Every finding on record at The Madison Health and Rehab

Based on observation, record review, staff interviews, and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program for one (1) of three (3) residents reviewed for infection control practices. (Resident #2)Findings Include: Record review of the facility policy Enhanced Barrier Precautions dated 10-23 revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Record review of the facility policy Hand Hygiene Policy dated 5-25 revealed, .6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. During an observation on 05/26/26 at 2:35 PM, Resident #2 was observed receiving incontinent care. Certified Nurse Assistant (CNA) #1 removed a brief that was visibly heavily soiled and saturated with urine to the extent urine was observed leaking from the sides of the brief. During the provision of care, CNA #1 removed her gloves and applied a new pair prior to performing perineal care. Following perineal care, CNA #1 again removed her gloves and applied a new pair before providing bowel incontinence care. During each glove change, CNA #1 failed to perform hand hygiene prior to applying clean gloves. CNA #1 was also observed providing incontinent care without wearing a gown despite Resident #2 being on Enhanced Barrier Precautions (EBP).During an interview on 05/26/26 at 2:45 PM, CNA #1 confirmed she failed to perform hand hygiene between glove changes. CNA #1 stated she should have performed hand hygiene between glove changes to prevent the spread of infection. CNA #1 further confirmed she failed to wear a gown during care and stated she should have worn a gown to comply with EBP and prevent infection transmission. CNA #1 stated residents requiring EBP are identified by a green indicator outside the resident's room.During an interview on 05/27/26 at 9:15 AM, the Director of Nursing (DON) stated staff are expected to follow EBP when caring for residents with chronic wounds or indwelling medical devices and are expected to perform hand hygiene between each glove change to prevent the spread of infection.During an observation on 05/27/26 at 10:37 AM, Licensed Practical Nurse (LPN) #1 was observed providing wound care to Resident #2's Stage IV sacral pressure injury. During the procedure, LPN #1 used gauze to cleanse stool from the lower portion of the wound area. After discarding the soiled gauze, LPN #1, while continuing to wear the same gloves contaminated with fecal material, obtained additional gauze and proceeded to cleanse the wound bed. LPN #1 then obtained another gauze and cleansed the skin surrounding the wound without changing gloves or performing hand hygiene.During an interview on 05/27/26 at 11:18 AM, LPN #1 confirmed she cleansed the wound bed after removing stool from the wound area while wearing the same gloves. LPN #1 stated this practice could contaminate the wound with bacteria from stool and potentially result in wound infection, sepsis, increased drainage, increased slough, increased exudate, delayed healing, or cessation of wound healing. LPN #1 further stated Resident #2 had recently completed a course of antibiotics for a positive wound culture within the previous 14 days.During an interview on 05/27/26 at 11:27 AM, the DON stated the nurse should have removed contaminated gloves and performed hand hygiene before proceeding with wound care. The DON stated failure to do so could contaminate the wound and increase the risk of infection. The DON further stated her expectation was that staff follow infection prevention practices during all resident care.During an interview on 05/27/26 at 11:30 AM, the Infection Preventionist (IP) stated CNA #1 should have performed hand hygiene between glove changes and worn a gown as required by EBP. The IP further stated LPN #1 should have removed contaminated gloves and performed hand hygiene after handling stool contaminated materials before cleansing the wound bed. The IP stated failure to follow these infection prevention practices increased the risk of contaminating the wound and exposing the resident to infection.A record review of the admission Record for Resident #2 revealed she was admitted on [DATE] with diagnoses that included nondisplaced fracture of the medial condyle of the right femur.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 04/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 was cognitively intact.A record review of the Order Summary Report with active orders as of 5/27/26 revealed an order dated 04/24/26 for treatment of a Stage IV sacral pressure injury with Negative Pressure Wound Therapy (NPWT) at 125 mmHg continuous pressure with dressing changes every Monday, Wednesday, and Friday and as needed. The record also revealed an order for Enhanced Barrier Precautions dated 05/26/26.

Based on observation, record review, facility policy review and staff interviews, the facility failed to ensure staff followed the plan of care related to Enhanced Barrier Precautions (EBP) during high contact resident care for one (1) of three (3) residents reviewed for infection prevention practices. (Resident #2).Findings Include: Record review of the facility policy Following the Care Plan Policy date 1/2011 revealed, Policy: It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be.required to follow the care plan. A record review of the Care Plan Report revealed Focus: Resident has pressure ulcer.Interventions/Tasks.Enhanced barrier precautions, follow facilities protocol.A record review of the admission Record for Resident #2 revealed she was admitted on [DATE] with diagnoses that included nondisplaced fracture of the medial condyle of the right femur.A record review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date of 04/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact.A record review of the Order Summary Report with active orders as of 5/27/26 revealed an order dated 04/24/26 for treatment of a Stage IV sacral pressure injury with Negative Pressure Wound Therapy (NPWT) at 125 mmHg continuous pressure with dressing changes every Monday, Wednesday, and Friday and as needed. The record also revealed an order for Enhanced Barrier Precautions dated 05/26/26.During an observation on 05/26/26 at 2:35 PM, Resident #2 was observed receiving incontinent care. During the provision of care, Certified Nursing Assistant (CNA) #1 was observed providing hands on care without wearing a gown despite the resident being identified for Enhanced Barrier Precautions.During an interview on 05/26/26 at 2:45 PM, CNA #1 confirmed she did not wear a gown while providing incontinent care to Resident #2. CNA #1 stated she should have worn a gown to prevent the spread of infection and to comply with the resident's Enhanced Barrier Precautions. CNA #1 further stated residents requiring Enhanced Barrier Precautions are identified by a green dot displayed outside the resident's room.During an interview on 05/27/26 at 9:15 AM, the Director of Nursing (DON) stated staff are expected to follow Enhanced Barrier Precautions when caring for residents with chronic wounds or indwelling medical devices to prevent infection transmission. The DON further stated staff should perform appropriate hand hygiene and utilize required personal protective equipment during resident care.During an interview on 05/27/26 at 1:05 PM, the facility's care plan nurses stated Enhanced Barrier Precautions should have been followed during incontinent care for Resident #2 as directed in the resident's care plan. The care plan nurses stated failure to follow resident specific care plan interventions could increase the risk of infection transmission and compromise resident safety. They further stated the purpose of the care plan is to direct staff regarding the individualized care needs of each resident.During a follow up interview on 05/27/26 at 2:25 PM, the DON confirmed Resident #2's care plan was not followed when CNA #1 failed to wear a gown during incontinent care. The DON stated the resident's chronic Stage IV sacral wound required Enhanced Barrier Precautions and acknowledged that failure to follow those precautions could increase the risk of wound infection.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure physician ordered Negative Pressure Wound Therapy (NPWT) was monitored and maintained in working order for one (1) of three (3) residents reviewed for wound care. Resident #2.Findings Include: Record review of the facility policy Negative Pressure Wound Therapy (NPWT) dated 7/2025 revealed, .9. Monitoring throughout the use of NPWT shall include, but is not limited to, the following: a. Pain associated with the therapy. b. Device is functioning. c. Settings as prescribed. d. Troubleshooting of any alarms, in accordance with pump/product specifications. e. Response of the therapy, including wound characteristics and progress towards healing . A record review of the Order Summary Report with active orders as of 5/27/26 revealed an order dated 04/24/26 for treatment of a Stage IV sacral pressure injury with Negative Pressure Wound Therapy at 125 mmHg (millimeters of mercury) continuous pressure with dressing changes every Monday, Wednesday, and Friday and as needed. During an observation on 05/26/26 at 12:30 PM, Resident #2's wound vacuum machine was observed connected to the resident but not functioning. The screen was not illuminated, no sounds were emitted from the unit, and no drainage was observed moving through the tubing.During a follow up observation on 05/26/26 at 2:30 PM, while incontinent care was being provided, the wound vacuum remained connected to the resident and continued to be nonfunctional. Following completion of incontinent care, the wound vacuum dressing was observed to have lost its seal and become detached.During an interview on 05/26/26 at 2:45 PM, Certified Nurse Assistant (CNA) #1 stated she was unaware the wound vacuum was not functioning prior to providing care and indicated she would notify the wound care nurse. Resident #2 and her granddaughter stated the resident frequently remains incontinent for extended periods despite using the call light. They stated the resident has a chronic Stage IV sacral wound and urine often causes the wound vacuum dressing to lose its seal. They further stated staff do not routinely monitor the wound vacuum's function. They reported that on the day of observation, Resident #2 returned from physical therapy wet with urine, called for assistance multiple times, and no staff responded before incontinent care was eventually provided. They stated the wound vacuum was not functioning during therapy and remained nonfunctional afterward.During an interview on 05/27/26 at 9:05 AM, Licensed Practical Nurse (LPN) #1, the wound care nurse, stated staff had been instructed to notify her if a wound vacuum was not working and to apply a wet to dry dressing if the device became nonfunctional until she could assess the resident. She stated no staff member notified her at approximately 12:30 PM on 05/26/26 that the wound vacuum was not functioning. She further stated she first became aware of the issue at approximately 2:45 PM when notified by CNA #1 after incontinent care had been completed. At that time, she contacted the Nurse Practitioner (NP) who instructed her to apply a wet to dry dressing rather than reapply the wound vacuum.During an interview on 05/27/26 at 9:15 AM, the Director of Nursing (DON) stated the facility did not have routine checks of wound vacuum functionality in place, such as every two hours. The DON stated implementing such monitoring may be necessary to ensure devices are functioning properly. The DON further stated a malfunctioning wound vacuum and prolonged exposure to urine could contribute to wound deterioration and infection. The DON stated nursing assistants are responsible for checking incontinent residents at least every two hours and providing care as needed to prevent skin breakdown and wound deterioration.During an interview on 05/27/26 at 2:10 PM, the NP stated a wound vacuum remaining inoperable for periods of time could delay wound healing. The NP further stated prolonged exposure to urine could contribute to breakdown of the peri wound tissue and reduce the wound's ability to heal.A record review of the admission Record for Resident #2 revealed she was admitted on [DATE] with diagnoses that included nondisplaced fracture of the medial condyle of the right femur.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 04/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 was cognitively intact.

Based on record review, facility policy review, and staff and resident interviews, the facility failed to prevent the misappropriation of property, specifically scheduled medication, for one (1) of four (4) sampled residents, Resident #1. Findings Included:Record review of the facility's Abuse Policy and Procedure with Review/Revision Date 1/24/22 revealed, Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal punishment, neglect and or misappropriation of resident property.7. 'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . On 4/13/26 State Agency (SA) conducted an investigation for complaint 2965461 and facility reported Incident 2961832 at the facility related to misappropriation of medication, medication administration and medication storage. Record review of the Facility Investigation dated 3/23/26 revealed that on 3/19/26 it was discovered during shift change by LPN (Licensed Practical Nurse) #2 and LPN #3 that Resident #1's medication, Clonazepam, was tampered with two (2) tablets removed from their blister pack and replaced with two (2) unidentified tablets. The tampered with blister pack that contained the unidentified tablets was delivered to the former Director of Nurses (DON) who replaced the blister pack with the unidentified tablets taped inside back in the Narcotic Lock box in the Medication Cart. According to the facility's investigation, all three nurses that had access to the 100 Hall medication lock box submitted to drug tests and the facility was unable to determine how or when or by whom the blister pack had been tampered with and the blister pack that had been tampered with and the remaining tablets therein were destroyed on 3/20/26 and the medications were replaced. The Facility Investigation included a printed statement dated 3/23/26 and signed by LPN #2 confirmed that the resident's medication card contained incorrect medications. Record review of the Controlled Drug Package Inventory log for the medication cart for the 100 Hall dated 3/14/26 through 3/20/26 revealed that on 3/20/26 one (1) package that contained thirteen (13) doses (tablets) of Clonazepam 2 mg (milligrams) that belonged to Resident #1 was removed from the 100 Hall Medication Cart Narcotics Locked Box. Record review of the Controlled Drug Record with delivery date 3/06/26 revealed Resident had forty-two (42) Clonazepam 2 milligram tablets, with description included as This medicine is a white, round-shaped, scored tablet imprinted with a 2, delivered to the facility for Resident #1. According to the Record, tablet number 17 was administered to Resident #1 by LPN #1 and tablet number 16 was wasted on 3/20/26 by the Staff Development Nurse.Record review of the Drug Wastage Destruction Log for controlled Substances dated 2/04/24 through 3/20/26 revealed that on 3/20/26 there was one (1) incorrect med for Resident #1 was destroyed by the Staff Development Nurse.Record review of the Order Summary Report with active orders as of 4/13/26 for Resident #1 revealed she had a physician's order for Clonazepam 2 milligram tablet, one (1) tablet by mouth three (3) times a day related to essential tremor. During an interview the Administrator on 4/13/26 at 11:30 AM revealed the facility had investigated and reported to appropriate agencies the misappropriation of two (2) 2 milligram Clonazepam tablets belonging to Resident #1 on 3/23/26. He explained that on 3/19/26, LPN #2 and LPN #3 conducted narcotics accountability count for the locked narcotics box on the 100 Hall medication cart at approximately 7:00 AM during shift change, realized that Resident #1's blister pack of Clonazepam 2 milligram tablets had been tampered with as the foil back of tablets numbers 16 and 17 had been punctured, and it was determined that there were unidentified tablets in the blister package in the damaged blisters. He confirmed that all three (3) of the nurses that had access most recently to the narcotics locked box on the 100 Hall medication cart submitted to drug tests and that the facility could not determine when or by whom the blister pack had been tampered with. He confirmed that the resident had been assessed following the discovery and determined to have no adverse effects and she was her own resident representative and her primary healthcare provider was notified with no new orders notes. He stated that the facility investigation did not result in determination of who had damaged the package, taken the resident's prescribed, scheduled medication, or replaced the missing tablets with unidentified tablets. On 4/13/26 at 12:45 PM an interview and observation with Resident #1 revealed she had essential tremors and was prescribed Clonazepam for the tremors for approximately thirty (30) years. She stated she felt safe at the facility and that having not received one dose of her Clonazepam had not affected her to the best of her knowledge. She stated she had constant tremors with or without the Clonazepam. The resident was neat, clean, well-groomed, appropriately dressed and seated in her wheelchair with good posture and constant nodding of her head and shaking hands. She said that she appreciated the facility's addressing the incident in an appropriate manner and that she had not had any adverse reaction from the medication error.Record review of the Controlled Drug Record for Resident #1's Clonazepam 2 MG (milligram) tablets revealed that on 3/06/26 forty-two (42) tablets had been delivered to the facility from the pharmacy.Record review of the Controlled Drug Package Inventory sheet for the 100 Hall revealed that on 3/20/26 a blister pack that contained thirteen (13) tablets of Klonopin (clonazepam) 2 MG for Resident #1 was removed from the 100 Hall medication cart locked narcotics box. Record review of the Drug Wastage Destruction log for Controlled Substances revealed that on 3/20/26 thirteen (13) tablets of Klonopin (clonazepam) 2 MG for Resident #1 were destroyed per facility policy and procedure.On 4/13/26 at 1:30 PM during interview LPN #3 confirmed that he had been on duty on the 100 Hall on the dayshift (7:00 AM through 3:00 PM) on 3/19/26 and that during the narcotics accountability count of the scheduled medications in the locked box in the 100 Hall medication cart he noted that the foil seal on the back of the blister pack of Resident #1's clonazepam had been punctured. He stated that upon further investigation it appeared that tablet #16 and tablet #17 had been replaced with two (2) unidentified tablets. He said that he and LPN #2 had reported the discovery to the Director of Nursing and the Administrator on the morning of 3/19/26. On 4/13/26 at 2:00 PM an interview with the Staffing Coordinator revealed she had participated in the facility investigation into the misappropriation of two (2) clonazepam tablets that belonged to Resident #1. She confirmed that she had administered drug test to the nurses responsible for the safekeeping of the 100 Hall medication cart and narcotics locked box therein; she reported that the facility was not able to determine when or by whom Resident #1's clonazepam was tampered with.On 4/13/26 at 2:15 PM during interview the DON confirmed that on 3/19/26 nursing staff determined that two clonazepam 2 milligram tablets that belonged to Resident #1 had been misappropriated and replaced with two unidentified tablets. Record review of the admission Record for Resident #1 revealed the facility admitted her on 2/09/26 and she had diagnoses of myasthenia gravis, abnormalities of gait and mobility and lack of coordination.Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 2/15/26 for Resident #1 revealed that the facility assessed her Brief Interview for Mental Status score as 13, which indicated no cognitive impairment.

