Every finding on record at The Green House Cottages of Wentworth Place

Based on observations, interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for two (Resident #11, Resident #66) of three residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding Resident #66's use of tobacco was accurately completed on the MDS and Residents #11's Special Treatments, Procedures, and Programs were accurately completed in the MDS. The findings include:Resident #66Review of Resident #66's Medical Diagnosis Report revealed, Resident #66 had diagnoses which included Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Asthma, Dementia, Cerebral Ischemic Attack, Vitamin D deficiency, Heart Failure, Respiratory Failure.Review of Resident #66's Care Plan dated 02/16/2026 revealed, Resident #66 smoked with smoking safety care planned.Review of Resident #66's admission MDS with an Assessment Reference Date (ARD) of 08/13/2024 identified Resident #66 as a current tobacco user. Review of Resident #66's annual MDS with an ARD of 08/11/2025 identified Resident #66 to be a non-current tobacco user. Review of Resident #66's quarterly Smoking Safety Screens dated 02/09/2026, 11/10/2025, 08/11/2025, and 05/12/2025 all indicated Resident #66 smoked 5 - 10 cigarettes a day.During an observation on 03/11/2026 at 1:11 PM, Certified Nursing Assistant (CNA) #3 was observed monitoring the residents' smoke break. CNA # 3 stated Resident #66 smoked but was at therapy and would smoke following the therapy session. During an observation on 03/11/2026 at 2:07 PM, Restorative CNA # 4 was observed monitoring Resident #66 during the smoke break. Restorative CNA # 4 stated Resident #66 attended smoke breaks regularly.During an interview on 03/12/2026 at 8:57 AM, MDS Coordinator #1 stated the facility used the Resident Assessment Instrument (RAI) manual to instruct and guide them in completing the MDS. MDS Coordinator #1 stated Resident #66's annual MDS dated [DATE] did not identify Resident #66 as a current tobacco user. MDS Coordinator #1 stated this was a coding error because Resident #66 smoked and used tobacco. MDS Coordinator #1 reviewed Resident #66 admission/entry MDS dated [DATE], and stated Resident #66 was identified to use tobacco. MDS Coordinator #1 stated Resident #66 had a period when they tried nicotine patches. MDS Coordinator #2 then stated Resident #66 had quit smoking for a period of one week from 04/10/2019 - 04/17/2019 but decided the patches did not work. MDS Coordinator #1 stated Resident #66 had smoked since that date in 2019. MDS Coordinator #1 stated it was important to ensure the residents' MDS data accurately identified what the patient condition was at the time of the assessment. It was important to ensure all information reported was accurate because the MDS data was sent to CMS. During a follow-up interview on 03/12/2026 at 9:25 AM, MDS Coordinator #2 stated she had corrected Resident #66's MDS after being alerted to the discrepancy by surveyors, and it had been accepted by CMS.Review of a Resident Assessment Instrument (RAI) version 3.0 Manual, provided by MDS Coordinator # 2 on 03/12/2026 @ 9:25 AM, revealed, Current Tobacco Use code 0 indicated no; code 1 indicated yes. Coding instructions are listed as: Code 0, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. Resident #11Review of Resident # 11 quarterly MDS with an Assessment Reference Date (ARD) of 02/24/2026 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score 03, which indicated the resident had severe cognitive impairment. The MDS revealed Resident #11 had diagnoses which included hemiplegia [severe or complete loss of motor function on one side of the body] and non -Alzheimer's dementia [brain disorder causing cognitive, behavioral or motor decline]. The MDS also revealed Resident #11 was on palliative care and that Resident #11 required tracheostomy care.On 03/09/2026 at 1:22 PM, this surveyor observed Resident # 11 sitting in a wheelchair in the day area. Resident # 11's neck revealed the resident did not have a tracheostomy or a scar that indicated the resident had a tracheostomy in the past.During an interview on 03/12/2026 at 9:00 AM, MDS Coordinator #1 confirmed, Resident # 11 did not have a tracheostomy and had never had a tracheostomy. MDS Coordinator #1 confirmed the MDS dated [DATE] identified Resident #11 as having a tracheostomy and required tracheostomy care. MDS Coordinator #1 stated, this is a coding error. MDS Coordinator #1 stated it was important to ensure the MDS data was accurate because all information reported on the MDS goes to Centers for Medicare and Medicaid Services (CMS) and the information was supposed to accurately identify what the patient condition was at the time of the assessment.During an interview on 03/12/2026 at 9:25 AM, MDS Coordinator #2 stated a correction had been made on Resident #11's quarterly MDS dated [DATE] after being alerted to the discrepancy by surveyors and it had been submitted to CMS. MDS Coordinator #2 indicated the changes were accepted by CMS. During an interview on 03/12/2026 at 1:25 PM, the Director of Nursing (DON) stated that the DON was not involved in the development of the MDS, other than at admission. The DON stated the MDS Coordinators were responsible for reviewing the MDS prior to submission to CMS. The DON stated it was important for the MDS Coordinators to correctly answer the questions to the best of their abilities. The DON stated she was not aware of any discrepancies in any MDS' prior to being notified by the surveyor of the discrepancies related to two residents MDS'. Review of a RAI version 3.0 Manual, provided by MDS Coordinator # 2 revealed, Tracheostomy care-code cleaning of the tracheostomy in this item.

42965 Based on interviews, record review, and facility policy review, it was determined the facility failed to notify and provide a copy of the written notice to the long-term care ombudsman when a resident was transferred to the hospital for 3 (Resident #88, #85, and # 212) of 3 sampled residents reviewed for hospitalization . The findings are: 1. Review of an annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/16/24 indicated Resident #88 had diagnoses of dementia, history of falling, personal history of healed traumatic fracture, muscle weakness. The MDS indicated Resident #88 had a Brief Interview for Mental Status (BIMS) score of 4 (0-7 suggests severe cognitive impairment). a. A Progress Note for 8/23/2024 at 09:38 AM read, This nurse called and notified elder's daughter of elder's condition. Daughter stated that she was not feeling well herself and that she was afraid she had got [Resident #88] sick. The Daughter was notified of [Resident #88] being sent out to (Name of Hospital) for further evaluation . b. On 9/18/24 at 10:00 AM, the surveyor examined Emergency Transfers from Facility log for the month of August, noting Resident # 88 was not on the list. c. On 9/18/24 at 12:05 PM, the surveyor requested notice of ombudsman notification for resident Hospital transfers for Resident # 88 and Resident # 85. d. On 09/18/24 at 2:29 PM, the surveyor received a revised Emergency Transfers from Facility log from the Social Services Director confirming the Ombudsman was notified 9/18/24 of Resident # 88's and Resident #85's hospitalization in August. 2. Review of the quarterly MDS with an ARD of 08/19/24 indicated Resident #85 had diagnoses of chronic obstructive pulmonary disease, stroke, and repeated falls, and scored 3 (0-7 indicates severe impairment) on the BIMS. a. An Advanced Practice Registered Nurse (APRN) progress note dated 6/30/2024 indicated Resident #85 had been found on the floor by staff and the resident reported hitting their head and experiencing neck pain. Following the assessment, the APRN ordered the resident be sent to the ER (emergency room ) for hitting their head post fall and abnormal vital signs. b. A History and Physical dated 06/30/2024 contained in the After Visit Summary report from (name of hospital) indicated Resident #85 was admitted to the hospital on 6/30/2024 with diagnoses of subarachnoid bleed after a fall where the resident hit their head and pneumonia. c. A review of the Emergency Transfer from Facility log and the Admission/Transfer to/from Report for both June 2024 and July 2024, provided by the Social Services Director at 8:50 AM on 9/18/2024 to confirm notification to the Ombudsman, did not show Resident #85's name. d. On 09/18/24 at 03:06 PM, the surveyor interviewed the Administrator and the Social Services Director regarding the Ombudsman not being notified of resident transfer to hospital for Resident # 88 in August 2024 and Resident # 85 in June 2024. Both staff stated it was overlooked, Ombudsman was notified on 9/18/2024. 3. Review of the admission MDS with an ARD of 7/27/24 indicated Resident #212 had a diagnoses of end stage renal disease, diabetes mellitus, and sleep apnea, and scored 12 (13-15 indicates cognitively intact) on the BIMS. a. Review of the Notice of Transfer/Discharge/LOA (Leave of Absence) with Bed Hold Policy form indicated Resident #212 was transferred to (Name of Hospital) for a change of condition on 8/21/24. b. Review of the Summary of Care report dated 9/10/24 from (Name of Hospital) indicated Resident #212 was admitted to the hospital from 8/21/24 to 9/10/24 with diagnoses of acute renal failure with acute tubular necrosis superimposed on chronic renal failure, sepsis and diabetes mellitus. c. Reviewed the forms titled Emergency Transfers from facility dated August 2024 and the Admissions/Discharge To/From Report for 8/1/2024 to 8/31/2024 provided by the Social Director on 9/18/2024 at 8:50 AM that documented the notification to the Ombudsman of residents that were transferred to the hospital in August of 2024 and neither of the forms included Resident #212 name. d. On 09/18/24 at 4:35 PM, the surveyor informed the Social Director and the Administrator Residents 212's name was not found after reviewing the lists provided by the facility showing notification of the Ombudsman of transfers to hospital during August. The Social Director stated the resident was not on the list because the resident was placed on bed hold and the list generated for the Ombudsman did not include bed holds. The Social Director stated they had come up with a process to ensure the monthly list sent to the Ombudsman included all resident transfers. e. On 09/19/2024 at 9:28 AM, the policy titled, Transfer and Discharge (undated) provided by the Administrator indicated before a resident is discharged the facility will notify the resident, a family member, or legal representative, and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and facility policy review, the facility failed to ensure the lift pad was free of fraying and holes for 1 (Resident #54) sampled resident reviewed for accidents and injuries, and to ensure a resident was not allowed to smoke outside without supervision affecting 1 (Resident #59) sampled resident of 2 Sampled (Resident #24, #59) residents reviewed for smoking. Findings include: 1. A review of Medical Diagnoses, revealed Resident #54 with a diagnoses of Huntington's disease, stroke, and major depressive disorders. a. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARDs) of 01/22/2024 indicated a Brief Interview for Mental Status (BIMs) score of 03 (0-7 suggest severely impaired). Section GG0130 indicated Resident #54 is totally dependent on staff for meals, transfers, dressing, toileting, and personal hygiene. b. A review of Resident #54's Care Plan, revised on 07/18/2024, revealed that Resident #54 is totally dependent on staff and requires a lift with two-person assistance for transfers. c. A review of an in-service dated 08/09/2024 revealed staff were educated in lift pad sizing and inspecting lift pads before use. d. On 09/16/2024 at 11:12 AM, Resident #54 was observed resting quietly in a geriatric chair in the common area at [NAME] House, on a purple lift pad with red trim with a small hole near the left of Resident #54's head, and three small areas of fraying around the trim near the head, and 2 frayed areas near the right arm. e. On 09/17/2024 at 01:55 PM, a purple lift pad with red trim was observed hanging on Resident #54's bathroom door. Shahbaz #7 and Shahbaz #8 were asked when a lift pad would be removed from service. They were not sure why a lift pad would not be used, or how to remove one from service. Shahbaz #8 picked up the purple lift pad with red trim and both examined it. Shahbaz #7 identified 3 burn holes, a small hole at the top of the lift pad, and a nickel size hole near the bottom nylon straps, and 2-3 areas of fraying around the edges of the lift pad. Shahbaz #7 confirmed they borrowed this lift pad from another cottage and was using it on Resident #54. Shahbaz #8 confirmed that the lift pad could rip while lifting a resident and cause an accident. f. During an interview with the Director of Nursing (DON) on 09/18/2024 at 03:45 PM, the DON was asked the process staff are expected to follow to remove lift pads from service. DON stated that if a lift pad is frayed, or has holes the Shahbaz can throw them away, and are expected to tell the charge nurse so that new lift pads can be ordered. Lift pads with holes and fraying would not be considered safe and could cause resident accidents. 2. Review of the Medical Diagnoses revealed Resident #59 had diagnoses of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and left foot contracture. a. Review of an in-service titled Smoking with or without Supervision and Apron requirements, revealed that all residents that smoke have a smoking assessment, and staff must be outside with a resident that requires supervision. b. A review of Resident #59's Care Plan, revised 09/20/2023, revealed Resident #59 has been educated on residents smoking evaluation and requires supervision of staff or a family member when smoking, and must wear a smoking apron. c. On 09/17/2024 at 12:47 PM, Resident #59 was observed sitting on the porch alone at [NAME] House smoking a cigar and had a second cigar resting on his/her chest. d. On 09/17/2024 at 1:00 PM, Shahbaz #9 came outside and assisted Resident #59 in lighting a second cigar, and then returned inside the cottage. e. On 09/17/2024 at 1:02 PM, Shahbaz #9 was followed inside the cottage and was observed looking in a drawer near the snacks, with her back to the front windows. The Surveyor asked Shahbaz #9 the process for smoking outside unsupervised and if Resident #59 had gone through that process. Shahbaz #9 stated that Resident #59 did not require supervision but was seated outside near the far-right corner window so he could be checked on. f. Review of the Smoking-Safety Screening dated 09/09/2024 revealed Resident #59 required supervision and a smoking apron while smoking. g. During an interview with the DON on 09/18/2024 at 03:40 PM, the DON was asked the facilities interpretation of supervised smoking, and if checking on someone from across the room and glancing out the window was considered supervision. The DON confirmed that a staff member should be outside with the resident while smoking to be supervision and confirmed watching out a window is not considered supervision, and a resident could burn themselves. h. On 09/18/2024 at 6:42 PM, a review of a policy titled Smoking, revealed the facilities policy is to ensure a safe environment for residents to smoke outside. All residents that want to smoke outside will be assessed to determine what the resident needs to be safe when smoking. The facility also provided page 2 of a document from the state agency confirming that a facility must assess a resident and describe the methods used to deem a resident safe to smoke unsupervised.

