Every finding on record at The Springs of Chenal

Based on observations, record review, interview, and facility policy review, it was determined that the facility failed to ensure that staff maintained sterility during deep tracheal suctioning and failed to ensure staff performed proper hand hygiene while providing resident care for one resident, Resident #1 reviewed for tracheal suctioning and trach care. The findings include: During an observation on 12/03/2025 at 10:06 AM, this surveyor observed Licensed Practical Nurse (LPN) #1 and LPN #2 enter Resident #1's room to provide tracheal suctioning and trach care. Both LPNs performed hand hygiene and utilized Enhanced Barrier Precautions (EBP). While setting up a sterile field on the bedside table, some supplies fell off the table and onto the floor. LPN #1 and LPN #2 agreed to start over. LPN #1 obtained new supplies, and both LPNs performed hand hygiene. At this time, no sterile drape was applied to the bedside table. LPN #2 touched the inside of the solution cup with a bare hand. During donning of sterile gloves, LPN #2 touched the outside of both gloves with her bare hands, contaminating the gloves. While donning the sterile gloves, the left glove tore. LPN #2 removed the gloves, opened the bedside table drawer and reached in the drawer to obtain another pair of sterile gloves. She did not perform hand hygiene before donning the next pair of sterile gloves. LPN #2 touched the outside of the sterile gloves with her hands again while donning the gloves. LPN #2 opened a sterile package containing a sterile tracheal suction catheter inside a paper sleeve. She placed the paper sleeve, which contained the tracheal suction catheter, on the bedside table which allowed the green attachment area of the catheter to rest on the non-sterile table. LPN #2 then performed tracheal suctioning with the catheter which had made contact with the non-sterile table, while using the gloves which were contaminated and not sterile. She reached in the bedside drawer for more gloves and to obtain the disposable inner cannula. LPN #2 did not perform hand hygiene after touching objects in the drawer, nor before donning more sterile gloves. LPN #2 picked up the sterile package which contained the new inner cannula, touched the bare table with gloved hands, and touched the resident's gown with gloved hands before placing the new inner cannula. A review of Resident #1's Medical Diagnosis indicated the facility admitted Resident #1 on 10/21/2025, with diagnoses that included tracheostomy status, non-traumatic intracerebral hemorrhage, non-traumatic intracerebral hemorrhage intraventricular, acute respiratory failure with hypoxia, pneumonia, and Parkinsonism. A review of Resident #1's comprehensive Minimum Data Set (MDS) with an assessment reference date of 10/27/2025, revealed a Brief Interview for Mental Status score of 10, which indicated the resident had moderate cognitive impairment. Resident #1's MDS also indicated the resident was dependent on staff for all self-care abilities. A review of Resident #1's Care Plan, initiated on 10/22/2025, revealed the resident had a tracheostomy related to respiratory failure. Resident #1's Care Plan also included interventions, initiated on 10/22/2025, that directed staff to suction as needed/per physician orders. A review of Resident #1's Physician Orders revealed the resident had an order dated 11/07/2025 for EBP for a Percutaneous Endoscopic Gastrostomy tube and a trach, an order dated 12/02/2025 to suction tracheostomy tube every dayshift for patency or to keep the airway open, and an order dated 12/02/2025 for tracheostomy care every shift and every one hours as needed for prevention, infection, and skin breakdown. A review of Resident #1's Medication Administration Record/Treatment Administration Record for December, revealed the resident had tracheostomy tube suctioning scheduled at 7:00 AM to 7:00 PM every day shift, at 7:00 PM to 7:00 AM every night shift, and every one hours as needed for patency or to keep airway open. During an interview on 12/03/2025 at 10:58 AM, LPN #2 reported sterile gloves were to be used while providing tracheal suctioning. She reported it was important to provide tracheal care and suctioning with sterile technique, to prevent infection and added, it is a portal of entry to their (resident's) lungs. LPN #2 indicated there should have been a sterile barrier on the side table and added she thought she had put a barrier down. She relayed the tracheal suction catheter should not have been able to touch the bare bedside table. She then stated that proper hand hygiene should be performed before putting on gloves, and after taking off gloves. When asked if she performed hand hygiene during the observation of Resident #1's tracheal suctioning and trach care she replied, I did most of the time. During an interview on 12/03/2025 at 11:24 AM, LPN #1 indicated it was important to maintain sterility during tracheal care and suctioning to protect the resident from infection. She reported providing tracheal care and suctioning was a sterile procedure, and that if a nurse broke the sterile field, the nurse should start over. She reported that an opened tracheal suction catheter should not be placed on a bedside table, without a sterile barrier