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

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to protect one (Resident #85) of two residents from physical abuse during a resident-to-resident altercation that occurred between Resident #85 and Resident #86 after the secured unit was left unsupervised by LPN #2 and CNA #5, staff who were assigned to the secured unit. The findings include: Resident #85 Review of an admission Record revealed the facility admitted Resident #85 on 03/28/2025 with diagnoses that included dementia, falls, panic disorders, heart conditions, anxiety, a pacemaker, a defibrillator, muscle weakness, lack of coordination, unsteadiness on feet, mild cognitive impairment, and insomnia. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2025, revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #85 had delusions, used a wheelchair and a walker for ambulation, required partial assistance for sitting and standing, and was taking antipsychotic medications on a routine basis. Review of Resident #85's Care Plan initiated on 04/28/2025, revealed the resident had impaired cognitive function due to dementia, and that antipsychotic medications were used for behavior management. Interventions included administering medications, reducing distractions, and supervision as needed. Review of Clinical Physician Orders revealed Resident #85 resided on the secured unit as of 04/01/2025. Review of Progress Notes dated 06/20/2025 at 9:56 AM, revealed Resident #85 started displaying behaviors of restlessness, exit seeking, and wandering. -On 06/21/2026 at 12:57 AM, Resident #85's behaviors of restlessness, exit seeking and wandering continued and Licensed Practical Nurse (LPN) #2 assisted Resident #85 to bed. -On 06/22/2025 at 3:30 AM, Resident #85 was found in the day room with Resident #86, Resident #85 was on the floor with a laceration and discoloration noted to the left eye and skin tear to right ring finger of Resident #85. -A marked-out section of notes on 06/21/2025 at 5:07 AM and 06/23/2025 at 8:51 AM indicated a detailed description of a resident entering the day room where a Certified Nursing Assistant (CNA) #5 and Resident #85 were. Resident #86 began hollering at Resident #85. CNA #5 attempted to redirect Resident #86 without success. Resident #86 then assaulted CNA #5 by hitting her and grabbing her hair, causing them to fall to the ground. LPN #2 arrived and helped CNA #5 get away from Resident #86 before both LPN #2 and CNA #5 left the secure unit. The aggressive resident, [Resident #86] then attacked Resident # 85, hitting Resident #85 in the face and causing Resident #85 to fall. Review of Resident #85's emergency room (ER) Report dated 06/21/2025 at 3:57 AM revealed Resident #85 was transported to the ER by Emergency Medical Services (EMS) for evaluation related to a physical assault by another resident. EMS reported, patient was pinned down by another resident and struck several times to the face and head. The ER report revealed, Per nursing home and EMS report the patient was the victim of an altercation where another resident was found beating up on [Resident #85]. Resident #85 reported being hit around the head and the neck area. The ER Report also revealed Resident #85 had a laceration to the left eyebrow measuring two millimeters. Resident #86 Review of an admission Record revealed the facility admitted Resident #86 on 01/02/2025 with diagnoses that included dementia, depression, mild cognitive impairment, delusional disorder, insomnia, history of falls, restlessness, and agitation. Review of a quarterly MDS with an ARD of 04/09/2025, revealed Resident #86 had a BIMS score of 10, which indicated moderate cognitive impairment. The MDS also revealed Resident #86 had no impairments to arms or legs and required supervision or touching assistance to independence for mobility. Review of Resident #86's Care Plan, initiated on 01/02/2025, revealed Resident #86 had aggressive behaviors towards staff, had a distorted sense of entitlement with explosive, impulsive behaviors, and could not be redirected at times. Resident #86's Care Plan also revealed a history of aggressive and inappropriate behaviors, conflicts/altercations with others and verbal or physical aggression. Interventions included using psychiatric management and using behavior techniques to promote and shape the desired behavior. Review of Resident #86's Clinical Physician Orders revealed Resident was admitted to the secured unit on 01/30/2025. Review of Resident #86's Progress Notes dated 06/09/2025 revealed aggressive and combative behaviors of Resident #86, which included yelling, cursing, and chasing/hitting multiple staff with fist and phone receiver after being unable to get the phone at the nurse's station to dial out. Staff were unable to redirect Resident #86. Resident #86 was sent out for psych evaluation and returned to the facility on [DATE]. - A marked-out section of notes dated 06/21/2025 at 3:47 AM and 06/23/2025 at 8:55 AM, revealed Resident #86 entered the day room of the secured unit where CNA #5 and Resident #85 were. CNA #5 reported Resident #86 began to holler at Resident #85. CNA #5 attempted to redirect Resident #86. Redirection was unsuccessful. Resident #86 cornered CNA #5, hit her, and grabbed her hair, causing both Resident #86 and CNA #5 to fall. LPN #2 helped CNA #5 to get away from Resident #86. Both CNA #5 and LPN #2 left the secured unit. The Progress Note revealed Resident #86 then got up and began hitting Resident #85 in the face causing Resident #85 to fall. Review of a document titled Emergency Discharge Letter dated 06/21/2025 at 4:30 AM, revealed an emergency discharge from the facility due to physical violence. Review of a document titled Daily Census dated 06/20/2025, revealed a total of eight residents resided on the secured unit, including Resident #85 and Resident #86 who were involved in the incident on 06/21/2025. The daily census dated 06/21/2025 indicated Resident #86 no longer resided on the secured unit. Review of a document titled Incident Report and dated 06/21/2025 from the local police department revealed on 06/21/2025 at approximately 3:18 AM officers were dispatched to an incident at the facility. The report revealed that after CNA #5 got away from Resident #86, she (CNA #5) exited the area and left Resident #86 unattended. The report revealed that nursing staff reported being ordered to leave the area by the Director of Nursing (DON). The report revealed the officers asked staff if there were any other residents in danger, and the officers were informed there were no staff on the secured unit. The report revealed there was a fight on the ground. Both Resident #85 and Resident #86 were found lying on the ground on their right sides and Resident #86 had a hold of Resident #85's right arm. EMS arrived and assessed each resident. Resident #86 had a bump to the back of the head, numerous skin tears to both arms, bruising on the right knee, and a skin tear to the right cheek. Resident #85 had an opened wound to the face above the right eye and a skin tear to the top of the right hand. The report revealed the nurse stated she was not going back in there and the nurse was told (by the DON) not to let anyone else go back onto the secured unit. Review of a document titled Office of Long-Term Care (OLTC) Incident and Accident Report (I&A) dated 06/21/2025 revealed Resident #85 and Resident #86 were found on the floor in the day room by two CNAs. The report revealed staff statements were taken. Only one CNA statement was obtained and LPN #2's statement was obtained. LPN #2's statement indicated she did not see the altercation between Resident #85 and Resident #86. The CNA's statement indicated she was called to the locked down unit to assist with an altercation between two residents. Both residents were on the floor on their sides. One resident had ahold on the other. Both residents had blood on them. Review of a document titled Employee File for Registered Nurse (RN) #1 revealed RN #1 was the Director of Nursing (DON) at the time of the incident on 06/21/2025. RN #1 was terminated on 09/24/2025 due to job performance. The employee file contained a document titled Residents Rights/Civil Rights signed by RN #1 on 04/10/2025 that revealed a resident has the right to remain free from abuse and neglect even at the hand of another resident. On 04/10/2025, RN #1 signed a document titled Resident to resident altercations: the prevention of resident altercations revealed the goal was to keep the agitated resident safe and keep residents around the agitated resident safe. On 04/10/2025 the RN #1 signed a document titled abuse prevention program which revealed, it is the policy of this facility to prevent resident abuse. During an interview on 05/06/2026 at 5:08 PM, Licensed Practical Nurse (LPN) #2 indicated on 06/21/2025 around 3:00 AM, there was an altercation between Resident #85 and Resident #86. LPN #2 reported the aggressive resident [Resident #86] punched CNA #5 in the face and had CNA #5 on the floor. Resident #86's legs were wrapped around CNA #5 with her hair in the resident's hands. The nurse was able to free CNA #5 from Resident #86. LPN #2 reported both CNA #5 and herself exited the unit to call the DON. LPN #2 reported that the DON instructed her and the other staff to stay off of the secured unit. LPN # 2 reported once the police arrived, they (the police) entered the secure unit and found Resident #85 and Resident #86 lying on the floor in the day room During an interview on 05/06/2026 at 8:44 PM, CNA #3 indicated on 06/21/2025 LPN #2 came outside to the smoking area and stated the police were on the way and that she had left the unit. CNA #3 stated, What do you mean you left the unit? CNA #3 indicated, you were never to leave the secured unit uncovered. CNA #3 reported meeting the police at the door of the secure unit and entering with them. CNA #3 indicated there were no staff members standing near the secured unit door when she approached and there were no staff present on the secured unit. CNA #3 reported after entering the secured unit with the police. Resident #85 and Resident #86 were found on the floor in the day room. CNA #3 reported the female police officer grabbed Resident #86 off the top of Resident #85. CNA #3 reported there was blood everywhere. CNA #3 reported, LPN #2 refused to reenter the secured unit to assess the residents, even with the police, sheriffs, and fire department present. During an interview on 05/07/2026 at 10:07 AM, CNA #4 indicated she was outside on a smoke break when LPN #2 came outside and said she needed help on the secured unit. CNA #4 indicated there were no other staff on the secured unit at the time. CNA #4 reported Resident #85 and Resident #86 were found in the day room on the floor. CNA #4 reported Resident #85 and Resident #86, had a hold of each other. CNA #4 reported staff were never to leave the secured unit alone. During an interview on 05/07/2026 at 12:50 PM, the current DON indicated the secured unit floor was never to be left uncovered (unstaffed). The DON indicated if a secured unit was left uncovered after an aggressive resident attacked a staff member, the resident could then turn and hurt the other residents. During an interview on 05/07/2026 at 1:03 PM, the Administrator stated, We protect the person being assaulted and remove the aggressor. The Administrator indicated his expectations of staff would be to stop any resident-to-resident altercation and that ideally the secured unit is not to be left alone; someone is expected to be on that unit at all times. The Administrator indicated a resident could get hurt if the secured unit was left without direct care staff present. The Administrator indicated he was not the Administrator at the time of the incident on 06/21/2025. The Administrator was unable to provide contact information of the CNA listed in the OLTC incident report, or for CNA #5, who was assaulted on 06/21/2025. The Administrator stated that both CNAs were working out of an agency. The Administrator indicated the facility put a wearable alarm in place for the CNAs to alert for help when needed on the unit but that it was broken and now the staff have been instructed to utilize the call lights for help. The Administrator stated, I would hope [the staff] would get to safety or at least a place where they weren't being assaulted. Maybe step on the other side of the door. You can't protect six other people at one time so I think they should hit the alarm and not leave but I don't expect them to stay there and be beaten either. Review of a facility policy titled Abuse, Neglect, and Exploitation with a reviewed date of 01/2024 revealed, 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 policy also revealed, The facility has developed policies and procedures which provides essential components to an abuse prevention and intervention program: Training staff annually and on an on-going basis on interventions, reporting, detection and prevention. Review of a facility policy titled Resident Rights with a reviewed date of 01/2024, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be free from abuse, neglect, misappropriation of property and exploitation; a safe, clean homelike environment including but not limited to treatment and supports daily living safely. Review of a document titled OLTC I&A Report, dated 06/21/2025, indicated an in-service was completed on abuse; the DON, LPN #3, and CNA #5's signatures were included. An Emergency Discharge Letter indicated Resident #86 was discharged from the facility immediately following the incident with Resident #85. The facility had implemented call devices to allow staff to request assistance if needed (currently inactive, but an alternate was provided). These corrective actions had been implemented prior to the survey team entering the facility, resulting in this finding being cited at Past Non-Compliance.

