAR. She stated their MARS were, .still on paper. There was no documentation of pain assessments on the MAR. At 9:34 a.m., LPN #2 was asked for the missing pages of the MAR. She brought the originals in, and asked what pages were missing. There was no pain assessment in the original paper MAR. She was asked who monitors the resident's pain, and if it should be on the MAR. She stated, The Medication Nurse. Let me go check to see if it's on the TAR (Treatment Administration Record). The Medication Administration Record (MAR) dated (MONTH) 2019 documented, .Day . Evening . Night . Pain monitoring . Non-verbal Pain scale for the cognitively impaired every shift . start date 8/12/19 . There was no documentation on the MAR for any shift, indicating there was no assessment of the level of pain for the resident, as ordered. q. On 8/28/19 at 9:54 a.m., the Assistant Director of Nursing (ADON) and LPN #2 stated they do not have a pain assessment on the MAR. They stated there was documentation in the resident's chart where they were monitoring the pain. They were asked how orders were put onto the paper MAR, since they were not utilizing the eMAR (Electronic Medication Administration Record). The ADON stated, The nurse comes in and puts the order in (Electronic Health Record software). After the nurse puts the order in, they print the MAR. Any new orders can be printed. They don't hand write them on the paper MAR. The following morning, Medical Records prints an order summary listing and any new orders. She is doing a match back to make sure they are putting them on the MARS. The ADON was asked why the pain assessments were not documented on the MAR. She stated, She (Medical Records) was on vacation. She was asked, who was responsible for taking over those duties while she was gone? She stated, We (ADON and LPN #2) split up her job duties between the 2 of us while she was gone that week. She was asked if the pain assessment orders for the resident were missed. She stated, Yes. r. On 8/28/19 at 1:49 p.m., LPN #4 was asked if he admitted (Resident #1). He stated, Yes, I did. He was asked if he remembered if she had any skin concerns or pain when she was admitted . He stated, No. I did her body audit. She was not in any pain. He was asked if she had any bruising. He stated, No. He was asked why there were two body audits completed on the admission date of [DATE], one done on the computer and one done on paper, and why they were different. He stated, I completed the audit the same day she came in. We had to do both. I think it's the process. The paper is more important than the computer. He was asked to describe the discoloration that he noted on the body audit. He stated, It was red. Not purple, green, yellow. It was not a bruise. She did not complain of pain. He was asked if he took care of her after she was admitted but before she was sent to the hospital. He stated, Yes. He was again asked if there was any bruising on her body. He stated, No. Just the same discoloration. He was asked if she fell the day she was admitted . He stated, Yes, she did. It happened in her room . I think it was around 9:00 p.m. She arrived at lunch time. By bed time, she was looking for her husband. We tried to calm her down. She was in front of her wheelchair. She was sitting on the floor. We put her back to bed. He was asked if the resident complained of any pain. He stated, No. He was asked if he notified anyone of the fall. He stated, Yes. I notified the ADON. He was asked if he notified the doctor or the family. He stated, No. s. On 8/28/19 at 2:58 p.m., the ADON was asked if she was notified of the fall that happened on 8/9/19. She stated, Yes. (LPN #4) called me later on, around 9:30 to 10:00 p.m. She (resident) was sitting in front of her wheelchair on her bottom and had

Complaint # (AR 028) was substantiated, all or in part, with these findings: A. Based on record review and interview, the facility failed to ensure the resident's environment was as free of accident hazards as possible, as evidenced by failure to secure a construction site that involved a large, deep hole in the floor, which resulted in an accident with injury for 1 (Resident #1) of 1 sampled resident who was visually impaired. The 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 partially fell , in her wheelchair, into a hole in the construction site, and had the potential to cause more than minimal harm to 4 residents who had highly or severely impaired vision, according to a list provided by the Social Director on 6/14/19 at 11:17 a.m The Administrator was informed of the past noncompliance at the level of immediate jeopardy on 6/13/19 at 10:40 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 4/22/19 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required no assistance for bed mobility; limited assistance / set up only for transfers, used a wheelchair for mobility and had severely impaired vision. a. The Progress Note dated 4/9/19 at 9:25 a.m., documented, .Nursing: Note Text: Resident noted self-propelling back from smoke break in wheelchair. Resident noted to be leaning forward and fell forward out of wheelchair. Resident fell on left side and noted to hit head against the wall. Resident denies pain or discomfort and refused to allow staff assist her back into chair. Resident vital signs within normal limits and neuro (neurological) checks initiated. No injuries noted at this time. MD (medical doctor), CEO (Administrator), ADON (Assistant Director of Nursing) and [MEDICAL TREATMENT] aware of resident fall. Resident is own responsible party . b. The Resident's Care Plan dated 7/10/18 documented, .Focus: .I am at risk for falls R/T (related to) Poor Safety Awareness, and Unsteady Gait . Interventions: Encourage resident to ask for assistance when attempting to transfer .provide a well lit environment . c. A Physician order [REDACTED].OT (occupational therapy) and PT (physical therapy) to evaluate and treat as indicated for strengthening and for positioning in w/c (wheelchair) . d. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 5/1/19 documented, .Date Incident Reported to OLTC: 05/01/2019 Time: 4:30 PM. Date and Time of Incident (if known) Date and Time of Discovery: 05/01/2019 Time: 4:00 p.m . Summary of Incident: . At 2:20 pm resident was found in her wheelchair stuck in the doorway of an unoccupied room that is under construction. Resident was sliding from her wheelchair when the housekeeping aide found her. He called for help and staff assisted resident back into her wheelchair, pulling the wheelchair from the doorway. Resident stated that she hit her side on the wheelchair arm as she was sliding from the wheelchair. Resident was assessed for injuries with none noted. Resident was assessed for pain with complaints of pain to her left ribs. MD (medical doctor) notified with new order obtained to be send to ER (emergency room ) for an evaluations and treatments as indicated. Facility staff called the ER at 4:00 pm to get an update on resident's condition. ER staff informed facility that resident's x-ray showed a fracture to her left 9th rib, unable to tell if the fracture is acute or chronic. ER staff unable to determine if resident will be admitted to the hospital at this time . e. An OLTC Witness Statement Form completed on 5/1/19 by the Business Office Manager (BOM) documented, .I was in my office, heard a noise in the hall and someone saying we need help. Went into the hallway and then heard (Maintenance #1) saying we need help in here. Went into (Room D38) the room next to my office where they are doing construction work. (Resident #1) was in her wheelchair, leaning over to the left, down in the hole in the floor and (Maintenance #1) was holding her up. At that time, the D hall nurse came down to the room, we started trying to pull her up, the staff came in the room. We got her out and back in her w/c (wheelchair). I left the room at that point and the nurses were taking care of her . f. An OLTC Witness Statement Form completed on 5/1/19 by Maintenance Worker #1 documented, .Sometime around 1:20 p.m., I was painting doors at the end of D-Hall close to the exit doors. When (Housekeeper #1) ask for assistance. I started toward him and he said a resident had fallen in the construction site. I rushed to the room and found a resident and wheelchair wedged in a 6' (6-foot) deep hole. I immediately