Based on observations, staff interviews, and facility policy review the facility failed to ensure items in the walk-in kitchen refrigerator were labeled and dated, discarded by the expiration date, and arranged in a manner to prevent possible cross-contamination for one (1) of three (3) kitchen tours Findings include: Review of the facility policy titled, Labeling and Dating Inservice revised 2/2023, revealed All foods should be dated upon receipt before being stored. Food labels must include: The food item name, the date of preparation/receipt/removal from freezer, and the use by date.Leftovers must be labeled and dated with the date they are prepared and the use by date. Review of the facility policy titled, Food Storage: Cold Foods revealed, 5 .All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. An observation and interview on the initial tour of the kitchen with the Dietary Manager (DM) on 1/14/25 at 8:05 AM, revealed in the walk-in refrigerator two white opened containers with a manufacturer label of Yoplait Vanilla Yogurt. The containers were not dated and had a manufacturer best-by date of [DATE]. An observation of a five-pound opened Sysco Tropical Fruit Supreme with no open date nor use-by date. The DM revealed she was unsure when it was opened. An observation of a five-pound white container of Wholesome Farm sour cream dated 12/17/24 with no use-by date, and a large clear plastic container dated 1/11 with no label or use-by date. The DM identified the food item as chicken salad. An unlabeled clear plastic container dated 1/7 with no use-by date, which the DM identified as pimento cheese, a 2-inch-deep rectangular metal pan unlabeled with a date of 1/14, with no use-by date, the DM identified as liquid eggs, a square clear container unlabeled with a date of 1/14, with no use-by date, the DM revealed that is chopped ham, a transparent plastic square container unlabeled with a date of 1/8 on one side and a date of 1/13 on the other side, the DM revealed they had this last night for supper and confirmed the food item was cooked sausage and peppers. She confirmed the date for the meal was last night but wasn't sure why they didn't change the date on the container. Observation revealed a small square pan unlabeled and undated which the DM confirmed the food items were four boiled eggs in a clear liquid and revealed she wasn't sure how long they had been there. An observation of a rectangular metal tray on the bottom shelf of the refrigerator revealed a labeled gallon-sized bag of chicken in a liquid substance; the bag was undated, and in the same pan wrapped in cellophane was an unlabeled and undated food item the DM identified as pork loin . A liquid substance was noted on the bottom of the metal tray where both food items were placed. The DM revealed they were both undated and should not have been in the same container thawing because this could cause bacteria, and the residents could get sick. She confirmed that the food items in the refrigerator were not properly labeled and dated and that all foods should have dates for when they should be discarded. In an interview on 1/14/25 at 8:20 AM with the Dietary Aide revealed that when the food items come in, he puts the dates that they arrived, and then when they open them, they are supposed to put that date and then a use by date. He confirmed the items in the walk-in refrigerator were not correctly labeled. In an interview on 1/15/25 at 12:05 PM, the Administrator confirmed that it is the facility policy that all food items be properly labeled, dated when they arrive at the facility, when they are opened and discarded within the proper time to prevent any food-borne illnesses.

Based on resident and staff interview, record review, and facility policy review, the facility failed to honor resident's rights to make health care decisions for three (3) of 24 residents reviewed for advanced directives. Resident #10, #36, and #48 Findings Include: Record review of the facility policy titled Do Not Resuscitate No Code Status Policy dated ,d+[DATE] revealed, It is the policy of this facility to inform residents of the right to choose to have CPR (cardiopulmonary resuscitation) or no CPR to be performed at such time of imminent death. The code status form will be completed at the time of admission. Resident #10 Record review of Resident #10's Order Summary Report revealed, DNR (Do Not Resuscitate): Need for death with dignity related to choice of code status DNR per family/Resident Representative (RR) request. Record review of the Code Status form for Resident #10 revealed a family member signed the form dated [DATE], with no signature from the resident. An interview with Resident #10 on [DATE] at 10:35 AM revealed he can make his own decisions and sign his paperwork. He stated that when he was admitted to the facility, he did not recall anyone asking him whether he wanted to be a full code or DNR and admitted that he did not sign any paperwork on it. He stated that it should be his choice since I can make my own decisions. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] for Resident #10 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated the resident was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #10 on [DATE] with diagnoses that included Chronic Systolic (Congestive) Heart Failure, and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Resident #36 Record review of Resident #36's Order Summary Report revealed full code related to family/Resident Representative choice of code status. Resident is a full code. Record review of the Code Status form for Resident #36 revealed a family member signed the form dated [DATE], with no signature from the resident. An interview with Resident #36 on [DATE] at 11:45 AM, revealed when she was admitted to the facility, she did not sign her code status form, and no one spoke to her about it. She stated that she can still make her own decisions, and even though she has Parkinson's, and it may take her a little longer, she can still sign. Record review of Resident #36's MDS with an ARD of [DATE] revealed, under Section C, a BIMS summary score of 14, which indicated the resident was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #36 on [DATE] with diagnoses that included Hypoglycemia, Unspecified, and Parkinson's Disease without Dyskinesia. Resident #48 Record review of Resident #48's Order Summary Report revealed, full code related to family/Resident Representative choice of code status. Resident is a full code. Record review of the Code Status form for Resident #48 revealed a family member signed the form dated [DATE], with no signature from the resident. In an interview on [DATE] at 8:50 AM, Resident #48 revealed that she did not sign her Advance Directives when admitted to the facility. She stated that no one at the facility had spoken with her about her code status. Record review of the MDS with an ARD of [DATE] for Resident #48 revealed, under Section C, a BIMS summary score of 14, which indicated the resident was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #48 on [DATE] with diagnoses that included Multiple Fractures of Pelvis without Disruption of Pelvic Ring, and Chronic Kidney Disease, Stage 3. An interview with the Social Services Director on [DATE] at 1:15 PM, revealed that when a resident was admitted to the facility, she had been discussing their code status with the family representative or power of attorney (POA) and had not been going over it with the resident. She confirmed that Residents #10, #36, and #48 did not sign their code status form, and they should have because it was their right. During an interview on [DATE] at 1:40 PM, the Administrator confirmed that the residents who were competent and able to sign their Advance Directive should be allowed to do so, and we should ensure that their wishes were honored. In an interview on [DATE] at 10:38 AM, the Director of Nurses (DON) confirmed that Residents #10, #36, and #48 were cognitive and able to make their own decisions and should have had the opportunity to decide what their end-of-life wishes were.

Based on staff interview and record review, the facility failed to accurately code section A of the Minimum Data Set (MDS) for a resident with a serious mental illness for one (1) of 16 MDS reviewed. Resident #16 Findings Include: The facility provided a statement on letterhead dated 1/15/25 that read, It is the policy of Proper Name of the Facility to follow the RAI (Resident Assessment Instrument) manual for completion and accuracy of the MDS (Minimum Data Set) assessments. Record review of Resident #16's Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 6/14/2017, revealed under, Mental Health . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Schizophrenia was listed as the diagnosis. Record review of Resident #16's Annual MDS with an Assessment Reference Data (ARD) of 4/01/24 revealed, under section A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was answered. An interview with the MDS Nurse on 1/15/25 at 2:35 PM, confirmed Section A of Resident #16's MDS was coded inaccurately. She confirmed that the resident had a serious mental illness, and the assessment should be accurate to develop a complete plan of care. An interview with the Director of Nursing (DON) on 1/15/25 at 2:52 PM revealed, his expectations were for the MDS assessments to accurately reflect each resident's status and plan of care. Record review of the Admission Record revealed the facility admitted Resident #16 on 5/03/17 with medical diagnoses that included Schizophrenia and Unspecified Psychosis.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene.(Resident #1, #2, #7) and adaptive equipment with meals (Resident #2) for three (3) of 16 care plans reviewed. Residents #1, # 2, #7 Findings Include: Review of the facility policy titled, Following the Care Plan Policy unrevised, revealed under, Policy: It is the Policy of this facility to follow a written and approved care plan for each resident. Resident #1 Record review of Resident #1's ADL (activities of daily living) Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia. Also revealed under, Intervention/Task: Personal hygiene/Oral care: The resident requires x (times) 1 (one) staff participation with personal hygiene . An observation on 1/14/25 at 9:20 AM revealed Resident #1 lying in bed with long facial hair on her chin, which was approximately three to four inches long. On 1/16/25 at 9:10 AM, an interview with the Director of Nursing (DON) confirmed the ADL care plan was not followed for Resident #1. Record review of the Admission Record revealed the facility admitted Resident #1 on 4/03/2017 with medical diagnoses that included Major Depressive Disorder and Muscle Weakness. Resident #7 Record review of Resident #7's ADL Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t Rhabdomyolysis. Also revealed under, Intervention/Task: Check nail length and trim and clean on bath day and as necessary. An observation of Resident #7 on 1/14/25 at 9:00 AM, revealed she was lying in bed and had long fingernails approximately one-half (1/2) to three-fourths (3/4) inches in length on both hands. On 1/15/25 at 1:20 PM, an observation and interview with CNA #1 confirmed Resident #7's fingernails were too long. On 1/16/25 at 9:10 AM, an interview with the DON confirmed the ADL care plan was not followed for Resident #7. Record review of the Admission Record revealed the facility admitted Resident #7 on 12/20/24 with a medical diagnosis of Rhabdomyolysis. 47874 Resident #2 Record review of Resident #2's ADL Care Plan revealed under, Focus: The resident has an ADL self-care performance deficit r/t weakness, osteoarthritis. Also revealed under, Interventions: Personal hygiene/Oral care: The resident requires x (times) 1 staff participation with personal hygiene and oral care. On 1/14/25 at 8:09 AM, an observation of Resident #2 revealed that she was sitting in her wheelchair in her room. As the resident was trying to communicate, a thick white substance was observed on her upper and lower teeth and on her gums. An observation and interview with the DON on 1/15/25 at 3:22 PM confirmed oral hygiene was not done and described Resident #2's teeth as plaque buildup and food particles. Resident #2 Record review of Resident #2's nutritional Care Plan revealed under, Focus: The resident at risk for potential nutritional problems related to diet restrictions . Also revealed under, Interventions/Task: Resident to have divided plate with meal, date initiated 9/15/22 and Resident to have sippy cup with meals, date initiated 9/22/23 . An observation of Resident #2's lunch meal on 1/14/25 at 11:55 AM revealed that she was served on a regular plate with a glass of tea and water in a goblet style. An observation of the resident's meal ticket at this time revealed, Divided plate, sippy cup. and the resident did not have these available. An interview with the DON on 1/14/25 at 12:01 PM, confirmed Resident #2 did not have the adaptive equipment that was listed on her meal ticket. An interview with the MDS Nurse on 1/16/25 at 8:16 AM revealed the purpose of the care plan was for the staff to know what care to provide for the residents. She confirmed Resident #2's care plan was not followed for oral hygiene and adaptive equipment. Record review of the Admission Record revealed the facility admitted Resident #2 on 10/28/20 with medical diagnoses that included Dysphagia and Left Wrist Drop.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide nail care, oral care and facial hair removal for resident's requiring assistance with activities of daily living (ADLs) for three (3) of 16 sampled residents. Resident #1, #2, and #7 Findings Include: Record review of the facility policy, ADL Care Policy undated, revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis . Resident #1 An observation and interview on 1/14/25 at 9:20 AM revealed, Resident #1 with facial hair on her chin that was approximately three (3) to four (4) inches long. An interview with the resident revealed that she did not like facial hair and stated, I want them gone. An observation and interview on 1/15/25 at 1:27 PM, with Certified Nursing Assistant (CNA) #1 revealed facial hair and fingernails should be taken care of during bath time or anytime it was noticed. She confirmed that Resident #1 had long hair on her chin and admitted it should have already been taken care of. Record review of the Admission Record revealed the facility admitted Resident #1 on 4/03/2017 with medical diagnoses that included Major Depressive Disorder and Muscle Weakness. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/24, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #7 On 1/14/25 at 9:00 AM, an observation and interview with Resident #7 revealed she had fingernails approximately one-half (1/2) to three-fourths (3/4) inches in length past the tips of the fingers. She admitted that she had never had fingernails this long before, and stated, I keep them very short; I feel like they are like claws now. The resident revealed she had been at the facility since December, and no one had offered to clip her nails. An observation and interview on 1/15/25 at 1:20 PM of Resident #7 with CNA #1 revealed that fingernails should be checked every day, cleaned and clipped when needed. She confirmed Resident #7's fingernails were long and Resident #7 stated to CNA #1, I have never had my nails this long before and I want them cut. CNA #1 stated that with the resident's fingernails that long she could scratch herself and cause skin tears or the spread of bacteria. On 1/16/25 at 8:30 AM, an interview with Registered Nurse (RN) Supervisor revealed that the nurses should be checking behind the aides to make sure the resident needs were taken care of. She revealed she was not aware Resident #7 had long fingernails and confirmed that nail care should be included in their personal hygiene task. On 1/16/25 at 9:10 AM, an interview with the Director of Nursing (DON) confirmed that the nurses and the aide supervisor should be overseeing the completion of ADL care. He revealed that anyone who noticed a need with a resident should take care of the problem or tell someone who could. Record review of the Admission Record revealed the facility admitted Resident #7 on 12/20/24 with a medical diagnosis of Rhabdomyolysis. Record review of Resident #7's MDS with ARD of 11/26/24 revealed under Section C, a BIMS score of 10, which indicated the resident was moderately cognitively impaired. 47874 Resident #2 An observation of Resident #2 on 1/14/25 at 8:09 AM revealed the resident was trying to talk and a thick white substance was observed on her upper and lower teeth and gums. An observation of Resident #2 on 1/15/25 at 8:06 AM revealed no change in the resident's teeth and gums. An observation and interview on 1/15/25 at 3:10 PM, with CNA #2 revealed she was assigned to Resident #2 today on day shift. She confirmed the resident had excess buildup on her teeth and that she did not brush the residents' teeth today. She explained that the resident was on the get up list and that the night shift should have done it. She admitted that she should have checked behind them to ensure it was done. An observation and interview with the DON on 1/15/25 at 3:22 PM described Resident #2's teeth as plaque buildup and food particles. He revealed that the aides and nurses were responsible for oral care and brushing the resident's teeth. The DON stated that the resident could develop decay and cavities from not getting the appropriate oral care. Record review of the Admission Record revealed the facility admitted Resident #2 on 10/28/20 with medical diagnoses that included Dysphagia and Left Wrist Drop.