in place. LPN #1 reported hand hygiene should be performed before gloves are put on, and after gloves are removed, every time. During an interview on 12/04/2025 at 10:14 AM, the Nurse Practitioner (NP) indicated tracheal suctioning was a sterile procedure and reported it was important to maintain sterility during tracheal suctioning and care to decrease infection. She then stated that the tracheal suction catheter should not touch a non-sterile side table. The NP indicated proper hand hygiene included washing hands before placing gloves and washing hands after removing gloves, to decrease transmission of bacteria from one patient to another patient. During an interview on 12/04/2025 at 11:49 AM, the Assistant Director of Nursing (ADON) reported handwashing was the number one way to spread infection. She reported hand hygiene should be performed before gloves were put on and after gloves were taken off. She reported tracheal suctioning is a sterile procedure and a sterile object should not be placed on a non-sterile field. The ADON indicated if a nurse broke the sterile field, the nurse should have started over. During an interview on 12/04/2025 at 12:17 PM, the Director of Nursing (DON) indicated a tracheal suction catheter should not be placed on a non-sterile bed side table. She reported it was important to perform hand hygiene for infection control and to protect the resident from infection. She then reported staff should perform hand hygiene before putting on gloves and after taking off gloves. The DON indicated tracheal suctioning was a sterile procedure, and that it was important to maintain sterility during tracheal suctioning to prevent infection. A review of a facility policy titled, Tracheostomy Care indicated aseptic technique (a method that prevents contamination in a sterile environment) must be used during tracheostomy tube changes and during tracheostomy dressing changes. A review of a facility policy titled, Training for Tracheostomy and Care and Management indicated while suctioning, dominant hand remains sterile.and will be inserting the catheter. A review of a facility policy titled, Handwashing/Hand Hygiene, revised on 08/01/2019, indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Step 7 indicated staff to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: f. before donning sterile gloves, g. before handling clean or soiled dressings, k. after handling contaminated equipment, l. after contact with objects in the immediate vicinity of the resident, m. after removing gloves.

Based on observation, record review, interviews, and facility policy review the facility failed to ensure staff donned the proper Personal Protective Equipment (PPE) while providing care to 1 (Resident #7) on Enhance Barrier Precautions of 3 sampled residents selected for a complaint against the facility for quality of care/treatment. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2025, revealed Resident #7 had a Brief Interview of Mental Status (BIMS) score of 00 indication of severely impaired cognition. A review of the Plan of Care for Resident #7 with a revision date of 10/21/2024, revealed Resident #7 required enteral tube feeding related to dysphagia and was care planned for enhanced barrier precautions (EBP). On 02/11/2025 at 2:00 PM, this surveyor observed Licensed Practical Nurse (LPN) #3 stop Resident #7 ' s continuous enteral feeding and disconnect the feeding pump from the Percutaneous Endoscopic Gastrostomy (PEG) tube without a gown in place. On 02/11/2025 at 2:07 PM, this surveyor observed Certified Nursing Assistant (CNA) #1 and CNA #2 transfer Resident #7 from the bed to the Geri-chair without gowns in place. On 02/11/2025 at 2:20 PM, this surveyor observed LPN #3 reconnect the enteral feeding pump to Resident #7's PEG tube while in the common area without a gown in place. On 02/11/2025 at 2:30PM, this surveyor observed CNA #1 and CNA #2 transfer Resident #7 back to bed without gowns in place. On 02/11/2025 at 2:37 PM, this surveyor observed CNA #1 and LPN #3 provide incontinence care to Resident #7 without gowns in place. On 02/11/2025 at 2:57 PM, during an interview, CNA #1 stated she was not familiar with Enhanced Barrier Precautions (EBP) and did not have a gown in place during transfers or while providing care to Resident #7. On 02/11/2025 at 2:59 PM, during an interview, LPN #3 stated she did not have a gown in place while disconnecting or reconnecting the feeding pump from Resident #7's PEG tube. LPN #3 stated the purpose of EBP was for precautionary measure to prevent transferring bacteria. On 02/11/2025 at 3:00 PM, during an interview, the Director of Nursing (DON) stated staff should wear gown and gloves when providing care to a resident on EBP to protect the resident from microorganisms, germs, or anything the resident could be susceptible to. A policy titled Enhanced Barrier Precautions (copy right date 2024) noted Enhanced Barrier Precaution refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and glove[s] use during high contact resident care activities. High contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linen, changing briefs, device care or use: central line, urinary catheter, feeding tubes, tracheostomy/ventilator tubes, wound care: any skin opening requiring a dressing.