reached in and grabbed the wheelchair to secure it from plummeting into the pit. At this point, the chair was absolutely sideways in the hole with the resident still inside. I told (Housekeeper #1) to go get help! Then I told the resident we were going to get her out. Soon after, various employees arrived and we hoisted her to safety . g. An OLTC Witness Statement Form completed on 5/1/19 by Housekeeper #1 documented, . (Resident #1) rolled her wheelchair into the plumbing construction hole and fell in. I was the first to find her. I called (Maintenance #1) to hold her while I got the nurse, then several nurses and CNAs (Certified Nursing Assistants) pulled her up. She fell in sideways and was stuck horizontal to the edge of the hole and she was pulled out before she could slip any deeper . h. An OLTC Witness Statement Form completed on 5/1/19 by Certified Nursing Assistant (CNA) #1 documented, .A page to D-Hall, so I was the CNA on that hall, so I went in room D38. (Resident #1) was in the hole in the floor. The D-Hall nurse (Licensed Practical Nurse #1), (Maintenance #1), and I got her out and she said her ribs hurt. We took her to her room. The nurse did a body check and I checked her v/s (vital signs). Then the nurse sent her to the hospital . i. A Diagnostic Imaging Report dated 5/1/19 documented, .Exams: XR (x-ray) Left Ribs Unilt (unilateral) . Left Rib Detail 3 Views . Impression: Fracture, left 9th rib . j. An OLTC Witness Statement form completed on 5/2/19 by Maintenance #2 documented, .On (MONTH) 29th 2019, I met with the crew and owner of (Contractor Name) before starting construction to repair and reline the main sewer. Before entering the building, I conducted a meeting with them concerning resident rights, proper behavior and safety. Each member of this crew was advised to conduct themselves in a professional (manner), not to engage with residents. During the safety portion of our discussion, they were told to never leave any tools or hazard areas unattended upon leaving the areas of dig site locations. Double check that all safety measures were secure and in place. This meeting was also restated and spoke at the start of each work day by me, and or (owner of Contractor Name) . k. An OLTC Witness Statement Form completed on 5/2/19 by Licensed Practical Nurse (LPN) #1 documented, .Housekeeper came to nurse's station and reported they needed this nurse on D-Hall b/c (because) said resident was in construction site room in hole. I got up and called another nurse. Upon arrival in room, resident was sideways in hole in w/c with maintenance supporting her head and neck the other nurse grabbed the wheel of the w/c and I put my arm under resident's arm while holding on to w/c and all three lifted resident out of hole with assistance from BOM supporting resident's legs. Resident c/o (complained of) left rib pain. Resident taken to room and assessed v/s (vital signs) WNL (within normal limits). Body audit completed by this nurse and MDS (minimum data set) nurse. Resident c/o pain again in ribs on left side. PRN (as needed) pain med (medication) administered. Call placed to (Advanced Practice Registered Nurse) and new order to send resident to ER given . l. A Medical Director form dated 5/3/19 documented, .Date of Service: 5/3/19 .The patient is . evaluated today after a fall and ED (emergency department) visit where she was found to have rib fracture. Pt (patient) is seen lying in bed today. She is awake and alert. Pt had a fall on 5/2/19. This occurred after pt. (patient), whom is legally blind, rolled her WC into a current construction area of the facility. It is reported that she rolled into a hole in the construction area. She was transferred to (hospital emergency room ) on 5/2 and found to have a fracture of Left, 9th rib . m. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities (DMS form 762) dated 5/6/19 documented, .Resident was evaluated in the ER and returned to the facility with new orders for a different pain medication that previously ordered. Resident's pain continues to be controlled by current medication regiment. MD (medical doctor) orders in place to have [MEDICATION NAME] 5/325mg (milligram) BID (twice a day) and every 8 hours prn (as needed), as well as orders to assess for s/s (signs/symptoms) of pain every shift . n. Progress Note dated 5/13/19 at 4:12 p.m. documented, .Nursing: Late Entry: Note Text: Resident discharged via other facility van. All belongings transferred with resident as well as medications. Body audit completed with no negative findings at this time. Report called to (Receiving Facility) . The resident no longer resided in the facility at the time of the complaint investigation survey. o. On 6/12/19 at 3:12 p.m., Maintenance #1 was interviewed via telephone and was asked Why was there a hole in the floor? He stated, They (Contractor) were fixing the main sewer line. I believe they left and left the door open. I think they went outside for some reason and left it opened and unlocked. He was asked, Was the hole taped off? He stated, No, it was in a resident room that was shut down for construction. He was asked, How deep was the hole? He stated, Four to five feet. He was asked what happened and stated, (Housekeeper #1) called for me to help. I was painting at the time. We secured the woman (resident) until we could get other help to get her out of the hole. I was down the hall by the exit door on the opposite end of the hall. He was asked, What stopped her from falling further into the hole? He stated, The wheelchair was wedged sideways inside the hole. We held her there until assistance arrived. He was asked, How was she reacting? He stated, She was asking for help. We comforted her the best we could. She seemed to be in pain. p. On 6/13/19 at 8:03 a.m., Housekeeper #1 was asked, Can you tell me what happened the day (Resident #1) fell in the hole? He stated, They (plumbing company) were working on the plumbing. The whole sewer for D hall was bad. None of the sinks or toilets worked until they started fixing it. I was getting my broom. I saw her (resident) go into a room at the end of the hall. There is the room they were working on and right next to it was the business office. She was mostly blind. She couldn't see people. She couldn't tell where she was going. I thought I should go check to see where she went because I wasn't sure if she went into the business office. I went to go check and sure enough she was in the hole. The hole was square, like the size of a grave. She had rolled in and tipped over sideways. She was hanging on to one side and the wheelchair was holding up the other side. I had (Maintenance #1) the maintenance guy come help. He stayed with her while I went to get help. She was freaking out. She was yelling. Then everybody got her out. q. On 6/13/19 at 8:13 a.m. Certified Nursing Assistant (CNA) #1 was asked Can you tell me what happened the day (Resident #1) fell in the hole? She stated, I was in the dining room. Obviously, she can't see real good. (sic) I wasn't there when it happened. When I got in there, her wheelchair was sideways in the hole. We picked her up and got her out. I think it was her chair arm that hurt her ribs. She's blind. I think she can see a little bit. She was opening every door. She would go in and out of rooms quite often. She was asked, Where was her room in conjunction with the room she entered and fell ? She stated, Her room at that point was the room all the way at the end of D hall on the left. The room she went into was right by the business office. (The business office had been relocated prior to the survey.) She was asked, So, she tried to go into other rooms a lot? She stated, Yes, if she came out of her room, she seemed to me, confused. She was a talker, though. If she needed help, she'd ask for it. She was asked, Did anybody ask the resident what happened? She stated, She said she thought she was going downstairs. Maybe she thought that she was going downstairs because of the downward fall. She said 'I'm okay.' She didn't even want to go to the hospital. She said it hurts right here (pointed to left side). r. On 6/13/19 at 8:27 a.m., the Social Director was asked if Resident #1 was blind and stated, She could see shapes. From what I understood, she could navigate herself through this place very well. She wasn't completely blind. She couldn't see my face but