Based on observation, staff and resident interviews, and facility policy review, the facility failed to properly store medications, as evidenced by, medications left in a resident's room for one (1) of 16 sampled residents. Resident #41 Findings Include: Record review of the facility policy Medication Storage dated 01/2024, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication cart and/or medication rooms according to the manufacturer's recommendation An observation on 1/14/25 at 11:00 AM and 2:00 PM revealed a one-ounce bottle of lubricant eye drops and a two-ounce tube of pain relief cream on the overbed table in Resident #41's room. An interview on 1/14/25 at 2:50 PM, with Resident #41 revealed he brought his eye drops and pain cream from home, and he applied them himself. He revealed that he used the eye drops every day and that he hardly ever used the pain cream. The resident explained he kept these items in his room so he could use them as needed. An observation and interview with Licensed Practical Nurse (LPN) #1 on 1/15/25 at 9:58 AM, confirmed Resident #41 had a bottle of lubricant eye drops and a tube of pain cream on his bedside table. She revealed the resident had not been assessed for self-administration and explained medications were not supposed to be in his room. LPN #1 agreed that leaving medications in a resident's rooms was a risk, and another resident could enter his room and take something they were not supposed to have. An interview on 1/15/25 at 10:40 AM, with the Director of Nursing (DON) confirmed that leaving medications in a resident's room should not happen. He revealed that some residents were used to self-administering medications at home before coming into the facility, and it was often hard for them to adjust. The DON stated that if a resident requested to self-administer their medications, then an assessment should have been done to ensure they were competent and knew how to use it. He revealed this one must have slipped through the cracks and explained that someone should have seen the medications in Resident #41's room and removed them. Record review of Resident #41's Admission Record revealed an admitted [DATE], with medical diagnoses that included Unspecified Injury of Left Lower Leg, Muscle Weakness, and Need for Assistance with Personal Care. Record review of Resident #41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24, revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment during meals for one (1) of two (2) dining observations. Resident #2 Findings Include: Review of the facility policy titled Assistive Feeding Devices with a revision date of 6/14 revealed under, Policy: Residents shall be provided assistive devices to maintain or improve their ability to eat independently. Also revealed under, Procedure: . 4. The assistive devices are placed on the resident's tray at the time of meal service. An observation on 1/14/25 at 11:55 AM revealed Resident #2's lunch meal was served on a regular plate with a goblet glass of tea and water with a meal ticket that read, Divided plate, sippy cup. An interview with the Director of Nursing (DON) on 1/14/25 at 12:01 PM confirmed that Resident #2 did not have the adaptive equipment that the resident should have had. Record review of the Order Details for Resident #2 revealed an order dated 11/15/21, Patient to have sippy cup at breakfast, lunch, and dinner with meal. A record review of the Order Details for Resident #2 revealed an order dated 11/19/21, . Divided plate with meals. An interview with Dietary Staff #2, on 1/15/25 at 8:10 AM confirmed when adaptive equipment was on a meal ticket, the dietary server should provide it during the tray preparation. She revealed the purpose of ensuring the adaptive equipment was available with the meal was to help the residents be more independent with feeding themselves. An interview with the DON on 1/15/25 at 8:20 AM confirmed that the purpose of the adaptive equipment was to assist the resident with feeding herself and confirmed it should be available with each meal. Record review of the Admission Record revealed the facility admitted Resident #2 on 10/28/20 with medical diagnoses that included Dysphagia and Left Wrist Drop.

Based on observation, staff interview, and facility policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) while providing resident care for two (2) of three (3) direct care observations. Resident #28 and Resident #49 Findings Include: Record review of the facility policy Enhanced Barrier Precautions with a revised date of 8/07/24, revealed under, Policy Explanation and Compliance Guidelines: . 2. Initiation of Enhanced Barrier Precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds . and/or indwelling medical devices ( .urinary catheters, feeding tubes .) even if the resident is not known to be infected . Resident #28 An observation on 1/15/25 at 8:55 AM revealed Licensed Practical Nurse (LPN) #2 administered Resident #28's medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube without wearing a gown for EBP. He revealed that EBP were supposed to be utilized when providing care to residents who had Covid-19 or open wounds. He stated that he did not think they had to follow the precautions for residents with PEG tubes. LPN #2 agreed that EBP were put in place to protect the residents and the staff to prevent the spread of germs. Record review of Resident #28's Order Summary Report with active orders as of 1/16/25 revealed an order for EBP related to PEG every shift and medication orders for administration through the PEG Tube. Record review of Resident #28's Admission Record revealed an admitted [DATE] with medical diagnoses that included Ventricular Fibrillation and Dysphagia. Resident #49 An observation on 1/15/25 at 10:50 AM revealed LPN #1 completed Resident #49's catheter care and changed the drainage bag without wearing a gown. LPN #1 revealed they (the staff) had to wear a gown if a resident had open wounds or something contagious like Covid-19. She stated that she was not aware that gowns had to be worn when providing catheter care. An interview on 1/15/25 at 11:25 AM, with the Director of Nursing (DON) revealed EBP were to be used with any residents who had indwelling medical devices to protect the residents from infection. He revealed the staff had been in-serviced and knew they were supposed to wear gloves and gowns when they provided care to these residents. Record review of Resident #49's Admission Record revealed an admitted [DATE] with medical diagnoses that included Malignant Neoplasm of the Prostate and Chronic Kidney Disease. Record review of Resident #49's Order Summary Report with active orders as of 1/16/25 revealed, Resident to be placed on EBP related to Foley and there was an order for catheter care every day related to Retention of Urine diagnosis.

Based on observation, staff interview, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on four (4) of five (5) housekeeping carts observed during annual survey. Findings include: Review of the facility policy titled, Hazardous Chemical Storage, revealed Policy: Environmental services shall maintain all hazardous chemicals in a safe, clean, and locked location when not in use. All hazardous chemicals shall be in control of facility personnel while being used . An observation on 09/19/23 at 08:12 AM, of a housekeeping cart on the 100-hall revealed one (1) bottle of Lysol cleaner, one (1) bottle of Pledge glass cleaner, 1 bottle of Tilex cleaner, 1 bottle of 4 in 1 Clorox cleaner and 1 bottle of Clorox cleaning wipes sitting on top of the housekeeping cart on the 100-hall unattended. An interview, on 09/19/23 at 8:17 AM, with Housekeeper #1 confirmed that the chemicals should be locked up when she is not with the cart and that if a resident gets them it could harm them. An observation on 09/20/23 at 09:45 AM, of the housekeeping cart on the 200-hall revealed the housekeeping cart was unlocked and unattended. Inside the cabinet on the cart was 1 bottle of Air neutralizer,1 bottle of Clorox urine odor remover, and 1 bottle of Pledge glass cleaner. An observation and interview, on 09/20/23 at 09:50 AM, with the Administrator (ADM) confirmed that chemicals were sitting on top of the cart on the 200-hall and in the general sitting area unattended. The (ADM) confirmed that the chemicals should be locked inside the cart. The ADM confirmed that the key to lock the carts was unable to be located. The ADM confirmed that the chemicals could be harmful if residents got them. An observation, on 09/20/23 at 10:00 AM, with the Housekeeping Supervisor and Housekeeper #2 revealed two (2) housekeeping carts located in the general sitting area, unattended, with cleaning chemicals sitting on the top of the cart. The chemicals included: 1 bottle of Clorox urine odor remover, 1 bottle of Pledge glass cleaner, and 1 bottle of Tilex cleaner. The cabinet on the housekeeping carts were unlocked. Housekeeper #2 confirmed that chemicals should not be left on top of the cart unattended and that they should always be locked inside the cabinet of the housekeeping cart. Housekeeper #2 stated that a resident could get the chemicals and swallow them. Housekeeper #2 confirmed she did not have a key to lock her housekeeping cart. An interview on 09/20/23 at 10:10 AM with the Housekeeping Supervisor confirmed that there were cleaning chemicals on the top of the housekeeping cart on the 200 hall and the 2 housekeeping carts located in the general sitting area. The Housekeeping Supervisor confirmed that the cabinet was unlocked on the housekeeping carts on 200 hall and the 2 carts located in the sitting area. The Housekeeping Supervisor confirmed that he was unaware of where the keys were located to lock these carts. The Housekeeping Supervisor confirmed that he was never trained in storage of chemicals when he was given the position of Housekeeping Supervisor 2 years ago. The Housekeeping Supervisor confirmed that he has five (5) housekeeping carts and they are used in the facility daily. The Housekeeping Supervisor confirmed that leaving chemicals unattended and the cabinets unlocked could be harmful if residents were to get them. An interview on 09/21/23 at 08:30 AM, with the Director of Nursing (DON) confirmed that there are no wandering residents in the facility, and they have had no incidents in the last 12 months involving chemicals. An interview on 09/21/23 at 10:28 AM, with the ADM confirmed that the Housekeeping Supervisor was a floor technician at this facility prior to being moved into the Housekeeping Supervisor position. The ADM confirmed that the Housekeeping Supervisor received training on storage of chemicals and locking housekeeping carts. An interview, on 09/21/23 at 11:00 AM, with the Housekeeping Supervisor confirmed that he did attend the in-services on 05/09/23 and 7/31/23 conducted by the Administrator and was aware that the chemicals should not be left unattended, and the housekeeping carts should be always locked when unattended. Record review of the in-service training dated 05/09/23 and 07/31/23 revealed that the Housekeeping Supervisor, Housekeeper#1 and Housekeeper #2 were present and received training on the storage of chemicals. Record review of the Material Safety Data Sheets (MSDS) for the unattended chemicals revealed: Air Neutralizer - If on skin; take off immediately all contaminated clothing; Rinse skin with water/shower. Pledge Cleaner - Avoid contact with skin, eyes, and clothing. Use only as directed. Keep out of reach of children and pets. Tilex - Causes eye irritation, wash contaminated skin thoroughly after handling. Clorox Urine Remover - If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes (min). Wash off immediately with plenty of water, if skin irritation persists, call a physician. Remove to fresh air if breathing is difficult. Drink one or two glasses of water. Do not induce vomiting without medical advice. Clorox four in one disinfectant - Inhalation - remove to fresh air. Eye contact - Rinse thoroughly with plenty of water. Skin contact - Wash skin with soap and water. Ingestion - Clean mouth with water and drink afterwards plenty of water. Lysol Cleaner Eyes-If in eyes, hold eye open and rinse slowly and gently with water for 15-20 min Skin- Remove contaminated clothing. Rinse skin immediately with plenty of water 15-20 min Inhalation-Move exposed person to fresh air. Get medical attention immediately Ingestion-If swallowed, call poison control center. Do not induce vomiting. Have person sip a glass of water if able to swallow. Clorox Wipes Eyes- Open eyelids wide apart. Continue to rinse for at least 15 minutes. Get medical attention if symptoms persist. Skin-Rinse with water Inhalation-If throat irritation or cough, move person to fresh air. Ingestion-Rinse mouth. Get medical attention if any discomfort continues. 39807