Based on observation, interviews, record review and facility policy review, it was determined that the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) and wore appropriate Personal Protective Equipment (PPE) to prevent the potential for cross contamination when providing direct, high contact care to a resident that had a feeding tube for one (Resident #34) of one resident reviewed for infection control. The findings include: Review of an admission Record revealed the facility admitted Resident #34 on 06/24/2025, with diagnoses that included cerebral palsy (a group of conditions that affect movement, balance and posture); lennox-gastaut syndrome (severe form of seizures), and dysphagia (difficulty or discomfort when swallowing). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 03/26/2026, revealed Resident #34 had a Brief Interview for Mental Status score of 0, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #34 had a feeding tube while a resident. Review of Resident #34's Care Plan initiated on 06/25/2025, revealed Resident #38 required EBP related to feeding tube. Interventions included gloves and gown were required prior to the high contact care such as dressing, bathing/shower, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use- central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care. On 05/06/2026 at 1:16 PM, this surveyor observed PPE available in a clear bin in Resident #34's room by the door and EBP signage on the door. Certified Nursing Assistant (CNA) #6 transferred Resident #38 from wheelchair to bed without Personal Protective Equipment (PPE) such as a gown. During an interview on 05/06/2026 at 1:45 PM, CNA #7 reported that PPE was used when EBP signage was on the door and then you will put on a gown, gloves, mask, and shoe covers if you need to. CNA #7 reported that EBP was used when someone had an infection that can spread, open sores, a feeding tube, or a catheter. During an interview on 05/06/2026 at 2:10 PM, CNA #6 reported that EBP was used when there is a sign on the door that says EBP and when someone has open wounds, a catheter or something like that. CNA #6 also reported that you wear gloves, gowns and shoe covers when someone is on EBP. During an interview on 05/06/2026 at 5:30 PM, the Director of Nursing (DON) reported that she expected staff to wear proper PPE when required. The DON stated that PPE bins were in rooms, always stocked and signage was on the residents' doors to alert staff that PPE was required. The DON stated that the outcome of not wearing proper PPE could be increased numbers of infections in the facility. Review of a facility policy titled Enhanced Barrier Precautions (EBP) dated 09/21/2022, indicated, The EBP requires gowns and gloves during high-contact resident care activities that provide opportunities to transfer of MDROs to staff hands and clothing. All residents with any of the following: Indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/shower, transferring, providing hygiene, changing briefs, or assisting with toileting, device care or use, wound care.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff thoroughly washed their hands and changed gloves when contaminated and before handling food and clean equipment when contaminated; food items stored in the refrigerator, freezer and dry storage area were covered or sealed. expired food items and spices were promptly removed/discarded on or before the expiration or use by date; 1 of 1 ice machine and 1 of 1 scoop holder were maintained in a sanitary condition for 2 of 2 meals observed. The findings are: 1. On [DATE] at 9:57 AM, Dietary Aide (DA) #1 pulled her hair net down. Without washing her hands, DA #1 picked up clean plates and stacked them on the cart with her fingers inside of them. 2. On [DATE] at 9:59 AM, the ice machine in the kitchen had wet mixture of colors on the panel where ice touched before dropping into the ice collector. The Surveyor asked Dietary Manager if she could wipe the area in the ice machine that had wet mixture of colors on it. She did, and residue easily transferred to the tissue, and she stated it was nasty. She was asked who used the ice from the machine and how often they cleaned it. She stated CNAs use it to fill beverages served to the residents at mealtimes and for the water pitchers in the resident's rooms. The kitchen staff cleans it every week. and they clean it every week. 3. On [DATE] at 10:02 AM, Dietary [NAME] (DC) #2 was interviewed about observations made in the ice machine and she was asked if anyone had used ice from the machine this morning. DC #2 stated CNAs used ice from the machine this morning to fill beverages served to the residents for breakfast meal. The kitchen staff also provided bags of ice, which were collected from the ice machine, and gave them to the CNAs to use for the water pitchers in the resident's rooms. 4. On [DATE] at 10:03 AM, Dietary Aide #1 interviewed about observations made in the ice machine and she was asked if anyone had used ice from the machine this morning. DA #1 stated she and DC #2 bagged ice from the machine this morning and stored them in the freezer to use for drinks during the meal service and the bags of ice are used for water pitchers in the resident's rooms. 5. On [DATE] at 10:05 AM, an opened box of salt was on a shelf above the food counter. The salt was in firm blocks and hard. The Dietary Manager confirmed salt was hard, staff had opened the box incorrectly and the contents needed to be discarded. She mentioned she wouldn't use it for herself. 6. On [DATE] at 10:07 AM, an opened can of ground ginger was on a rack in the kitchen with an expiration date of [DATE]. 7. On [DATE] 10:09 AM, an opened box of heavy cream was on a shelf in the refrigerator with an expiration date of ,d+[DATE] /24. 8. On [DATE] at 10:12 AM, the following observations were made on a shelf in the freezer: a. An opened bag of pie shells. The bag was not sealed. b. An opened box of cookie dough. The box was not covered or sealed. 9. On [DATE] at 10:26 AM, an opened gallon of barbeque sauce was on a shelf in the storage room. The manufacture's specification on the gallon indicated to refrigerate after opening. The Dietary Manager after reviewing the manufacture's specification on the gallon confirmed barbeque sauce should have been refrigerated as soon as it was opened. 10. On [DATE] at 10:49 AM, the holder scoop on the wall by the ice machine had reddish slimy residue at the bottom of it. The ice scoop was resting directly on residue. Asked the Dietary Manager if she could wipe off the area at the of the scoop holder. She did and stated it was brown-reddish color, nasty, dirty, and slimy. 11. On [DATE] at 10:51 AM, the following observation were made in the refrigerator in the nourishment room by the front of the nurses' station were: a. nutritional drinks on a shelf in the refrigerator did not have received date on them. b. Six bottles of nutritional drinks. Nine cartons of Nutritional drinks. There was no received date on them. c. A bag of prune. There was no opened or received date on the bag. 12. On [DATE] at 11:02 AM, the following observation were made in the back medication room: a. One bottle of lemon lime on a shelf in the refrigerator had an expiration date of [DATE]. b. An opened bag of chips was in a basket on top of the freezer. The bag was not sealed. c. One packet of peanut crackers had an expiration date of [DATE]. 13. [DATE] 11:07 AM, an opened bottle of thickener was observed on a shelf. The manufacture's specification on the bottle indicated to refrigerate after opening. The Dietary Manager confirmed it should be stored in the refrigerator once opened. 14. On [DATE] at 11:22 AM, DA #1 turned on the hand washing sink faucet and washed her hands. After washing her hands, she turned off the faucet using pieces of tissue paper, thereby contaminating the tissue. She then used same tissue to dry her hands, without re-washing her hands afterwards. Then, she picked up a clean blade and attached it to the base of the blender to be used in portioning food items to be served to the residents for lunch meal. DA #1 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment she stated she should have her hands. 15. On [DATE] at 11:33 AM, Dietary [NAME] (DC) #2 picked up a pot of meat sauce from the stove and placed it on the counter. DA #2 pushed a food cart that contained a pan of spaghetti towards the food preparation counter. Without washing her hand, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to the served the residents who required pureed diets. The DC #2 was interviewed and asked what she should have done after touching dirty objects before handling clean equipment and she stated she should have washed her hands. 16. On [DATE] at 11:55 AM, the following observations were made on a shelf in the storage room. a. A bottle of strawberry fruit spread. Some of the fruit spread has been used from it. The manufacture's specification on the bottle indicated to refrigerate after open. b. An opened bag of rice cake, there was no received or opened date on the bag. c. One can of broccoli with cheese soup with an expiration date of [DATE]. d. One can of coffee with an expiration date of [DATE]. 17. A review of facility policy titled, Hand Washing, not dated, provided by the Dietary Manager on [DATE] indicated, employees should wash their hands after engaging in other activities that contaminate the hands.