could recognize my voice. She saw well enough to get around through the facility. She was asked if the resident ever wandered into other residents' rooms and stated, Maybe once or twice she would go to the wrong room. s. On 6/13/19 at 8:58 a.m., Resident #1 was called at the facility where she currently resides and was asked, Are you legally blind? She stated, Yes. She was asked, Do you remember what happened when you fell ? She stated, They were doing construction on the same hall my room was on. She was asked, Why did you go into that room? She stated, I was going in there to get away from the rest of the people and lay down. She was asked, Do you remember what happened when you got into the room? She stated, Yeah, I fell into the hole. The wheelchair fractured my rib. She was asked, Did physical therapy ever work with you after any of your recent falls? She stated, No. t. The facility removed the immediate jeopardy and corrected the failed practice related to accident hazards on 5/1/19 prior to the survey entrance date, as evidenced by the following: 1.) The DMS form 7734 dated 5/1/19 documented, .Steps Taken to Prevent Continued Abuse or Neglect during the Investigation: .Investigation initiated at time of the incident. It was found that the construction worker failed to lock the door to the construction zone upon exiting the area. Construction worker terminated and all construction workers educated on ensuring entries to construction zones are properly secured upon exit. 1:1 (one on one) monitoring initiated by facility staff on construction site entrances until completion of the job. Facility staff in-serviced on ensure construction zone entrances are closely monitored for closure to prevent accidents. (Police Department) notified . 2.) The DMS-762 form 5/6/19 documented, .1:1 (one on one) monitoring of construction site entries initiated by facility employees and will continue until job is completed. Construction Company immediately terminated their employee who failed to properly secure construction site doorway upon exiting. Maintenance Director in-serviced all of the construction employees on ensuring construction zones to ensure residents are kept safe . 3.) An Individual In-Service Training form documented, Subject: Safety Conduct . Associate Name: (Contractor Name). Date: 5/1/19 . Notes: All employees of (Contractor Name) hired for the sewer main relining project will conduct themselves in a professional (manner) and put resident safety above all other considerations. Upon leaving any or all areas that expose a danger or risk of injury. All safety measures will be double checked. Doors locked, holes sealed, and or barriered (sic) off to staff and residents . The signatures of 4 contractor's employees were documented on the form. 4.) A Staff In-Service Sheet dated 5/1/19 documented, .Information provided during in-service: Staff is to ensure construction zone entry is monitored for closure to prevent accidents of residents. If doing one on one for construction zone, you are not to leave that area without coverage, no exceptions. One on one's must be completed, no exceptions . There were 51 staff signatures documented on the in-service form. 5.) The OLTC Witness Statement form completed on 5/2/19 by Maintenance #2 documented, .Upon discovery of the incident that occurred on 5/1/19, I stopped all work, made all work areas safe, and asked the crew to meet me outside. I conducted a(n) inquiry to identify the crew member who left the door and area unsecure. I notified (owner of Contractor Name) that I terminated his (employee's) employment for this project . Although the facility corrected the failed practices related to hazards, there were current failed practices related to fall prevention, as follows. B. Based on record review and interview, the facility failed to ensure falls were consistently and thoroughly evaluated for causative factors and interventions were developed and implemented based on those causative factors, to minimize the potential for further falls for 3 (Resident #2, #3, #4) of 5 (Residents #1 - #5) case mix residents who fell in the last 3 months. This failed practice had the potential to affect 56 residents who fell in the last 3 months, as documented on a list provided by the Director of Nursing (DON) on 6/14/19 at 10:15 a.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. a. The Resident's Care Plan dated 12/19/17 documented, .Focus: I am at risk for falls r/t (related to) Confusion, Deconditioning, Incontinence, Poor communication / comprehension, Unaware of safety needs .Interventions: .5/11/19 fall unwitnessed without injury. Resident slipped on a grape in the hallway that another resident had dropped. I (intervention): To educate the other resident on making sure that food is in proper containers when carrying in the halls. Date Initiated: 05/14/2019 . Fall UTI/ABT (urinary tract infection/antibiotic treatment) Date initiated: 05/18/2019 . b. A Fall Risk Evaluation form dated 5/18/19 documented the resident's total fall risk score was 10, with a score of 10 or greater indicating a high risk for falls. c. An Incident and Accident Report dated 5/18/19 at 7:00 a.m. documented, Fall . Nursing Description: Resident noted to be sitting in chair when nurse walked to nurse's station. Approximately 5 mins (minutes) later this nurse walked into lobby and resident was in floor on right side c/o (complaining of) pain but would not say where. Resident was able to move legs and arms with no difficulty. Resident got up with no difficulty, and stated she was not in any pain at this time . Immediate Action Taken: Assessed resident with no injury noted. No pain noted. Neuro checks initiated . Notes: 5/20/19 Intervention: UA (urinalysis) with C&S (culture and sensitivity) if indicated . No immediate fall prevention interventions were documented. d. On 6/14/19 at 10:12 a.m., the Director of Nursing (DON) was asked about the interventions related to the fall on 5/18/19 and stated the interventions were a UA and antibiotics. She was asked if that was an appropriate long-term intervention to prevent falls and stated, No. We should have in-serviced on care. 2. Resident #3 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 4/3/19 documented the resident scored 3 (0-7 indicates severely impaired cognition) on a Brief Interview for Mental Status, required extensive 1 person physical assistance for bed mobility, toilet use, and bathing; required extensive 2 person physical assistance for transfers, and had 2 or more falls with no injury since date of last assessment. a. The Resident's Care Plan dated 4/18/17 documented, .Focus: I am at risk for falls r/t (related to) cognitive loss/poor safety awareness, hx (history) of falls with [MEDICAL CONDITION], daily [MEDICAL CONDITION] medications usage, incontinence and is non-weight bearing Interventions: . 3/15/19 fall: UTI to hospital. 5/28/19 Fall: UA (urinalysis) urology appointment. 6/6/19 Fall: low bed . Keep my bed in the lowest position . b. An Incident and Accident Report dated 3/15/19 documented Fall . Nursing Description: At 2400 (12:00 a.m.) CNA (Certified Nursing Assistant) called to res (resident) room. Res laying on the floor at bedside with pillow under head. Bed was in lowest position. Fall mat in place . A Progress Note dated 3/15/19 attached to the report documented, .Res states 'I flipped over and fall (off) the bed. I hit my head. My head hurts!' Assessed for injury. Slight redness to back of the head on left side. Staff lifted resident back to bed, (initiated) neuro checks (neurological checks), obtained VS (vital signs) they are WNL (within normal limits). Called APN (Advanced Practical Nurse) with order received to send res to ER (emergency room ) for eval (evaluation) and treatment . There was no documentation of any fall prevention interventions developed and implemented as a result of this fall. c. A Fall Risk Evaluation form dated 5/25/19 documented, .1. Total Score: 8. A score of 8 indicates moderate risk for falls. 