Based on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented to meet a resident's needs for 1 (Resident #4) of 3 sampled residents reviewed for Respiratory/Tracheostomy (Trach) care. The findings are: A review of a Medical Diagnosis sheet indicated Resident #4 had diagnoses of malignant neoplasm of the larynx and acquired absence of larynx. The admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 09/22/2024, revealed Resident #4 scored 15 (cognitively intact) on a Brief Interview for Mental Status (BIMS). Section O revealed oxygen use: No, Suctioning: Yes, and Trach care: Yes. The baseline Care Plan did not address the resident having a trach. A review of the Progress Notes, Note Text Type: Orders with Administration revealed an order, effective 09/27/24 11:16, to clean the crust off the surgical incision on the neck with 50/50 saline and hydrogen peroxide. Gently wash with soap and water, pat dry, and apply double antibacterial ointment or petroleum jelly to keep it moist. During an interview, on 12/04/2024 at 10:24 AM, the Assistant Director of Nursing (ADON) confirmed she was familiar with Resident #4 and the resident was admitted with a [NAME] tube (a flexible silicone tube that helps keep the airway open after a laryngectomy [surgery that involves removing part or all of the larynx or voice box]). The ADON said that upon admission, Resident #4 had swelling around the trach site and physician orders to clean the surgical incision. She confirmed the baseline care plan should include that the resident had a trach. During an interview, on 12/04/2024 at 10:30 AM, the Director of Nursing (DON) confirmed the baseline care plan should have addressed the presence of the trach and include use and interventions. During an interview, on 12/04/2024 at 10:35 AM, the Treatment Nurse (TN) confirmed that he had been following physician orders to clean the crust off the surgical incision on the neck with 50/50 saline and hydrogen peroxide, gently wash with soap and water, pat dry, and apply double antibacterial ointment or petroleum jelly to keep it moist. Review of a facility policy titled Care Plans - Baseline revised March 2022 indicated A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care

Based on observation, record review, and interview, the facility failed to ensure foods in the freezer and storage room were covered, sealed and dated to maintain freshness and prevent potential cross contamination; and expired food items foods were promptly removed from stock to maintain freshness and prevent potential cross contamination; dietary staff practiced good hand washing techniques to prevent potential cross contamination of food and clean dishes. The findings are: 1. On [DATE] at 7:41 AM, Dietary [NAME] #1, on the tray line serving the breakfast meal, picked up tray cards and placed them on a tray. Without washing his hands, he picked up the breakfast plates, and with his fingers inside the plate he placed breakfast food on the plate. 2. On [DATE] at 7:50 AM, the following observations were made on the spice rack: a. Rubbed sage with an expiration date of [DATE]. b. Ground cayenne pepper with an expiration date of [DATE]. 3. On [DATE] at 8:00 AM, on a stand in the walk in freezer, the following observations were observed: a. An opened bag of mixed vegetables with no open date. b. An opened bag of chicken fingers with no open date. 4. On [DATE] at 8:04 AM, the following observations were made on bread rack: a. A bag that contained one hot dog bun with received date of [DATE], did not have opened date. b. A bag that contained two hamburger buns with a received date of [DATE], with no opened date. 5. [DATE] at 8:07 AM, the following observations were made on storage area: a. opened gallon container of soy sauce; the manufacturer specification noted, refrigerate after opening. 6. On [DATE] at 8:25 AM, an unidentified gray item was observed in a sugar container. The surveyor showed the item to Food Supervisor #2 who used a spoon to scoop it out. 7. On [DATE] at 9:27 AM, Dietary Aid #3 lifted the plate warmer and placed clean plates on it, then pushed the lid down. Without washing her hands, she cleaned up clean plates with her fingers inside of them and placed them in the plate warmer. 