Based on observation, facility policy review, and staff interviews, the facility failed to prevent possible food contamination as evidenced by observations during the initial kitchen tour of improper thawing of raw chicken and three (3) and one-half (,d+[DATE]) loaves of expired sliced sandwich bread, for 51 of 53 residents receiving dietary trays. Findings include: Record review of facility policy titled, Thawing Food revised ,d+[DATE] revealed, Policy: The facility shall ensure that foods served to residents are thawed in a manner to prevent contamination. PROCEDURE: Frozen food is thawed in one of these ways: 2. Running water .b. Completely submerge food under running potable (drinking) water at 70 degrees or below. Review of facility policy titled, FOOD STORAGE LABELING . with a revision date of ,d+[DATE] revealed POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures .5.i. Identify the food item's use by date or expiration date. ii. Store items with the earliest use-by or expiration date in front of items with later dates. iii. Use items stored in front first. iv. Foods stored in storage units will be surveyed routinely to identify and discard food that have passed it manufacturer use-by-date or expiration date. Suggested time frames: 1. Dry Storage - Weekly . An observation, during the initial kitchen tour, on [DATE] at 10:34 AM, revealed raw chicken thawing in one side of the deep two (2)-compartment sink, completely submerged with no running water. The raw chicken sat at the bottom of the opposite side of the sink that was away from the faucet. The initial kitchen tour observation also revealed three (3) full loaves of sliced sandwich bread and one-half (,d+[DATE]) loaf of sliced sandwich bread with an expiration date of [DATE]. An interview on [DATE] at 10:35 AM, with the Dietary Department (DD) #2 (Manager), confirmed the raw chicken was being thawed in the 2-compartment sink full of water. The chicken sat at the bottom of and on the opposite side of the sink, away from the faucet, there was no water running over the chicken to thaw it, and that was not the proper process to be used to thaw raw chicken. DD #2 revealed that the incorrect thawing process could possibly cause Salmonella bacteria to grow, which could lead to sickness for the residents. DD #2 revealed she did not know the 3 ½ loaves of sliced sandwich bread was expired. There was no specific dietary employee assigned to ensure bread was disposed of after the expiration dates, and that it was the responsibility of all dietary staff to monitor the bread for expiration dates. DD #2 revealed the process for usage of the bread was to stack the oldest bread on the top of all the bread in storage to be used first, before the expiration date, and confirmed the expiration date of [DATE], was on the 3 ½ loaves of sliced sandwich bread. DD #2 revealed the bread could have possibly molded from being kept and used past the expiration date, and could possibly cause the residents to be contaminated with whatever bacteria that could have possibly grown on the sliced sandwich bread. DD #2 revealed that sandwiches were made every evening and are sent to the nursing units to be used as part of the Diabetic residents' evening snack. DD #2 (Manager) revealed she had not conducted in-services with the dietary staff pertaining to proper thawing of foods or storage/disposal of expired foods since she started. An interview on [DATE] at 09:00 AM, with the DD #1, revealed she was thawing the raw chicken out and was not using the correct thawing process. DD#1 revealed she would normally put raw meat in a deep pan and then place the deep pan of raw meat under cool running water to thaw. DD #1 revealed not thawing the raw chicken correctly could possibly cause the residents to get Salmonella or food poisoning of some kind. An interview on [DATE] at 11:30 AM, with the Administrator confirmed the residents could possibly get Salmonella poisoning due to the dietary staff not using the correct thawing process to thaw out the raw chicken. The Administrator also confirmed there was a possibility of growth of bacteria on the sliced sandwich bread that expired on [DATE], which could possibly cause some form of illness to the residents.

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possible spread of COVID-19 as evidenced by failure to fully implement their policy to ensure that all staff are fully vaccinated or received an exemption for two (2) of 97 employee records reviewed. Findings Include: Record review of the facility policy titled, Employee COVID-19 Vaccinations undated, revealed It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless religious or medical exemptions are granted. 2. Employees, who provide any care, treatment, or other services for the facility and/or its residents regardless of clinical responsibility or resident contact are required to be fully vaccinated against COVID-19 . Record review of the facility form COVID-19 Staff Vaccination Status for Providers revealed that Certified Nurse Assistants (CNA) #12 and #13 were not fully vaccinated and did not have a granted exemption. Record review of CNA #12's vaccination record revealed she received her one dose of a multi-dose COVID-19 vaccination on 2-3-21 and has continued to work at the facility full time with her last day to work being 4-2-22. Record review of CNA #13's vaccination record revealed she received one dose of a multi-dose COVID-19 vaccination on 11-17-21 and has continued to work full time at the facility with her last day to work being 4-5-22. An interview on 4-5-22 at 9:30 AM, with the Infection Preventionist (IP) revealed she just started as the IP about a month ago and she is not aware of any deadline they have had in regards to the staff completing their COVID-19 vaccination or requesting an exemption. She revealed she is aware of the guidance that all staff is suppose to be fully vaccinated or have a granted exemption at this point. She confirmed there are three CNA's that are not fully vaccinated, but one of them is not due for her second vaccination yet. She confirmed that CNAs #12 and #13 should have had their second COVID-19 vaccine already and they have continued working here. She confirmed she understands the risk of those CNAs continuing to work in the facility without being fully vaccinated. An interview on 4-5-22 at 3:45 PM, with the Director of Nurses (DON) revealed the facility has had no positive COVID-19 residents or staff in the last 4 weeks and they test unvaccinated staff twice per week and those unvaccinated staff have to wear an N95 mask. An interview on 4-6-22 at 9:38 AM with the Administrator revealed that she is aware of the regulations and confirmed that she knew they were suppose to have all staff fully vaccinated or exemptions granted at this point. She revealed that the facilities last IP left on 1-12-22 and the current IP started about a month ago. The Administrator revealed she was not aware that they had two CNAs that had not had their 2nd COVID-19 vaccine and was continuing to work. The Administrator revealed that the IP that left on 1-12-22 was probably aware that those two CNAs needed their second COVID-19 vaccination. The Administrator revealed that they had told all staff that they had to have their 1st vaccination by the first deadline or an exemption. The Administrator confirmed she was unaware of who was keeping up with the staff vaccinations and the new guideline, but she wasn't. She confirmed the facility did develop a policy to ensure all staff were fully vaccinated or had an exemption, but had not fully implemented it. She confirmed that CNA #12 and #13 must have slipped through the cracks. An interview on 4-6-22 at 9:49 AM, with CNA #12 revealed that a facility staff member called her yesterday afternoon and told her she had to have her second COVID-19 vaccination before she could return to work. She revealed this was the first she had heard of it. She revealed she has been trying to get an appointment with the local pharmacy and she wishes she had known sooner so she did not have to miss work. She confirmed that she had been being tested twice per week and was wearing an N95 mask at work. She denied having COVID-19 or any signs or symptoms of COVID-19. She confirmed that her last day to work was 4-2-22. An interview on 4-6-22 at 4:20 PM, with the DON confirmed that having two CNAs working and not being fully vaccinated could increase the risk of spreading COVID-19 infection within the facility. An interview on 4-7-22 at 5:00 PM, with Human Resources (HR) staff revealed she completes the work schedule for the facility. She revealed that she was told on 4-5-22 that CNA #12 and #13 could not come back to work until they received their second COVID-19 vaccination. HR staff revealed CNA #13 was already at the end of her shift on 4-5-22 before she was made aware.

Based on observations, staff interviews, record reviews, and facility policy review the facility failed to provide a sufficient volume level on the resident call light system as evidenced by the inability to hear the call light system alarm on the nursing unit halls for four (4) of 4 days of survey. Findings include: Review of the facility policy titled, Call Light, Answering, undated, revealed, Purpose - The purpose of this procedure is to respond to the resident's requests and needs . An observation on 4/4/22 at 10:30 AM, revealed the call light globes, located above the resident room doors would light up when the call light system was activated, but no call light system alarm was heard on the nursing unit halls to alert the staff that the call light was activated. The call light system monitor was located at the 200 Hall nurse's desk and all the resident calls for assistance for the 100 Hall, 200 Hall, and 300 Hall, were to be answered through that one (1) call light system monitor. The State Agency (SA) was able to hear the call light system alarm while at the nurse's desk, which was at a low volume, but could not hear the call light system alarm at one of the closest resident rooms, #201, which was approximately 20-25 feet away from the 200 Hall nurse's station desk. The State Agency walked down to the end of the 100 Hall, which was approximately 40-50 feet away from the 200 Hall nurse's desk, walked down to the end of the 200 Hall, which was approximately 40 to 50 feet away from the 200 Hall nurse's station, and walked down to the nurse's station on the 300 Hall, which was approximately 30-40 feet away from the 200 Hall nurse's station, and was not able to hear the call light system alarm. An interview on 4/5/22 at 04:35 PM, with Registered Nurse (RN)#2 revealed that some nursing staff members had revealed to her as the RN Supervisor that they could not hear the call light system alarm if they were not directly at the nurse's station. RN #2 also revealed that there was not a staff member assigned to the desk to be able to monitor the call light system at all times. RN #2 revealed not being able to hear the call light system alarm was a problem the facility staff had been dealing with for a while but could not reveal how long the problem had existed. RN #2 revealed a verbal report had been made to the higher-level staff regarding the problem. An interview on 4/5/22 at 04:38 PM, with Certified Nurse Aide (CNA)#5, who was located behind the 300 Hall nurse's desk revealed that the CNA staff had expressed to her, as the Lead CNA, they are not able to hear the call light system alarm on the 100 Hall, 200 Hall, or the 300 Hall. CNA #5 revealed she could not hear the call light system alarm while she sat at the nurse's desk on the 300 Hall, and could only hear the call light system alarm when she stood at the 200 Hall nurse's station desk. CNA #5 revealed she had instructed the CNA staff to look up at the globes over the residents' rooms to see if a call light was on when they were out on the halls. An interview on 4/6/22 at 09:40 AM, with the Director of Nursing (DON), revealed the call light system alarm volume was too low to be heard down the nursing unit halls from the 200 Hall nurse's desk. The DON revealed the call light system alarm volume being down that low could possibly cause a call light not to be answered timely. An interview on 4/7/22 at 09:25 AM, with CNA #9 who was located on the 300 Hall, revealed she was not able to hear the call light system alarm when out on the nursing unit. CNA #9 revealed she could hear the alarm if she stood at the 200 Hall nurse's station desk. An interview on 4/7/22 at 09:29 AM, with CNA #10 who was located on the 300 Hall, revealed she was not able to hear the call light system alarm when she was away from the 200 Hall nurse's station desk. An interview on 4/7/22 at 09:34 AM, with RN #1 who was located on the 100 Hall, revealed she cannot hear the call light system alarm when away from the 200 Hall nurse's station desk. An interview on 4/7/22 at 12:30 PM, with Licensed Practical Nurse (LPN) #4, who was located on the 300 Hall, revealed she cannot hear the call light system alarm on the 300 Hall, because the call light system's volume was too low to hear from the 200 Hall nurse's station desk. An interview on 4/7/22 at 12: 35 PM, with CNA #11, who was located on the 300 Hall, revealed she could not hear the call light system alarm when she was on the 300 Hall. An observation and interview on 4/7/22 at 03:25 PM, with the Administrator revealed the Administrator increased the call light system monitor's volume, located at the 200 Hall nurse's station desk from medium to high. The SA went down the 200 Hall to listen for the call light system alarm's sound. The call light system alarm sound could be heard down to the end of the 200 hall, 40-50 feet away from the 200 Hall nurse's station desk, due to the increased volume. The Administrator also walked down the 200 Hall, past room #212, approximately 30 feet from the 200 Hall nurse's station desk, confirmed she was able to hear the call light system alarm. She revealed she had assigned the RN Charge Nurses to stay at the nurse's desk to monitor the call light system alarm and inform staff when a resident needed assistance but revealed there was not a written schedule for the assignment. The Administrator revealed that the call light system volume was low because she thought the high volume was too much noise. The Administrator revealed the call light system volume not being heard by the nursing staff could have possibly caused residents call lights not to be answered in a timely manner.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to utilize assistive devices available to maintain resident's communication abilities for three of four survey days. Resident #20. Findings include: Review of the facilities policy, Communications Within and External to the Facility updated 2/21/21 reveals the facility will protect and facilitate the resident's right to communicate with individuals and entities within and external to the facility. An observation on 04/04/22 at 10:15 AM, Resident #20 could be heard loudly down the hall. Upon entering Resident #20's room the resident had a splint in her left hand and continued to make verbal sounds and shake the splint. Resident #20 tried to communicate via sign language in a frustrated manner. Certified Nurse Assistant (CNA) #1 entered the room and said that she doesn't like the splint, and gets upset when she has to wear it. An observation on 04/04/22 at 03:00 PM, revealed Resident #20 sitting in a Geri-chair in her room. She was attempting to communicate via sign language and hand gestures. An interview on 04/06/22 at 02:55 PM, with Licensed Practical Nurse (LPN) #1 confirmed it's very difficult to understand what she wants, but I think the aides can understand her. The nurse confirmed there wasn't anything in the room to aide in communication with the resident. An interview on 04/06/22 at 03:00 PM , with the Social Worker (SW), revealed Resident #20 is deaf and mute. The social worker stated, the resident has a communication board, a whiteboard, and a phone in her room that is used for communication. An observation and interview on 04/06/22 at 03:10 PM, in Resident #20's room with the SW and Director of Nurses (DON) confirmed there was no communication board or white board visible in the room. The DON began looking in the resident's chest of drawers for the communication board and found it in the second drawer under a brief. The SW found the whiteboard on the top shelf of the residents closet. The SW and DON confirmed that there was not a marker in the room to write on the communication board. The SW picked up a remote for the communication device for the deaf, which was located on top of the chest of drawers. The SW revealed to the resident there is a light on top of the machine that will alert the resident when a call is coming through. The social worker SW picked up the power cord to the communication device and stated that it was disconnected. The SW revealed she had connected the device two (2) weeks ago but it is disconnected now. The DON and SW confirmed that the staff would not be able to communicate with her with the whiteboard in the top of the closet and the communication board in the drawer and the device not plugged in. The SW revealed that she had done an inservice at the old facility, but had not done one since being in the new facility. An interview on 04/06/22 at 03:35 PM, with Certified Nurse Assistant (CNA) #2, revealed the Resident is very hard to understand, she gestures and nods. CNA #2 stated that Resident #20 used to write on a board, but she can't anymore. CNA #2 stated that she didn't even know if she had a board anymore. An interview on 04/06/22 03:36 PM, with Certified Nurse Assistant (CNA) #3 stated that Resident #20 is very hard to understand, but she can point some. When the SA questioned her about devices for communication, she stated she was not sure where it was. An interview on 04/06/22 at 03:37 PM, with Certified Nurse Assistant (CNA) #4 revealed that the resident is hard to understand. CNA #4 stated that she did not work with this resident much. A record review of in-service training, by Social Worker (SW) dated 11/10/2020, Title and detailed content of inservice: Information on how to use the communications device (with attached phone number), information on communicating with deaf and mute persons, Resident in 15B is deaf and mute. She has a communication book and board to make her needs known. Staff can use communication board to communicate with resident. White board is available to write on in order to communicate. A record review of Resident #20's Admission Record revealed she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/2022 revealed a Brief Interview for Mental Status (BIMS) score of 01 indicating Resident # 20 had severe cognitive impairment.