2. Additional Comments: unsteady gait . d. An Incident and Accident Report dated 5/28/19 at 9:30 p.m. documented, .Fall . Nursing Description: This nurse called to room by another nurse. Found resident sitting on floor beside bed with his legs in front of him and his back against bed . There was no documentation of fall prevention interventions. e. An Incident and Accident Report dated 6/6/19 documented, Nursing Description: This nurse called to resident's room and found resident on floor leaning against the other bed in his room with his feet under him and his torso leaning against bed . A Progress Note dated 6/6/19 attached to the report documented, .When asked what happened he was unable to verbalize why he was where he was. When asked if he was hurting, he said yes and was able to tell me that his left thigh and hip was (sic) hurting. He audibly complained when his leg was touched and said he couldn't move it without pain. Notified APN and she gave order to send him to hospital . There was no documentation of fall prevention interventions. f. On 6/13/19 at 2:25 p.m., the Director of Nursing (DON) was asked about interventions for the above falls for Resident #3. She stated on 3/15/19, He went to the hospital and had a UTI and was started on antibiotics. She was asked if that was an appropriate long-term intervention to prevent falls and stated, No. She stated on 5/28/19, they scheduled a urology appointment. She was asked what the outcome of the appointment was and stated the resident had not yet been seen by urology and she was unsure if it had been scheduled. She was asked if that could be considered a fall prevention intervention, since it had not yet been implemented and the resident had fallen since 5/28/19. She stated No. She stated on 6/6/19 .We just re-educated staff to put the bed in the lowest position. We've had a lot of turn over and new staff. 3. Resident #4 had [DIAGNOSES REDACTED]. The Significant Change MDS with an Assessment Reference Date of 5/27/19 documented the resident scored 7 (0-7 indicates severely impaired cognition) on a Brief Interview for Mental Status, required limited one-person physical assistance for bed mobility, and transfers, and had 2 or more falls with no injury since date of last assessment. a. The Resident's Care Plan dated 11/27/17 documented, .Focus: I am at High risk for falls r/t (related to) Confusion, Psychoactive drug use, Unaware of safety Needs . Interventions: . 3/11/19 fall without injury I: therapy to evaluate for use of a walker. Date Initiated: 04/12/2019. 4/22/19 Fall: labs 5/10/19 fall due to pushing w/c (wheel chair) too fast. Reopened an old abrasion to the knee. I: PT (physical therapy) to evaluate for use of walker. No need for a treatment at this time. 5/9/19 fall with small abrasion right knee. I: ua (urinalysis) and c/s (culture/sensitivity) if indicated cxr (chest x-ray) and k+ (potassium) level . b. An Incident and Accident Report dated 3/19/19 at 10:30 a.m. documented, .Fall . Nursing Description: Notified by nurse of resident walking outside for smoke break and fell on her right side. Has abrasion noted to LUE (left upper extremity) and LLE (left lower extremity). Small red abrasion to right eye orbital area .Immediate action taken: Assessed . c. An Incident and Accident Report on 4/22/19 at 5:00 p.m. documented, .Fall . Resident found on floor in front of her wheelchair in lobby . Immediate Action Taken: Assessed for injury, ROM (range of motion) WNL vitals. No injury noted. Body audit performed. Skin intact, clean and dry. Resident denied any pain, denied hitting her head. Assist back to wheelchair per facility policy. Educated resident to use the w/c (wheelchair) as per order . d. A Fall Risk Evaluation form dated 5/9/19 documented, .1. Total Score: 10 . Per the scale on the form, a total score of 10 or above indicated a high risk for falls. e. An Incident and Accident Report on 5/9/19 at 11:28 a.m. documented, .Fall .Nursing Description: This nurse walked into dining room as resident was pushing w/c and started to go down on knees. This nurse attempted to get to resident in time, unsuccessful. Resident did not hit head. Noted with small abrasion on right knee. Redness noted to left knee. Resident had no c/o pain and was assisted back to w/c. Resident noted with non-skid socks on . Immediate action taken: Assessed resident no injury noted . f. An Incident and Accident Report on 5/10/19 at 8:45 a.m. documented, .Fall .Nursing Description: Resident was pushing wheelchair down the hall and noted to be unsteady. Resident was educated by staff to stop and sit in wheelchair. Before staff was able to reach resident, she fell to her knees and let go of wheelchair .Immediate Action Taken: Resident assessed for injury and noted to reopen abrasion to right knee. Knee noted to be swollen and warm to touch. Received new order to obtain x-ray to right knee . g. On 6/13/19 at 3:05 p.m., the DON was asked about interventions for Resident #4. She stated, On 3/19, we did a UA with C&S. She was treated with antibiotics. She was asked if that was a long term fall prevention intervention and stated Not really. We should have educated staff. She stated, On 4/22/19, we did labs and UA. Her potassium was elevated. She was given [MEDICATION NAME]. She was asked if that was a long-term intervention for falls and she stated, No we should have found out why (her potassium was elevated). She stated, On 5/9/19, the interventions were a UA and labs. The urine was clean and the potassium was 5.7. She was asked if a different intervention should be put in place for falls since the labs and UA were normal and she replied, Yes. She was asked about interventions for the fall on 5/10/19 and she said that PT was ordered. She was asked if the resident was ever seen by physical therapy and stated, No.

Complaints # (AR 719) and # (AR 760) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure licensed nursing staff avoided duplication of medication administration to prevent serious and significant medication errors, which resulted in complications that required hospitalization for 1 (Resident #4) of (Residents #4, and 8) case mix residents who received medications from Licensed Practical Nurse (LPN) #3. The facility also failed to ensure physician orders [REDACTED].#4) who had physician orders [REDACTED]. The failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #4, who received her scheduled evening medications twice on the evening of 7/4/18, and subsequently experienced a decrease in her level of consciousness, fell , sustained a contusion to the shoulder and was comatose upon arrival at the hospital emergency room (ER). The failed practices also had the potential to cause more than minimal harm to 21 residents who received medications from LPN #3, as documented on a list provided by the Director of Nursing (DON) on 8/8/18 and 1 residents who had physician orders [REDACTED]. The Administrator was informed of the immediate jeopardy situation on 7/20/18 at 9:15 p.m.The facility removed the immediate jeopardy situation and corrected the failed practices on 7/5/18. The findings are: 1. Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 6/22/18 documented the resident scored 14 (13-15 indicates cognitively intact) on a brief interview for mental status, required limited assistance of 1 person for transfers, ambulation in the room and personal hygiene, had no falls since the prior assessment and received antipsychotic, antianxiety, antidepressant and anticoagulant medication on 7 of the past 7 days. a. A Physician order [REDACTED]. A Physician order [REDACTED]. A Physician order [REDACTED]. 1.) The (MONTH) (YEAR) Medication Administration Record (MAR) documented the scheduled administration time for the Klonopin was changed from 2000 (8:00 p.m.) to 2200 (10:00 p.m.), beginning on 6/8/18. The MAR documented the scheduled administration time for the evening dose of [MEDICATION NAME] 75 mg was 8:00 p.m. 2.) On 7/20/18, the Narcotic Book was reviewed and documented the following entries: 6/4/18 at 2100 (9:00 p.m.): [MEDICATION NAME] 50 mg was documented as administered at this time, which was 1 hour after the scheduled administration of [MEDICATION NAME] and 1 hour prior to the scheduled administration of Klonopin. 6/14/18 at 2100 (9:00 p.m.): [MEDICATION NAME] 50 mg was documented as administered at this time, which was 1 hour after the scheduled administration of [MEDICATION NAME] and 1 hour prior to the scheduled administration of Klonopin. 6/29/18 at 2300 (11:00 p.m.): [MEDICATION NAME] 50 mg was documented as administered at this time, which was 1 hour after the scheduled dose of Klonopin. 