8. On [DATE] at 9:32 AM, the following observations were made on a shelf in the refrigerator locked in the Med Room: a. A bottle of vanilla protein drink. There was no name on the bottle to identify who it belonged to and no received by date. b. Two cartons of fruit yogurt smoothie had no name or received by date. c. A peach sports drink had no name or received by date on it. d. A bottle of thickened water with no name or no received by date. e. Two cans of prune juice with no name or received by date. f. One bottle of fruit punch with no name or no received by date. Licensed Practical Nurse (LPN) #5 said all the food items in the Med (Medication) Room refrigerator belonged to residents. 9. On [DATE] at 9:38 AM, the following items were observed in the freezer located in the Medication Room: a. There was no temperature gauge in the Medication Room freezer. b. All frozen food items in the freezer were frozen solid. c. Two boxes of chicken broccoli alfredo meals with no name or received by date. d. Three boxes of chocolate ice cream with no name or no received by date. e. One bag of microwaveable turnovers with noted freezer burns. The surveyor asked the Food Supervisor to describe the appearance of the food item, he stated It is freezer burnt. f. Two cartons of cherry and lemon Italian ice with no name or received by date. 10. On [DATE] at 9:48 AM, Dietary [NAME] #4 while wearing gloves, picked up a pan of cake and placed the pan on the counter. Without changing gloves, she began removing cake from the pan and placed the cake on a tray, before icing to serve to the residents for lunch. 11. On [DATE] at 11:04 AM, Dietary [NAME] #1 opened the refrigerator door and took out a bottle of 1% milk and placed it on food preparation counter contaminating his hands. Without washing his hands, he removed two slices of bread and placed them in a blender. Then he unzipped a zip top bag that contained loose gloves, he removed gloves and placed them on his contaminated hands, contaminating the gloves. Without replacing his gloves or washing his hands he added two more slices of bread to the blender and added 1% milk to puree. 12. On [DATE] at 11:12 AM, Dietary [NAME] #1 used a rag to wipe up spilled bread puree from the food preparation area. Without washing his hands, he attached the blade to the base of the blender to be used to puree food for the residents who require puree diet. As he was ready to pour food into the blender, the surveyor immediately stopped Dietary [NAME] #1 and asked what he should have done before handling food items. He stated, Wash my hands and rewash the blender. He then removed the blender and rewashed the blender and washed his hands. 13. On [DATE] at 11:30 AM, Dietary [NAME] #1 used his bare hands to pick up bowls to be used in portioning pureed desert, with his fingers inside of the bowls. 14. On [DATE] at 8:08 AM, Food Supervisor #2, and the District Dietary Manager, called Dietary [NAME] #1 for an interview conducted by the surveyor. The surveyor asked Dietary [NAME] #1 what the steps to hand hygiene were after washing one's hands. He stated, I wash them to get the soap off, then dry them, and turn off the faucet with the paper towel. When asked if it was appropriate to dry hands with a paper towel, turn off the faucet with paper towel, and use same paper towel to again dry hands before throwing the paper towel away, he stated, no. 15. On [DATE] at 8:15 AM, review of the facility provided hand washing policy titled, Hand Washing stated, .2. How to wash your hands: -Wet your hands, -Apply soap, -Rub your hands for 10 seconds, -Rinse your hands for 10 seconds, -Turn off water with clean paper towels, -Dry your hands, -Keep your hands clean. Food Supervisor #2 and the District Dietary Manager stated that the hand washing policy is contradictory in nature and will be revised. 16. On [DATE] at 8:33 AM, the District Dietary Manager provided the Surveyor with a revised facility hand washing policy and stated that will replace the previous hand washing policy.