Based on observation, record review, and interview, the facility failed to ensure the meals were prepared in a method that maintained nutritive value and taste that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The findings are: 1. A review of document titled, Quantified Recipe .Breaded Chicken On Bun, initiated for 3/20/2024 and provided by the Dietary Manager on 9/18/2024 at 12:14 PM, indicated for 5 residents placed 5 sandwiches use 1.75 cup plus 2 tablespoons of water or stock. a. On 9/17/24 at 4:09 PM, Dietary [NAME] (DC) #1 placed 5 servings of fried chicken breast into a blade, added 4 cups of hot water from the sink and stated they used 5 chicken breasts, and the same amount of water to help maintain the consistency, instead of 1.75 cup plus 2 tablespoon of water or stock. 2. A review of a document titled, Quantified Recipe .Vegetable Blend, initiated 3/20/2024 and provided by the Dietary Manager on 9/18/2024 at 12:14 PM, indicated for 5 residents use 5.5 cups of vegetable blend of choice and 1 tablespoon plus teaspoon of thickener and no water, a. On 09/17/24 at 4:31 PM, DC #1 used a 4-ounce spoon to place 5 servings of mixed vegetables into a blender, added 1.25 cups of tap water and 2 tablespoon of thickener and pureed, instead 1 tablespoon plus 2 teaspoons of thickener and no water. 3. A review of a document titled, Quantified Recipe .puree dinner roll, initiated 3/20/2024 and provided by the Dietary Manager on 9/18/2024 at 12:14 PM, indicated for 5 residents use dinner roll, 1 each, plus 0.75 teaspoon thickener and 2 tablespoons of water or milk. a. On 09/17/24 at 4:38 PM, DC #1 placed 6 slices of bread into a blender, added 1.25 cups of tap water, instead of 0.5 cup plus 2 tablespoon water or milk. 4. On 9/17/24 at 6:12 PM, DC #1 stated food pureed with water would taste bland.

Based on observations, interview, and facility policy review, 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 2 of 2 meals observed. The findings are: 1. On 9/17/24 at 5:17 PM, during observation of supper meal in [NAME] House, the following pureed food items were in a crock pot awaiting service: a. Pureed fried chicken breast. The consistency was chunky. There were pieces of chicken visible in the mixture. b. Pureed mixed vegetables. The consistency of the pureed was lumpy and not smooth. There were pieces of vegetables and stems visible in the mixture. c. Pureed tarter tots. The consistency was lumpy and not smooth. There were pieces of potatoes still in the mixture. 2. On 9/17/24 at 6:01 PM, the Dietary Manager stated the consistency pureed fried chicken breast was chunky, there were still pieces of chicken in the mixture. It is supposed to be pudding consistency. Pureed mixed vegetables has pieces of vegetables and vegetables stems in it and for the pureed tartar tots they were pieces of potato in it. They should have been pureed longer. 3. On 9/17/24 at 6:03 PM, Shahbaz #6 stated the consistency of the pureed fried chicken breast was chunky. Pureed vegetables have stems and lumps in it and pureed tarter tots was lumpy. 4. On 9/17/24 at 6:05 PM, Shahbaz #5 who prepared the supper meal stated the consistency of the pureed chicken was chunky, pureed mixed vegetables has lumps and vegetable stems sticking out. 5. On 9/18/24 at 9:13 AM, during observation of the breakfast meal in [NAME] House the pureed food items served to the residents who required pureed diets were not properly pureed: a. Pureed bread was runny and there were pieces of bread visible in the mixture. b. Pureed sausage had more of a mechanical texture. (Mechanical soft texture foods can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew. It differs from a pureed diet, which includes foods that require no chewing.) 6. On 9/18/24 at 9:14 AM, the Dietary Manager stated the pureed bread was lumpy and runny, she can see particles of bread and pureed sausage is mechanically like. 7. On 9/18/24 at 9:14 AM, Shahbaz #5 stated the pureed bread has particles of bread in it, and the pureed sausage is mechanically soft and not pureed. 8. On 9/18/24 at 9:15 AM, Shahbaz #6 who prepared breakfast meal stated pureed bread had particles of bread in it and pureed sausage is mechanical like. I should have added more liquid to it. 9. The pureed fried chicken, pureed tarter tots, and pureed mixed vegetables remained as thick and lumpy as they were when first observed in the crock pot. This consistency persisted when they were served to the residents. 10. A review of a facility policy titled, In-service: Puree Foods, not dated, and provided by the Dietary Manager on 9/18/2024, indicated pureed food should be the consistency of pudding or mashed potatoes.

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff and Shahbaz thoroughly washed their hands and changed gloves when contaminated and before handling food and clean equipment to decrease the potential for food borne illness for residents receiving meals from 2(Pavilion House and [NAME] House) kitchens; expired food items and spices were promptly removed/discarded on or before the expiration or use by date to minimize the potential for food borne illness for residents who received meals from 4 A(Pavilion House, [NAME] House, [NAME] House and [NAME] House) kitchens; hot food items were maintained at the required temperatures on the mini crock pots to prevent potential food borne illness for residents who received meals from 1(Brown House) kitchen. These failed practices had the potential to affect residents who received meals from the kitchen (with a total census of), according to the list provided by the Dietary Manager. The findings are. Pavilion House: 1. On [DATE] at 4:01 AM, the following observations were made in the kitchen during supper meal preparation: 2. Dietary [NAME] (DC)#1 wore mittens on her hands when she removed a pan of chicken from the oven and placed it on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 3. On [DATE] at 4:19 PM, DC #1 turned on the 3-compartment sink faucet and washed the blender bowl, blade and the lid with hot water but didn't use soap. Without sanitizing it, she attached the blender bowl to the motor and attached a blade at the base of the blender. As DC #1 was about to use it to puree food items to be served to the residents on pureed diets for supper, DC #1 was asked if food processors should be washed with soap and sanitized before been used. DC #1 stated, Yes. 4. On [DATE] at 4:22 PM, Dietary Aide (DA) #2 removed cartons of thickened liquids from the storage and placed them on the counter. DA #2 pushed a cart that contained glasses towards the counter, contaminating her hands. Without washing her hands, she picked up glasses by their rims and poured beverages in them to serve the residents for supper. 5. On [DATE] at 10:09 AM, the following observations were made on a shelf in the freezer located in the storage room: a. One container of cottage cheese with an expiration date of [DATE]. b. One container of potato salad with an expiration of [DATE]. [NAME] House 1. On [DATE] at 9:53 AM, one container of chili powder in the kitchen cabinet had expiration date of [DATE]. Brown House 1. On [DATE] at 4:55 PM, the temperatures of the food items when checked and read by Shahbaz #4 were: a. Ground fried chicken breast in a crock pot was 128 degrees Fahrenheit. b. The fried chicken breast was 130 degrees Fahrenheit. c. Mechanical tarter tots in a foil pan on the counter was 125 degrees Fahrenheit. [NAME] House. 1. On [DATE] at 8:47 AM, the following observations were made in the kitchen cabinet. a. One gallon of garlic powder with an expiration date of ,d+[DATE] 2023. b. One container of ground thyme with an expiration date of [DATE]. c. One container of Mediterranean style ground oregano with an expiration date of [DATE]. Brown House. 1. On [DATE] at 9:07 AM, one container of potato salad was on a shelf in the refrigerator with an expiration date of [DATE]. 2. On [DATE] at 9:09 AM, the following observations were made on a shelf in the storage room: a. One bag of hot buns with an expiration date of [DATE]. b. One bag of bread with an expiration date of [DATE]. A review of a facility policy titled, Handwashing and Glove Usage in Food service, not dated and provided by the Dietary Manager on [DATE], indicated, hands must be washed before starting work and when engaging in any activities that may contaminate hands.