Based on record review, interview, facility document review, and facility policy review, it was determine the facility failed to ensure written information regarding the right to formulate an advanced directive was provided to residents or their responsible parties, to enable them to make informed decisions regarding which measures would be provided or withheld at end of life for 02 (Resident #62, #2) of 2 sample mix residents reviewed for Advance Directive. The findings are: Review of Resident #62's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of August 12, 2024, noted a score of 6 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and noted a diagnosis of paralysis (quadriplegia), traumatic brain injury, and post-traumatic stress disorder (PTSD). Review of Resident #62's electronic medical record contained a Physician Ordered Life Sustaining Treatment (POLST) form with advance directive selected that indicates it is available to review and signed on 5/9/24. No advance directive was located. Review of Resident #62's Care Plan with an initiated date of 10/22/2024 noted to follow instructions as detailed inside the advance directive if the resident has one. During an interview with the Director of Nursing (DON) on 11/7/24 at 9:49 AM, she confirmed Resident #62 has a POLST, and it notes the resident wants an advance directive, but no advance directive wishes were noted, and no separate advance directive wishes on file. Review of Resident #2's electronic medical record contained a Resuscitation Designation Order that is not dated that noted I do have an advance directive selected with no advance directive wishes on file. Review of Resident #2's Care Plan with an initiated date of 6/28/2019 noted to follow instructions as detailed inside the advance directing if the resident has one. Review of Resident #2's Quarterly MDS with an ARD of 11/4/2024, noted a score of 3 (0-7 indicates severe cognitive impairment) on the BIMS and noted a diagnosis of Dementia. During an interview with the DON on 11/7/24 at 9:49 AM, she confirmed Resident #2 has a Resuscitation Designation Order that notes the resident has an advance directive, but no advance directive wishes were noted, and no separate advance directive wishes on file. Review of a facility policy titled, Advance Directives with an effective date of 4/2021 noted Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse of accept medical or surgical treatment and to formula an advance directive if he or she chooses to do so. 7. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive.

51064 Based on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 2 (Resident #54, #72) of 2 sample mix residents reviewed for care plan. The Findings are: 1. During an interview with Resident #54 on 11/04/24 at 11:54 AM, the resident said I fell here in my room trying to use the urinal. My chair went out from under me, hit my head on the wall and ended up on my left side. My ribs are still sore. I got sent for x-rays. I've fallen twice and didn't have my brakes locked. Review of Resident #54's Care Plan with an initiated date of 2/5/2024 did not note an intervention for the residents fall on 9/27/2024. Review of Resident #54's Progress Notes dated 9/27/2024 at 1:35 PM, noted Resident #54 fell out wheelchair onto the floor and complained of head and left rib pain. Emergency Medical Services (EMS) were called. Review of Resident #54's Progress Notes dated 9/27/2024 at 1:46 PM, noted Resident #54 had a transfer/ discharge notice sent their Representative. Review of Resident #54's Progress Notes dated 9/27/2024 at 6:08 PM, noted the resident had arrived back to the facility at 6:00 PM by facility van in a wheelchair accompanied by staff. Review of Resident #54's Progress Notes dated 9/28/2024 at 1:33 AM noted day two (2) of Incident and Accident (I&A) due to falling. Review of Resident #54's Assessment list does not reveal an Incident and Accident Reports (I&A) for the residents fall on 9/27/2024. During an interview with the Director of Nursing (DON) on 11/7/24 at 2:32 PM, she stated Resident #54 has brake extenders for an intervention for the fall on 9/27/2024, but it is not on the care plan and there is no I&A. She also confirmed the fall with intervention should be on the care plan for staff to know the resident is a high risk for falls. 3. Review of Resident #54's Administration Orders dated 5/27/2024 reveal the resident has an order for Ultram oral tablet 50 milligrams (mg) (Tramadol Hydrochloride (HCL)) give 50 mg by mouth every eight (8) hours as need for pain (PRN). Opioid Monitoring: Monitor for side effects of opioid use including tolerance, increased sensitivity to pain, constipation, nausea/vomiting, dry mouth, sleepiness, dizziness, confusion, respiratory depression, itching, and sweating. Review of Resident #54's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/7/2024 noted opioid use. Review of Resident #54's Care Plan with an initiated date of 2/5/2024 does not document opioid use or the black box warning. During an interview with the DON on 11/7/24 at 2:40 PM, she confirmed Resident #54 was not care planned for opioid use and there was no black box warning on the care plan and there should be. During an interview with the Minimum Data Set (MDS) Coordinator on 11/7/2024 at 3:12 PM, she confirmed Resident #54 was not care planned for opioid use and there was no black box warning on the care plan, but that it needs to be listed on the care plan. Review of facility policy titled, Care Plans, Comprehensive Person-Centered with a revision date of December 2016 noted Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; h. Incorporate risk factors associated with identified problems. Resident #72 Admission Record reported admitted [DATE]. Diagnosis of bone disease, paralysis, spinal cord injury, and muscle wasting recorded. Review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of September 24, 2024, reported Brief Interview for Mental Status (BIMS) of 11. Review of Order Summary Report active 11/04/2024 recorded Resident #72 was prescribed and given antidepressants, opioids, and anticoagulants. Review of Care Plan with initiated date 3/25/2024 does not report Black Box Warnings for prescribed and given antidepressants, opioids, and anticoagulants including but not limited to potential side effects. During an interview with the DON on 11/6/2024 at 2:20 PM, the DON confirmed that Black Box Warnings should be included for medications such as antidepressants, opioids, and anticoagulants.

49413 51064 Based on observation, interview, record review, facility document review, and facility policy review, it was determined the facility failed to ensure female residents had hair removed from their face for 1 (Resident #46) of 1 sample mix resident to promote good hygiene; ensure residents clothing was changed when stained or dirty for 2 (Resident #24, #52) of 2 sample mix residents to promote good hygiene; to ensure residents fingernails were kept clean and trimmed for 3 (Resident #2, #179, #52) of 3 sample mix residents to promote good hygiene. The findings are: 3. On 11/4/24 at 11:30 AM, the Surveyor observed Resident #2's fingernails untrimmed with a brown/ black substance underneath the nails. Review of Resident #2's Admission Record with an admitted [DATE] revealed the resident has a need for assistance with personal care, Rheumatoid Polyneuropathy (simultaneous malfunction of many nerves throughout the body) with Rheumatoid Arthritis, and lack of coordination. Review of Resident #2's Care Plan with an initiated date of 7/6/2023 noted check the resident's fingernail length and trim as needed. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/2024 noted a score of 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) with a diagnosis of Dementia and revealed the resident is substantial to maximal assistance with shower/bathing. On 11/5/24 at 9:52 AM, the Surveyor observed Resident #2's fingernails untrimmed with a brown/ black substance underneath them. During an interview with Social Worker in the resident's room on 11/5/24 at 9:54 AM, she confirmed Resident #2's fingernails were long and dirty and said the family prefers them cleaned and trimmed not long and dirty. During an interview with Certified Nurse Aide (CNA) #9 in Resident #2's room on 11/5/24 at 9:58 AM, she confirmed Resident #2's fingernails were long and dirty and needed cleaned and trimmed. On 11/4/24 at 11:01 AM, the Surveyor observed Resident #179's fingernails with a brown/ black substance underneath them. Review of Resident #179's Admission Record with an admitted [DATE] revealed the resident has a need for assistance with personal care. Review of Resident #179's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2024 a score of 10 on the Brief Interview for Mental Status (BIMS) with a diagnosis of symptoms and signs involving the musculoskeletal system and revealed the resident is dependent for shower/bathe. Review of Resident #179's Care plan with an initiated date of 10/25/2024 noted check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an interview with Resident #179 on 11/5/24 at 9:22 AM, the resident confirmed their fingernails were dirty and the resident wants them cleaned. During an interview with CNA #10 in Resident #179's room on 11/5/24 at 10:51 AM, she confirmed the resident's fingernails were dirty and should be kept clean. During an interview with CNA #11 in Resident #179's room on 11/5/24 at 10:51 AM, she confirmed the resident's fingernails were dirty and should be kept clean. During an interview with the Director of Nursing (DON) on 11/7/2024 at 2:40 PM, she confirmed the resident's fingernails are to be kept clean and trimmed for the resident's health and hygiene. Resident # 46 had diagnoses of: cognitive communication deficit is when someone has trouble with one or more cognitive processes involved in communication, adult failure to thrive is defined as four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment. (National Institute of Health), dementia, anxiety, muscle decrease, difficulty swallowing. Resident # 46 has a Brief Interview of Mental Status of 4 indicating they are unable to answer or provide a sensible answer to the question asked. During an observation on 11/4/24 at 2:23 PM, Surveyor observed Resident #46 in wheelchair at the nurses' station unshaved with hair on lip and chin. During an observation on 11/4/24 at 3:10 PM, Resident #46 had unshaved facial hair above upper lip and on chin. October 4, 2024, through October 31, 2024, Resident # 46 shower task sheet showed to have received 16 showers. Shower task sheet showed nine not applicable dates, one refusal, one day staff provided over half the shower and grooming help and one day staff did all shower and grooming for Resident # 46. October 8, 2024, Minimum Data Set, section GG Functional Abilities, showed that personal hygiene, to include shaving, to be a level 3. Level 3 is a partial/moderate assistance where the helper does less than half the effort. Resident #46 - care plan shows ADL self-care performance deficit; provide step by step instructions Resident # 46 is scheduled for showers on Wednesday and Saturday of each week. Resident # 46 entered Facility on Resident #52's Admission Record reported admitted [DATE]. Diagnosis reported dementia, depression, reduced mobility, need for assistance with personal care, muscle weakness, lack of coordination, cognitive communication deficit, weakness, abnormal posture, unsteadiness on feet. Resident #52 Minimum Data Set (MDS) with Assessment Record Date (ARD) of September 23, 2024, reported Brief Interview of Mental Status (BIMS) score of 03. During initial rounds on 11/4/2024 at 10:00 AM Resident #52 was noted to have a shirt with what appeared to be food on it and long, dirty looking fingernails. During a concurrent observation and interview on 11/5/2024 at 1:00 PM, Resident #52 was noted to have on a shirt with what appeared to be food on it and long, dirty looking fingernails. The Licensed Practical Nurse (LPN) #4 stated Resident #52 should have on a clean shirt and nail care should be provided. During an observation on 11/7/2024 at 11:45 AM, Resident #52 had long fingernails with black matter underneath Resident #52's Care Plan with initiated date of 4/4/22 reported Resident #52 requires assistance with activities of daily living (ADL) including substantial/max assistance with oral hygiene, toilet hygiene, bathing/showering, upper and lower body dressing, and personal hygiene. Review of the facility provided a policy titled, Care of Fingernails/ Toenails with a revision date of October 2010 noted Purpose: The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes cleaning and regular trimming; 2. Proper nail care can aid in the prevention of skin problems around the nail bed; 4. Trimmed and smooth nails prevent resident from accidentally scratching and injuring his or her skin.