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written quantified recipe and menu to meet the nutritional needs of the residents for 2 of 2 meals observed. The findings are: 1. On 07/24/2024 at 7:40 AM, the surveyor asked Dietary [NAME] #1, who was on the tray line serving the breakfast meal, how he prepared the fortified cereal for the residents receiving fortified foods, he stated, I added about one fourth quart of butter and two cups of brown sugar. 2. On 07/25/2024 at 8:50 AM, the District Dietary Manager, Food Supervisor #2, and Dietary [NAME] #4 were interviewed by the surveyor. When asked what foods were served to the residents on fortified oatmeal on 07/24/2024 for breakfast they indicated they were served oatmeal prepared by Dietary [NAME] #1. When shown the recipe for fortified oatmeal provided by the facility that documented for 6 servings: whole milk 1 quart 2 cups, cereal 2 cups, margarine 1/4 lb., brown sugar 1/2 cup, granulated sugar 1/2 cup, whole milk 1/2 cup. The District Dietary Manager, Food Supervisor #2, and Dietary [NAME] #4 confirmed that the recipe for fortified oatmeal was not followed. 3. On 07/25/2024 at 9:00 AM, District Dietary Manager, Food Supervisor #2, and Dietary [NAME] #4 were interviewed by Surveyor. When asked what fortified foods were provided to the residents on a fortified diet for lunch on 07/24/2024. Dietary [NAME] #4 stated, We normally provide fortified potatoes, but yesterday we didn't. I put two sugar packs on the trays for the residents on the fortified diet. When asked why fortified foods were not provided to the residents on fortified diets, she stated, I didn't even think about it. Food Supervisor #2 stated, We usually always have fortified potatoes. The Menu provided by Food Supervisor #2 documented fortified cheesy noodles for residents on fortified diet for lunch on 07/24/2024.

Based on record review and interview, the facility failed to ensure the residents' decisions as to whether they desired to have, or not have, an advanced directive, were documented in a prominent part of the clinical record to ensure their wishes were known regarding acceptance or rejection of any life-sustaining treatments in the event of their incapacitation for 1 (Resident #154) of 1 sampled resident whose clinical records were reviewed for advanced directive information. The findings are: 1. Review of the July Order Summary Report noted Resident #154 was admitted on [DATE] with diagnoses of diabetes mellitus, heart failure, and peripheral vascular disease. a. On 07/23/2024 at 8:03 AM, the Surveyor reviewed Resident #154's electronic record and was unable to locate any information for the resident on whether the resident had formulated an advanced directive or not. b. On 07/23/2024 at 12:55 PM, the Director of Nursing (DON) was asked for a copy of Resident #154's advanced directive information. c. On 07/23/2024 at 1:15 PM, the Director of Nursing (DON) came to the surveyor and stated, I cannot find any advanced directive information on this resident. I talked with admissions, and (Resident #154) has been gone from the facility over 30 days, so we are going to get one (new advanced directive information) done now. The DON was asked, Should the advance directive information be gotten when the resident is first admitted ? The DON stated, Yes. The DON was asked, Why is it important that the advanced directive information is gotten when the resident is first admitted ? The DON stated, It is part of the admission paperwork and consent to treat and code status is all vital information we should get when the resident is first admitted . d. On 07/23/2024 at 3:55 PM, the policy titled Advance Directives provided by the Director of Nursing (DON) indicated, Policy Statement: Advanced directives will be respected in accordance with state law and facility policy .Policy Interpretation and Implementation: 6. Prior to or on admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directive .7. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record .