Based on observation, interview, and record review, the facility failed to ensure there was a physician's order for oxygen therapy for 1(Resident #212) of 3 (Resident #59, #212 and #366) sampled residents that were reviewed for respiratory care. The findings are: 1. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/2024 indicated Resident #212 had diagnoses of end stage renal disease, diabetes mellitus, and sleep apnea, and scored 12(13-15 indicates cognitively intact) on the Brief Interview for Mental Status). a Review of Resident #212's Order Summary Report for September 2024 did not show that the resident had an order for oxygen therapy. b. On 09/16/2024 at 12:13 PM, Resident #212 was sitting up in a recliner, eyes closed, with oxygen in use per nasal cannula at 1.5 liters. c. On 09/16/2024 at 02:44 PM, Resident #212 was sitting up in chair watching television, with oxygen in use at 1.5 liters per nasal cannula. The resident was unsure if they used oxygen continuously but knew it was always available. d. On 09/17/2024 at 03:20 PM, Resident #212 was lying in bed with oxygen in use at 1.5 liters per nasal cannula. e. On 09/18/20244 at 12:05 PM, Resident #212 was sitting in a wheelchair in their room with oxygen in use at 1.5 liters per nasal cannula. f. On 09/18/2024 at 12:08 PM, Registered Nurse (RN) #11 was asked to accompany the surveyor to Resident #212's room and asked to tell the Surveyor what the resident's oxygen flow rate was set at. RN #11 looked at the resident's oxygen and stated it looked like it was set at 1.5 (liters). RN #11 was asked what Resident #212's oxygen flow rate should be set on and after looking in the electronic record, RN#11 stated she did not see an oxygen order for the resident. RN#11 was asked if there should be a physician's order telling you what the oxygen flow rate should be if the resident is receiving oxygen, and stated there should be so that the resident gets the correct oxygen perfusion through their body based on their diagnosis. g. On 09/18/2024 at 01:50 PM, the Director of Nursing (DON) was asked if the use of oxygen require a physician's order and what the physicians order should include, and she stated there should be an order and it should include the flow rate and whether the oxygen is PRN (as needed) or continuous. The DON was asked if she was aware that Resident 212 was receiving oxygen without a physician's order, and she stated she was made aware by the resident's nurse earlier and they had obtained an order for the oxygen. The DON was asked why it was important that there is a physician's order for oxygen, and she stated there should be an order because oxygen is a medication. h. On 09/18/2024 at 2:50 PM, the Administrator came to the surveyor and stated that they did not have a policy on use of oxygen.

Based on observation, record review, interview, and facility policy review, it was determined that the facility failed to ensure resident medications were stored behind a lock to prevent unauthorized staff or resident access. This failed practice had the potential to affect 1 (Resident #32) sampled resident. The findings are: 1. A review of a policy titled Medication Storage in the Facility, revised January 2018, revealed that medications should be stored behind locks, and be accessible to licensed and pharmacy personnel. Medication rooms and carts are to be locked up when not being attended by authorized personnel. 2. A review of Medical Diagnoses for Resident #32 revealed diagnoses of stroke, dementia, and diabetes mellitus. 3. On 09/17/2024 at 12:58 PM, the surveyor walked in Resident #32's room and the door to the bottom drug cabinet near the doorway fell open. The Surveyor pulled on the knob of the upper drug cabinet, and the door swung open easily revealing: a. Jardiance 25 mg (milligram) tablet, 1 tab b. Metformin 500 mg oral twice a day, 1 tab c. Vitamin D 1250 mg bottle d. Lantus 100u/ml (unit/milliliter), 10 ml vial e. Fiber lax 625 mg tables x 2 bottles f. Loratadine allergy relief 10 mg 1 bottle g. Acetaminophen 500 mg tablets, 2 bottles h. Fish oil 1000 mg bottle i. Glucosamine chondroitin advanced bottle j. Pen needles, 1 box k. Gabapentin 300 mg capsule at night, 1 tablet l. Atorvastatin 40 mg nightly, 1 tablet m. Metoprolol 50 mg, 1 tablet n. Losartan 25 mg twice a day, 1 tablet o. Terazosin 2 mg oral, 1 capsule 4. During an interview at [NAME] House with Registered Nurse #10 (RN) on 09/17/2024 at 1:05 PM, RN #10 was asked about the process for storing medications in resident rooms. RN #10 stated that both medication cabinets in Resident #32's room are supposed to be locked to prevent residents from taking someone else's medications. 5. During an interview with the Director of Nursing (DON) on 09/18/2024 at 3:45 PM, the DON confirmed that staff are expected to make sure medications are kept behind locked doors to prevent residents from self-medicating and hurting themselves.

Based on observation, record review, and interview, it was determined that the facility failed to ensure oxygen/nebulizer tubing and masks where changed every week in a timely manner to prevent respiratory infections affecting 1(Resident #59) of 3 sampled (Resident #59, #212, #366) residents reviewed for respiratory. Findings include: 1. A review of the Medical Diagnoses, revealed Resident #59 had diagnoses of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and left foot contracture. a. A review of the Physicians Order, dated 06/29/2023, revealed Resident #59 gets albuterol updrafts three times a day. b. A review of Resident #59's Care Plan, revised on 07/21/2024, revealed Resident #59 has COPD and obstructive sleep apnea and to give medications as ordered. c. On 09/16/2024 at 10:24 AM, a storage bag and nebulizer mask on Resident #59's bedside table was dated 09/05/2024. d. On 09/17/2024 at 10:15 PM, a stored nebulizer mask with 09/5/2024 written on the side was stored on the right bedside table. e. A review of Resident #59's Medication Administration Record, dated September 2004 on 09/18/2024 at 08:51 AM, revealed that Resident #59 is compliant with nebulizer treatments three times a day. f. On 09/18/2024 at 09:46 AM, Resident #59 gave permission to open his/her bedside drawer to look at Resident #59's nebulizer tubing and mask was dated 09/05/2024. g. During an interview at [NAME] House with Licensed Practical Nurse #12 (LPN) on 09/18/2024 at 10:14 AM, LPN #12 was asked the process for changing oxygen tubing and nebulizer mask, and what process staff follows if they find oxygen tubing or nebulizer masks that have not been changed out. LPN #12 confirmed that night shift nurses change out oxygen tubing and nebulizer masks on Wednesday nights, but staff should notify a nurse on duty if they see tubing or nebulizer mask that are dated past one week. h. On 09/18/2024 at 10:17 AM, LPN #12 accompanied Surveyor to Resident #59's room and confirmed the oxygen mask and tubing were last changed on 9/05/2024, and they should have been changed after 7 days for sanitary reasons, and to prevent infection. i. During an interview with the Director of Nursing (DON) on 09/18/2024 at 03:35 PM, DON was asked what the process was for changing tubing and nebulizer mask. DON stated that nursing is expected to change out oxygen tubing and nebulizer mask every Wednesday night. DON confirmed that if staff finds tubing or nebulizer masks that were not changed out, they are expected to notify a nurse and confirmed that tubing and nebulizer mask dated 09/05/2024 should have already been changed out for cleanliness, and to prevent respiratory infections. The DON revealed that they do not have a policy addressing changing out oxygen tubing and nebulizer mask, but it is expected to be done every 7 days. j. On 09/19/2024 at 09:31 AM, Social Services Director (SSD) provided a letter from the administrator stating the facility does not have a policy or procedure for oxygen tube use.

Based on observation, record review and interview, the facility failed to ensure dented food cans were promptly removed/ discarded; expired food items were promptly removed/discarded on or before the expiration or use by date; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 2 ([NAME] House and [NAME] House) kitchens; dietary staff wore hairnets to prevent the potential for cross contamination for residents who received meals from 2 ([NAME] House and [NAME] House) kitchens; dietary staff handled glassware items properly to prevent the potential for cross contamination for residents who received meals from 1 ([NAME] House) of 7 (Pavilion, [NAME] House, [NAME] House, [NAME] House, [NAME] House, [NAME] House and [NAME] House) kitchens. The failed practices had the potential to affect 104 residents who received meals from the kitchen (total census: 107). The findings are: 1. [NAME] House: On [DATE] at 10:14 AM, the following observations were made in the Dry Storage Room: a. One package of hamburger buns with no opened date. b. One loaf of sliced bread with no opened date. c. A tall container of frosted cornflakes with no opened or received date. d. A plastic storage container of cornmeal with the back latch missing, was not sealed. e. One 28 ounce can of diced tomatoes with green chilies was dented. 2. [NAME] House: On [DATE] at 8:49 AM, the following observations were made in stand-up refrigerator #1: a. Eleven individually wrapped super donuts were stored on the bottom shelf with raw hamburger meat on the shelf above. On [DATE] at 8:52 AM, the following observations were made in stand-up refrigerator #2: a. A vial of Humalog Insulin was on the fourth shelf with food. A staff member stated it was another staff's medication. On [DATE] at 8:54 AM, the following observations were made in the stand-up freezer: a. One large ziplock bag with 18 slices of garlic bread was not sealed with no opened date. b. One ziplock storage bag with 11 cookie dough balls was not sealed. On [DATE] at 08:56 AM, the following observations were made in the Dry Storage Room: a. One package of hamburger buns with no opened date. b. One loaf of sliced bread with no opened date. c. One 46 ounce can of tomato juice was dented. d. One large bag of tortilla chips with an expiration date of [DATE]. 46868 3. [NAME] House: On [DATE] at 12:49 PM, a visitor visiting with Resident #207 walked into the kitchen area of Cottage 2 without a hair net on or washing her hands. The visitor opened the freezer and moved food around then shut the door and asked the staff where the twelve water bottles were that she had put in the freezer yesterday. Shahbaz #2 stated, They are in a bowl on the counter. The Surveyor asked Shahbaz #2 if visitors could go into the kitchen area at any time and store and retrieve items in the freezer. Shahbaz #2 stated, No. On [DATE] at 11:40 AM, the Surveyor asked Shahbaz # 3 who could enter the kitchen in Cottage 2. Shahbaz #3 stated, Staff can be back here and must wear gloves and put on a hair cover. 47916 4. [NAME] House: On [DATE] at 12:15 PM, during observation of the lunch meal in [NAME] House. Dietary #1 touched the upper rim of one resident's cup while pouring drinks. On [DATE] at 7:52 AM, the Surveyor asked the Dietary Manager (DM) what the process was for serving drinks to the residents. The Dietary Manager demonstrated with her hands that cups are to be handled from the bottom, and it is not acceptable to hold cups near the rim where a resident might place their lips due to germs. 5. [NAME] House: On [DATE] at 8:57 AM, observed Shahbaz #4 at the kitchen island attending to the lunch meal preparation. Observed Licensed Practical Nurse (LPN) #2 walk into the kitchen area without a hairnet. LPN #2 opened the refrigerator and poured a drink into a glass and walked off. On [DATE] at 8:59 AM, the Surveyor asked Shahbaz #4 what process was used for nurses to get a drink for a resident while passing medications. Shahbaz #4 said if they were not cooking, and the nurses were quick, then it was okay for them to come into the kitchen without a hairnet. The Surveyor pointed out that she had a large bowl of greens on the kitchen island and was chopping up potatoes and asked if meal prep required a hairnet. Shahbaz #4 did not respond. On [DATE] at 9:01 AM, the Surveyor asked LPN #2 what procedure she followed for getting drinks for residents from the kitchen. LPN #2 said, If they are not preparing the meal, and I am quick then I don't think I have to wear a hairnet. 6. On [DATE] at 12:57 PM, the Surveyor asked the Dietary Manager what staff were supposed to wear while in the kitchen. The Dietary Manager replied, The staff are supposed to wear an apron, mask, and hairnet. The Surveyor asked, What is your procedure for storing food once opened in the dry storage, refrigerator, and freezer? The Dietary Manager replied, Food must be in a sealed container and dated. The Surveyor asked if employee's medications should be stored in the refrigerator with resident foods? The Dietary Manager replied, No because some residents go into the kitchens. The Surveyor asked, What do you do with dented cans? The Dietary Manager replied, We now throw them away. The Surveyor asked, What is your process for removing expired food items? The Dietary Manager replied, We do inventory weekly and check for expired items. When they are expired, we throw them away.