Based on observation, staff interviews, resident interviews, record review, and facility policy review, the facility failed to ensure that each resident was treated with dignity as evidenced by failure to provide verbal communication to residents during care, knock on resident's door before entering, cover a resident and close door during care, and failure to provide a privacy bag for a catheter for 4 of 24 residents observed. Resident #19, #27, #42, #43. Findings Include Resident #27 Review of the facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 1-19, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under Compliance Guidelines. #1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .#5. When interacting with a resident, pay attention to the resident as an individual . #7. Explain care or procedures to the resident before initiating the activity. #8. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused, and resident centered .#12. Maintain resident privacy. An observation on 04/04/22 at 11:59 AM, revealed Certified Nurse Assistant (CNA) #7 yelled from Resident #27's room to CNA #6 who was in the hall and asked her to come help pull the resident up in the bed. State Agency (SA) observed CNA #6 enter Resident #27's room without knocking and assisted CNA #7 to pull the resident up in the bed. Observed that neither CNA spoke to the resident while performing the task and before leaving the resident's room. An interview on 4/5/22 at 3:30 PM, with CNA #5 revealed that when staff enters a resident's room the staff member should knock on the door, speak to them, and let them know why they are entering their room. She revealed that not speaking to a resident while performing care would be rude and a dignity issue. She revealed that it is all about how you approach people when providing care. An interview on 4/5/22 at 4:30 PM, with CNA #8 revealed that the staff should always knock and tell the resident their name and what you are needing to do when entering their room. An interview on 4/6/22 at 1:00 PM, with CNA #6 revealed that it could be a dignity issue if staff did not speak to a resident when they entered their room and performed a task. She revealed that staff should knock, speak, and let them know what you are needing to do. She revealed that if staff does not speak to residents, then the residents may think we are upset with them or just having a bad day. She revealed that if people do not get spoken to then they sometimes will not speak. She revealed she did not remember not speaking to Resident #27 while helping pull her up in the bed. She revealed that she feels like sometimes the staff gets in a hurry and busy trying to complete the task and forget we need to socialize with them more. An interview on 4/7/22 at 10:00 AM, with the Director of Nursing (DON) revealed that staff should knock on the resident's door and introduce themselves if the resident does not know them, explain the care that needs to be performed and just socialize with them. She revealed that she is not sure if it would be a dignity issue or just non-sociable when a staff member does not speak to a resident while performing care An interview on 4/7/22 at 12:15 AM, with Resident #27 revealed that most of the time the staff does not speak to her when they come in to do something. She revealed that the staff will talk to each other in front of her, sometimes they have their blue-tooth headphones on and take personal phone calls on their cell phones. She revealed that she does not care if they want to ignore her, but it would be nice to be included. Record review of Resident #27's Admission Record revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the residents Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/22 revealed a Brief Interview of Mental Status (BIMS) of 15, which indicates the resident is cognitively intact. Resident #43 An observation on 04/04/22 at 10:40 AM, revealed Resident #43 lying in bed, awake, alert and with speech that is hard to understand due to a [CONDITION(S)] Disease with an onset date of 10/15/13. An observation of CNA #7 enter the resident's room with a fresh glass of water and sit it on the resident's over-bed table. Observed CNA #7 point to the two glasses of water that were already on his over-bed table without speaking. Observed the resident speak to CNA #7, pull one of the glasses toward him and pushed the other glass toward the CNA #7. CNA #7 took the glass of water that the resident pushed toward her and left the room without speaking to the resident. An observation on 4/4/22 at 12:25 PM, revealed Resident #43 lying in bed, awake and alert. Observed CNA #6 enter Resident #43's room with his lunch tray, set it up on his over-bed table and leave the room without speaking to the resident. An interview on 4/6/22 at 1:00 PM, with CNA #6 revealed that it could be a dignity issue if staff did not speak to a resident when they entered their room and performed a task. She revealed that staff should knock, speak, and let them know what you are needing to do. She revealed that if staff does not speak to residents, then the residents may think we are upset with them or just having a bad day. She revealed that if people do not get spoken to then they sometimes will not speak. She revealed Resident #43 is hard to understand, but she did not remember, not speaking to him while setting his lunch tray up. She revealed that she feels like sometimes the staff get in a hurry and busy trying to complete the task and forget we need to socialize with them more. An interview on 4/7/22 at 11:58 AM, with Resident #43 revealed the staff usually does not talk to him when they come in his room. Record review of Resident #43's Admission Record revealed an initial admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #43's MDS with an ARD of 2/26/22 revealed a BIMS of 15, which indicates the resident is cognitively intact. Resident #19 On 04/04/22 at 10:18 AM, an observation of Resident #19 from the hallway, revealed the door was open, and Resident #19 was lying in bed with only a brief on. No top sheet or blanket was covering him. On 04/05/22 at 08:51 AM, an observation of Resident #19 from the hallway, revealed him lying in bed exposed with only a brief on. Licensed Practical Nurse (LPN) #1 was in the room working on the resident's gastrostomy tube. The nurse exited the room leaving the door open with the resident remaining exposed with only a brief on. A Certified Nursing Assistant (CNA) entered the room closing the door behind her. An interview on 04/06/22 at 03:02 PM, with Licensed Practical Nurse (LPN) #1 revealed that Resident #19 should be covered when the door is open. LPN #1 stated that it could embarrassing to him, and it is a dignity issue. Record review of Resident #19's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS with an ARD of 01/25/2022 revealed Resident #19 with a BIMS score of 03, which indicated the resident has severe cognitive impairment. Resident #42 Review of facility policy titled, Maintaining Privacy and Dignity For Residents with Foley Catheter Drainage Bags, with a revision date of 2/16 revealed, It is the policy of this facility to provide privacy and dignity to all residents that have a urinary drainage bag in use. The procedure revealed the drainage bag will be maintained in a storage pouch to hide the contents and prevent embarrassment to the resident. On 04/04/22 at 10:57 AM, 12:05 PM, and 03:05 PM, observations revealed Resident #42's urinary catheter bag was visible to the hallway. The catheter bag was on the right-hand side of the bed facing the entrance room door without a privacy bag. Urine was noted in urinary catheter bag. On 04/05/22 at 8:50 AM, and again at 3:50 PM, observations revealed Resident #42's urinary catheter bag on the right side of the bed facing the entrance room door without a privacy bag and visible to the hallway. During an observation on 04/06/22 at 09:33 AM , Resident #42's urinary catheter bag was on the right side of the bed without a privacy bag and facing the entrance room door. The catheter was visible from the hallway. During an observation and interview, on 04/06/22 at 1:00 PM, with the Director of Nurses (DON), she confirmed the resident had a privacy bag on the back of his wheelchair, but he should have a privacy bag for his bed, and his catheter bag should not be visible to the hallway. A record review of Resident #42's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS with an ARD of 02/22/2022, revealed Resident #42 had a BIMS score of 15, which indicated the resident was cognitively intact.

Based on facility policy review, record reviews, and staff interviews, the facility failed to complete a Preadmission Screening (PAS) Level One (I) Assessment for a resident for one (1) of two (2) residents reviewed for Preadmission Screening and Resident Review (PASARR). Resident #34 Findings include: Review of the facility titled PASRR Policy, with no date on the policy, revealed POLICY - It is the policy of this facility to do the Pre-Admission Screening process. Preadmission Screening (PAS) must be submitted within 30 days of the physician's certification. All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility. Record review revealed there was not a copy of a PAS Level I Assessment available from admission for Resident #34. An interview on 4/5/22 at 04:20 PM, with Social Services, confirmed the PAS Level I Assessment was not completed, upon admission to the nursing facility for Resident #34. Social Services revealed a PAS Level I Assessment needed to be completed for every resident that would be a long term stay in the nursing facility and confirmed a PAS Level I Assessment not being completed for Resident #34 prevents her from knowing if Resident #34 was appropriate for a nursing facility placement. Social Services also confirmed a completed PAS Level I Assessment could have possibly triggered a Preadmission Screening and Resident Review (PASRR) Level II Assessment that could have possibly provided additional information of whether Resident #34 was appropriate for nursing facility placement and/or possible recommendations of mental health services, to be provided to Resident #34, while living in the nursing facility. An interview on 4/6/22 at 09:50 AM, with the Administrator confirmed Resident #34 should have had a PAS Level I Assessment done upon admission, which could have possibly generated a PASRR Level II Assessment, and would have possibly provided the nursing facility with the information of whether Resident #34 was appropriate for nursing facility placement and if Resident #34 needed additional mental health services to be provided while in the nursing facility. Record review of the Admission Record revealed Resident #34 was admitted to the nursing facility on 11/25/20, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, record reviews, and staff interviews, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one of two residents reviewed for PASRR. Resident #34. Findings include: Review of the facility titled. PASRR Policy, with no date on the policy, revealed POLICY - It is the policy of this facility to do the Pre-Admission Screening process. PAS must be submitted within 30 days of the physician's certification. All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility. There was no information included in the policy regarding submissions for a change in a resident's mental health status. Record review revealed there was not a copy of a Change in Status Form available for a geriatric inpatient psychiatric facility admission on 2/19/21, for Resident #34. An interview on 4/5/22 at 04:20 PM, with Social Services, confirmed the Change in Status Form was not completed/submitted for Resident #34 to update the state mental health agency on the mental status change that resulted in a geriatric inpatient psychiatric facility admission on 2/19/21. Social Services also confirmed that the Change in Status Form should have been submitted to the state mental health agency, to allow for possible update of the PASRR Level II process, to inquire about possible additional mental health services recommendations to be provided to Resident #34 in the nursing facility. An interview, on 4/6/22 at 09:50 AM, with the Administrator, confirmed that Resident #34 should have had a Change in Status Form completed/submitted to the state mental health agency to provide an update that Resident #34 had a mental status change that required a geriatric inpatient psychiatric facility admission on 12/19/22. That would have provided a possible update to the PASRR Level II process, and the facility could have possibly obtained mental health services recommendations for care for Resident #34 in the nursing facility. Record review of the Admission Record revealed Resident #34 admitted to the nursing facility on 11/25/20. Record review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan related to care observations, medication administration, and an incident related to a fall, for three (3) of 23 resident care plans reviewed. Resident #14 for catheter care, Resident #16 for falls, and Resident #18 for medication administration. Findings include: A review of the facility's Care Plans-Comprehensive policy, dated 10/2016, revealed: Our facility's Care Planning Interdisciplinary team develops and maintains a Comprehensive Care Plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's Comprehensive Care Plan is designed to incorporate identified problem are; reflect treatment goals, timetables, and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aid in preventing or reducing declines in the residents functional status and/or functional levels; and enhance the optimal functioning of the resident by focusing on a rehabilitative program. A review of the facility's Following the Care Plan Policy, dated 2011, revealed it is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan. Resident 14 Review of Resident #14's comprehensive care plan, initiated 1/10/19, with a review date of 7/13/19, included an indwelling urinary catheter, which included interventions to provide peri-care and catheter care every day with soap and water (which would include providing the care correctly). On 9/23/19 at 10:37 AM, an observation revealed Resident #14 lying in bed with an indwelling urinary catheter to gravity drainage. On 9/24/19 at 2:53 PM, an observation revealed Certified Nursing Assistant (CNA) #3, with the assistance of CNA #2 and CNA #1, performed catheter care to Resident #14. CNA #3 wiped the left groin area in an upward motion and wiped the catheter tubing upward, without securing the tubing. CNAs #1 and CNA #2 repositioned Resident #14 onto her right side, while the catheter drainage bag remained hanging on the opposite side of the bed. CNA #3 wiped the resident's buttock areas in an upward motion twice on each side and up the middle between the buttocks twice, from the back toward the front of the perineal area. On 09/25/19 at 1:23 PM, an interview with RN #2 revealed she would expect the CNAs to perform catheter care appropriately, to wipe in a downward motion of the groin areas instead of upward, to prevent cross contamination. RN #2 stated she expected the staff to secure the catheter tubing while wiping outward from meatus towards the urinary drainage bag, to prevent pulling on the catheter tubing, which could cause irritation and/or injury. Review of the facility's Face Sheet revealed the facility admitted Resident #14 on 1/8/19, with [DIAGNOSES REDACTED]. Resident #16 A review of the comprehensive care plan for Resident #16, initiated 4/17/18, revealed the resident is a high risk for falls related to (r/t) gait balance problems. The care plan indicated Resident #16 had a fall on 6/7/19, resulting in a major injury. The care plan did was not developed for securing the resident appropriately in the wheelchair for safe transport to [MEDICAL TREATMENT] via facility van. Review of a Facility Reported Incident (FRI), dated (MONTH) 13, 2019, revealed Resident #16's wheelchair was not secured properly during transport in the facility van, which resulted in a fractured humerus for the resident. Resident #16 was transported by Certified Nurse aide (CNA) #6 on 6/7/19, from [MEDICAL TREATMENT] to the facility, when Resident #16 slid out of her wheelchair. Resident #16 was found seated on the lift sling directly in front of her wheelchair. Resident #16's left arm was leaning on the inside wall of the van. LPN #4 assessed Resident #16 for injury, with findings of pain in the left arm. Using the lift sling already in place, three (3) employees lifted Resident #16, placed her back in her wheelchair, and continued transport to the facility. Upon arrival to the facility, Resident #16 was assessed with [REDACTED]. Pain medication was administered and a stat X-ray was ordered, which revealed a fracture to the left humerus head. Resident #16 was transferred to the hospital and returned the next day with instructions to keep a sling in place. An interview on 09/26/19 at 11:25 AM, with RN #2/Minimum Data Set (MDS)/Care Plan nurse, revealed, My expectations for a care plan is to create a plan of care and set goals and come up with interventions. She stated she expected everyone to provide the appropriate interventions to reach the Resident's goal. RN #2 stated, If there is a care plan in place, I expect it to be followed. Resident #18 Review of Resident #18's comprehensive care plan, revised 1/19/18, revealed the use of anti-anxiety medications and antidepressant medications, with interventions to give medication as the physician ordered. Review of the Nurse Practitioner (NP) progress note for Resident #18, dated 8/7/19, revealed a note in response to a pharmacy recommendation, to decrease [MEDICATION NAME] to 10 milligram (mg) twice a day. Review of Resident #18's orders and Medication Administration Record [REDACTED]. During an interview on 09/25/19 at 02:46 PM, the Director of Nursing (DON) verified Resident #18's progress note/order by the NP on 8/7/19, to decrease [MEDICATION NAME] to 10 mg by mouth twice a day from three (3) times a day. The DON also confirmed Resident #18 had current orders for [MEDICATION NAME] 10 mg three (3) times a day. She said it was the Nursing Supervisor's responsibility to write the orders in the medical record the day the NP wrote them. Interview on 09/26/19 at 9:18 AM, with RN # 2 revealed she would only be aware to make the changes in the care plan when she received copies of the orders for the resident from medical records. She said she was not aware of any changes for Resident #18's medication. An interview on 09/26/19 at 11:05 AM, with the DON, revealed, My expectations for the care plan is that it should address the needs of the residents and as their condition changes, it should be updated. The Care Plan should be clear and concise to each resident. The care plan should be followed by all staff that it pertains to.