51064 Based on record review, observations, and interviews, the facility failed to ensure that clean linen carts were properly covered and Enhanced Barrier Precautions (EBP), were implemented for 1 (Resident #279) of 1 sampled resident to prevent potential infection and/or the spread of infections. The findings are: During observation on 11/4/2024 at 10:18 AM, the clean linen carts had the front flap completely open on halls 100, 200, 300. 400, and 500. During observation on 11/5/2024 at 4:32 AM, the clean linen carts had the front flap completely open on halls 100, 200, 300, 400 and 500. 11/7/2024 at 3:24 PM, the Director of Nursing (DON) confirmed the clean linen carts should be covered because it is clean linen. Review of a facility policy provided by the (DON) titled Policy and Procedures with subject being Enhanced Barrier Precautions had a revised date of 03/12/2024, indicated that residents with indwelling medical devices such as a central line, catheter or feeding tube should be placed on EBP to prevent the spread of infections. The policy indicated staff should wear correct personal protective equipment (PPE). Per the policy, EBP is an approach of targeted gown and glove use during high-contact resident care activities such as providing incontinent care. A review of an Admission Record indicated the facility admitted Resident #279 with diagnosis of infectious disease that included kidney failure and urine retention. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicates the resident was independent for their daily decision making. Review of Resident #279's Care Plan revised on 05/22/2024 revealed the resident required Enhanced Barrier Precautions due to indwelling urinary catheter. Interventions included that gloves and gowns were required prior to performing high-contact care. On 11/04/2024 at 11:30 AM, Certified Nursing Assistants (CNA) #5 and #6 were observed performing incontinent care for R#279. While performing care they did not have on a gown. Resident was on Enhanced Barrier Precautions. On 11/04/2024 at 11:45 AM during an interview, CNA # 5 stated she should have put on a gown and mask. On 11/04/2024 at 11:50 AM, during an interview CNA # 6 stated she should have worn a gown and mask sue to the potential for spreading infections. On 11/05/24 at 3:10 PM, during an interview the DON stated both CNAs should have worn gloves and a gown because the resident had an indwelling catheter and was on EBP During an observation on 11/5/2024 at 9:50 AM, CNA #5 entered a contact precaution room. Without donning personal protective equipment (PPE) or performing hand hygiene the CNA #5 grabbed the resident in contact isolation by the shoulders and repositioned the resident. During an observation on 11/5/2024 at 3:00 PM, Licensed Practical Nurse (LPN) #4 entered a contract precaution room. Without donning PPE or performing hand hygiene the LPN #4 grabbed the residents over-the-bed table and brought it into the hallway to hold wound care supplies. During an interview on 11/5/2024 at 3:30 PM, the Registered Nurse (RN) #7 stated that before entering a contact isolation room the staff should perform hand hygiene and don PPE. Facility provided Infection Prevention & Control Program policy dated 04/21 stated that gloves and disposable gown should be worn when providing care for residents on contact precautions.

Based on observation, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure residents were dressed appropriately for the day for 1 (Resident #179) of 1 sample mix residents. The findings are: On 11/4/2024 at 11:01 AM, Surveyor observed Resident #179 lying in bed in a hospital gown. Review of Resident #179's Admission Record with an admitted [DATE] revealed the resident has a need for assistance with personal care. Review of Resident #179's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2024 noted a score of 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS) with a diagnosis of symptoms and signs involving the Musculoskeletal system, and revealed the resident requires partial assistance with dressing upper body and dependent for dressing the lower body. Review of Resident #179's Care plan with an initiated date of 10/25/2024 noted the resident requires partial assist to dress upper and lower body. On 11/5/2024 at 9:29 AM, the Surveyor observed Resident #179 is sitting in wheelchair in their room in a hospital gown. Resident #179 confirmed they preferred to be dressed in their own clothing and showed this surveyor the dresser with the residents daily clothing in it. The resident confirmed needing assistance to put on clothing. During an interview with Certified Nursing Assistant (CNA) #10 in Resident #179's room on 11/5/2024 at 10:49 AM, the CNA confirmed the resident was dressed in a hospital gown and should be dressed in their own clothing. During an interview with CNA #11 in Resident #179's room on 11/5/2024 at 10:49 AM, the CNA confirmed the resident was dressed in a hospital gown and should be dressed in their own clothing. During an interview with the Director of Nursing (DON) on 11/7/2024 at 2:40 PM, she confirmed it is a resident's right to be dressed to maintain their dignity. Review of a facility policy titled, Resident Dignity with an effective date of 4/2021 noted Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation: Residents shall always be treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 1 of 1 meal observed. The findings are. 1. On 11/04//2024, the menu for noon meal documented residents on pureed diets were to receive 3/4 cup of pureed spaghetti. a. On 11/04/24 at 11:34 AM, DC #2 used a 4-ounce ladle spoon (1/2 cup) to place 4 servings of spaghetti with meat sauce into a blender and pureed, instead of 3/4 cup. At 11:35 AM, DC #2 poured the pureed spaghetti into a pan, covered it with foil and placed it in the oven. 2. On 11/04/24 at 12:20 PM, DC #2 used a #10 scoop (1/3 cup) to serve a single portion of pureed spaghetti with meat sauce to the residents who required pureed diets, instead of 3/4 cup. 3. On 11/04/24 at 12:50 PM, DC #2 when asked during an interview what spoon size she had used when portioning spaghetti with meat sauce into a blender to be pureed. DC #2 stated she used 4-ounce ladle spoon when putting it into a blender to puree and used #10 scoop to give a single serving to each resident. When asked if she looked at the menu, DC #2 mentioned she did not. They should have received the same amount as the other residents.

Based on observation, record review, interview, and review of the facility policy, 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 those residents who required pureed diets for 1 of 1 meal observed. The findings are: 1. On 11/04/24 at 11:34 AM, during the noon meal preparation. The DC #2 used a 4-ounce ladle spoon to place 4 servings of spaghetti with meat sauce into a blender and pureed. At 11:35 AM, DC #2 poured the pureed spaghetti into a pan, covered it with foil and placed in the oven. The consistency was chunky and was not smooth. There were chunks of noodle visible in the mixture. 2. On 11/04/24 at 12:20 PM, the following observations were made during the noon meal service in the kitchen. a. The residents on the pureed diets were served pureed spaghetti. The consistency was lumpy and was not smooth. There were pieces of noodles in the mixture. b. Pureed bread consistency was runny. c. At 12:47 PM, DA #1 confirmed the consistency of the pureed bread was runny because she had used too much milk and less bread. Also stated pureed spaghetti needed more juice, it was thick, and you can still see pieces of noodles. d. On 11/04/24 at 12:50 PM, DC #2 confirmed the pureed spaghetti was chunky that it should have been like pudding or mashed. e. On 11/04/24 12:51 PM, the Dietary Manager confirmed pureed spaghetti was chunky and was not smooth. Pureed foods should be like pudding or mashed potato with no lumps. f. A review of a facility policy titled, Puree Definition, not dated and provided by the Dietary Manager on 11/5/2024, indicated all foods are moistened and processed until smooth (no lumps) to an applesauce-like or pudding consistency. Food should be prepared so that it is smooth throughout, there are no lumps, it is not pasty, sticky or gummy and not runny.