Based on observation, interview, and record review the facility failed to ensure medications were not left unattended at the bedside and controlled substances were properly stored behind two secured locks, and access only permitted by authorized, licensed personnel to prevent misappropriation of resident medications in [NAME] House; insulin bottles were dated after opening in [NAME] House; and medications were not left with and administered by residents without self-administration rights in [NAME] House. The findings are: 46868 1. [NAME] House: On 10/10/23 at 8:22 AM, Resident #206 was lying in bed. An unopened vial of Ipratropium-Albuterol Solution (breathing medication) was lying on the bedside table. On 10/10/23 at 2:02 PM, the Surveyor asked LPN #1 about the unopened vial on Resident #206's bedside table. LPN #1 stated, Medication should not be left in a resident's room. On 10/10/23 at 1:50 PM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to the Laundry Room where the narcotics were stored. Observed a key hanging on the wall beside the door. LPN #1 removed the key and unlocked the door. LPN #1 opened an unlocked bottom cabinet door and slid out a permanently affixed large wooden box with a latch and lock on top. The Surveyor asked, Who has access to this laundry room? LPN #1 stated, CNAs [Certified Nursing Assistant] do use the laundry room for residents' laundry. The Surveyor asked, Is the cabinet door lock broken? LPN #1 responded, The narcotic cabinet lock is broken, and they are waiting on maintenance to fix it. The Surveyor asked, How long has the lock been broken? LPN #1 responded, I do not know. The contents of the narcotic box were as follows: a. Hydrocodone 5/325 milligram - 46 pills b. Norco 10/325 milligram - 57 pills c. Lyrica 75 milligram - 50 pills d. Tramadol 50 milligram - 30 pills e. Clonazepam 0.5 milligram - 21 pills f. Tramadol 50 milligram - 27 pills g. Clonazepam 0.125 milligram - 21 pills On 10/10/2023 at 1:55 PM, the Surveyor and LPN #1 exited laundry room and LPN #1 hung the laundry room key back on the hook outside the door. Within moments Shahbaz #3 entered the laundry room using the key hung outside of the door on the hook. 2. [NAME] House: On 10/10/23 at 2:43 PM, observed the medication cabinet in [NAME] House room [ROOM NUMBER]A and observed an opened, undated multi dose vial of Humulin R Insulin. LPN # 5 stated, Whoever opened the insulin forgot to date the vial with an open and use by date. The vial should have an open date. 47916 3. [NAME] House: On 10/10/23 at 8:33 AM, observed Resident #66 sitting on the porch in a wheelchair beside another resident holding an opened plastic bag with a medication label visible. Resident #66 said the nurse went to get a pill she forgot and told her to go ahead and take her Trelogy inhaled medication like usual. Resident #66 stated, I gave it to myself, and now I am waiting on my pill. I can give it to myself better anyway. On 10/10/23 at 8:35 AM, LPN #3 came outside on the front porch and immediately told the Surveyor that Resident #66 was just supposed to hold the plastic bag containing the Trelogy inhaler while she went inside for a forgotten pill. The Surveyor informed LPN #3 that Resident #66 said she used the inhaler while she went inside for a forgotten pill. LPN #3 confirmed Resident #66 was not assessed for self-administration of medication. A Physicians Order dated 05/12/23 noted Resident #66 is to receive a Trelogy (Fluticasone-Umeclidin-Vilant) Inhaler one time a day for Chronic Obstructive Pulmonary Disease (COPD). 4. On 10/12/23 at 2:09 PM, the Surveyor asked the Director of Nursing (DON) what is the procedure when you open a new vial of insulin. The DON replied, Open the vial and date it. The Surveyor asked, When a key is hung up beside a locked door in the cottage, who could enter the room? DON replied, All staff and if it is a linen closet or supply closets family and elders can enter. 5. A facility policy titled, Pharmaceutical Services, provided by the Administrator on 10/11/23 at 8:04 AM documented, .Storage of drugs: All drugs and biologicals are stored in a locked compartment . Only authorized personnel are permitted to have access to the medication keys .

Based on observation, record review, and interview, the facility failed to ensure staff and proper handling of filling up water bottles to prevent the potential spread of infection to other residents. The failed practices had the potential to affect all 107 residents who resided in the facility. The findings are: On 10/09/23 at 1:45 PM, Shahbaz #1 came out of a resident room that had a resident who was on isolation precautions with a lunch tray with a glass plate, glass bowl, utensils, and napkins on it. Shahbaz #1 carried the tray to the kitchen and placed it on the counter. At 1:52 PM, Shahbaz #1 gathered the utensils from the dirty trays including the tray from the isolation room and placed them in the sink and placed the bowls, plates, and glasses all together. On 10/09/23 at 2:51 PM, without washing her hands, Shahbaz #3 placed ice into two water bottles for a resident and used her hand/fingers to guide the ice into the bottles. On 10/11/23 at 8:25 AM, Certified Nursing Assistant (CNA) #1 donned a gown, gloves, mask, and face shield to enter Resident #87's isolation room. CNA #1 entered the isolation room and provided care then exited the room with a breakfast tray. CNA #1 placed the tray on the 3 drawer rolling cart outside the door. CNA #1 removed her gown, face shield and gloves. CNA #1 left her mask on and walked down the hall and then back, picked up the tray that was in the isolation room and placed it on the cart with the other breakfast trays without gloves on. CNA #1 did not clean or disinfect the top of the 3-drawer rolling cart where she placed the tray that she had brought out of the isolation room. On 10/11/23 at 8:34 AM, CNA #2 exited Resident #17's room fully dressed in Personal Protective Equipment (PPE) carrying 2 contaminated meal trays and walked 6 feet to place the contaminated meal trays on a cart with the other trays. On 10/11/23 at 8:40 AM, the Surveyor asked CNA #1 to describe the correct sequence of removing PPE after exiting an isolation room. CNA #1 stated, gloves, gown, face shield, mask. The Surveyor asked if she felt she had properly doffed her PPE. CNA #1 stated, No. On 10/12/23 at 12:57 PM, the Surveyor asked the Director of Nursing (DON) The Surveyor asked if it was appropriate to wear contaminated PPE in the hall. The DON stated, No. The Surveyor asked if it was appropriate to touch ice with your fingers/hand. The DON stated, No. The Surveyor asked if it was appropriate for trays from isolation rooms to be placed on the counter tops/hall carts uncovered and then taken to the kitchen with the rest of the trays. The DON stated No. A facility policy titled, Infection Control Program, provided by the Administrator on 10/11/23 at 3:37PM documented, .OVERVIEW: Policy: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection . The facility policy titled, Personal Protective Equipment (PPE) documented, Gloves Procedure: .3. Remove gloves after contact with a patient and/or surrounding environment . Gown Procedure: 1. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient care activities . 3. Remove gown and perform hand hygiene before leaving the patient's environment . Mask/Goggles/Face Shields: 1. Use PPE to protect the mucous membranes of the eyes, nose and mouth . Environmental & Equipment Cleansing/Disinfectants Patient-care equipment and instruments/devices: .Clean and disinfect surfaces that are likely to be contaminated with pathogens .

Based on observation and interview, the facility failed to ensure meals were served in a method that maintained the appearance, and temperature that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 11 residents who resided in [NAME] House. The findings are: On 10/09/23 at 12:17 PM, observed the lunch meal at [NAME] House. A pan of ham was sitting on the kitchen island uncovered. The ham was dark brown and/or pink, and dry. The temperature of the food taken by Dietary #1 was as follows: a. Mashed Potatoes - 165 degrees Fahrenheit. b. Ham - 87 degrees Fahrenheit. On 10/09/23 at 12:25 PM, Dietary #1 said the crock pots were keeping the mashed potatoes warm. The Surveyor asked what their process was to keep meat warm after it is cooked. Dietary #1 said, We have a warmer. On 10/11/23 at 7:52 AM, the Surveyor asked the Dietary Manager (DM) the process for keeping meat at the proper temperature. The Dietary Manager said meat can be heated in the microwave, crockpots, and they have warmers in the cottages. The DM confirmed 87 degrees Fahrenheit was not appropriate to serve meat. A facility policy titled, Diet, Sanitation, and Menu, provided by the Administrator on 10/12/23 at 9:26 AM documented, Policy. The nursing facility will provide each Resident/Elder with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident/elder . 5. On 10/12/23 at 10:00 AM, the Administrator said the facility does not have a food service policy.

Based on observation and interview, failed to ensure expired food items were promptly removed /discarded on or before the expiration or Use by dates and Dietary Staff washed their hands before handling clean equipment or food items to prevent potential food borne illness. These failed practices had the potential to affect 96 residents who received meals from of each kitchen in7 of 7 houses (Total Census: 96), according to the lists provided by the Dietary Supervisor dated. The findings are: 1. On [DATE] at 9:13 AM, the following observations were made in the Griffin House a. There was an opened Sysco plain salt was stored on a shelf above the food preparation. The box was not covered. b. There was one 32 fl. (fluid) oz (ounce) of nectar thickened sweet tea stored on a shelf in the storage room. The box had an expiration date of [DATE]. c. There was one 32 fl. oz of med pass stored on a shelf in the storage room. The box had an expiration date of [DATE]. 2. On [DATE] at 9:38 AM, the following observations were made in [NAME] House: a. There was an opened Sysco plain salt stored on a shelf above the food preparation counter. The box was not covered. b. An opened box of oatmeal was stored on a shelf in the storage room. The box was not covered. c. One bag of hamburger buns was on a shelf in the storage room. The bag had an expiration date of [DATE]. d. On [DATE] at 12:08 PM Certified Nursing Assistant (CNA) #1 turned off the sink faucet with her bare hand. Then, picked up the clean blade and attached it to the base of the blender to be used in pureeing food items for the residents who received pureed diets. 3. On [DATE] at 9:54 AM, the following observations were made in Brown House: a. CNA #2 lifted a trash can lid and threw away tissue papers. Without washing her hands, she picked up clean bowls from the food preparation counter to be used in portioning dessert to be served to the residents for lunch meal and stacked them up on the counter with her fingers inside the bowls. The CNA placed gloves on her hands, removed lettuce head from the refrigerator and placed it on the counter. She removed gloves from the glove box and placed them on her hands, contaminating the gloves. She turned on sink faucet and rinsed lettuce, then placed it on the cutting board and sliced. She then transferred slices of lettuce into a bowl to be served to the residents for lunch meal. At 12:56 PM, she was asked what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 4. On [DATE] at 10:10 AM, the following observations were made in the [NAME] House: a. Twelve boxes of 32 fl. oz med pass was stored on a shelf in the storage room. Each box had an expiration date of [DATE]. b. CNA #3 was wearing gloves on her hands. She opened the refrigerator door and removed a lettuce head and two tomatoes and placed them on the counter. She turned on the sink faucet and rinsed the lettuce head. She placed the lettuce on the cutting board and cut it in pieces. The CNA did not remove the gloves and washed her hands before using her contaminated gloved hands to pick up slices of lettuce and put them in a bowl, In the process she sliced tomatoes without rinsing them and put them on the slices of lettuce in a bowl to be served to the residents for lunch meal. She was asked what should she have done after touching dirty objects and before handling clean food items or clean equipment? She stated, I should have washed my hands. She was asked what should you have done with the lettuce and tomatoes before preparing salad to be served to the residents for lunch and she stated, Rinsed them off . 5. On [DATE] at 04:42 PM, in the [NAME] House CNA #4 turned on the sink faucet and washed her hands, then turned off the faucet with her bare hand, and dried them with tissue papers. She lifted the trash can lid and threw away tissue papers, contaminating her hand in the process. At 4:44 PM She opened a drawer and removed gloves from the glove box and placed them on her hands, contaminating the gloves. When she was about to reach and pick up fried fish to place in the blender, she was immediately stopped and was asked what should she have done after touching dirty objects and before handling clean equipment and she stated, should have washed my hands. 6. On [DATE] at 10:38 AM, in the Hidden House kitchen there was one bag of hamburger buns on a shelf in the storage room with an expiration date of [DATE]. 7. On [DATE] at 4:22 PM, in the PAV House Dietary Employee #5 was wearing gloves on her hands. She opened the oven door and removed pans that contained fried catfish and cabbage and placed them on the counter. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. At 4:24 PM when she was ready to place fried fish into the blender, she was stopped and was asked what should she have done after touching dirty objects and before handling clean equipment and she stated, I should have removed the gloves and washed my hands. 8. The facility policy on hand washing documented, to wash hands, After handling dirty dishes or any other time deemed necessary.