Based on staff interview, record review, and facility policy review, the facility failed to prevent injury related to a fall from a wheelchair during van transportation, as evidenced by not securing the resident properly in the wheelchair, prior to transport. This affected one (1) of three (3) residents reviewed for accidents, Resident #16. Resident #16 received a fracture to the left humerus head during the fall, resulting in X-rays and treatment at the local hospital. Findings include: Review of facility's Incident/accident During Transport in the Facility Van policy, dated 10/08, revealed: It is the policy of this facility to transport residents per facility van, providing the safest reasonable environment and to implement the facility Incident/Accident policy for any injury to the resident during such transport. A review of a document provided by the facility titled Operation Instructions Attaching the Combination Lap/Shoulder Belt, dated 2/11, revealed: Grasp the triangular fitting on the retractable belt and thread it down and through the gap between the wheelchair back and seat or side panel and seat. Grasp the triangular fitting on the push button buckle belt and thread it down and through the gap between the wheelchair back and seat or between the side panel and seat. Insert the buckle connector into the push button buckle. Tension the buckle connector belt comfortably using the web adjuster. Ensure that the lap belt is worn low across the front of the pelvis, bearing upon the bony structure of the body and that the push button buckle is located near the occupant's hip opposite of the side from where the shoulder belt is anchored. Pull on the lap belt to ensure attachment of the triangular fittings to the rear retractor studs and the connection of the push button buckle and buckle connector. When connecting the shoulder belt to the lap belt, always ensure that the push button buckle and buckle connector are located at the occupant's hip opposite of the vehicle sidewall where the shoulder belt anchorage is installed. Ensure that the lap belt buckle is located in such a way that it is clear and is not in contact with any of the wheelchair components or any structures during operation as to minimize any potential contact during its use or in case of an accident. Review of a Facility Reported Incident and initial/final investigation, dated 6/13/19, revealed Resident #16 slid out of her wheelchair while transported via facility van on 6/7/19, which resulted in a fractured left humerus for the resident. The investigation revealed the resident was not secured properly in the wheelchair during transport. Resident #16 was transported by Certified Nursing Assistant (CNA) #6 on 6/7/19, from [MEDICAL TREATMENT] to the facility, when Resident #16 slid out of her wheelchair. Resident #16 was found seated on the lift sling, directly in front of her wheelchair, with her left arm leaning on the inside wall of the van. Assessment revealed no bruising/swelling to the reported area of pain in the left arm. Pain medication was administered and a stat X-ray was ordered upon return to the facility, which revealed a fracture to the left humerus head. Resident #16 was transferred to the hospital and returned the next day, with discharge instructions to keep a sling in place. Review of the facility investigation, dated 6/13/19, through re-enactment, with CNA #6 demonstrating how she secured Resident #16 in the van on 6/7/19, showed that the 4-point restraint system and seat belt were used, however the seat belt as placed through the arm rests allowed space between the person sitting in the wheelchair and the lap belt. This would have allowed Resident #16 to slide out of the wheelchair during transport. A second re-enactment on 6/10/19, revealed the route taken during transport was very bumpy, uneven, and with many pot holes. The DON was secured in a wheelchair and had to brace herself with her feet to prevent sliding out of the wheelchair. The report determined Resident #16's fall and injury was a result of being improperly secured in the wheelchair prior to transport. An interview on 09/26/19 at 2:14 PM, with Resident #16, revealed that she did not remember the incident on the van. Review of X-rays, dated 6/7/19, of Resident #16's left clavicle, left shoulder, and left humerus revealed an acute [MEDICAL CONDITION] humeral head. Review of a statement signed by the Administrator and Director of Nursing (DON), dated 6/10/19, revealed, Resident #16 was interviewed by the Administrator and DON. When asked to tell the events of the van incident, Resident #16 stated that the driver hit a bump and she fell from her wheelchair and hurt her arm. During an interview, via phone, on 09/25/19 at 3:37 PM, CNA #6 stated that she was trained to put the lap belt in front of the arms of the wheelchair. She stated on the day of the transport, she buckled the wheelchair with the belt in front of the arms of the wheelchair and Resident #16 slid out of the chair. CNA #6 stated that she did not secure the shoulder strap to the chair. Instead, she just pulled it across the resident's left shoulder, because she was trained to put it that way. Further interview via phone on 09/26/19 at 10:08 AM, with CNA #6, revealed I just pulled the shoulder strap across the resident's left shoulder and I did not run it through the wheelchair arm to secure it to her chair. I placed the lap belt in front of the wheelchair arms. The strap was not through the arms of the wheelchair. She stated, I didn't know about a video until the incident. Review of a statement written by LPN #4, dated 6/7/19, revealed she arrived at the scene and noticed Resident #16 was located on the floor of the van, sitting directly in front of her wheelchair. The wheelchair was locked and secured in place and Resident #16 was sitting upright with the lift sling directly up under her in the proper position. LPN #4 assessed Resident #16 and did not notice any bleeding. However, Resident #16 stated that her left arm was hurting. On 09/25/19 at 2:52 PM, an attempt was made to contact LPN #4, with a message that the phone had calling restrictions, with no ability to leave a message. During an interview, via phone, on 09/25/19 at 2:59 PM, CNA #7 stated that she did not know how Resident #16 slid out of her chair, but when she got to the van, Resident #16 was sitting on the floor in front of her wheelchair. CNA #7 stated that she could not say if the belts were secured appropriately, but the chair had not moved from the spot where the wheelchair goes; wasn't turned over or crooked, and sitting where it normally sat. During an interview on 09/25/19 at 3:05 PM, CNA # 4, stated she had been employed at the facility for approximately five (5) years and they were trained to put the seat lap belt in front of the wheelchair during transport and the shoulder strap across the resident's shoulder, without securing it across the wheelchair. CNA #4 stated that after the incident with the Resident #16, the previous Administrator showed staff a video of the proper technique of securing a wheelchair during transport, and the Maintenance man demonstrated the proper way to secure a wheelchair during transport. CNA #4 stated that she realized after the video that they were doing it wrong. CNA #4 stated that now they secure the strap through the arms of the wheelchair. Further interview with CNA #4 on 09/25/19 at 5:01 PM, revealed that she guessed the previous Administrator had videos that were available prior to the incident, but staff didn't watch the videos until after the incident with Resident #16. CNA #4 stated that she was trained by the previous transportation driver on how to secure the wheelchair in a van. She stated that she was trained to pull the lap strap across the front of the arms of the wheelchair and not secure the back safety shoulder strap on the wheelchair, just pull it across the resident's shoulder and buckle it. CNA #4 stated that she trained CNA #6 like she had been trained. She stated that she had been in transportation for five (5) years and this is the first time that she could remember an incident happening on the van. She stated that anyone can load a resident on the van, but it is the transportation team's responsibility to strap the resident safely in position. An observation on 09/26/19 at 9:50 AM, with Transportation CNA #4, revealed demonstration of how she trained CNA #6 to secure a resident in a wheelchair during transport in the van. CNA #4 placed the four (4) floor straps onto the wheelchair and secured them by turning a knob to tighten the four (4) straps. CNA #4 placed the shoulder strap, which was on the left side of the van, across the resident's left shoulder, not securing it in any way to the chair. CNA #4 placed the lap strap in front of the wheelchair arms and secured it to the wheelchair. CNA #4 stated, And that's how I was trained to do it before the incident with Resident #16, and before watching the video. CNA #4 stated since she'd watched the video, she learned the shoulder strap was to come directly over the left shoulder and through the left arm of the wheelchair. She stated she never knew until after watching the video, that it was supposed to be ran through the arm of the wheelchair to secure the resident in the chair. She stated the lap strap was placed in front of the arms of the wheelchair, and it should have been ran through the arms of the wheelchair and secured to the wheelchair. CNA #4 stated, in her opinion, Resident #16 could have slid out of the chair, with the shoulder strap not being applied correctly, because the strap would not have caught her the way we were placing the strap just across her shoulder. She stated the lap strap being placed in front of the arms of the wheelchair and not through the arms of the wheelchair would have not helped catch her from sliding out either. During an interview on 09/25/19 at 3:08 PM, CNA #5 revealed that she had been working at the facility for approximately 18 months. CNA #5 stated that she was checked off on putting the lap belt in front of the wheelchair and placing the shoulder strap across the shoulder of a resident, not through the arms of the wheelchair. In a further interview on 09/25/19 at 6:11 PM, CNA #5 revealed that she didn't know about any training videos of how to secure a resident in the van, and wasn't shown the videos until after the incident with Resident #16. CNA #5 stated she was trained by the prior Staff Development Nurse and by CNA #4, to put the strap across the front of the arms of the wheelchair, but she wasn't shown to use the shoulder strap on the chair. During an interview on 09/25/19 at 4:04 PM, Maintenance #1 stated that he trained the CNA's properly on the placement of the straps on a wheelchair during a transport, after the incident with Resident #16, and after the video was shown by the previous Administrator. Maintenance #1 was unaware of videos prior to the incident. An interview on 09/26/19 at 3:03 PM, with the Administrator, revealed she didn't think there was a video prior to the incident for Resident #16, that was used for training specifically for wheelchair safety. She stated she thought it was a you tube video that was pulled for training purposes. The Administrator stated she would attempt to call the prior Administrator to verify. Further interview revealed she was unable to reach the prior Administrator.