Based on observation, interview, record review, and facility document review, it was determined that the facility failed to ensure proper assistive devices are utilized during meals for 1 (Resident #52) of 1 sample mix residents observed during meals who feed themselves. Findings include: During an observation on 11/4/2024 at 12:49 PM, Resident #52 was observed having difficulty with feeding self with regular fork. Using fingers of the resident's other hand to assist with food placement on utensil. A review of the Admission Record noted Resident #52 was admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease (condition that affects blood flow to limbs. Resident also has diagnosis of Dementia (condition that affects brain function such as memory, judgement, and daily function), reduced mobility, muscle weakness, lack of coordination, Dysphagia (difficulty swallowing food), and abnormal posture. Review of Resident 52's Care Plan, initiated 4/9/2024, revealed the resident demonstrates some or high risk to potentially choke, aspire foods or liquids. This problem is related to diagnosis of Dysphagia. It also noted some interventions staff would do is provide needed assistance PRN (as needed), and that the resident is setup/clean up assist with meals, an intervention for Physical and Occupational Therapy to evaluate and screen as needed and ordered. Review of OT (Occupational Therapy) Discharge Summary on 5/24/2024, patient will safely perform self-feeding tasks with supervised assist with use of built-up spoon and occasional verbal cues and 0% tactile cues for grasp / release of items and for use of compensatory strategies due to body part awareness impairments in order to increase ability to eat in environment with minimal to no supervision or assistance needs. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/23/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 03, which indicates the Resident had severe cognitive impairment. During an interview with Certified Nursing Assistant (CNA) #12 on 11/4/2024 at 12:50 PM, she said Resident #52 would benefit with a different kind of eating device and was having trouble eating the spaghetti. During an observation on 11/5/24 at 12:25 PM, the Surveyor observed Resident #52 putting fingers in food and scooping it on to the spoon. Staff was assisting feeding Resident #52 at times. Resident continues to have difficulty with feeding self. During an observation on 11/6/2024 at 12:20 PM, the Surveyor observed Resident #52 eating lunch with the lunch plate sitting on a tray. Resident #52 was observed by Surveyor attempting to feed self by dropping food on the clothing protector and tray and continued having difficult with using a spoon. During an interview on 11/7/2024 at 2:30 PM with Director of Rehabilitation, she confirmed based on the last assessment, Resident #52 needed a built-up spoon for eating.

Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure physician orders were in place for wound care treatment for 1(Resident #24) of 1 sample mix residents reviewed for pressure ulcer that was acquired within the facility. Findings include: A review of an Admission Record noted Resident #24 was admitted to facility on 4/12/2024 with a diagnosis of Alzheimer's Disease (Disease that destroys memory and mental functions). Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 03, which indicates the Resident had severe cognitive impairment. Section M subsection M0300 part F revealed that there was one (1) unstageable pressure ulcer. Review of Resident 24's Care Plan, with an initiated date of 7/19/2024, revealed Resident #24 has an unstageable pressure ulcer to the coccyx (small triangular bone at lower back); unstable pressure injury coccyx with interventions that include: assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the Medical Doctor (M. D.), Notify M.D. of abnormal findings/changes to site. Review of Resident #24's Clinical Physician Orders with a start dated of 10/22/2024 noted the use of debridement ointment to be applied to coccyx. Review of Resident #24's Order Report Weekly Wound Eval with a date of 11/4/2024 revealed that current treatment order that was ordered on 10/21/2024 and noted clean unstable pressure injury coccyx with wound cleanser, apply debridement ointment/bordered gauze qd (every day) /prn (as needed) till healed. During an interview with Licensed Practical Nurse (LPN) #4 on 11/7/2024 at 10:11 AM, she confirmed Resident #24's pressure ulcer treatment only mentioned in the physician's orders for the medication to be used and that she will put the full order in now.

Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure physicians orders were followed for follow up doctor's appointments and physician's orders for wound care for 1 (Resident #6) of 1 resident reviewed for discharge from hospital following surgery. Findings include: On 07/03/2024 at 5:21 PM, the DON (Director of Nursing) stated the facility did not have a policy for physician's orders. A review of the Admission Record, indicated the facility admitted Resident #6 with diagnoses that included displaced bimalleolar fracture of left lower leg, other fracture of left lower leg, and repeated falls. A review of Resident #6's Care Plan revealed the resident was at risk for falls, and the resident returned with left lower leg splinted from orthopedic surgical repair of the left ankle. Interventions included encourage resident to use call light in bathroom for assistance related to a fall on 05/06/2024 this was initiated on 05/07/2024. A review of Patient Visit Information, revealed Resident #6 had been seen by the emergency roiagnom on [DATE] and diagnosed with bimalleolar ankle fracture with instructions to see orthopedic doctor next day or return to the emergency room with worsening symptoms. A review of Patient Visit Information, revealed Resident #6 had orders at discharge from the hospital to please keep splint clean, dry, and intact. Follow up with primary physician for one week follow up and follow up with orthopedic surgeon in 10 days this was dated 05/14/2024. A review of Visit Notes, revealed Resident #6 had a follow up appointment on 06/17/2024 which was a visit in the nursing home seen for open trimalleolar fracture of left ankle which stated in the plan missed the first orthopedic follow up appointment but there was a plan for a rescheduled appointment upcoming. A review of Progress Note, revealed Resident #6 had a follow up appointment with orthopedic surgeon on 06/19/2024 with a new order for wound care due to incisional infection to the medial side that included wet to dry dressings daily. See back in one week for wound check. A review of a physician's order on 06/19/2024 revealed Resident #6 had daily or as needed wound care to the left medial malleolus for open surgical site. A review of June TAR (Treatment Administration Record), revealed Resident #6 had a physician's order for daily dressing changes of the 7 ordered days 2 days were blank on the TAR, June 21-22. A review of Progress Note, revealed Resident #6 had a follow up appointment on 06/26/2024 with orthopedic surgeon with a plan to admit to hospital following a clinic evaluation which revealed medial side open incision with hardware exposed. Consider possible BKA (below the knee amputation). During an interview on 07/02/2024 at 5:09 PM, the DON stated there was not a separate visit note for the primary care follow up, the physician combined the follow up with the monthly visit. No documentation was provided to show Resident #6 had seen the doctor one week following hospital discharge. As far as the orthopedic follow up the resident had an appointment for 06/10/2024 but the transport was a no call no show and ended employment so the follow up appointment was rescheduled for 06/19/2024. During an interview on 07/03/2024 at 3:35 PM, the treatment nurse stated treatments in the building are done by treatment nurse and house supervisor on the weekend. The treatment nurse stated if it is not signed off then it is not done. The treatment nurse was aware of daily wound care but was working the floor one of the missing days and the other was a weekend day. During an interview on 07/03/2024 at 4:54 PM, the DON confirmed if wound care is not signed off on the TAR, then it is not done and if the treatment nurse is unavailable then the charge nurse should ensure wound care is completed.

Based on observation, interview, and record review, the facility failed to remove damaged canned goods from storage areas, and to maintain the kitchen can opener in a clean and sanitary manner. These failed practices had the potential to affect 77 residents who received meals from the kitchen. The findings are: On 12/05/2023 at 04:45 PM, the industrial can opener that was attached to the metal preparation table in the kitchen was encrusted with solid, dried substances. On 12/07/2023 at 10:31 AM, a tour of the kitchen pantry revealed: 1. One 6 pound 9 ounce can of sliced pears with a dent on the top of the can to include the seal. 2. Two 7 pound 5 ounce jellied cranberry sauce with dent on top of the can to include the seal. 3. One can of pork and beans indented on the side of the can. 4. Four 6 pound 10 ounce cans with dents on top of the cans to include the seal. On 12/07/2023 at 12:10 PM, the Dietary Manager confirmed there should not be any dents on the canned food and there should not be any debris on the can opener from previously opened cans to prevent contaminating the food that was being served to the residents. A policy provided by the DON on 12/7/23 at 4:35 PM titled, Employee Sanitary Practices documented, .9. Clean and sanitized equipment and work areas after use . A policy provided by the Administrator on 12/08/2023 at 09:07 AM titled Food Storage documented, .Procedure: .7.d. Foods will be stored and handled to maintain the integrity of the packaging until ready for use .