Based on interview, and record review, the facility failed to ensure an Advanced Beneficiary Notice (ABN) was provided, as required, to allow the resident and/or the resident representative family, decide if the resident wishes to continue receiving skilled services that may not be paid for by Medicare; and of their financial liability for care and services after the Medicare coverage was discontinued for 1 (Resident #3) sampled resident. The findings are: 1. Review of Resident #3's PPS (Prospective Payment System) Part A Discharge (End of Stay) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/2024, indicated Resident #3 scored 12 (8-12 indicates moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS). a. A review of the Physician Order Summary Report indicated Resident #3 had diagnoses of pneumonitis, acute kidney failure, hypertension, major depressive disorder, anoxic brain damage, type II diabetes mellitus, and dysphagia following cerebral infarction. b. Resident #3 Care Plan with a revision date of 06/13/2024 noted Resident #3 had an alteration in neurological status related to disease process anoxic brain damage, with a goal for the resident to show improvement to maximum potential with mobility and cognition. c. On 07/23/2024 at 10:29 AM, the Administrative Consultant (AC) returned the completed SNF (Skilled Nursing Facility) Beneficiary Notification Review forms to the surveyor. The AC stated, We did not send the Advanced Beneficiary Notice (ABN) to Resident #3, or Resident #3's care conference person. We should have, but we didn't. d. On 07/23/2024 at 1:20 PM, the surveyor conducted an interview with the Social Director (SD). The SD was asked who sends out the Advanced Beneficiary Notice (ABN) when a residents Medicare days are ending. The SD stated, I do. The surveyor asked if an ABN was sent out to Resident #3 and Resident #3's designated care conference person. The SD stated, No, The Interdisciplinary Team (IDT) did not notify me that I needed to send it. The surveyor asked the SD how she is notified. The SD stated, During the Medicare, or IDT meeting on Tuesday, they notify me who is coming off Medicare or who isn't skill-able anymore. I found out he was going to long-term care, but I wasn't given a date as to when. On 07/02/2024, the IDT said Resident #3 wasn't skill-able but nothing about sending an ABN. The surveyor asked the SD why it is important to send the ABN to a resident. The SD stated, It lets them know the last covered day of Medicare so the resident can file an appeal to stop the discharge. We set up a Care Plan meeting and Resident #3 went Long-Term Care. The surveyor asked if the family and resident attended. The SD stated, No, the meeting was held on a phone call to the care conference person. The resident was not on the call. This phone meeting took place on 07/03/2024. Resident #3 was already on Medicaid, and we informed the resident's care conference person of the change from Medicare to Medicaid payment for Resident #3's stay. The surveyor asked why Resident #3 was discharged from Part A Medicare services. The SD stated, The IDT team said they did not have any skill-able need.

Based on observation and interview, the facility failed to ensure expired beverage/food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen and hot food items on the steamtable were maintained at a temperature at or above 135 degrees Fahrenheit while awaiting service, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 40 residents who received meals from the Kitchen (Total Census: 40), according to the list provided by the Dietary Supervisor on [DATE] at 3:40 PM. The findings are: 1. On [DATE] at 8:21 AM, a can of cocoa on a shelf above the food preparation counter had an expiration date of [DATE]. 2. On [DATE] at 9:19 AM, Dietary Employee (DE) #1 turned off the 3-compartment sink faucet. With her bare hands, scratched her head, contaminating her hands. Without washing her hands, she removed clean dishes, and placed them on the trays to be used in portioning food items to be served to the residents for lunch with her fingers inside the plates. 3. On [DATE] at 9:44 AM, DE #1 lifted the plate warmer lid, contaminating her hands. Without washing her hands, she picked clean plates and placed them in the plate warmer with her fingers touching the inside of the plates. 4. On [DATE] at 9: 49 AM, DE #2 washed the blender bowl in the 3-compartment sink. After washing the bowl, she turned off the faucet with her bare hands, contaminating them. She then, sanitized the bowl, then picked up a clean blade that was on the clean side of the dishes and attached it to the base of the blender to be used in pureeing food items to serve to the residents on regular diets. 5. On [DATE] at 11:10 AM, DE #2 turned on the 3-compartment sink faucet and washed the blender bowl, then sanitized it. Without washing her hands, she picked a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for lunch meal. 6. On [DATE] at 11:14 AM, DE #1 pushed a cart that contained two trays with glasses of ice towards the counter attached to the steam table. At 11:15 AM, DE #1 opened the refrigerator and took out a pitcher of punch and placed it on the counter. Without washing her hands, she picked up glasses from the tray by the rims and placed them on the counter and poured punch in them. She placed the glasses back on the trays, covered them with a lid and placed them in the refrigerator to be served to the residents for the lunch meal. At 12:06 PM, the Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 7. On [DATE] at 11:23 PM, DE #2 turned on the 3-compartment sink faucet and washed the blender bowl, then sanitized it. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in grounding meat products to be served to the residents on mechanical soft diets. At 1:18 PM, the Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 8. On [DATE] at 11:48 AM, DE #2 placed 2 dinner rolls into a blender. When she was about ready to pour a carton of milk that had been sitting on the counter since 11:35 AM on the dinner rolls to puree, the Surveyor asked for the temperature of the milk to be checked. She did so, and stated, It is 50 degrees Fahrenheit. I will use another milk. 9. On [DATE] at 12:07 PM, the temperatures of the food items on the steam table when checked and read by DE #2 were as follows: a. Pureed broccoli - 127 degrees Fahrenheit. b. Pureed rolls with milk - 89 degrees Fahrenheit. The above food items were not reheated before being served to the residents on a puree diet. At 1:18 PM, the Surveyor asked DE #2, What would you do, if food items were not hot enough on the steam table? She stated, Take them out and reheat them. 10. The facility policy titled, Hand Washing , provided by the Dietary Supervisor on [DATE] at 11:38 AM documented, Policy: Staff will wash hands and exposed portions of their arms. Purpose: To remove contamination after entering the kitchen, touching bare human body parts ., handling soiled utensils or equipment, during food preparation . before donning gloves for working with food, and after engaging in their activities that contaminates the hands . Procedure: 1. Rinse hands under clean, running warm water. 2. Apply soap. 3. Rub together vigorously for approximately 20 seconds. 4. Rinse thoroughly under clean, running warm water. 5. Shut off the water faucet without contaminating clean hands (i.e., by using a paper towel) .