Based on observations, record review, and interview, the facility failed to ensure oxygen was ordered and administered at the prescribed flow rate and failed to ensure nebulizer mask was stored in a closed bag or container when not in use to prevent potential cross contamination that could result in respiratory infection for 1 (Residents #75) of 10 (Residents #75, 79, 12, 66, 81, 31, 99, 88, 24 and 5) sampled residents who had orders for oxygen and 1 (Resident #75) of 2 Residents (#75 and 94) sampled residents who had orders for updraft nebulizer treatments. This failed practice had the potential to affect 24 residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R75 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 6/8/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) was Short of Breath (SOB) or had trouble breathing with exertion, when sitting at rest and when lying flat and received oxygen therapy while a resident. a. The July 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2/08/21 [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] 3 ml inhale orally four times a day related to [CONDITION(S)], Unspecified . b. The Resident Plan of Care documented, .Problem: I have altered respiratory status/difficulty breathing r/t [related/to] [CONDITION(S)], dx [diagnosis] of sleep apnea, and SOB [shortness of breath]. Intervention: Administer respiratory medication/treatment as ordered. Observe for effectiveness and side effects. [LPN (Licensed Practical Nurse), RN (Registered Nurse)] Elevate my head of bed as needed. [CNA (Certified Nursing Assistant)] Observe for s/sx [signs/symptoms] of respiratory distress and report to MD [Medical Doctor]/Nurse PRN [as needed] [LPN, RN] OXYGEN SETTINGS: O2 via nc @ 2-3L humidified PRN [CNA, LPN, RN] . c. On 07/11/22 at 3:30 PM, the resident was lying in bed with O2 via NC at 2 L/M (liters per minute) and O2 nebulizer tubing/mask lying on top of the residents over bed table (OBT) not bagged. d. On 07/12/22 at 10:04 AM, the resident was lying in bed with O2 at 2 L/N via NC and O2 nebulizer tubing/mask laying on top of OBT not bagged. The resident was asked, When do they change your O2 tubing? She stated, They change O2 tubing every week. She was asked, Who sets up and takes off your updraft treatments? She stated, The nurses do. e. On 07/13/22 at 12:00 PM, LPN #3 was asked to go to the resident ' s room and was asked, What is her O2 flow rate supposed to be at? She said, (while looking at the flow rate) 2. After LPN #3 stated 2, [R75] said,2. LPN #3 was then asked, Where is [R75] UDN mask? She stated, (While pointing toward her OBT next to her bed) There. She was asked, Where should her UDN mask be when not in use? She stated, In a bag. R75 asked LPN #3, What's wrong? LPN #3 told her, It's supposed to be in a bag when you ' re when not using it. Resident #75 stated, Oh, ok. After leaving the resident ' s room LPN #3 was ask, What could the complications be not bagging her UDN mask when she is not using it? She said, I guess it good get dirty. She was then asked, What could happen if it got dirty? She said, Infection? f. On 07/13/22 at 11:08 AM, the resident was lying in bed receiving O2 via n/c at 2 L/M.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. These failed practices had the potential to affect 10 residents who received a regular or mechanical soft diets and 2 residents who received pureed meal trays from [NAME] House diets and 2 residents who received pureed diets from PAV House kitchen according to a list provided by the Dietary Supervisor on 7/12 at 8:21 AM The findings are: 1. The Spring/Winter noon menu for 2022 specified for the residents on regular and mechanical soft diets were to receive 6 oz (ounces) of spaghetti sauce each and ½ cup of spaghetti each. The residents on pureed diets were to receive a #6 scoop of pureed spaghetti sauce each. a. On 7/11/22 at 11:20 AM, Certified Nursing Assistant (CNA) #1 used 3 oz spoon which was equivalent to 1/3 cup and placed 2 servings of spaghetti sauce into a blender and pureed. She poured the pureed sauce in a bowl and placed in the oven to serve to the residents on pureed diets. The menu specified 6 oz of spaghetti sauce for each person. b. On 7/11/22 at 12:51 PM, Certified Nursing Assistant #1 used a 3 oz ladle spoon to serve a single portion of spaghetti and a single portion of spaghetti sauce to the residents on a regular and mechanical soft diet. She was asked what spoon size did she use to serve spaghetti and the sauce to the residents and how many servings did you give to the residents on regular and mechanic soft diets and she stated, I used a 3 oz spoon to serve spaghetti and 3 oz spoon for serving spaghetti sauce and I gave one serving to each person. 2. The Spring/winter supper menu for 2022 specified for the residents on pureed diets were to receive pureed seasoned cabbage, pureed fish, pureed Chatue potatoes, pureed bread and pureed cookie. a. On 7/11/22 at 5:30 PM, the residents on pureed diets were served pureed fish, pureed bread, and mashed potatoes. There were no vegetables prepared for the residents on pureed diets for supper meal. b. On 7/11/2022 at 5:31 PM, Dietary Employee #1 was asked the reason residents on pureed diets did not receive vegetables and she stated, I forgot to puree cabbage.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 2 residents who received pureed diets in PAV House, 2 residents who received pureed diets in [NAME] House and 1 resident who received pureed diet in [NAME] House as documented on the Diet List provided by Dietary Supervisor on 7/12/2022 at 8:21 AM The findings are. 1. On 7/11/22 at 11:20 AM, the following observations were made in the [NAME] House during the noon meal preparation a. Certified Nursing Assistant (CNA) #1 used 2 oz spoon to place 2 servings of spaghetti sauce into a blender and pureed. She poured the pureed sauce in a pan and placed in the oven. The consistency of the pureed spaghetti sauce was lumpy and not smooth. There were pieces of meat visible in the mixture. b. CNA #1 used a 3 oz spoon to place 2 servings of noodles into a blender added hot water, 2 tablespoons of thickener and pureed. She poured the pureed noodles in a bowl, covered with foil and placed in the oven. The consistency of the pureed noodles was thick, lumpy and was not smooth. There were pieces of noodles in the mixture. c. CNA #1 placed 4 servings of garlic bread into a blender, added chicken broth, 3 tablespoons of thickener and pureed. She poured the pureed garlic bread in a bowl and placed it in the oven. The consistency of the pureed bread was lumpy and was not smooth. d. At 12:15 PM, A bowl that contained pureed mixed vegetables to be served to the residents on pureed diets was in the oven. The consistency was loose, lumpy and was not smooth. e. At 12:35 PM, Dietary Employee #1 was asked to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, The pureed meat sauce was lumpy and more of mechanical meat, not very smooth. The pureed spaghetti had pieces of noodles in it, the pureed bread was lumpy and not smooth and the pureed vegetables were not formed, it was lumpy and not smooth. 2. On 7/11/22 at 12:20 PM, CNA #2 used a 6 oz spoon to place a serving of sauce into a blender, added chicken broth, thickener and pureed. She poured the pureed sauce in a bowl, covered with foil and placed in the oven. The consistency of the pureed sauce was not smooth. There were pieces of meat visible in the mixture. 3. On 7/11/22 at 5:26 PM, the following observations were made on the steam table in PAV House: a. A pan of pureed bread was on the steam table. The consistency of the pureed bread was thick, lumpy, and not smooth. b. A pan of pureed catfish was on the steam table. The consistency of the pureed catfish was lumpy and not smooth. There were pieces of fried fish still visible in the mixture. c. On 7/11/22 at 5:32 PM, Dietary Employee #1 was asked to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, The pureed fish and pureed bread were thick and not smooth at all.

Based on observation, record review and interview, the facility failed to ensure the Annual Minimum Data Set (MDS) was completed accurately related to smoking for 1 (Resident #43) of the 3 sampled residents (Resident #43, #51 and #5) of those who smoke in the facility. The findings are: Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an assessment reference date of 11/17/21 documented a Brief Interview for Mental status as 15 (13-15 indicates cognitively intact) current tobacco use as no. a. The care plan documented on 04/04/22 Smoking Safety: I am safe to smoke unsupervised. Facility stores lighter for me. I have an e-cigarette that I use occasionally. b. On 07/11/22 at 3:24 p.m., the resident was out on the front porch smoking. c. On 07/11/22 at 3:35 p.m., Smoking assessments completed on 08/18/21, 11/17/21, 02/10/22 and 05/11/22 all identifying she smokes in the morning, afternoon, evenings, and nights. d. On 07/12/22 at 8:04 a.m., the resident was asked, How long have you been smoker? She stated, Forever. e. On 07/13/22 at 9:54 a.m., Licensed Practical Nurse (LPN) #1 was asked, Is [R#43] a smoker? She stated, Yes. She was shown the Annual MDS and asked, What was answered at current tobacco use? She stated, It's wrong, I'll have it fixed immediately.

Based on record review and interview, the facility failed to ensure a written discharge summary was completed that included a recapitulation of the resident's stay that consisted of a concise summary of the stay, course of treatment for 1 (Resident #102) sampled resident who was discharged in the past 90 days. The findings are: Resident #102 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an assessment reference date of 03/24/22 documented a Brief Interview for Mental Status of 8 (8-12 indicates moderately impaired.) a. On 07/12/22 at 10:32 a.m., the Discharge Return Not Anticipated MDS with an ARD of 04/18/22 documented discharge unplanned to the community. b. On 07/12/22 at 11:07 a.m., the Discharge Instructions and Summary documented under the section titled Recapitulation of Residents Stay on 4/18/22 documented PT [Physical Therapy]/OT [Occupational Therapy] as ordered per MAR [Medication Administration Record]. c. On 07/13/22 at 09:48 AM, Registered Nurse (RN)#1 was asked, Who's responsibility is it to complete the Discharge Summary Recapitulation of Stay? RN #1 stated, The nurses do. She was asked, What is a recapitulation supposed to identify? She stated, The course of their treatment at the facility. She was asked, Is a recapitulation documenting PT/OT as ordered per MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated, No, not really, it needs more. d. The Discharge Transfer Policy did not document the completion of the Discharge Summary or the recapitulation of stay.