Based on observation, interview, and record review the facility failed to ensure isolation precaution signs with instructions for personal protective equipment (PPE) (gown, mask etc.) needed when entering the room was placed on the door for 2 (Residents #29 and #340) and staff provided proper isolation procedures when dispensing ice for 1 (Resident #340) of 2 (Residents #29 and #340) sampled residents who were on isolation precautions. The findings are: 1. On 12/5/23 at 4:24 pm, observed on Resident #340's door a 'see nurse before entering' sign, and the door was open with 2 large red barrels by the door. There was no signage indicating the resident was on isolation or what personal protective equipment (gown, mask etc.) was needed when entering the room. a. On 12/6/23 at 8:20 am, observed no isolation signage on Resident #340's door. The door was open with 2 red barrels in front of door and a 'see nurse before entering' sign was on the door. b. On 12/6/23 at 2:06 pm, observed no isolation signage on Resident #340's door. The door was open with 2 red barrels in front of door and a 'see nurse before entering' sign was on the door. Observed CNA #1 removing a water cup from Resident #340's isolation room and use a community ice scoop and ice to fill the cup and then return the scoop to the ice container. c. On 12/6/23 at 2:12 pm, the Surveyor asked CNA #1 if that was the proper way to get ice water for a resident in isolation. CNA #1 confirmed I didn't even know she was in isolation. The Surveyor asked what is the proper way to get ice water for a resident who is in isolation? CNA #1 said I guess do hers last. d. On 12/7/23 at 10:43 am, the Surveyor asked Certified Nursing Assistant (CNA) #2 how do you know a resident is in isolation. CNA #2 said that there is a sign that states see nurse before entering. The Surveyor asked if you can't find a nurse immediately and you have an emergency going on in that room, how do you know what PPE to don and doff? CNA #2 said well, I would put on my gown and gloves for sure. The Surveyor asked CNA #2 what the proper way is to give a resident water when they are in isolation. CNA #2 said I don't know. e. On 12/7/23 at 10:50 am, the Surveyor asked the Infection Preventionist what your policy is for providing ice water to a resident who is in isolation? The Infection Preventionist said nothing should come out of that room. So, bring a cup in and leave it in the room. The Surveyor asked when the last training was to your staff on isolation regarding the proper way to pass ice water. The Infection Preventionist said I have never done an in service on passing ice water for isolation residents. f. On 12/7/23 at 10:55 am, the Surveyor asked the Director of Nursing (DON) when a resident is in isolation what should be on the door. The DON said a see nurse before entering sign. The Surveyor asked how do staff and visitors know what PPE to don and doff? The DON said the nurse will tell them what to put on. The Surveyor asked what if a visitor cannot find a nurse on the hall, what do they do? The DON said well that is the only signage since covid that they want us to use. The Surveyor asked the DON what your policy is for providing ice water to a resident who is in isolation. The DON said you would take a new cup of ice water into the room each time. You would never bring the cup out of the room. 2. Resident #29's Physician's Order Summary showed contact isolation related to extended spectrum beta-lactamase (ESBL) (an enzyme found in some strains of bacteria) in the urine. a. The Care Plan showed the resident was on contact isolation related to ESBL in the urine. Set up isolation per facility protocol. b. On 12/05/23 at 11:50 PM, observed Resident #29 had a barely legible sign on the door covered by a Christmas stocking that read, 'See Nurse before Entering'. No other signage was available on the door with instructions for the type of isolation. c. On 12/06/23 at 08:17 AM, observed no isolation instruction sign on the door. The only sign was a 'See Nurse before Entering' that is covered by a Christmas stocking. d. On 12/06/23 at 03:14 PM, observed no isolation sign on Resident # 29 door. The only sign available showed a barely legible See Nurse before Entering sign that was covered by a Christmas stocking. e. On 12/8/23 at 11:35 AM, the Surveyor asked the DON how staff and visitors were made aware that a resident is on isolation. The DON said there is a sign on the door that says, 'See Nurse Before Entering'. The Surveyor asked what if the sign is unreadable. The DON said It shouldn't be. The Surveyor asked should a sign be covered by an item. The DON said No. The DON confirmed the sign on the door was unreadable and should not be covered. 3. A policy provided by the DON on 12/7/23 at 11:25 AM titled, Isolation-Categories for Transmission Based Precautions (Effective Date: 4/2021) showed, .8. Signs .v. This facility utilizes a system for identification of Contact Precautions for staff and visitors . 49071

Based on observation and record review, the facility failed to ensure an effective pest control program was in place to keep the kitchen area free of rodents. The findings are: On 12/05/2023 at 4:50 PM, the Surveyor witnessed a mouse run out of the rodent trap located under the dishwasher sink on the right-hand side by the wall. The mouse ran to the end of the leg of the dishwasher sink then turned around and entered back into the rodent trap. The mouse remained in the trap just beyond the opening. The facility pest control logs showed evidence of rodents being active within the facility beginning on 08/03/2023 as follows: 1. On 08/03/2023, a (Pest Control Company Name) Detailed Service Report noted a mouse glue board and bait was placed throughout the building. 2. On 08/15/2023, a (Pest Control Company Name) Detailed Service Report noted the company returned to the facility with one rodent captured outside the building. All rodent traps were cleaned and rebaited. 3. On 09/20/2023, the facility contacted (Pest Control Company Name) confirming there were mice in the kitchen area. (Pest Control Company Name) checked the inside rodent traps, no rodents were in the traps. The kitchen was treated for general pests. Rodent traps were cleaned and baited, and glue traps were set out. 4. On 10/20/2023 the facility contacted (Pest Control Company Name) to confirm there were mice in the kitchen area. No rodents were in the traps. Traps were cleaned and repositioned. 5. On 11/06/2023 the facility contacted (Pest Control Company Name) to confirm there were mice in the kitchen area. No rodents were in the traps. Traps were cleaned and repositioned. A policy provided by the Director of Nursing (DON) on 12/08/2023 at 08:12 AM titled Pest Control [Effective 4-2021] showed, Our facility shall maintain an effective pest control program. On 12/08/2023 at 10:28 PM, the Dietary Manager confirmed that the facility kitchen had an issue with rodents and that mice were frequently seen. On 12/08/2023 at 10:45 PM, the Administrator confirmed the facility did have issues with pests, and while there was a pest control program in place, it was not effective if rodents were being seen in the kitchen.

Based on observation, interview, and record review, the facility failed to follow care planned interventions for nail care for 1 (Resident #51) of 6 (Residents #12, #37, #43, #50, #51 and 78) sampled residents who had a diagnosis of Diabetes and required assistance with nail care. The findings are: Resident #51 had diagnoses of traumatic brain injury, type 2 diabetes without complications, and need for assistance with personal care. On 12/05/2023 at 04:20 PM, Resident #51 was lying in bed. Contractures were noted in both hands. The fingernails on both hands extended 3/8 inch beyond the tips of the fingers and had jagged edges. The fingernails were pressing into the resident's palms. On 12/06/2023 at 08:06 AM, Resident #51 was lying in bed with contractures noted in both hands. The fingernails on both hands extended 3/8 inch beyond the tips of the fingers and had jagged edges. The fingernails were pressing into the resident's palms. On 12/07/2023 at 11:47 AM, Resident #51 was lying in bed with contractures noted in both hands. The fingernails on both hands extended 3/8 inch beyond the tips of the fingers and had jagged edges. The fingernails were pressing into the resident's palms. A Care Plan with an initiated date of 09/02/2022 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] Disease Process diffuse brain injury with resulting impairment of bilateral upper and lower extremities . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . On 12/07/2023 at 03:40 PM, Licensed Practical Nurse (LPN) #3 confirmed that Resident #51 had a diagnosis of Diabetes and was care planned to have fingernails maintained to avoid sharp or jagged edges. LPN #3 confirmed that Resident #51 required nail care from a nurse or podiatrist due to the diagnosis of Diabetes and the resident did not refuse nail care. On 12/07/2023 at 3:50 PM, the Director of Nursing (DON) confirmed that Resident #51 had a diagnosis of Diabetes and required nail care from a nurse or podiatrist. The DON confirmed that Resident #51 was care planned to receive nail care with baths. A policy titled, Care of Fingernails/Toenails, provided by the Administrator on 12/08/2023 at 08:30 AM documented, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes cleaning and regular trimming .4. Trimmed and smooth nails prevent the resident from accidentally scratching or injuring his or her skin .

Based on observation, record review and interview, the facility failed to ensure the environment was free of potential accident hazards as evidenced by failure to ensure a curling iron was not plugged in for 1 (Resident #20) sampled resident who was independently ambulatory on the 200 Hall; and mouthwash and razors were not left in the bathroom for 1 (Resident #37) sampled resident who was independently ambulatory on the secured unit as documented on a list provided by the Administrator on 12/7/23 at 2:17 PM; and oxygen signage was placed on the door for 5 (Residents #28, #42, #44, #50 and #339) sampled residents who received oxygen as documented by a list provided by the Administrator on 12/7/23 at 4:45 PM. The findings are: 1. On 12/5/23 at 3:08 PM, observed a curling iron by Resident #20's bedside plugged in and turned on. a. On 12/5/23 at 5:46 PM, observed a curling iron by Resident #20's bedside plugged in and turned on. b. On 12/6/23 at 3:51 PM, observed a curling iron by Resident #20's bedside plugged in and turned on. c. On 12/7/23 at 10:55 AM, during an interview the Surveyor asked the Director of Nursing (DON) what the facility policy was regarding a resident keeping a curling iron in their room. The DON confirmed that there should not be a curling iron in a resident's room. d. On 12/7/23 at 11:34 AM, during an interview the Surveyor asked Licensed Practical Nurse (LPN) #1 what the facility policy was for leaving a curling iron out in a resident room. LPN #1 confirmed that they should not have one. 2. On 12/5/23 at 2:52 PM, observed Resident #339 receiving oxygen at 2 liters via nasal cannula. There was no oxygen signage on door. a. On 12/5/23 at 6:08 PM, observed Resident #339 receiving oxygen at 2 liters via nasal cannula. There was no oxygen signage on door. b. On 12/6/23 at 2:12 PM, observed Resident #339 receiving oxygen at 2 liters via nasal cannula There was no oxygen signage on door. 3. Resident #37's diagnoses showed Alzheimer's disease and dementia with agitation. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/23 showed the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with indoor mobility and had no impairment to functional range of motion. a. On 12/05/23 at 04:50 PM, observed 5 disposable razors on top of the sharp's container on the wall beside the sink and a 7.5-ounce bottle of mouthwash sitting on the sink. b. On 12/05/23 at 05:58 PM, observed 5 disposable razors on top of the sharp's container and a 7.5-ounce bottle of mouthwash sitting on the sink. c. On 12/07/23 at 03:32 PM, the Surveyor asked Certified Nursing Assistant (CNA) #4 what is your process after completing activities of daily living? CNA 4 stated I wash my hands, discard the used razors in the sharps container and put away all other items. The Surveyor asked where the items are stored. CNA #4 stated we have our sharp items in a locked cabinet in the supply room. The Surveyor asked where do you store the mouthwash? CNA #4 stated in a labeled bag in the same locked cabinet. The Surveyor asked is it appropriate to leave unused items in the resident's bathroom such as razors and mouthwash? CNA #4 stated, Absolutely not. d. On 12/07/23 at 03:40 PM, the Surveyor asked LPN #4 who was responsible for putting away toiletries. LPN #4 stated the CNA's when they are done with them. The Surveyor asked what type of supervision is provided to the residents and by whom. LPN #4 said there is a CNA always assigned to the secure unit, if the CNA needs a break, then I go sit back there. The Surveyor asked if it was appropriate for used and unused toiletry items, such as razors and mouthwash, to be left in the resident's bathroom. LPN #4 stated, No. 49071