Based on observation and interview, the facility failed to ensure hot foods were maintained at or above 135 degrees Fahrenheit (F) on the steam table while awaiting service and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 40 residents who received meals from the kitchen (total census: 41), as documented on a list provided by Dietary Employee #1. The findings are: 1. On 4/18/22 at 6:18 PM, the temperature of the food items was checked and read by Dietary Employee#1. The temperatures were: Turnip greens were 120 degrees F and pork chops were 110 degrees F. 2. On 4/18/22 at 6:22 PM, Dietary Employee #2 was in the dish washing machine area, wearing gloves. He picked up the water hose, used it to spray off leftover food items from the dishes contaminating the gloves he was wearing. He placed dishes in the dirty racks and pushed them into the dish washing machine to wash while wearing the same contaminated gloves. Dietary Employee #2 then moved to the clean side in the dishwasher area and without changing gloves, picked up clean dishes from the dish rack and stacked them on the clean rack. At 7:06 PM, Dietary Employee #2 was asked, What should you have done after touching dirty equipment and before handling clean equipment? He stated, I should have changed gloves and washed my hands. 3. On 4/18/22 at 6:37 AM, in the freezer there was an Open box of sausage patties and hamburger patties were on a shelf in the freezer that were not covered or sealed. 4. The policy on Hand Washing provided by the Food Service Supervisor on 4/19/22 documented, During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. After engaging in any other activity that contaminates the hands.

Based on observations, record review, and interview, the facility failed to ensure oxygen was ordered and administered at the prescribed flow rate for 1 (Resident #24) of 9 (Residents #6, #22, #24, #31, #35, #36, #37, #39 and #241) sampled residents who received oxygen and failed to ensure a nebulizer mask was stored in a closed bag or container when not in use to prevent potential cross contamination for 2 (Residents #37 and #6) of 5 (Residents #6, #35, #37, #39 and #241) sampled residents who used updraft treatments and failed to ensure infection control practices were completed during the administration of an updraft treatment via a [CONDITION(S)] to prevent potential contamination for 1 of 1 (Resident #37) sampled resident who had a [CONDITION(S)]. The findings are: 1. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 04/18/22 at 06:33 PM, the resident was lying in the bed on her back with oxygen on at 6 liters per minute (lpm) via nasal cannula. The was no humidifier attached to the concentrator. b. On 04/19/22 at 10:12 AM and at 12:41 PM, the resident was lying in the bed on her back with oxygen on at 6 lpm via nasal cannula. The was no humidifier attached to the concentrator c. On 04/20/22 at 10:00 AM, the Director of Nursing (DON) was shown a picture of the oxygen setting dated 04/18/2022 and was asked, What is that set on? She said, It's close to 6. She was asked, What is her order for oxygen? She said, I don't see one. She was asked, Should you have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She said, Absolutely. d. An Oxygen Management policy provided by the Administrator on 04/20/22 at 10:51 AM documented, . It is the policy of this facility to require physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Humidifier (if applicable) and nasal cannula shall be changed every week and when needed . Procedure/Protocol: 1. Verify order in the patient's medical record . 