Based on observation and interview, the facility failed to ensure Dietary Staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination; failed to ensure expired food items were promptly removed /discarded on or before the expiration or use by dates; failed to ensure 1 ([NAME] House) of 4 ([NAME] House, [NAME] House, Main House, and Brown House) ice machines were maintained in a clean and sanitary condition; failed to ensure meat items stored in the freezer and / or refrigerator were covered or sealed; failed to ensure hot food items were maintained at or above a temperature of 135 degrees Fahrenheit on the counter while awaiting the meal service, to prevent potential cross-contamination of residents food or beverages, and to prevent potential food borne illness for residents who received meals from 1 of 7 kitchen. These failed practices had the potential to affect 19 residents who received meals from the Main Kitchen, 12 residents who received meals from the [NAME] House, and 11 residents who received ice from the ice machine from the kitchen in the [NAME] House (Total Census: 88), according to the lists provided by the Dietary Supervisor dated [DATE] at 3:47 p.m. The findings are: 1. On [DATE] at 1:05 p.m., the following observations made in PAV House (Main House): a. On [DATE] at 1:07 p.m., Dietary Employee #1 picked up a box of gloves from a shelf above the counter. She did not wash her hands after picking up the box of gloves. She removed gloves from the box and placed them on her hands, contaminating the gloves. She picked up clean dishes and stacked them on a cart with her fingers touching the interior surfaces of the plates and bowls. On [DATE] at 5:20 p.m., Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. b. On [DATE] at 1:30 p.m., one open packet of cream cheese log was stored on a shelf in the refrigerator. The packet of cream cheese had a use by date of [DATE]. The cream cheese had black discoloration all over it and extended outside the packet. The Dietary Supervisor immediately was asked to describe the appearance of the cream cheese. She stated, It was bad. It's covered in black. c. On [DATE] at 1:44 p.m., one bag of hot dog buns with total of 8 buns in the bag was stored on a rack in the dry storage room. The bag of hot dog buns had an expiration date of [DATE]. Two bags of white [MEDICATION(S)] bread were stored on a rack in the dry storage room. The bags of bread had an expiration date of [DATE]. d. On [DATE] at 9:59 a.m., Dietary Employee #2 used tissue paper to dry around the handing washing sink. Without washing her hands, she picked up gloves and placed them on her hands, contaminating the gloves. She used her gloved hand to pick up a clean blade and attached it to the blender base to be used in pureeing food items to be served to the residents who required pureed diets at the lunch meal. At 12:20 p.m., Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 2. On [DATE] at 2:34 p.m., the following observations were made in the Brown House: a. On [DATE] at 2:35 p.m., one container of pimento cheese was stored on a shelf in the refrigerator. The container of pimento cheese had an expiration date of [DATE]. b. On [DATE] at 2:36 p.m., one 5-pound container of cottage cheese was stored on a shelf in the refrigerator. The container of cottage cheese had an expiration date of [DATE]. 3. On [DATE] at 11:51 a.m., the following observations were made on the counter in the [NAME] House: a. On [DATE] at 11:52 a.m., the temperature of the ground Barbeque Chicken on a serving plate on the counter was tested and read by Certified Nursing Assistant #3. The temperature of the ground Barbeque Chicken was 98 degrees Fahrenheit. The meat was not reheated before being served to the residents. 4. On [DATE] at 10:40 a.m., the following observations were made in the [NAME] house kitchen: a. On [DATE] at 10:41 a.m., the ice machine had a wet, grayish-brown residue on the metal sections where the ice is formed before dropping it in the ice collector. The Dietary Supervisor was asked to wipe the residue on the metal sections with a tissue. She did, and the grayish-brown colored residue easily transferred to the tissue. She was asked to describe the contents within the ice machine. She stated, There was a grayish-brown residue. b. On [DATE] at 2:53 p.m., Certified Nursing Assistant #3 was asked, How often do you clean the ice machine and who uses the ice from the ice machine? He stated, We clean it once a month. The CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms, and to fill beverages served to the residents at mealtime. The Dietary Supervisor was asked to describe the appearance of the grayish-brown wet residue on the sections of the ice machine. She stated, There was a grayish-brown residue. 5. On [DATE] at 11:10 a.m., one package of opened pink lemon aid mix was inside a sealable plastic bag. The plastic bag was not sealed. The Dietary Supervisor was asked, Should the bag be sealed? The Dietary Supervisor stated, Yes. a. On [DATE] at 12:45 p.m., Dietary Aide #3 was asked, If an open food item is inside a sealable plastic bag, should the bag be sealed? Dietary Aide #3 stated, Yes, and dated. Dietary Aide #3 was asked, Why should the bag be sealed? Dietary Aide #3 stated, Because it should not be open, and bugs can get inside. b. On [DATE] at 12:50 p.m., Dietary Aide #4 was asked, If an opened food item is inside a sealable plastic bag, should the bag be sealed? Dietary Aide #4 stated, Yes. Dietary Aide #4 was asked, Why should the bag be sealed? Dietary Aide #4 stated, So no bugs or debris can get inside.