Based on observation, interview, and record review, the facility failed to follow care planned interventions to elevate the head of bed when administering medications and enteral nutrition for to one (Resident #51) of three (Residents #29, 51, 79) sampled residents with percutaneous endoscopic gastrostomy (PEG) tubes. The findings are: On 12/05/2023 at 04:20 PM, Resident #51 was lying in bed with a PEG tube in place. The PEG tube was connected to an infusion pump set to administer 55 cubic centimeters (cc) per hour. The head of Resident #51's bed was positioned at 15 degrees from horizontal. On 12/06/2023 at 08:06 AM, Resident #51 was lying in bed with a PEG tube in place. The PEG tube was connected to an infusion pump set to administer 55 cc per hour. The head of Resident #51's bed was positioned at 19 degrees from horizontal. On 12/06/2023 11:47 AM, Resident #51 was observed lying in bed with the head of the bed at 9 degrees from horizontal. [NAME] foam and bubbles were flowing from Resident #51's mouth. On 12/06/2023 at 11:49 AM, the Director of Nursing (DON) was asked to accompany the Surveyor to the room of Resident #51. The DON asked Resident #51's nurse, LPN #2, to assess the resident. LPN #2 stated the resident had been [producing foam and bubbles] for a while. The DON asked LPN #2 if the provider for Resident #51 had been informed. LPN #2 stated the provider had not been informed and left the room without elevating the head of Resident #51's bed. On 12/07/2023 at 4:40 PM, the DON confirmed that the head of Resident #51's bed should have been inclined 30 to 45 degrees when the resident was receiving enteral nutrition or medications through their PEG tube. Resident #51 had a diagnosis of traumatic brain injury. Resident #51 had a PEG tube in place with Physician Orders as follows: 1. (Nutritional Supplement) 1.5 at 55cc per hour, flush every 4 hours with 170 milliliters of water. Order Date 01/11/23. 2. Flush enteral tube with 30 milliliters water before and after medications. Order Date 09/02/22. 3. Nothing by Mouth (NPO) diet. Order Date 09/02/22. The Care Plan with an initiated date of 09/02/2022 documented, .I am receiving a tube feeding & it has been determined to be medically necessary and at risk for complications: .is being used as the only source of nutrition and hydration .Elevate the resident head of bed @ 30-45 degrees unless contraindicated . A policy and procedure provided by the DON on 12/08/2023 at 08:12 AM titled, Policies and Procedures .Enteral Nutrition, documented, Policy Statement Adequate nutritional support through enteral feeding will be provided to residents as ordered .will be consistent with current standards of practice, the resident's advanced directives, treatment goals, and facility policies .

Based on interview, and record review the facility failed to ensure 3 (Residents #22, #29, and #35) sampled residents had an Advance Directive readily available in their clinical record. The findings are: 1. Resident #22's diagnosis showed dementia without anxiety, behavioral, psychotic, or mood disturbance. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] showed the resident scored 7 (,d+[DATE] indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) a. A Physician's Order dated [DATE] showed DNR (do not resuscitate). b. The Care Plan with an initiated date of [DATE] showed Resident #22 had requested that no cardiopulmonary resuscitation (CPR) measures are to be performed. Please follow my DNR instructions. Please follow my instructions as detailed inside my Advance Directives &/or Living Will if I have one. c. On [DATE] at 02:10 PM, the Surveyor requested the Advance Directive for Resident # 22. d. On [DATE] at 02:44 PM, the Admissions Coordinator provided a Power of Attorney/Health Care Proxy for Resident #22 signed by the resident on [DATE]. This paperwork was in the Admissions office and not readily available. 2. Resident #29's diagnoses showed dementia with other behavioral disturbance, schizophrenia, cognitive communication deficit, and oral dysphagia. The MDS with an ARD of [DATE] showed the resident was severely cognitively impaired. a. The Care Plan with an initiated date of [DATE] showed Resident #29 had requested that CPR measures are to be performed and to follow the instructions as detailed inside my Advance Directives &/or Living Will if I have one. b. On [DATE] at 12:36 AM, the Surveyor reviewed a Physician's Orders for Life Sustaining Treatments (POLST) on file with a Resuscitation Designation Order dated [DATE] signed by a family member. c. On [DATE] at 02:10 PM, the Surveyor requested an Advance Directive for Resident # 29. d. On [DATE] at 02:44 PM, A Resuscitation Designation Order provided by the Admission Director signed by Resident # 29's family member dated [DATE] showed, .I do desire cardiopulmonary resuscitation to be performed . No selection for living will, Power of Attorney/Health Care Proxy, or to formulate/not formulate an Advance Directive. 49071 3. On [DATE] at 2:35 PM, during record review, Resident #35's electronic medical record did not contain an Advance Directive. a. On [DATE] at 11:18 AM, during an interview the Surveyor asked the Social Worker what the facility's policy was regarding a resident having an Advance Directive. The Social Worker confirmed that it is in the admission packet. The Surveyor asked should an Advance Directive be available for staff to locate. The Social Worker said yes, we have it in the computer for them. b. On [DATE] at 11:24 AM, during an interview the Surveyor asked Licensed Practical Nurse (LPN) #1 what is your facility policy regarding a resident having an Advance Directive. LPN #1 confirmed that every resident should have one. The Surveyor asked should an Advance Directive be available for staff to see. LPN #1 confirmed yes it should. The Surveyor asked where it was located. LPN #1 confirmed it is in (Facility Computer Software) under documents. c. On [DATE] at 11:33 AM, during an interview the Surveyor asked the Admissions Coordinator what the facility's policy is regarding Advance Directives. The Admissions Coordinator confirmed that it is in the admission packet, and she scans them into the computer. The Surveyor asked should an Advance Directive be available for staff on the computer. The Admissions Coordinator said yes, that is why I scan them in. The Surveyor asked should an Advance Directive be in an office instead of the computer. The Admissions Coordinator said that she scans them into the computer and keeps a copy in the resident' folder in my office as a backup. The Surveyor asked if the staff have access to her office all the time. The Admissions Coordinator said no they do not. e. On [DATE] at 2:07 PM, the Director of Nursing (DON) provided a policy titled, Policy and Procedures .Advance Directives, documented, .7. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record .

Based on record review and interview the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a mechanical lift transfer of 1 (Resident #1), which resulted in a fall with the resident sent to the emergency room for evaluation of complaint of pain to touch of right hip. This failed practice had the potential to affect 12 residents who require a mechanical lift for transfers. The findings are: Review of Resident #1's comprehensive plan of care dated [DATE], showed the resident was a potential risk for falls, had contractures to bilateral hips and legs, was non ambulatory, and required a mechanical lift x 2 staff for all transfers with a bariatric lift #13 pad. Review of Resident #1 ' s nurses note dated [DATE] at 7:29 AM, showed the nurse was called into Resident #1's room by a Certified Nursing Assistant (CNA) who reported the resident fell and landed on the floor during a mechanical lift transfer. During post fall assessment, the resident complained of right hip pain to touch and was transferred to the emergency room for evaluation and treatment. During an interview with the Director of Nursing (DON) on [DATE] at 11:11 AM, she said on the morning of [DATE], one CNA attempted to transfer the resident using a mechanical lift from the bed to a chair when a strap became unhooked and caused the resident to slip from the lift to the floor. The DON stated the facility recommendation is to use 2 persons for a mechanical lift transfer and the facility policy is for 2 persons. The diagnostic tests from the hospital were negative for acute intracranial abnormalities, acute fractures, or injuries. The emergency room physician kept the resident for observation. During the hospital stay, the resident expired. Review of the facility policy titled, Use of a Mechanical Lifting Machine provided by the Administrator on [DATE], showed general guidelines of two staff members when available, are needed to move a resident with a floor-based full body lift.