Based on observations, interviews, record review, policy review and the facility investigation review, the facility failed to follow Resident #1's Plan of Care for use of a lift and additional assistance for transfer of a resident, which resulted in a fall with a Right Tibia Plateau fracture on 4/19/19, for one (1) of four (4) residents reviewed for following the plan of care, Resident #1. During the investigation, the SA determined a Past Non-Compliant (PNC) harm level (G) existed. Due to the facility's implementation of all corrective measures as of 5/5/19, prior to the SA entrance on 5/9/19, F656 was determined corrected as of 5/6/19. Findings include: Review of the facility's, Following the Care Plan Policy, dated 2011, noted, it is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan. A review of Resident #1's Kardex revealed Resident #1 required the use of the Vander Total Lift with two (2) person assist, for transfers related to weakness. The onset date was on admission, 5/15/18. This Care Plan was in the Kiosk and part of the electronic record for Certified Nursing Assistants (CNA)s to use for the care of each resident. Review of a facility investigation, dated 4/23/19, revealed on 4/19/19, CNA #1 lifted Resident #1 by herself, instead of utilizing the lift and the assistance of another person, as required by the care plan, which resulted in the resident's fall to the floor, with a subsequent Right Tibia Fracture. In an interview on 5/9/19 at 2:45 PM, Registered Nurse (RN) #1 stated the CNAs are supposed to review the Kardex for each resident's plan of care. RN #1 stated, If they do not use the proper lift and number of people, then they are not following the resident's plan of care. RN #1 stated that all assessments are completed for each resident on admission and on-going at least quarterly or as needed. RN #1 stated the Minimum Data Set (MDS) nurses decide which lifts to use, based on each resident's assessment. During the interview on 5/9/19 at 1:40 PM, Resident #1's Responsible Party (RP) stated that on 4/19/19, he was notified that his mother had a fall and had been taken to the hospital. The RP stated the next day the facility notified him there had been an investigation and it was determined that his mother had been lifted by a CNA alone, not using the lift like she was supposed to. Resident #1's RP also stated he was notified at that time the nurse (CNA) had been terminated and the other staff had training to make sure this did not happen again. Interview with Resident #1's roommate at the time of the fall, Unsampled Resident #B, on 5/9/19 at 4:15 PM, revealed that CNA #1 dropped Resident #1 while transferring her alone from the bed to the chair and did not use a lift. Resident #1's roommate stated she (Resident #1) was yelling out loud in pain at the time of the fall. Resident #1's roommate was alert and oriented with the most recent Brief Interview for Mental Status (BIMS) score of 15, dated 2/19/19, which indicated no cognitive impairment. Review of the investigation and interview with the Facility Administrator on 5/9/19 at 9:55 AM, revealed Resident #1 was at the [MEDICAL TREATMENT] unit when they called and said that she was complaining of pain and they were sending Resident #1 to the emergency room for an evaluation. The Administrator confirmed the facility investigation revealed CNA #1 transferred Resident #1 from the bed to the chair alone and without the use of a lift. During the investigation CNA #1 confirmed she lifted Resident #1 without assistance and her legs gave way and she slid Resident #1 to the floor. CNA #1 was terminated for not using the lift and not having two (2) people present as per Resident #1's plan of care and the facility's policy for using the lift. The Administrator confirmed Resident #1's care plan was not followed and stated CNA #1 knew better, but she did it anyway. The State Agency (SA) was unable to reach Certified Nursing Assistant (CNA) #1 by phone. Attempts were made twice on 5/9/19, with no answer. The SA left a message on voicemail with no return call. Review of CNA #1's training for the Modified Lifting Policy for the Zero Back Injury Program, revealed the form was signed by CNA #1 on 2/7/19, when hired, with acknowledgment of understanding. This training documented the staff were to use a lift and assistance of other staff for transferring dependent residents. The facility admitted Resident #1 on 4/12/18, with the [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) on 415/19, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of four 4, which indicated Resident #1 was severely cognitively impaired. The SA determined the facility had identified the incident of Resident #1's fall and fracture as a result of CNA #1 improperly transferring the resident without the use of a lift and assistance of another staff, as required by the assessment and care plan. The facility implemented the following corrective measures prior to the State Agency's entrance on 5/9/19, and alleged corrections were completed as of 5/5/19: An investigation was initiated on 4/19/2019, related to Resident #1 having an unreported fall with injury on 4/19/2019 at 10:38 AM. CNA #1 transferred Resident #1 via stand and pivot transfer by herself, however Resident #1 was care planned for a total lift times two (2) staff members. Resident #1 was transferred from [MEDICAL TREATMENT] and was admitted to an area hospital on [DATE]. She returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. Corrective measures were as follows: 1. CNA #1 was terminated on 4/19/2019, for failure to follow Resident #1's care plan to provide assistance with transfers. 2. In-Service related to following the lift protocol was initiated on 4/19/2019, by the Administrator, to nursing staff. 3. In-Services related to Abuse and Neglect, Accidents/Incidents, timely reporting of Accidents/Incidents, and Proper Use of Lifts for Each Resident was initiated by RN Supervisor #1 on 4/22/2019, to nursing staff. 4. In-Services related to Abuse and Neglect, Lift Protocol, and following care plan/kardex were initiated/continued on 4/25/2019, by the Administrator and Director of Nursing (DON), to nursing staff. 5. A Quality Assurance (QA) Meeting, related to the incident, was held on 4/26/2019, with QA members: Medical Director, Administrator, Director of Nursing (DON), Social Services Director, Dietary Manager, Therapy Director, Medical Records, MDS Coordinator, Business Office Manager, Maintenance Director, and RN Supervisor #1. The QA team reviewed the incident, the policy/procedures (without changes) and actions taken with education. 6. The DON/RN Supervisor initiated lift competency check offs beginning the week of 4/29/2019, with nursing staff (for the lift protocol.) 7. The DON/RN Supervisor began monitoring transfer/lift protocol during four (4) random patient care observations beginning the week of 4/29/2019. 8. An audit of care plans was completed by RN Supervisor #2 on 5/5/2019, to ensure that care plans included the lift type, sling size, and that two (2) staff members were required for all transfers using lifts. Revisions were made at that time. 9. Notifications were made to the MS State Department of Health, the Attorney General's Office, the Physician and the Resident Representative were made by the administrative staff, of Resident #1's fall with fracture and CNA #1's inappropriate transfer of the resident. The State Agency validated the facility's corrective measures by record review, interview with staff, in-service documentation review and QA document review: During record review the State Agency validated the facility conducted an investigation, that was initiated on 4/19/2019, related to Resident #1 having an unreported fall with injury on 4/19/2019 at 10:38 AM. CNA #1 transferred Resident #1 via stand and pivot transfer times one (1) staff, however Resident #1 was care planned for a total lift times two (2) staff members. Resident #1 was transferred from [MEDICAL TREATMENT] and was admitted to an area hospital on [DATE]. She returned to the facility on [DATE], with [DIAGNOSES REDACTED]. The SA validated the facility's documented corrective measures and determined the corrective measures were completed as of 5/5/19, and were as follows: 1. Review of the personnel action documentation and interview with administration revealed that CNA #1 was terminated on 4/19/2019, for the incident of Resident #1's fall/fracture. 2. Review of in-Service sign-in sheets and interview with staff revealed the Administrator initiated education related to following lift protocol, on 4/19/2019. 3. Interview with nursing staff and review of the In-Service sign-in sheets, revealed RN #1 initiated education related to Abuse and Neglect, Accidents/Incidents, timely reporting of Accidents/Incidents, and Proper Use of Lifts for Each Resident, on 4/22/2019. 4. Interview with nursing staff and administrative staff and review of the In-Service sign-in sheets, revealed education was initiated related to Abuse and Neglect, Lift Protocol, and following care plan/kardex were initiated/continued on 4/25/2019, by the Administrator and Director of Nursing (DON). The SA validated that all nursing staff had completed education prior to working. 5. Review of sign-in sheets and interview with attending staff as well as the Medical Director, revealed a QA Meeting was held, related to the incident of Resident #1's fracture, on 4/26/2019, and attended by QA members: Medical Director, Administrator, DON, Social Services Director, Dietary Manager, Therapy Director, Medical Records, MDS Coordinator, Business Office Manager, Maintenance Director, and RN Supervisor #1. 6. Review of documentation and interview with the DON/RN Supervisor, revealed lift competency check offs beginning the week of 4/29/2019, were completed with all nursing staff. 7. Interview with the DON, and documentation review, revealed the DON/RN Supervisor began monitoring transfer/lift protocol during four (4) random patient care observations beginning the week of 4/29/2019. 8. Interview with RN #2 and review of the care plans revealed an audit of care plans was completed by RN Supervisor #2 on 5/5/2019, to ensure that care plans included the lift type, sling size, and that two (2) staff members were required for all transfers using lifts. 9. Review of documents and interview with administrative staff revealed that notifications were made to the RP and Medical Director on 4/19/19, and the SA and Attorney General's office on 4/22/19, of the incident with Resident #1's fall and subsequent fracture.

Based on observations, interviews, record review, policy review, and facility investigation review, the facility failed to prevent an accident by staff's failure to use a mechanical lift and assistance of another staff member for transferring Resident #1, as assessed and care planned. That action resulted in the resident's fall with a subsequent Right Tibia Plateau fracture on 4/19/19, with hospitalization until 4/21/19. This affected one (1) of four (4) residents reviewed for accidents and incidents, Resident #1. During the investigation, the SA determined a Past Non-Compliant (PNC) harm level (G) existed. Due to the facility's implementation of all corrective measures as of 5/5/19, prior to the SA entrance on 5/9/19, F689 was determined corrected as of 5/6/19. Findings include: Review of an Accident/Incident Reporting policy, updated 10/2016, revealed all accidents/incidents including residents, employees, or visitors will be reported to the Charge Nurse and to the appropriate department heads immediately when it occurs. Accident/Incident is defined as an unexpected happening, which may or may not have caused injury (ie Resident falls). A document, Responsibility For Accident/Incident Reports Policy, dated 7/2016, revealed all incident and accidents involving a resident will be investigated immediately upon knowledge of the incident. In a review of the facility's policy, Modified Lifting Policy, (Mechanical Lift), undated, noted it is the policy of this facility to help lift residents who are unable to be lifted manually and to promote comfort and to maintain proper body alignment while the resident is being moved. The need for the use of a lift, lift type, sling type, and sling size will be determined by the facility Mechanical Lift Assessment. This assessment will be done upon admission and updated quarterly with the Minimum Data Set (MDS) as well as when needed. The policy also noted staff will follow the documented lifting protocol deemed appropriate for each resident. Review of an incident report, Fall, dated 4/19/19 at 10:38 AM, revealed, Writer notified per CNA that res (resident) legs got weak et CNA lowered res to the floor. Body audit obtained no injury noted @ (at) this time. Location was in the resident's room. Review of the facility's investigation report, dated 4/23/19, revealed upon interview with CNA #1, the CNA lifted Resident #1 alone during a transfer and the resident's legs gave out. The CNA stated she didn't notify the nurse at the time because the resident didn't hit the floor. Resident #1 was assessed, due to report of pain prior to going to [MEDICAL TREATMENT], without noted injury. Resident #1 went to [MEDICAL TREATMENT] and was transferred to the emergency room from [MEDICAL TREATMENT] on 4/19/19, after complaint of continued pain, where X-rays were obtained, with a fracture diagnosis. It was determined during the investigation that Resident #1 fell during the transfer by CNA #1, and this fall resulted in a Right Tibia Fracture for Resident #1. CNA #1 transferred the resident without another staff member, and did not use a lift, per assessment and care plan, which resulted in the resident's fall and subsequent fracture. The report documented that Resident #1 was hospitalized from [DATE], until 4/21/19, when she returned to the facility with a leg immobilizer and an order for [REDACTED].#1 was terminated for improper transfer of Resident #1. A review of the hospital admission history and physical, noted on 4/20/19 at 2:36 AM, Resident #1 was admitted with the complaint of right shoulder pain and right leg pain after a fall at the nursing home. Resident #1 was diagnosed with [REDACTED]. In a review of Resident #1's Kardex (CNA care plan), from the electronic Kiosk, Resident #1 required the use of the Vander Total Lift, with two (2) person assist for all transfers, related to weakness, with the onset date 5/15/18, on admission. In an interview with Resident #1's Responsible Party (RP) on 5/9/19 at 1:40 PM, the RP reported he was notified on 4/19/19, that his mother had fallen and had been transferred to the hospital. The RP stated the next day the facility notified him there had been an investigation, which determined that his mother had been lifted by a CNA alone and that she had not used the lift like she was supposed to. Resident #1's RP also stated he was notified at that time that the nurse (CNA) had been terminated and the other staff had been trained to make sure this did not happen again. In an interview with Resident #1's roommate, (Unsampled Resident #B), on 5/9/19 at 4:15 PM, she stated CNA #1 dropped Resident #1 while transferring her from the bed to the chair and did not use a lift. The roommate stated another staff member came and assisted the CNA in getting the resident off the floor. Resident #1's roommate stated she was yelling out loud in pain at the time of the fall. She stated a nurse did come in and check the resident. Review of Unsampled Resident #B's most recent MDS, with an Assessment Reference Date (ARD) of 2/21/19, revealed a BIMS score of 15, which indicated no cognitive impairment. In an interview on 5/9/19 at 9:55 AM, the Facility Administrator revealed Resident #1 was at the [MEDICAL TREATMENT] unit when they called and said Resident #1 was complaining of pain and was being transferred to the emergency room (ER) for an evaluation. The Administrator stated that the facility investigation revealed CNA #1 transferred Resident #1 from the bed to the chair alone and without the use of a lift on 4/19/19. The Administrator stated during the investigation, CNA #1 confirmed she lifted Resident #1 without assistance and the resident's legs gave way and she slid Resident #1 to the floor. The Administrator stated that CNA #1 was terminated for not using the lift and not having two (2) people present, as per Resident #1's plan of care and the facility's policy for using the lift. The Administrator stated CNA #1 stated that she knew better, but she did it anyway. The facility Administrator confirmed the facility had a Quality Assurance (QA) meeting and no policies were changed for use of the lift or following the care plan. The Administrator stated that all staff had been in-serviced again on the use of the lift and following the care plan. The Administrator stated that no other incidents regarding improper use of the lift have been identified and audits have been initiated. The Administrator confirmed the Responsible Party (RP) for Resident #1 was notified and the resident's physician, the Medical Director, and the incident was reported to the Mississippi State Department of Health and the Attorney General's office. Attempts were made to contact Certified Nursing Assistant (CNA) #1 by phone on 5/9/19, twice with no answer. The Surveyor left messages on voicemail, with no return call. Review of the statement, documented by CNA #1, received during the investigation by the facility on 4/19/19, revealed she transferred Resident #1 by herself and without a lift. She stated during the transfer that the resident's legs broke (gave out) and she lowered the resident to the ground. Record review of CNA #1's training for the Modified Lifting Policy for the Zero Back Injury Program was signed by CNA #1 on 2/7/19, when hired. This policy indicated that she was aware she was to use the lift and utilize a second person during a transfer of a dependent resident. Review of CNA #1's Personnel Action, dated 4/19/19, revealed the CNA was separated from employment due to failure to follow the care plan for using the lift and two (2) person assistance; the resident's strength gave out during a transfer and the CNA lowered her to the floor (considered a fall), causing injury to the resident. Observation of Resident #1 on 5/9/19 at 2:05 PM, revealed the resident lying in bed with the head of the bed elevated, side rails up x two (2) and the call light in reach. Resident #1 was not interviewable. The facility admitted Resident #1 on 4/12/18, with the [DIAGNOSES REDACTED]. The Annual MDS on 415/19, revealed Resident #1 had a BIMS score of 4, which indicated Resident #1 had severe cognitive impairment. The SA determined the facility had identified the incident of Resident #1's fall and fracture as a result of CNA #1 improperly transferring the resident without the use of a lift and assistance of another staff, as required by the assessment and care plan. The facility implemented the following corrective measures prior to the State Agency's entrance on 5/9/19, and alleged corrections were completed as of 5/5/19: An investigation was initiated on 4/19/2019, related to Resident #1 having an unreported fall with injury on 4/19/2019 at 10:38 AM. CNA #1 transferred Resident #1 via stand and pivot transfer by herself, however Resident #1 was care planned for a total lift times two (2) staff members. Resident #1 was transferred from [MEDICAL TREATMENT] and was admitted to an area hospital on [DATE]. She returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. Corrective measures were as follows: 1. CNA #1 was terminated on 4/19/2019, for failure to follow Resident #1's care plan to provide assistance with transfers. 2. In-Service related to following the lift protocol was initiated on 4/19/2019, by the Administrator, to nursing staff. 3. In-Services related to Abuse and Neglect, Accidents/Incidents, timely reporting of Accidents/Incidents, and Proper Use of Lifts for Each Resident was initiated by RN Supervisor #1 on 4/22/2019, to nursing staff. 4. In-Services related to Abuse and Neglect, Lift Protocol, and following care plan/kardex were initiated/continued on 4/25/2019, by the Administrator and Director of Nursing (DON), to nursing staff. 5. A Quality Assurance (QA) Meeting, related to the incident, was held on 4/26/2019, with QA members: Medical Director, Administrator, Director of Nursing (DON), Social Services Director, Dietary Manager, Therapy Director, Medical Records, MDS Coordinator, Business Office Manager, Maintenance Director, and RN Supervisor #1. The QA team reviewed the incident, the policy/procedures (without changes) and actions taken with education. 6. The DON/RN Supervisor initiated lift competency check offs beginning the week of 4/29/2019, with nursing staff (for the lift protocol.) 7. The DON/RN Supervisor began monitoring transfer/lift protocol during four (4) random patient care observations beginning the week of 4/29/2019. 8. An audit of care plans was completed by RN Supervisor #2 on 5/5/2019, to ensure that care plans included the lift type, sling size, and that two (2) staff members were required for all transfers using lifts. Revisions were made at that time. 9. Notifications were made to the MS State Department of Health, the Attorney General's Office, the Physician and the Resident Representative were made by the administrative staff, of Resident #1's fall with fracture and CNA #1's inappropriate transfer of the resident. The State Agency validated the facility's corrective measures by record review, interview with staff, in-service documentation review and QA document review: During record review the State Agency validated the facility conducted an investigation, that was initiated on 4/19/2019, related to Resident #1 having an unreported fall with injury on 4/19/2019 at 10:38 AM. CNA #1 transferred Resident #1 via stand and pivot transfer times one (1) staff, however Resident #1 was care planned for a total lift times two (2) staff members. Resident #1 was transferred from [MEDICAL TREATMENT] and was admitted to an area hospital on [DATE]. She returned to the facility on [DATE], with [DIAGNOSES REDACTED]. The SA validated the facility's documented corrective measures and determined the corrective measures were completed as of 5/5/19, and the were as follows: 1. Review of the personnel action documentation and interview with administration revealed that CNA #1 was terminated on 4/19/2019, for the incident of Resident #1's fall/fracture. 2. Review of in-Service sign-in sheets and interview with staff revealed the Administrator initiated education related to following lift protocol, on 4/19/2019. 3. Interview with nursing staff and review of the In-Service sign-in sheets, revealed RN #1 initiated education related to Abuse and Neglect, Accidents/Incidents, timely reporting of Accidents/Incidents, and Proper Use of Lifts for Each Resident, on 4/22/2019. 4. Interview with nursing staff and administrative staff and review of the In-Service sign-in sheets, revealed education was initiated related to Abuse and Neglect, Lift Protocol, and following care plan/kardex were initiated/continued on 4/25/2019, by the Administrator and Director of Nursing (DON). The SA validated that all nursing staff had completed education prior to working. 5. Review of sign-in sheets and interview with attending staff as well as the Medical Director, revealed a QA Meeting was held, related to the incident of Resident #1's fracture, on 4/26/2019, and attended by QA members: Medical Director, Administrator, DON, Social Services Director, Dietary Manager, Therapy Director, Medical Records, MDS Coordinator, Business Office Manager, Maintenance Director, and RN Supervisor #1. 6. Review of documentation and interview with the DON/RN Supervisor, revealed lift competency check offs beginning the week of 4/29/2019, were completed with all nursing staff. 7. Interview with the DON, and documentation review, revealed the DON/RN Supervisor began monitoring transfer/lift protocol during four (4) random patient care observations beginning the week of 4/29/2019. 8. Interview with RN #2 and review of the care plans revealed an audit of care plans was completed by RN Supervisor #2 on 5/5/2019, to ensure that care plans included the lift type, sling size, and that two (2) staff members were required for all transfers using lifts. 9. Review of documents and interview with administrative staff revealed that notifications were made to the RP and Medical Director on 4/19/19, and the SA and Attorney General's office on 4/22/19, of the incident with Resident #1's fall and subsequent fracture.