Based on observation, record review and interview, the facility failed to ensure the Plan of Care for transfers was consistently implemented to prevent injury for 1 (Resident #5) and failed to ensure the axillae and arms were not utilized during transfers to decrease the potential for injury for 2 of 2 (Residents #5 and #11) case mix residents who lived in the Hughes House and were assessed for gait belt use during minimal assistance transfers. The failure to consistently implement the Plan of Care for transfers resulted in harm for Resident #5. The failed practices had the potential to cause more than minimal harm for 4 residents who lived in the Hughes House and were assessed for gait belt use during transfers, according to a list provided by the Administrator on 8/20/15. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of 6/17/15 documented the resident was sometimes understood and sometimes understood others; was severely impaired in cognitive skills per staff assessment for mental status; was continuously inattentive, had physical behavioral symptoms directed toward others for 1 to 3 days of the last 7 days; had other behavioral symptoms not directed toward others for 1 to 3 of the last 7 days; required extensive physical assistance of one person for bed mobility, transfers and dressing; was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position, walking turning around while walking and during surface-to-surface transfer; was always incontinent of bladder and frequently incontinent of bowel; and had experienced one fall without injury since admission or prior assessment. a. The Transfer Assistance Assessment form dated 3/17/15 documented, Minimum Assist . Minimum Assist - Gait Belt / Stand-Up lift . 1 person assist, Stand (and) pivot technique with prompting / cueing . b. The Plan of Care dated 7/15/15 documented, .Fall Hx (History) . Fall 6/9/15 Use gait belt with all her transfers . has a hx (history) of being physically Abusive toward staff and Resists care Related To: Dementia Dx (diagnosis) . Has hx of showing resistance when staff attempts to provide care for elder and has hx of striking at staff .Re(-)approach resident later, when (she) becomes agitated . c. The Nurse's Notes entry dated 7/3/15 at 9:15 a.m. documented, This a.m. (at) approx. (approximately) 4:12 a.m. Shahbaz performing incontinent care, elder became combative and struck Shahbaz in (left) eye. Shahbaz stated she reported incident to Nursing Supervisor. Elder (with) Dx (diagnosis) of Alzheimer's Disease and agitation . d. The Nurse's Notes entry dated 7/3/15 at 1:30 p.m. documented, .Elder becomes combative during incont (incontinent) care and while staff is taking elder to the restroom for (every) 2 hrs (hours) and prn (as needed) checks (one) pushing episodes so far this shift, elder pushed this nurse and Shahbaz during incont care and treatments . e. The Event Report dated 7/4/15 documented, .Date of Occurrence 7/4/15 . Time 0230 (2:30 a.m.) . Type of Event: Fall / Observed on Floor . Location of Event . Resident Room . Type of Injury . Swelling / Edema . Redness . Witness to Actual Event? (Certified Nursing Assistant (CNA) #12) . Describe what occurred: Staff assisting elder from chair in room back to bed, when elder stood for CNA to pull up her pull up, elder fell side ways (and) hit her (left) posterior rib cage on nightstand. Upon first assessment quarter size red mark noted. (No) other (changes). When reassessed Elder (at) 0600 (6:00 a.m.) swelling present. Moaning (and) grunting upon palpation (and) (with) movement . Immediate or Initial Intervention/s: Call onsite . for CXR. Explain importance of Gait belt (and) proper transfers. An anatomical diagram of the posterior body had a circle drawn on the upper left area and documented, swelling. 1) The Event Investigation Report documented, Date of Event 7/4/15 . Time of Event (2:30 a.m.) . Possible Contributing Factors . Specify Type of Event . Fall Type . Fall, witnessed, staff present . Describe exact location . and elder's position . Elders room. Staff assist (with) ambulation, fell against nightstand . Behaviors . Specify Behavior: (Examples - Resisting Care, Personal Preferences, Wandering. Did not request or refused help, Removed Safety Device) . (No) behaviors . Physical Status / Function . Poor Balance . Activity (What was elder doing or trying to do) . Ambulating (with) assist of staff to bed (and) fell into night stand . Transfer . Type of Transfer Assistance Required - Specify . One person . Type of Transfer / Amount of Assistance Provided . one person . Proper use of Mech (mechanical ) Lift / Gait Belt during Transfer . (No) gait belt . 2) The Safety Committee Event Investigation Follow-Up Report dated 7/6/15 documented, .Staff assisting elder from chair in room back to bed. While elder was standing for CNA, CNA tried to pull her pull-up up for her and elder fell side ways and hit her (left) posterior rib cage on the night stand. Upon first assessment quarter size red mark noted. When reassessed (at) (6:00 a.m.), swelling present moaning and grunting upon palpation (and) with movement . Describe corrective actions taken to prevent recurrence of this event . Explained the importance of gait belt and proper transfer 6-9-15 . 3) An Employee Counseling Record form dated 7/6/15 was provided by the Administrator on 8/20/15 and documented, .Employee Name (CNA #12) . Department (and) Title: (11:00 p.m. to 7:00 a.m.) Shabaz Hughes House . Reason for Counseling . Counseling provided due to an incident involving an elder on 7/4/15. Employee instr (instructed) to use proper technique with transfers 1-2 person assist requires use of a gait belt for safety. Improvement expected Employee will use proper transfer technique (with) all elders . Action Resulting from Counseling: Employee stated elder was 'about to fall' when she observed her. Understands safety precaution (and) use of gait belt . f. The Nurse's Notes entry dated 7/4/15 at 7:30 a.m. documented, .(No) behaviors noted this shift. N/O (new order) obtain CXR (chest x-ray) R/T (related to) recent fall for possible rib fx (fracture) . 1) The Nurse's Notes entry dated 7/4/15 at 4:05 p.m. documented, .Elder continues to be combative during care pushing Shahbaz, resisting care during treatment, pinching staff hand and fingers. (No) facial grimacing this shift. Facial grimacing only when (left) (lower back) area is touched. Elder receives scheduled Tylenol Elixir 30 ml (milliliter) BID (twice a day). 2) The Nurse's Notes entry dated 7/4/15 at 10:30 p.m. documented, .Received elder sitting (at) dining room table, facial grimacing, moaning / groaning (and) holding (left) side under her (left) breast. s/s (signs and symptoms) of pain (increase) (with) movement (and) palpation. Red mark, quarter size noted to (left) posterior rib cage (with) swelling . Onsite imaging arrived . for CXR (and) (primary care clinic) notified of (increase) symptoms. N/O for (left) Rib x-ray obtained (At) 845 p.m. Radiologist (Physician Name) calls to report critical findings from CXR. Reports small Pneumothorax, less than 10% to (left) lung (and) 6th (and) 7th Rib fx (fracture). (primary care clinic) (and) (physician) paged numerous times. (primary care clinic) returns call (at) 9:15 p.m. (with) N/O send elder to ER (emergency room ) . for eval (evaluation) . (at) 9:36 p.m. (ambulance service) arrived (and) departed (with) (resident) (at) 9:40 p.m. 3) The on site x-ray provider final Radiology Report with Addendum dated 7/4/15 at 8:45 p.m. documented, .Clinical History / Indication for Exam: Pain in rib cage after fall . Addendum . There are fractures of the left sixth and seventh ribs . Findings: Lungs: There is minimal left basilar atelectasis. There is subcutaneous emphysema over the left upper chest. Pleural spaces: There is a left basilar pneumothorax which is likely less than 10% . g. The hospital History and Physical with the examination dated 7/4/15 at 10:02 p.m. documented, admitted : 07/05/2015 . Chief Complaint: Left flank pain . Skin: Unable to examine due to the combativeness of the patient . Chest . decreased breath sounds in the lower quadrant of the left side . Left sided tenderness of chest wall . Impression and Plan: 1. Pneumothorax secondary to fall: admitted inpatient (medical surgical) unit for observation . 2. Rib fractures secondary to fall . 1) The hospital Progress Note dated 7/7/15 documented, .CXR on 7/7/15: Left rib fractures and roughly 10% pneumothorax laterally, slightly more pronounced on today's exam. Increasing probably atelectasis versus pulmonary contusion in the left base . Impression and Plan: 1. Left sided pneumothorax: 10% pneumothorax . 2) The hospital Discharge Summary dated 7/8/15 documented, .Principal Diagnosis: [REDACTED]. Persistent infiltrate or pulmonary contusion in the left base, mildly improved . h. Staff interviews were conducted regarding the 7/4/15 incident when resident fell while staff was assisting resident: 1) On 8/21/15 at 8:40 a.m., Licensed Practical Nurse (LPN) #1 (7:00 p.m. to 7:00 a.m. shift) was asked to recall the incident of Resident #5's fall that occurred on 7/5/15. She stated, About 2:30 a.m., the CNA (CNA #12) called me to the resident's room and said the resident had fallen while trying to pull up her (the resident's) pull up (brief). I assessed her . I noted a red area on the left posterior rib cage about a quarter size. The LPN was asked, Did you counsel (CNA #12) for not using a gait belt during the transfer of the resident? LPN #1 stated, Yes. It was my impression that she was to transfer the resident with a gait belt. The LPN was asked, Should the CNA have used a gait belt? The LPN stated, She stated she was not transferring the resident, just from sit to stand position. The LPN was asked, Do you think she was changing position and should have used a gait belt been if it was assessed? She stated, Sit to stand is not what we have been trained to use the gait belt to sit to stand. The LPN was asked, Was the resident's behavior unpredictable and did she have problems following directions? LPN #1 stated, Yes. 2) On 8/21/15 at 9:19 a.m., CNA #12 was asked to recall the incident of 7/4/15 when Resident #5 fell . She stated, She (Resident #5) was in her recliner in a sitting position with her pull up around her ankle. I put my hand out to pull up the brief and she fell against her nightstand. As I was pulling up her brief she fell after shifting a little. She fell from a standing position. She was moving like she was trying to get away from me. The CNA was asked, Did the resident have a history of falls? She stated, I don't know. CNA #12 was asked, Should you have used a gait belt when transferring (Resident #5)? She stated, No, it was not a transfer. I was assisting her up to a standing position and when I stood her up she lost her balance some kind of way and she fell against the nightstand. She was asked if she had a gait belt available to use. She stated, I did not have a gait belt on my person. The CNA was asked, Where was your gait belt during the time of the incident? She stated, My gait belt was in my bag. CNA #12 was asked, where her bag was located. She stated, I don't remember . The CNA was asked, Do you think it is good practice to keep gait belt in your bag? She stated, If I don't have to use it. She was asked, Did you have any other resident in the Hughes House who required assistance with transfers by using a gait belt? She stated, She (Resident #5) is the only one. She was asked, How do you know which residents require the use of a gait belt? She stated, The other shifts tell me what needs to be done. It is in the ADL (Activities of Daily Living) book. She was asked, When do you look at what care the resident needs in the ADL book? She stated, At the end of the shift. She was asked, Do you think the use of a gait belt is important? She stated, Yes, for those who need it. She was asked, Who makes that determination for the resident to have a gait belt to be worn during a transfer? She stated, The DON (Director of Nursing) or the doctor. She was asked, Should their assessment be followed? She stated Yes. She was asked, Were you counseled after the resident fell ? She stated, Yes. She was asked, Have you been in-serviced on the use of the gait belt since the incident of the resident falling? She stated, Yes, but it was a list of things discussed, I really wasn't paying any attention . 3) On 8/21/15 at 10:14 a.m., LPN #2 who worked the 7:00 a.m.to 7:00 p.m. shift on 7/4/15 was asked to recall the incident in July 2015 regarding Resident #5's fall. She stated, I remember the nurse reported the resident had fallen. The area hurt when you touched it. The LPN was asked, Should a gait belt have been placed on (Resident #5) before she was transferred? LPN #2 stated, Yes, (Resident #5) may jerk away often . 4) On 8/21/15 at 11:22 a.m., the Director of Nursing (DON) was asked to recall the incident of Resident #5's fall on 7/4/15. She stated, The CNA was pulling her brief up. The resident lost balance and fell against the night stand. The DON was asked, Had the resident been assessed for being unsteady on her feet? The DON stated, Yes, probably, but she doesn't ambulate by herself. She was asked, If a resident is assessed for minimum assist from staff, to wear a gait belt, should the gait belt be worn? She stated, Yes, but they don't always have to have the gait belt on them. The DON was asked, Did the CNA get counseled for not using the gait belt on (Resident #5) after the injury? She stated Yes . 5) On 8/20/15 at 3:45 p.m., the Administrator was asked if the staff should have a gait belt with them if the resident had been assessed for a gait belt to be used. She stated, Yes, if the resident was transferring. In the case of (Resident #5) she was not being transferred . The CNAs do not have to wear a gait belt on their person. She was asked, Did the resident have Dementia or problems understanding instructions? She stated, Yes. She was asked, Was the resident unsteady on her feet? She stated, Yes. 6) On 8/21/15 at 12:30 p.m., PTA (Physical Therapy Aide) #2 was asked, What does it mean to transfer a resident? She stated, When moving from one surface to another, such as sitting to standing, standing to walking . She was asked, Should a gait belt be worn anytime a resident switches from a sitting to a standing position? She stated, Yes. She was asked, If a gait belt is assessed to be worn, should the resident be grabbed on their arm or under their axilla? She stated, No, they should never have their hands on the resident, only on the gait belt. She was asked, Does Physical Therapy train the nursing staff on the proper use of the gait belt? She stated, We don't train the nursing staff as a whole. We may train the Restorative Aide and the Restorative Aide trains the CNAs. The PTA was asked, Have you ever provided transfer assistance with (Resident #5)? She stated, Yes, we always used a gait belt on her. i. The Significant Change MDS with an ARD of 7/15/15 documented the resident reentered the facility from an acute care hospital on [DATE], was severely impaired in cognitive skills for daily decision making per staff assessment for mental status; was continuously inattentive; had physical behavioral symptoms directed toward others for 4 to 6 of the last 7 days; had other behavioral symptoms not directed toward others for 1 to 3 of the last 7 days; rejected care for 1 to 3 of the last 7 days; had behavioral symptoms that were worse as compared to the prior assessment; was totally dependent on the physical assistance of two-plus people for bed mobility, dressing, toilet use and bathing; required extensive physical assistance of two-plus people for transfers and walking; was unsteady and only able to stabilize with staff assistance when moving form a seated to standing position, walking turning around while walking and during surface-to-surface transfer; was incontinent of bowel and bladder; and had experienced no falls since admission or prior assessment. j. The Plan of Care dated 7/15/15 documented, .at risk for fall related injury d/t (due to) Fall history: extensive / dependent assistance (times) 2 staff and disease process / condition: Alzheimer's disease . 7/4/(15) Staff attempted to pull up residents adult brief when resident lost her balance d/t resisting care. Resident fell against the nightstand. (Pneumothorax) and fracture to 6th and 7th rib noted . 7/4/15 Two person assist with all transfers, standing and providing care. k. On 8/19/15 at 10:05 a.m., CNA #13 and CNA #14 moved the resident from her recliner in her room at the Hughes House to a standing position. CNA #13 placed a gait belt around the resident's waist. CNA #13 placed her left hand under the resident's left axilla and held the gait belt in front with her right hand. CNA #14 grabbed the resident under the right axilla with her right hand and grabbed the gait belt in back with her left hand. The CNAs assisted the resident into a standing position; the gait belt was loose and moved up underneath the resident's breasts. 2. Resident #11 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 5/12/15 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on the brief interview for mental status; required the extensive physical assistance of two people for transfers, did not walk, was unsteady and only able to stabilize with the assistance of staff during surface-to-surface transfer; and had limitation in range of motion in one lower extremity. a. The Resident Plan of Care dated 5/12/15 documented, .has ADL self-care deficit as evidenced by . Needs assistance with .Transfer: extensive . is at risk for fall related injury as evidenced by: Previous Fall . 7/19/15 . Fall from bed to floor mat. (no) injuries . 8/10/15 Elder found lying on her fall matt beside her bed . b. On 8/19/15 at 10:15 a.m., CNA #13 and CNA #14 used a gait belt to transfer the resident from a recliner chair in her room at the Hughes House into a wheelchair, and then from the wheelchair to the resident's bed. CNA #13 applied the gait belt around the resident's waist. During the transfer, CNA #13 grabbed under the resident's left axilla area with her left hand and with her right hand she grabbed the back of the gait belt and completed the transfer to the bed where incontinent care was provided. Upon completion of incontinent care, CNA #13 and CNA #14 transferred the resident from the bed to the wheelchair. CNA #14 applied the gait belt loosely around the resident's waist. During the transfer, the gait belt was positioned under the resident's breasts and CNA #13 grabbed the resident under her left axilla and grabbed the gait belt in the back. CNA #14 grabbed the resident under her right axilla and grabbed the side of the gait belt with her left hand to transfer resident into the wheelchair. 3. The instructions titled Gait Belt - Metal Buckle were provided on 8/20/15 at 4:55 p.m. by the Administrator and documented, Purpose . Gait belts are used to assist patients during transferring and walking activities. The belt provides a place for the caregiver to securely hold the patient. Instructions . Position the gait belt around the patient's waist, not the patient's chest . a. On 8/20/15 at 9:45 a.m., the Assistant Director of Nursing (ADON) was asked, When is the staff trained in the use of the gait belt? She stated, They are instructed during orientation. I am not sure of the frequency. She was asked, Should the staff grab under the resident's arm or grab the resident arm to transfer the resident? The ADON stated, They should not chicken-wing the resident. They should not be grabbing the resident's arm. b. On 8/20/15 at 10:30 a.m., LPN #2 was asked, Where should the gait belt be placed on a resident during a transfer? She stated, It should be placed at the hip / waist, not under the breast. They should not be grabbing the resident's arm. c. An in-service sheet titled Hughes House 7-16-15 was provided by the Administrator on 8/20/15 at 3:40 p.m. and documented, .Gait Belts An attached sheet contained signatures of 10 people. 1) On 8/20/15 at 4:00 p.m., the CNAs that worked in the Hughes House were asked, Have you been in-serviced or trained on the use of a gait belt? The CNAs provided the following responses: CNA #15 stated, The therapy did an in-service about a month ago. CNA #16 stated, Another CNA (CNA #17) trained me. CNA #17 stated, The Physical Therapy in-serviced us seven or eight months ago. 2) On 8/20/15 at 4:45 p.m., Physical Therapy Aide (PTA) #1 was asked, Has Physical Therapy or does Physical Therapy train the staff in the proper use of a gait belt? He stated, We train one CNA, generally the Restorative CNA, and that CNA trains the other CNAs. 3) On 8/20/15 at 7:15 p.m., the Administrator provided a written statement signed by CNA #15 that documented, On July 17, 2015 I, (CNA #15) performed a demonstration on how to use the gait belt to all employees. I didn't however have them to demonstrate .