6/30/18 at 1809 (6:09 p.m.): [MEDICATION NAME] 50 mg was documented as administered at this time; the evening dose of [MEDICATION NAME] for this date was documented as administered at 7:00 p.m. 3.) On 7/26/18 at 9:35 a.m., the Interim Director of Nursing (IDON) and the current Assistant Director of Nursing (ADON) were asked about the findings from the Narcotic Book entries for this resident and whether the physician order [REDACTED]. The IDON stated, Yes. b. A Progress Note dated 7/5/18 at 8:15 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, Upon entering resident's room, this Nurse noted resident was not in bed and the w/c (wheelchair) was pushed up against the bed. This Nurse noted resident was laying (sic) on the floor underneath the w/c on her left side. Resident stated she wasn't on the floor. CNA (Certified Nursing Assistant) and this Nurse assisted resident back into bed. Assessment completed. Resident is alert to self, lethargic, reoriented to time/place. PERRLA (pupils equal, round, reactive to light and accommodation) no lumps, bumps or discoloration on or about the head. Resident denies hitting head or pain in head or pain in head, no bleeding noted. Resident c/o (complained of) pain to bilateral hips and left shoulder, noted discoloration to left shoulder with small protrusion. Lungs noted with bilateral wheezes and crackles. SPO2 (oxygen saturation) noted 81% on 2 LPM (liters per minute) via nasal cannula then noted to drop quickly to 60%. Humidifier placed, increased to 5 LPM, no change. [MEDICATION NAME] Rescue inhaler administered 2 puffs. Increased slowly to 75%. Resident on Eliquis 5 mg (milligram) bid (twice a day). Notified (ambulance) for transport to ER (emergency room ). EMTs (Emergency Medical Technicians) placed on small C (cervical)-collar to assist in maintaining airway and transferred her to stretcher, resident to (Hospital). 0500 (5:00 a.m.) Report called to (Hospital) emergency room . At 0500 POA (Power of Attorney) (name of Adult Protective Service Case Worker), APN (Advanced Practice Nurse), DON (Former Director of Nursing), ADON (Former Assistant Director of Nursing) made aware. c. The Arkansas Department of Health and Human Services, Division of Medical Services (DMS) Office of Long Term Care (OLTC) summary of incident form dated 7/5/18 documented, .MARs (Medication Administration Record) were reviewed and it was determined that this resident received her PM (evening) medications twice including the following: Klonopine 0.5 mg (milligram) (0.25 mg ordered) Eliquis 10 mg ( 5mg ordered) [MEDICATION NAME] 30 mg (15 mg ordered ) [MEDICATION NAME] 50 mg (25 mg ordered) [MEDICATION NAME] 150 mg (25 mg ordered) It was determined that day-shift LPN had given PM meds at 1800 (6:00 p.m.) as permitted by MD (Medical Doctor) order at resident's request. Day-shift LPN had notified night-shift LPN that meds had been given. Day-shift LPN signed MAR and provided written 24 H (hour) report that stated the only medications needed to be given was Klonopin 0.25 mg at 2000 (8:00 p.m.) . In addition to giving PM meds again, even tho MAR was signed by previous nurse and 7/4/18 pills have popped, this LPN also gave Klonopin 0.5 mg (1) tab instead of the ordered 0.5 (1/2) tab dosage . d. The Hospital History and Physical dated 7/5/18 documented, Presented to ER via EMS (Emergency Medical Service). She was found on the floor of NH (Nursing Home) unresponsive with pinpoint pupils. Last known time was between 2-4 a.m. She was given [MEDICATION NAME] in the ambulance. Per NH (Nursing Home) report she was given double medication. PCO2 (partial pressure of carbon [MEDICATION NAME]) greater than 96 and GCS (Glasgow Coma Scale) less than 8 in ER. Diagnosis 1. Altered Mental Status, 2. Right Lower lobe Pneumonia 3. Fall 4. Contusion of Left Shoulder. Patient was intubated due to a PCO2 greater than 96 (Range 35-48) and GCS (Glasgow Coma Scale) less than 8 (8 or less indicates Comatose Client) at 5:50 a.m. placed on the ventilator. The Chest x-ray showed focal opacities in the right lower lobe measuring 2.4 cm (centimeters) x (by) 2.9 cm. Resident was admitted to Intensive Care Unit. [MEDICAL CONDITION] Consult documented, Acute on Chronic Hypoxemic Hypercapnic [MEDICAL CONDITION], Decreased Level of Consciousness secondary to medications, [MEDICAL CONDITION] Acute Exacerbation and Bibasilar Pneumonia most likely caused by aspiration. The CT (computed tomography) of the neck revealed apparent food in the esophagus. d. The (MONTH) (YEAR) Physician order [REDACTED]. 1.) [MEDICATION NAME] capsules 75 mg (milligram) 1 capsule by mouth two times a day related to [MEDICAL CONDITION] and Chronic Pain. Order date 1/22/18; 2.) Eliquis tablet 5 mg give 1 tablet by mouth two times a day for PE (Pulmonary [MEDICAL CONDITION]) / Arrhythmia. Order date 11/3/17; 3.) [MEDICATION NAME] Tablet 25 mg, give 1 tablet by mouth two times a day related to Essential Hypertension. Hold if sbp (systolic blood pressure) is less than 110. Order date 4/14/18. 4.) [MEDICATION NAME] Tablet 15 mg 1 tablet by mouth at bedtime related to Anxiety Disorder. Order Date 11/29/17. 5.) Klonopin tablet 0.5 mg, give 0.25 mg by mouth at bedtime for anxiety related to Anxiety Disorder. Order date of 7/1/18. 6.) As of 7/20/18 at , there was no documentation of a physician order [REDACTED]. The resident was not in the facility, and the (MONTH) (YEAR) MAR was not available for review during the survey. According to Former ADON and the Interim DON, the medications that were duplicated on the evening of 7/4/18 were Eliquis 8 mg, [MEDICATION NAME] 75 mg, Metroprolol [MEDICATION NAME] 25 mg, [MEDICATION NAME] 15 mg and Klonopin 0.5 mg (instead of Klonopin 0.25 mg was ordered by the physician). f. On 7/20/18 at 2:30 p.m., the Interim Director of Nursing (IDON) was asked for the (MONTH) (YEAR) Medication Administration Record. The IDON stated they had searched for the (MONTH) (YEAR) MAR and, at this time, it could not be located. The IDON was asked to review the resident's clinical records, both paper and electronic, for a physician order [REDACTED]. The IDON reviewed the clinical records, then stated I can't find the physician order [REDACTED]. The IDON was asked if the facility still had the medication cards for Resident #4 and stated the Pharmacist had picked up the medication cards; however, the narcotics medication cards were still in the medication cart. g. The Narcotic Record, provided by the IDON on 7/20/18 at 3:30 p.m., documented the following for Resident #4: 1.) The record documented [MEDICATION NAME] 75 mg 1 cap (capsule) was to be administered 2 times daily. The medication was signed out on 7/4/18 at 6:00 p.m. by LPN #2 and again on 7/4/18 at 10:00 p.m. by LPN #3. The record also documented the [MEDICATION NAME] 75 mg had been signed out and given early at 1800 (6:00 p.m.) by LPN #2 on 6/2/18, 6/3/18, 6/12/18, 6/15/18, 6/16/18, 6/17/18, 6/20/18, 6/22/18, 6/29/18, 7/1/18 and 7/4/18. 2.) The record for Klonipin 0.5 mg had a sticker attached which documented, Directions changed refer to chart. The record documented 40 tablets of the 0.5 mg Klonipin were available prior to 7/4/18 at 2200 (10:00 p.m.). One tablet was signed out by LPN #3 at that time, and the balance brought forward was 39, indicating the resident received Klonopin 0.5 mg at bedtime on 7/4/18, instead of Klonopin 0.25 mg, as ordered by the physician. h. On 7/20/18 at 4:08 p.m., during a telephone interview, LPN #1 was asked to explain the incident that occurred with Resident #4. The LPN stated, I went in to do a body audit at 2:15 a.m. (on the morning of 7/5/18). We do body audits on the night shift. The CNA and I went in the room, and she was lethargic, which is not uncommon for her. I repositioned her. I went back to check on her at 4-ish. That's when I found her on the floor. When I checked her, she was under her wheelchair and complained of pain on her left side. I got an aide to assist her back in bed, so I could assess her. The resident complained of pain on her left side. The back of her shoulder had discoloration, her O2 sats (oxygen saturations) were low in the 70s. I put on O2 (oxygen), even increasing the O2, the sats remained low. Our policy says when they (fall and) are on blood thinner, we sent them to the hospital. The LPN was asked, who did you notify? The LPN stated, I did notify the APN (Advanced Practice Nurse), the ADON and left message for APS - they weren't there - and left a message to call back and gave report to