Based on interview, record review and policy review, the facility failed to ensure that one (1) of four (4) residents, Resident #1, had been assessed and treated for [REDACTED]. Resident #1 was admitted to the hospital on [DATE] with documented bilateral lower extremity ulcers and the facility had not assessed and treated for [REDACTED]. Findings include: Resident #1 Resident #1 was admitted to the facility 2/09/09 with a re-admission date of [DATE] and had [DIAGNOSES REDACTED]. Resident #1 was transferred to the hospital on [DATE] for fever and decreased oxygen saturation with subsequent discharge from the facility effective 6/30/11 per physician's orders [REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 4/25/11 revealed that Resident #1 required total assistance of two (2) persons for transfers. Resident #1 was incontinent of bowel and bladder and had two (2) Stage II pressure ulcers. Review of Resident #1's medical record revealed that on 6/1/11 she was assessed for skin pressure sore risk. On 6/1/11 she had a documented Braden Scale score of 22. A score of 12 or higher reflects a high risk for predicting pressure sores. Review of Resident #1's care plan dated 2/17/11 with an update of 5/5/11 revealed that she was at risk for further development of pressure ulcers due to incontinence, [MEDICAL CONDITION], decreased mobility and spending most of the day in the wheelchair or bed. Currently has wound to left heel/outer ankle. One of the interventions was to observe skin integrity daily and report to the nurse immediately of any red areas or skin irritation. Review of Resident #1's "Nurse Aide's Information Sheet" dated 4/25/11 revealed interventions that included to check skin daily and report redness to nurses, turn/reposition every two hours, heel protectors, air mattress and Geri-sleeve to the right lower leg. Review of the June 2011 "Body Audit MAR (Medication Administration Record)" for Resident #1 revealed documentation on 6/21/11 "continue with PU (pressure ulcer) to Lt (left) outer ankle et (and) Lt heel". Review of Resident #1's June 2011 physician's orders [REDACTED]. There was another order to clean the ulcer to the left outer ankle with normal saline, pat dry and apply Xerform dressing and cover with a 4 x 4 gauze and wrap with Kerlix daily and as needed. There was also and order to apply [MEDICATION NAME] to her feet daily and as needed for dry skin until the dryness subsided. Review of a physician's orders [REDACTED]. Review of a weekly documented assessment for Resident #1's left heel dated 5/23/11 revealed that the wound was 2.0 x 1.2 x 0.1 cm. with 100 % granulation. Documentation on 6/13/11 revealed that the left heel wound measured 0.1 x 0.1 x 0.1 cm and had 100% granulation. Documentation on 6/20/11 revealed that Resident #1's left heel had closed and had "0" measurements. Review of a weekly documented assessment for Resident #1's left outer ankle dated 6/6/11 revealed that the wound was 0.1 x 0.1 x 0.1 cm. Documentation on 6/13/11 revealed that the left outer ankle was 0.1 x 0.1 cm. Documentation on 6/20/11 revealed that Resident #1's left outer ankle had closed and had no measurements. Review of a "Dietary Progress Note" dated 6/25/11 revealed that Resident #1 was sent to the hospital today ....has Stage II on left heel and left outer ankle. Will assess if needed upon return back to the facility. Review of a "Progress/Admit Note" dated 5/13/11 and signed by the physician revealed that Resident #1 had ulceration to the left heel and left toes. Review of a "Progress/Admit Note" dated 6/10/11 and signed by the Nurse Practitioner revealed that Resident #1 had ulceration to the left heel and left toe. Review of "Nurses Progress Notes" dated 6/13/11 at 9:10 a.m. revealed that Resident #1 continued with a stage II to the left outer ankle that measured 0.1 x 0.1 and was scabbed. A stage II to the left heel measured 0.1 x 0.1 and closing. Current treatment was continued. A note dated 6/20/11 at 9:45 a.m. revealed that Resident #1's left outer ankle and left heel was closed. Review of a "Nurses Note" dated 6/25/11 at 1:45 p.m. revealed that Resident #1 had increased temperature of 100.5 degrees and an oxygen saturation of 88 per cent (%). Oxygen was applied and breath sounds were assessed. The physician and Responsible Party (RP) were notified and the ambulance was notified for pickup to transfer Resident #1 to the hospital. There was no documented skin assessment for Resident #1 in the nurse's note. Nor did the facility provide a transfer form for Resident #1. Further Nurse's notes for Resident #1 on 6/25/11 at 2:20 p.m. revealed that Resident #1 left the facility via stretcher. Review of an "Acute Emergency Department RN Flow Sheet" dated 6/25/11 revealed that Resident #1 had an ulcer to the left heel. Review of a History and Physical from the hospital dated 6/25/11 revealed that Resident #1 had chronic lower extremity ulcers. Review of the skin revealed lower extremity ulcers: a 1 cm eschar on the right lateral malleolus and 1.5 cm eschar on the left heel with multiple excoriations in the bilateral lower extremities. Review of hospital nurse's notes dated 6/25/11 at 1800 revealed five (5) documented wound sites. Wound #1: multiple sites (abrasion/shearing/friction) bilateral foot, head, knee and toes that were encrusted and measuring 1 x 1 x 0.25 cm.; Wound #2: multiple sites bilateral shoulder (abrasion) that measured 1 x 1 x 0.25 cm.; Wound #3: right hip blister; Wound #4: right heel pressure ulcer with eschar measuring 1 x 1 x 0.5 cm.; and Wound #5: left heel pressure ulcer with eschar and measuring 2 x 1.5 x 0.5 cm. Review of a Discharge Summary from the hospital dated 6/30/11 revealed that Resident #1 was admitted and noted to have severe dementia and chronic bilateral lower extremity ulcers. Interview with Resident #1's RP on 7/14/11 at 11:10 a.m. revealed that Resident #1 had been admitted with a pressure sore on the heel that had finally healed up after about a year of treatment. She stated that there were some sores on Resident #1's toes when she had gone to the hospital and some scratches on her shoulder. She stated that the facility had not informed her of any sores on the resident's toes. Further interview with Resident #1's RP on 7/14/11 at 6:00 p.m. revealed that she had seen open sores and dark areas on Resident #1's bilateral big toes and some of the small toes on the same day (6/25/11) that she was admitted to the hospital. She stated that the staff in the emergency room and in the Intensive Care Unit (ICU) had pointed them out and had asked her if they were new. Interview with the Director of Nursing (DON) on 7/14/11 at 9:30 a.m., with the Administrator present, revealed that Resident #1 did have pressure ulcers but she thought that they had healed prior to going to the hospital. Further interview with the DON on 7/14/11 at 4:20 p.m. revealed that as far as she knew there were no open areas on Resident #1 when she went to the hospital on [DATE]. She stated that any time a resident's wounds had closed that they allowed three weeks before they were considered healed. The DON reviewed the discharge summary from the hospital that documented bilateral lower extremity ulcers on admit (6/25/11). The DON stated that Resident #1 did still have ulcers that were closed. The DON stated that the discharge summary did not say that the ulcers were open. The DON also reviewed the note of the Nurse Practitioner of 6/10/11 and note of 5/13/11 which documented ulceration of the toes and stated that she had not been aware of any ulcers on Resident #1's toes or any open areas on 6/25/11 when the resident had gone to the hospital. Interview with LPN #1 on 7/14/11 at 10:15 a.m. revealed that Resident #1 had a pressure ulcer to heel and outer ankle and had a [DIAGNOSES REDACTED]. Further interview with LPN #1 on 7/14/11 at 4:00 p.m., while reviewing Resident #1's medical record, revealed that she was not aware of any open areas on the resident's toes. She stated that there may have been some bruising or something. She stated that when the resident left the facility the ulcers on the left heel and outer ankle were closed. She stated that ulcers weren't considered healed until after several weeks of monitoring to ensure that they don't break down again. Interview with the Nurse Practitioner on 7/14/11 at 4:40 p.m. revealed that she had made a mistake in documentation for Resident #1's ulceration. She stated that it should have been documented that the resident had an ulcer on her heel and outer ankle, not her toe. She stated that she had never observed any open areas on Resident #1's toes. Interview with Certified Nursing Assistant (CNA) #1 on 7/14/11 at 10:28 a.m. revealed that she recalled a dressing on Resident #1's heel that was done by the nurses and did not recall any sores on the resident's feet/toes. She stated that they were supposed to check a resident's skin daily during bath and incontinent care for any concerns and report to the nurse. Interview with LPN #2 on 7/14/11 at 4:50 p.m. revealed that she recalled Resident #1 wearing heel boots all of the time and did not recall any sores on her toes but did recall a sore on her ankle and some skin tears that had healed. Interview with CNA #2 on 7/14/11 at 5:00 p.m. revealed that she had taken care of Resident #1 and had not recalled any actual sores on the resident because of bandages on the foot. She did not recall any sores on Resident #1's toes. She stated that she kept Resident #1 turned and got her up as much as possible and used skin protectors and boots. She stated that she would have reported any skin concerns to the nurse while providing care to the resident. Review of the facility's policy "Pressure Sore Prevention For Residents at Risk Policy" with a revised date of 9/2010 revealed: "It is the policy of this facility to identify residents at risk for developing pressure sores and to implement appropriate nursing interventions". The procedure documented that "All pressure sores, which develop, will be documented in the resident's clinical record".