Based on observation, record review and interview, the facility failed to ensure portable oxygen was not on the resident's wheelchair and nasal cannula did not remain in the resident's nares while smoking to prevent the potential for injury from combustion for 1 (Resident #12) of 2 (Residents #4 and #12) case mix residents who used oxygen and smoked. The failed practice resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury, or death, for Resident #12 who had history of smoking while oxygen was on and had the potential to cause more than minimal harm for 11 other residents who resided in the cottage per the Room-Bed List dated 8/2/12. The facility removed the Immediate Jeopardy on 7/24/12, however, the underlying failed practices were not corrected. The Administrator was notified of the Immediate Jeopardy Removed on 8/2/12 at 3:15 p.m. The facility also failed to ensure interventions to prevent falls consistently implemented to reduce the potential for injuries from falls for 2 (Residents #6 and #13) of 3 (Residents #6, #11 and #15) case mix residents who were at high risk for falls. The failed practices had the potential to affect 23 residents who were at high risk for falls, as documented on a list provided by the Administrator on 7/26/12. The findings are: 1. Resident #12 had a [DIAGNOSES REDACTED]. The 5-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/12 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), had shortness of breath with exertion, sitting, at rest, and lying flat and received oxygen therapy. a. The Resident Plan of Care last updated on 4/18/12 documented, "3/8/12 (Resident name) has potential for difficulty R/T (related to) DX (diagnosis) COPD (Chronic Obstructive Pulmonary Disease), chronic smoker, easily short of breath with minimal activity, and requires supplemental oxygen... Administer Oxygen... as ordered by physician... Remind not to use O2 (oxygen) while smoking... Ensure oxygen safety practices in place: ...oxygen off while elder is smoking...Elder will ensure his oxygen turned off while smoking ... Monitor and report all unsafe smoking practices to charge nurse and physician..." b. The Smoking Safety assessment dated [DATE] documented, "...Smokes safely with minimal supervision... Instruction given for oxygen usage & (and) safety while smoking..." c. The Medicare Nurse's Note dated 7/19/12 6:30 p.m. documented, "...Goes in (and) out to porch to smoke. Falls asleep on scooter while smoking. Refuses to turn O2 off while smoking..." d. The Medicare Nurse's Note dated 7/20/12 12:00 p.m. documented, "... Has been asked to take O2 off while smoking & refuses..." e. On 7/23/12 at 2:00 p.m., the resident was sitting in his electric scooter chair on the front porch with his O2 nasal cannula (tubing to administer oxygen) in his nares. The cannula was connected to a portable O2 in a black bag which sat in the foot section of the scooter. The resident held a cigarette in one hand and a lighter in the other. The resident turned off the O2 at the portable concentrator and lit the cigarette. The O2 cannula remained in the resident's nares while he smoked. f. On 7/24/12 at 8:45 a.m., the resident was sitting in his electric scooter chair on the front porch smoking with O2 nasal cannula in his nares. Two other residents were on the porch smoking, as well as 2 visitors. At 9:00 a.m., the resident stated, "Oxygen does not catch on fire. Only the medical field teaches that, you have to have something else that is the fire." He stated portable oxygen concentrator tank takes air from the environment and changes it in the machine, it only comes through the cannula when he breathes so it is not constantly coming out. He stated, "It (oxygen) stops when I'm not breathing." g. On 7/24/12 at 9:42 a.m., the surveyor asked Licensed Practical Nurse (LPN) #3 if the resident had lit a cigarette while he had O2 on and she stated, "Yes. I've reprimanded him many times and he tells me oxygen doesn't burn ... I know he falls asleep and I know he doesn't always turn his oxygen off." The surveyor asked if any intervention was tried, other than talking to the resident about it. LPN #3 stated, "We take his E (oxygen) tank off. We go out there and turn it off. He's very noncompliant." h. On 7/24/12 at 11:20 a.m., the Administrator stated, "...I honestly didn't know he had that (portable concentrator)... I've talked to him many times about the E tank, we had an in-service with the staff about not letting him go out the door with the E tank but, I didn't know he had that..." The EverGo User Manual for the portable oxygen concentrator, provided by the Administrator on 7/24/12 at 11:20 a.m., documented, "Warnings ...A warning represents the possibility of harm to the operator or patient...Oxygen supports combustion. Oxygen should not be used while smoking or in the presence of an open flame..." i. On 7/24/12 at 11:30 a.m., the Incident/Accident logs for the last 3 months (April 2012 thru July 2012) were reviewed. There were no reported incidents of resident burns for this or any other resident. j. The resident's clothing was observed on 7/24/12 at 4:45 p.m. and 7/25/12 at 4:36 p.m. no obvious burn holes. k. The facility removed the Immediate Jeopardy and reduced the scope/severity to "E" when the following corrective actions were taken: 1) The Cottage Employees received mandatory inservice (verbal with handouts) on 7/24/12 on the "Dangers of Smoking While Using Oxygen" A posted notice signed by the Director of Nursing stated: "This inservice is notify all (facility) employees that any elder currently on oxygen therapy who happens to be a smoker may not, under any circumstances, smoke while they have oxygen on. If you witness an elder with oxygen on and they want to smoke, we must ensure that oxygen is removed before smoking." 2) The resident's Smoking Safety Assessment was updated to reflect: "(Resident #12) observed smoking (with) portable oxygen on w/c (wheelchair) - poor judgement ...Change from initial assessment (checked) Remarks Staff to ensure/ assist Elder in removing portable oxygen devices from w/c/scooter when going out to smoke." The assessment was completed by MDS Coordinator and dated 7/24/12. 3) On 8/2/12 at 5:50 p.m., the Administrator documented, "As soon as we (management) were made aware of resident smoking with O2 (oxygen) on DON (Director of Nursing) immediately spoke with resident and informed him that he couldn't have O2 on while smoking - 7/24/12 ...resident monitored each time he went to smoke to ensure O2 was not present - 7/24/12 to present ...SSD (Social Services Designee) called family members and informed them of situation and requested that they reinforce that smoking with O2 is unsafe and unacceptable - 7/24/12 ...As of 8/2/12 resident on one on one care by facility." 2. Resident #6 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an ARD of 6/25/12 documented the resident scored 8 (indicates moderately impaired) on the BIMS and was not ambulatory. a. The facility's Event Investigation Reports for the resident from February 2012 through May 3, 2012 documented the following: 1) 2/28/12 - "The resident was found in a sitting position on the bathroom floor. Bruise under left eye and to left knee. Intervention - reminded to use walker and Therapy screen." 2) 4/22/12 - "Elder stated that she needed to use the bathroom. Helped to bathroom via wheelchair. Instructed to use the call button for assistance. Helped on commode and left to get CNA. When returned the elder had fallen off commode onto floor. Lying on left side with head against wheelchair wheels. Elder unresponsive. Called ambulance and sent to the hospital and admitted . In-service staff to remain with elder while on toilet while providing as much privacy as possible due to risk of falls. 3) 5/3/12 - "Found on floor in room in front of wheelchair and had tried to get out of bed and put herself in the wheelchair. No injuries. Reminded to use call light." b. The Resident Plan of Care last updated on 5/7/12 documented, "Falls - At risk for fall related to impaired cognition with poor short term memory, anxiety, depression. Fall risk assessment 14. Approaches - Instruct and remind her to use call light in bedroom and restroom to alert staff for needs, concerns and preferences. Assist her to wear appropriate footwear daily. Complete fall risk assessment screening tool quarterly and as needed... Utilize (wheel chair locks), assistance with transfers, railings in restroom and halls, personal belongings in easy reach, proper footwear, oxygen as needed." c. An Event Investigation Report dated 5/13/12 documented, "The resident was transferred to the commode per 2 CNA and given call light. THE ELDER WAS LEFT ALONE IN THE BATHROOM AGAIN PAST THE INTERVENTION DATED 4/22/12 TO NOT LEAVE ALONE. No injuries. New interventions: bed in low position with mat, wheelchair alarm applied." d. A Fall Risk Assessment and Post Fall assessment dated [DATE] documented the resident had a score of 18. Fall Risk Assessment and Post Fall Assessments dated 6/11/12 through 7/12/12 documented the resident had a score of 20 and "If total score is 12 or greater the resident is considered to be at high risk for falls and placed on the fall prevention program immediately". e. An Event Investigation Report dated 6/9/12 documented, "The elder fell on the floor in her room on her mat trying to go to the bathroom. The elder's alarm was on but did not go off. No injuries. Alarm batteries changed and will be checked biweekly. Encouraged to use call light." f. An Event Investigation Report dated 7/12/12 documented, "Found on the floor on the right side on mat. Both areas on knees were red. Intervention - when resident anxious get out of bed, reassess anxiety medication." g. An Event Investigation Report dated 7/17/12 documented, "In room laying on back by the closet door. Left side of head bleeding slightly. Elder had gotten out of bed. Bed alarm in place but NOT ON. Body pillow in place. Sent to the emergency room for evaluation. Cord pulled from the alarm base. Encourage use of call light. Counsel CNA to turn bed alarm on when turned off. New intervention of pressure pad bed alarm. Neuro (neurological) checks done." h. An Event Investigation Report dated 7/19/12 documented, "Assisted to the bathroom and grabbed roommate's bed and fell to the floor. Monitor resident more closely during wheelchair locomotion." 3. Resident #13 had [DIAGNOSES REDACTED]. The 5-Day Medicare MDS with an ARD of 4/20/12 documented the resident scored 8 (8-12 indicates moderate impairment) on the BIMS and required the extensive assistance of two persons for transfers. a. A Fall Risk assessment dated [DATE] documented the resident scored 14 and, "score of 12 or greater is high risk for falls and placed on the Fall Prevention Program immediately." b. The Care Plan last updated 5/16/12 documented, "Actual Fall 5/16/12...WC (wheelchair)/bed alarm. Check placement/function every shift and prn (as needed)..." c. On 7/24/12 at 4:30 p.m., LPN #4 found the resident in the floor beside the bed. The CNAs (Certified Nursing Assistants) entered the room and assisted the resident back to bed. LPN#4 took the alarm off a wheelchair in the resident's room and attached it to the resident's bed. LPN#4 stated, "... CNAs did not transfer the alarm from the wheelchair to the bed." d. On 7/25/12 at approximately 8:30 a.m., the surveyor asked CNAs #4 and #5, who worked the day shift on the resident's hall, when the resident's personal alarm should be moved. Both CNAs stated the alarm should be on the bed when the resident was in bed and on the wheelchair when the resident was in the chair. 4. The facility's Fall Protocol provided by the Administrator on 7/26/12 documented, "Purpose: 1. To assess resident at risk for falls. 2. To follow up and evaluate all falls. 3. To identify the reason for the fall. 4. To prepare a plan of care to reduce the potential for injury related to falls... Procedure NOTE: All residents will be assessed for fall risk using the Fall Risk Assessment upon admission, readmission, quarterly, significant change in status and at the time of the fall. Those residents that are to be determined high risk will have care plan indicated. Examples of Interventions which may be incorporated into care planning... 24. Provide frequent monitoring by staff with scheduled toileting ..."