the hospital. The LPN was asked if she was aware of an order stating the resident's medications could be administered 2 hours early at 6:00 p.m. The LPN stated, I was aware of the order to give the meds early. The LPN was asked if she had seen the order. The LPN stated, I don't know where the order went to. (LPN #2) and I pulled the MARs when we found the medication error. I believe the order had come from the old APN (Advanced Practice Nurse) . When I counted with (LPN #3), the count for the [MEDICATION NAME] was off, and he (LPN #3) signed out the [MEDICATION NAME] when we were counting on the morning of 7/5/18. I looked at the MAR and he had signed the Klonopin and [MEDICATION NAME] at the same time 2200 (10:00 p.m.). (LPN #3) didn't tell me anything about (Resident #4) when I took the keys around midnight. I looked at the MARs. (Resident #4) would get too sedated, that why they changed the times of the medication administration of the [MEDICATION NAME] and Klonopin, so they wouldn't be given together. i. On 7/20/18 at 5:57 p.m., Licensed Practical Nurse (LPN) #2 was asked to explain the incident involving Resident #4. The LPN stated, I had given report to a new hire (LPN #3). (LPN #3) was coming to work 7:00 p.m. -11:00 p.m. I had explained to (LPN #3) that I had given the bedtime medication early per the resident's request. There was an order on the MAR (Medication Administration Record) that we could give her HS (hour of sleep) meds at 6:00 pm. The order was on there and had been written by (former Assistant Director of Nursing (ADON)), and had been given by (Physician #1), that she can be given the medication early. I had given the medications Eliquis 8 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 25 mg and [MEDICATION NAME] 15 mg. The LPN was asked if she had noted on the MAR that she had administered the bedtime medications 2 hours early. The LPN stated, No, I just signed the MAR. The LPN was asked if there was documentation on the MAR to indicate she had given the bedtime medications 2 hours early. The LPN stated, No. The LPN was asked, Did you document in the Nurses Notes that you gave the bedtime medication 2 hours early? The LPN stated, No because there was an order. The LPN stated the resident had an order that the narcotic couldn't be given within 2 hours of the [MEDICATION NAME] and the Klonopin. The [MEDICATION NAME] and Klonopin scheduled administration times had been changed so the 2 medications would not be administered at the same time. The LPN stated, The resident has had several falls and it wouldn't take much for her too be oversedated. I would go in her room and find her slumped over in her wheelchair several times. The LPN also stated, (LPN #3) had oriented with me, and he knew that she would ask for frequent medication. I wrote that the resident only needed Klonopin on the 24-hour report. The next morning, I found that (Resident #4) had been sent out, and I asked if anything had been given to the resident that would make her sedated. I checked the Narcotic Book and the MARs. I had signed out the medication and saw that he had signed out on the Narcotic Book that he had given the [MEDICATION NAME]. I checked the medication cards; he had popped out the medication for the following day, (MONTH) 5th. That's when we discovered that (LPN #3) had given her the medications again. So, we (LPN #1 and LPN #2) went directly to (Former ADON's) office at that time. We called (former DON) from the office, around 7:00 a.m. The LPN was asked where the physician order [REDACTED]. The LPN stated the order was written on the (MONTH) (YEAR) MARs. The LPN was asked where the (MONTH) (YEAR) MARs were located at this time. The LPN stated they had taken the (MONTH) MARs into the former ADON's office (at the time of the incident). j. On 7/20/18 at 7:30 p.m., the IDON provided the survey team with the 24-Hour j. There was no date on the 24 Hour Report, but the third square, to the upper corner of the form, documented a notation for Resident #4 in an area that measured approximately ½ inch by 1 inch, all meds Klonopin. k. On 7/24/18 at 4:55 p.m., Physician #1 was asked about the order to administer the resident's bedtime medications two hours early at the resident's request and stated that he did not recall giving the facility an order to give Resident #4's medication 2 hours early. He stated, I would not give an order like that. I did talk to them regarding the issue of spacing the medication out, due to she liked to try to get all of the medication at one time. When I speak to the Nurses, they go through my Nurse, who calls me, and we have a 3-way conversation, and she documents the phone call, because I am not good at taking notes. The Physician's Nurse stated she documented the notes from these conversations on her phone and that she had no notes related to an order to allow the Nurses to administer the resident's medication early. l. On 7/26/18 at 11:02 a.m., during a telephone interview, the former ADON was asked, Can you explain the events that took place involving (Resident #4)? The former ADON stated, I came to work on (MONTH) 5th; I came in early. According to (LPN #2), (LPN #3) had worked a bridge shift so we would have 3 Nurses. The day shift nurse (LPN #2) notified me that the resident had fallen and was sent to the hospital. (LPN #1) and (LPN #2) came to my office with the MARs and the 24 hour report. (LPN #2) had given (Resident #4) the bedtime medications ordered on the MAR for 2000 (8:00 p.m.) - the medications had been given at 1800 (6:00 p.m.) and had been documented on the MARs that the bedtime medications had been given before she (LPN #2) had left and had written on the 24 hour report. She had several medications that made her sleepy. The former ADON stated she had spoken with the APN and Physician #1 regarding spreading the medications out. The former ADON was asked where this was documented. The former ADON stated, I didn't document that. The former ADON was asked where the order came from that Resident #4 could have the medications administered early upon request and stated, I'm assuming the Nurses. The former ADON was asked, Did you get that order? The former ADON stated, No, I don't work the floor unless we are short. The Nurses usually get those orders. The former ADON was asked, did you see that order on the (MONTH) (YEAR) MARs? The former ADON stated, I don't recall seeing that order on the MARs. I was told that the order was documented on the MARs by the Nurses. The former ADON was asked, did you talk to (LPN #3)? The former ADON stated, I texted (LPN #3) to call and he had a critical medication error. I reviewed the MAR and the medication card, and it showed that the (MONTH) 5 medications had been popped out, and that (Resident #4) had received double doses of the bedtime medications. I called the hospital and reported that the resident had been given double medications. I called (former DON) and the Nursing Consultant. I attempted to call APS and left a message. (LPN #1) stated she had also called the APS worker. I and (former DON) asked (LPN #3) if he had followed the MAR and (LPN #3) stated, 'Yes, I gave meds to the best of my ability.' The LPN stated he had given medication to those residents who were awake, and he was suspended and later that day, he was terminated. The former ADON was asked, do you know where the (MONTH) (YEAR) MARs are located? The former ADON stated they were left in Medical Records. The former ADON was asked, should the Nurse have documented in the Nurses Notes that these medications were administered early? The ADON stated, No, not if it's an order to give them early. m. The facility removed the immediate jeopardy and corrected the failed practices on 7/5/18, as evidenced by the following: 1.) An Internal Investigation Report dated 7/5/18 documented, .At 0945 (9:45 a.m.), (LPN #3) answered text message and was told to come to facility immediately . LPN was terminated and removed from schedule pending further investigation . after investigation was complete, I filed a 7734 (Office of Long Term Care (OLTC) Incident and Accident Report) with OLTC and filed a Police Report with (local Police Department . (Investigation form) completed in its entirety and mailed via Certified Mail to the OLTC in accordance with all state and federal guidelines . As a precaution, MARs for all other residents were audited immediately with the following findings: Non-case mix Resident #1: Did not receive [MEDICATION NAME] 0.5 mg. LPN signed MAR as given but did not remove medication from narcotics box. Non-case mix Resident #2: Did not receive full dose of [MEDICATION NAME] 5 mg (2) tabs (tablets). Received only 1 tab. LPN signed MAR as given, but did not remove medication from narcotics box. Non-case mix Resident #2: Did not receive [MEDICATION NAME] 6 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 60 mg. LPN signed MAR as given, but did not remove medication from cards or narcotics box . All of the above medication errors were from the 7/4/2018 bridge shift performed by (LPN #3) . Residents will be closely observed for adverse effects post incident x (times) 24H (24 hours). All nursing personnel will be educated on the importance of correct medication administration. All nursing personnel will be observed by administrative nurses during individual medication pass . 