Complaints # (AR 946) and # (AR 947) were substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure mechanical lift transfers were conducted in accordance with the manufacturer's instructions to prevent potential accidents / injuries for 1 (Resident #1) of 4 (Residents #1, #3, #4 and #5) case mix residents who required a mechanical lift for transfers. This failed practice resulted in immediate jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #1, who was transferred via mechanical lift with her wheelchair tilted backwards at approximately 45 degrees and the brakes unlocked as she was lowered into the wheelchair, had the potential to affect 8 residents who required the use of a mechanical lift, according to a list provided by the Administrator on 8/21/18 at 6:10 p.m The facility Administrator was informed of the Immediate Jeopardy situation on 8/21/18 at 5:55 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/18 documented the resident scored 15 (13-15 indicates cognitively independent) on the Brief Interview for Mental Status (BIMS), was totally independent on 2 staff for transfers and had functional limitation in range of motion to the upper and lower extremity on both sides. a. The Plan of Care dated 7/31/18 documented in the Focus section, I require total assist x (times) 2 staff with bed mobility, transfer . The Intervention section documented, .I require assist x 2 staff with a mechanical lift with all transfers. b. A Nurse's Note dated 8/10/18 at 2:10 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, While transferring resident into W/C (wheelchair), part of the lift (where the pad hooks) touched resident's face and caused a bruise to left side of chin. No other injury noted. Resident stated no pain, just a little sore. Resident, family and physician aware. c. An Accident/Incident Report dated 8/10/18 at 2:30 p.m. documented, 500 hall CNA (Certified Nursing Assistant) notified this nurse when transferring (Resident #1) into her w/c, the part of lift where the pad hooks touched the chin of resident . Recommended steps to prevent recurrence: One on one in-service with the CNA about proper lift usage. d. On 8/21/18 at 1:45 p.m., Resident #1 was asked if she had ever been involved in an accident involving the mechanical lift. She stated, Yes. I was dropped out of one about 4 years ago. Then, not long after that, I was dropped again. One of the straps broke on the pad. She was asked if there had been a more recent incident. She stated, A week ago this past Friday, that hook thing hit me right here (pointing to her chin). I know she didn't mean to, but you have to be careful with those things and not get in a hurry. She had unhooked two of the straps and then she somehow jerked the thing, and it hit me in face. I screamed because it hurt. e. On 8/21/18 at 1:50 p.m., CNAs #1 and #2 were observed transferring the resident using a mechanical lift. A lift pad with purple trim was under the resident in the w/c. The lift pad loops (green and pink) were attached to the 4-point cradle. The resident was transferred to the bed without incident. Peri-care was performed on the resident, and then she stated she was ready to get back in the w/c. CNA #1 stated, This will be a unique transfer. I mean, it's sort of an illegal transfer. But it is what we have figured out is easiest on her, because her knees don't bend . At this time, the resident's sling was connected to the mechanical lift as previously described, then CNA #2 operated the lift to raise the resident off of the surface of the bed. CNA #1 then sat on the edge of the resident's bed, took the resident's w/c, and tilted the wheelchair back at a 45-degree angle, holding the back of the w/c against her lap. When CNA #2 got the resident maneuvered closer to the w/c, CNA #1 held onto the tilted w/c with one hand, and reached and grabbed the loop on the back of the lift pad with her other hand to guide the resident into the chair. The w/c brakes were not locked at any time during this procedure and the w/c remained in the tilted position until the resident was completed lowered into the chair. The w/c with the resident in it was then placed back into the upright position by CNA #1. CNA #1 stated, See? This was easy for her. The CNAs were asked why it was possible to lift the resident from the w/c to the bed using a standard and safe technique, but not possible to put her back in the w/c using the same standard and safe technique. CNA #1 stated, Her knees don't bend, and this is the most comfortable way to do it for her. CNA #1 was asked if the facility had tried a different type of chair, such as a Broda or high-back w/c, that would recline, to allow the resident to be safely transferred and lowered into a position that was suitable for her. She stated, She used to be in a geri-chair, but she didn't want that. At this time the resident stated, I didn't like the geri-chair and I wanted out of it. CNA #1 was asked who all transferred the resident using this technique. She stated, Everyone does, but there's only a handful of us who know how to do it like this . She was asked how the resident was transferred if she wasn't here to get her up. She stated, She has been known to refuse to get up if there was no one here she trusted to do it. Day shift gets her up, evening shift lays her down. f. On 8/21/18 at 2:24 p.m., the surveyor began explaining the observation of the transfer to the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) when the DON stated, Oh yeah. That transfer technique is what works for her. Therapy has actually watched them do it and said it was okay . The surveyor proceeded to explain to the Administrator and ADON how the transfer was done and used a chair to demonstrate how the w/c was positioned. g. On 8/21/18 at 3:45 p.m., the DON was asked why a Broda chair or reclining w/c of some type was not being used for the resident, if a reclined position was more comfortable for the resident during transfer. She stated, I can't really answer that, because I didn't know they were transferring her that way. She was asked about the earlier comment regarding that being the best transfer technique for her and that therapy had approved it. She stated, I think I was getting a different resident mixed up with this one. If I had known they were doing it like that or were having trouble, I could have ordered a Broda, because I've done that for several others. h. On 8/21/18 at 4:00 p.m., the resident was asked about the incident on 8/10/18 when the lift bar hit her in the chin. She was asked if it happened when the CNAs were transferring her from the w/c to the bed, or from the bed to the w/c. She named the two CNAs involved and stated, It happened when they were putting me in the w/c. She was asked if those two CNAs transferred her the same way as the two CNAs had when the surveyor observed earlier and stated, Everyone does it that way. Except for (male CNA). He doesn't. It makes me nervous when I'm transferred. I'm always afraid something is going to happen. The surveyor explained to her that the primary concern was her safety and that she did not need to be transferred in the manner she was transferred earlier. She stated, God sent you here, didn't he? I think things will be better now. I feel better already. i. On 8/22/18 at 9:17 a.m., CNA #3 was asked about the incident involving the resident on 8/10/18. She stated, We had already put her in her w/c. I had already unhooked two of the hooks, and then when I went to unhook the left side . I know what was wrong. The lift arm wasn't down low enough and when I went to unhook it, it snapped up and hit her in the chin. She was asked if the resident was transferred using the same technique of tilting the w/c back and lowering the resident into it. She stated, I did not feel comfortable tilting her w/c back and sitting her in it. I've never seen a transfer done that way. I told her just to get behind her and pull her back into the w/c as I lower her. The other CNA said they normally tilt the w/c back but I said, 'we are not going to do it that way'. j. On 8/22/18 at 9:34 a.m., a representative from the lift company was asked if the transfer technique of tilting the w/c back and lowering the resident into it with the mechanical lift was an acceptable safe method. She stated, I've never heard of that being done. It's not meant to be done that way. It doesn't sound like a safe technique. k. On 8/22/18 at 10:05 a.m., the Physical Therapist was asked if she was familiar with Resident #1 and she stated, I haven't personally worked with her in a long time. I know she does not want to be in a geri chair. She was asked about the transfer technique of tilting the w/c back and lowering the resident into it with a mechanical lift. She stated, With the w/c tilted back like that, I would be worried that the w/c would slip or the brakes wouldn't work. She was asked if she had ever observed the resident being transferred like that and told staff that it was acceptable to use that method. She stated, Oh no. I observe transfers if it's reported to me there's a problem, and that had not been reported to me. l. The Drive Bariatric Battery Powered Lift instruction booklet documented, .Transfer patient to the wheelchair or commode and position above seat surface. Lock brakes of both lifter and commode or wheelchair . During the descent, assist patient to attain correct sitting posture. m. The Immediate Jeopardy was removed and the scope and severity lowered to D on 8/22/18 at 8:41 a.m., when the facility implemented the following Plan of Removal: 1.) The resident who received the improper transfer with the mechanical lift received a full body audit by treatment nurse on 8/21/18 upon notification of the deficient practice with no negative findings. 2.) All mechanical lift transfers were stopped on 8/21/18 by Regional Clinical Consultant at 5:39 p.m. until competency validated on staff currently working in the facility. There were no residents up at this time. 3.) The facility staff will receive in-service training regarding proper use of the mechanical lift and manufacturing guidelines with competency check offs. This in-service began immediately on 8/21/18 by DON/designee with those staff on duty and will be ongoing until all staff have been trained. Competency will be validated on all employees prior to using the lift for transfers. 4.) Documentation review initiated on 8/21/18 at 6:05 p.m. by DON/designee on all other residents who require the use of the mechanical lift to ensure there have been no injuries related to transfers. 5.) Body audits began on 8/21/18 at 5:45 p.m. by DON/designee on all residents who require the use of the mechanical lift for transfers to ensure no injuries related to improper transfers. 6.) All residents with a BIMS score of 12 and above are being interviewed by Administrator/designee on 8/21/18 at 6:07 p.m. regarding the use of lift to ensure no negative findings. 7.) Staff interviews initiated on 8/21/18 at 6:07 p.m. and will continue until all staff are complete. 8.) Therapy will screen all residents beginning 8/22/18 who require the mechanical lift for transfers. 9.) DON/designee will monitor all residents transferred with mechanical lift weekly beginning on 8/22/18 to ensure safe technique and manufacturing guidelines followed x 8 weeks or until compliance achieved.