2.) A written statement dated 7/23/18 and signed by the former ADON documented, .I in-serviced nursing staff re: (regarding) med errors, MAR observation and admin (administrative) notification of med errors . All took place on 7/5/18 . 3.) A written statement dated 7/23/18 and signed by LPN #6 documented, .I was in-serviced by (former ADON) regarding med pass on 7/5/18. (Former ADON) also watched my med pass that morning on 7/5/18 . 4.) A written statement dated 7/23/18 and signed by LPN #7 documented, .I was in-serviced about med pass and watched during a med pass about 2 weeks ago . 5.) The facility's additional written corrective actions documented the following: On 7/20/18 Administrator, designee initiated in service with nursing staff on ensuring medications are administered per physician orders. All nurses will be in serviced prior to starting their shifts. Any Nurse on leave will be in serviced prior to returning to work. On 7/20/18 Administrator, designee initiated in service with nursing staff on ensuring medication rights are performed prior to medication administration. All nurses will be in serviced prior to starting their shifts. Any Nurse on leave will be in serviced prior to returning to work. DON, designee will monitor medication administration documentation to ensure medications are administered per physician orders [REDACTED]. All nurses will be in serviced prior to starting their shifts. Any Nurse on leave will be in serviced prior to returning to work. DON, designee to perform medication administration performance evaluations three times a week times eight weeks or until compliance is achieved to ensure Nurses are administering medications per facility policy. All nurses will be in serviced prior to starting their shifts. Any Nurse on leave will be in serviced prior to returning to work. DON, designee to present findings to QAPI (Quality Assurance Performance Improvement) committee monthly . DON, designee will monitor the obtaining and documenting of Physician orders [REDACTED]. DON, designee will monitor nursing documentation to ensure all issues of resident's care are documented and followed up on. Three times per week for eight weeks or until compliance is achieved.

Complaint # was substantiated all or in part with this finding. Based on observation, record review and interview, the facility failed to ensure wheelchairs were regularly inspected for hazards and protruding metal brake handles were covered to prevent potential injury for 3 (Resident #2, 4 and 7) of 8 (Resident #2, 4, 5, 6, 7, 8, 9 and 10) case mix residents who required extensive assistance for transfers to a wheelchair. This failed practice resulted in actual harm to Resident #1 who sustained an 8 centimeter laceration to the lower leg that required sutures and had the potential to affect 33 residents who required extensive assistance for transfers to a wheelchair according to the list provided by the Administrator on 9/28/12. The facility failed to ensure ensure gait belts were applied per manufacturer's instructions to minimize the potential for injury for 1 (Resident #4) of 9 (Residents #2, 4-11 ) case mix residents who required gait belts for transfers. This failed practice had the potential to affect 33 residents who required gait belts for transfers according to the lists provided by the Administrator on 9/28/12. The facility failed to ensure personal alarms were applied to minimize the potential for falls for 2 of 2 (Resident #4 and #7) case mix residents who used a personal alarm on the chair or bed. This failed practice had the potential to affect 16 residents who used a personal alarm on the chair or bed according to the lists provided by the Administrator on 9/28/12. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/12 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 2 persons for transfer and had no falls or skin problems. a. The Plan of Care documented, "Problem onset: 1/12/2010. (Resident #2) is at risk for skin alterations r/t (related to) dx (diagnosis) of PVD (Peripheral Vascular Disease) and fragile and thin skin. ... Approaches: ... Avoid shearing of skin during transfers..." b. The Resident Incident Report dated 9/11/12 at 10:16 a.m. documented, "Narrative of Incident and description of Injuries: Called to resident's room by CNA (Certified Nursing Assistant) who reported that while transferring resident from bed to w/c (wheelchair) for shower resident's leg began to bleed. Upon entering room noted resident's L (left) lower leg was bleeding. Laceration to L lower leg, resident would not allow measurement. Immediate Actions Taken: First aid provided, ambulance called." c. The Incident Investigation dated 9/11/12 at 10:16 a.m. documented, "6. New Interventions: Assessed head to toe, first aide, sent to ER (emergency room ) for sutures, continue 2 person assist for transfers, tx (treatment) per MD (medical doctor) order, monitor for s/s (signs and symptoms) of infection, padded wc (wheelchair) for safety." d. The hospital emergency room record dated 9/11/12 documented, "... History of Present Illness: ... HPI (History of Present Illness) Comments: Patient arrived from the nursing home after sustaining a laceration to her left lower leg. Patient has some baseline confusion. Nursing home staff states that they were placing the patient in the wheelchair and bumped her leg against a part causing laceration. ... Leg Laceration: The incident occurred 1 to 2 hours ago. The laceration is located on the left leg. The laceration is 8 cm (centimeters) in size. The laceration mechanism was a metal edge... Procedures: This laceration is a large deep V-shaped laceration to her anterior lower leg. The skin is extremely thin and friable. ... One side of the V-shaped laceration was able to be closed with stitches. The remaining side of the head is quite a bit of tension on the wound edges and due to her thin skin will not hold stitches and will remain open without suturing to heal by secondary intention. ... Clinical Impression: Laceration of leg not thigh, complicated." e. On 9/24/12 at 4:00 p.m., the resident was in the bed, the wheelchair was across the room. The hand brake on the left side of the wheelchair had no rubber cover. There was padding on the lower front legs of the wheelchair where the foot rests attached to the wheelchair. The hand brake protruded out from the frame of the wheelchair at a 45 degree angle. f. On 9/25/12 at 9:50 a.m., Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 entered the room and removed the dressing to the resident's leg. A large V-shaped laceration with sutures was noted on the lower left leg slightly to the left of the mid shin area. The lower point of the V shaped wound area had no skin covering the wound. The area of skin between the two upper "V" points was bulging up approximately ? centimeter (cm) above the surrounding skin area and the bulging extended down to within ? cm of the lower "V" point. g. On 9/26/12 at 9:13 a.m., the resident was transferred to the bed from the wheelchair after physical therapy. The wheelchair was rolled to the wall across the room from the resident. The brake handle on the left side of the wheelchair was not covered with the rubber tip, and the metal was exposed and protruded out from the wheelchair. h. On 9/26/12 at 9:30 a.m., LPN #2 was asked, "Were you the person who completed the incident report on (Resident #2)?" LPN #2 stated, "Yes." LPN #2 was asked, "Can you tell me who the nurse's aides were that did the transfer?" LPN #2 stated, "(CNA #3) and (CNA #4)." LPN #2 was asked, "Can you tell me what happened on 9/11/12?" LPN #2 stated, "After they (CNA #3 and CNA #4) got her in the chair, they saw blood and came to get me. Her wheelchair had a brake. It didn't have a handle cover on it (the left side). I looked at the bed and the chair and there were no sharp objects on the bed. The brake handle was the only thing that could do it. I left a message with Maintenance." LPN #2 was taken to the resident's room and shown the brake handle with no cover on it. LPN #2 stated, "Looks like they haven't fixed it." LPN #2 was asked, "Did you tell Maintenance?" LPN #2 stated, "Yes. I don't know if they had to order some of those. There's a lot of wheelchairs that don't have them (handle covers)." i. On 9/26/12 at 9:38 a.m., the Maintenance Director was asked, "What did you do when nursing called you (about Resident #2's wheelchair)?" The Maintenance Director stated, "I inspected the bed and wheelchair. There wasn't anything on the bed or wheelchair that was sharp, so I didn't do anything." The Maintenance Director was asked, "What about the cover to the brake handle?" The Maintenance Director stated, "That must have come off since then. I have some more. Those things come off or sometimes they take them off to put on brake handle extenders." The Maintenance Director was asked, "Does the resident have brake handle extenders?" The Maintenance Director stated, "No." j. On 9/26/12 at 9:50 a.m., during a telephone interview, CNA #4 was asked, "What did you do when you saw the blood?" CNA #4 stated, "I told the nurse. She came down and looked at it. She wasn't sure herself (how the skin tear happened). It was most certainly the wheelchair." CNA #4 was asked, "Was the rubber cover missing from the brake handle?" CNA #4 stated, "Yes. I think it was." k. On 9/26/12 at 9:55 a.m., during a telephone interview, CNA #3 was asked, "What do you think caused it?" CNA #3 stated, "Bumping the wheelchair. The brake handle cover was missing." l. On 9/27/12 at 10:00 a.m., the Administrator was asked to provide a copy of the manufacturer's instructions for the resident's wheelchair and any inspections performed on the wheelchair. On 9/27/12 at 10:20 a.m., the Administrator produced a two page product pamphlet for the Invacare 9000 XT series wheelchair that contained pictures and model numbers for the wheelchair, recliner wheelchair, a brief statement of the features and a table of weight capacities. The Administrator stated, "As far as a maintenance log, there are no wheelchair inspections." The Administrator was asked, "They (maintenance staff) don't do a routine inspection of wheelchairs?" The Administrator stated, "The CNAs clean the wheelchairs at night and tell maintenance if there is something wrong." The Administrator was asked for any documentation of the inspections performed by the CNA's. The Administrator was asked, "Do the CNAs have the manufacturer's specifications on what is supposed to be on the wheelchair?" The Administrator stated, "No." The Maintenance Request Book was reviewed. There were no maintenance requests or inspections of the wheelchair for Resident #2 documented in the book. m. On 9/27/12 at 11:55 a.m., the Director of Nursing (DON) and Administrator were asked, "Is there any documentation of inspections of wheelchairs performed by the CNAs?" The DON stated, "No." n. The User's Manual for the Invacare 9000 Series wheelchair obtained from the Invacare web site by the Administrator on 9/27/12 documented, "4. Safety Inspection/Trouble Shooting: Every six months or as necessary, take your wheelchair to a qualified technician for a thorough inspection and servicing..." 2. Resident #4 had [DIAGNOSES REDACTED]. Hypertension, and Osteoporosis. The Annual MDS with an ARD of 6/21/12 documented the resident scored 9 (8-12 indicates moderately impaired) on the BIMS, required extensive assistance of one person for transfers and had no falls since admission or last assessment. a. The Plan of Care documented a problem dated 7/6/12 of, "Requires Extensive Assist with ADLs (Activities of Daily Living) ... Approaches: ... Alarm in place at all times in chair and bed; assure alarm is in place and functioning every shift. ... Transfers X (times) 2 assist." and Risk for Injury from falls related to history of falls, ... Approaches: ... Pin alarm in wheelchair and bed..." b. On 9/24/12 at 2:00 p.m., the resident was in a wheelchair in the front lobby with the clip alarm dangling behind the back of the wheelchair and not attached to the resident. A 4 ounce cup of vanilla ice cream was on the floor to the left of the front left wheel of the wheelchair and the resident was leaning forward trying to pick up the ice cream from the floor. c. On 9/25/12 at 8:29 a.m., the resident was in her room sitting in a wheelchair with the alarm box attached to wheelchair. The alarm cord was wrapped around the hand grip on the right side of the wheelchair and the clip on the end of the cord was not visible. The cord was not able to disengage the pin to sound the alarm. d. On 9/26/12 at 9:05 a.m., the resident was in the bed with no alarm on the bed. A clip alarm was on the empty wheelchair that was beside the bed. The wheelchair brake handles did not have the rubber cover on either side of the wheelchair. e. On 9/26/12 at 2:09 p.m., CNA #1 and CNA #2 placed a gait belt around the resident's chest. CNA #1 stood in front of the resident, and with the gait belt over the right breast, stood the resident and pivoted the resident with the gait belt pressing into the right breast and chest area. CNA #1 was asked, "Where is the gait belt located?" CNA #1 stated, "It's over her breast." The manufacturer's instructions for the use of the Val Med Gait Belt provided by the Administrator on 9/26/12 documented, "Place belt around patient's waist only, not around chest." 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/24/12 documented the resident scored 3 (0-7 indicates severe impairment) on the BIMS, required extensive assistance of two people for transfers and no falls since admission or prior assessment. a. The Plan of Care documented, "Problem Onset: 10/18/2011: Requires Total Care for all ADLs. Approaches: ... PIN alarm may be applied while in bed every shift. ... Problem Onset : 10/18/11: (Resident #7) has a history of falls, at risk for further falls d/t impaired cognition, confusion, poor safety awareness. ... Approaches: ... Pin alarm while resident in bed and wheelchair." b. The physician's orders [REDACTED]." c. On 9/24/12 at 2:35 p.m., the resident was in bed asleep. There was no alarm on the resident in the bed. The alarm was on the empty wheelchair beside the bed. d. On 9/25/12 at 8:10 a.m., the resident was in the lobby in a wheelchair. A clip alarm box was on the back of the wheelchair with the cord clipped to the cord next to the box. The clip was not fastened to the resident. There was no brake handle cover on the right brake handle of the wheelchair. At 8:18 a.m., the MDS Coordinator rolled the resident to the hallway by the resident's room, then CNA #5 rolled the resident into her room and did not connect the alarm prior to leaving the room. At 8:24 a.m., CNA #6 entered the resident's room and stated, "We're going to get you back to bed", then left the room. The resident was unattended by staff, and the clip alarm was not connected to the resident. At 8:26 a.m., CNA #5 returned to the room. CNA #5 was asked, "Where is the alarm clip fastened?" CNA #5 stated, "To itself." CNA #5 was asked, "Is that how it's supposed to be fastened?" CNA #5 stated, "No. It's released for meals." CNA #5 was asked, "Did the resident eat in the front lobby?" CNA #5 stated, "No. She rolls herself to the lobby." e. On 9/25/12 at 4:20 p.m., the resident was in bed with a half side rail elevated in the center of the bed. An alarm box was fastened to the side rail, but the alarm clip was not fastened to the resident. LPN #3 was asked, "Is that how the alarm is supposed to look?" LPN #3 stated, "No. It should be attached. It looks like she took it off." f. On 9/26/12 at 9:05 a.m., the resident was in the bed. The wheelchair beside the bed had a brake handle cover taped on the left brake handle, but no brake handle cover was on the right side of the wheelchair.