2. Resident #37 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quartley Minimum Data Set with an Assessment Reference Date of 3/3/22 documented the resident scored 3 (3 indicates severe cognitively impairment) on the Staff Assessment for Mental Status (SAMS) and required total dependent assist of 1 person for eating. a. 04/18/22 06:25 PM The Surveyor observed the oxygen concentrator set on 4 LPM. The humidifier was not dated. b. 04/19/22 09:58 AM The Surveyor observed the oxygen concentrator set on 4 LPM. The humidifier was not dated. c. 04/19/22 12:57 PM The Surveyor observed the oxygen concentrator set on 4 LPM. The humidifier was not dated. d. 04/19/22 01:19 PM The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . please apply humidified oxygen to [CONDITION(S)] . e. 04/20/22 10:00 AM The Surveyor showed the DON a picture of the humidifier not dated on 04/18/2022 and ask, should that be dated? She said, Yes. 3. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/18/22 documented the resident scored 5 (0-7 indicates severely impaired in cognitive skills) on the Brief Interview of Mental, was totally dependent on the assistance of two plus people for bed mobility and transfer and had no documentation of oxygen use. a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 05/17/2021. Start Date: 05/18/2021 . b. On 4/18/22 at 6:28 PM, Resident #6 was lying in bed. UDN The Updraft Nebulizer mask was on the top drawer of her bed side table not bagged. c. On 04/19/22 at 10:57 AM, Resident #6's Updraft Nebulizer mask was on the top drawer of her bed side table not bagged. The resident was asked, Do you get breathing treatments? She stated, Yes. Asked, How often? She said, All the time. Asked, Do you give them to yourself? She stated No, the nurses do. d. On 4/20/22 at11:05 AM, the Director of Nurses (DON) was asked, Should her updraft treatment mask be stored like this? She stated, No. She was asked, How should it be stored? She said, It should be bagged and dated. She was asked, What might the outcome be being stored like this? She said, Cross Contamination and possible URI [Upper Respiratory Infection]. She was asked, Should her updraft treatment be care planned? She said, Yes.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. These failed practices had the potential to affect 33 residents who received regular diets and 6 residents who received mechanical soft diets from the kitchen, according to a list provided by the Dietary Supervisor on 4/21/2022 at 10 AM. The findings are: 1. The menu extension on Monday 4/18/2022 specified for the residents on regular diets were to receive 4 ounces of smothered and covered pork chop for dinner at the supper meal. a. On 4/18/2022 at 6:18 PM, residents on regular diets were served a small amount of pork chops. Dietary Employee #2 was asked to weigh the same amount of pork chop served to the residents for supper meal. He did so, and it weighed at 2.4 oz [ounces]. 2. The menu extension on Thursday 2/21/2022 specified the residents on mechanical soft diets were to receive ground fried chicken for lunch. a. On 4/21/2022 at 9:54 AM, Dietary Employee #3 placed 6 ½ servings of boiled chicken breast into a blender, ground and poured it into a pan. She covered the pan with foil and placed in the oven to be served to those residents that were on mechanical soft diets. The menu specified for the residents on mechanical soft diets to receive ground fried chicken. b. On 4/21/22 at 12:32 PM, Dietary Employee #3 was asked the reason mechanical ground boiled chicken was prepared for the residents and not fried chicken, which was stated in the menu. She stated, I was told to use boiled chicken.

Based on record review and interviews, the facility failed to ensure [MEDICATION(S)] was to be given according to Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failed practices had the potential to affect 6 Residents who received [MEDICATION(S)] according to a list provided by the Administrator on 4/21/22 at 12:35 PM. The findings are: Resident (R)17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .every 4 (four) hours as needed for High Blood Pressure (Systolic [greater than] 160 Diastolic [greater than] 90.) Start Date: 4/20/2022 . The DON clarified the order and stated that she read the order as either/both. b. The February 2022 Medication Administration Record (MAR) documented, .Blood Pressure 2/4/22 AM 174/81, PM 174/81; 2/18/22 AM 173/77, PM 178/78; 2/19/22 AM 178/78; 2/21/22 155/92 . The February 2022 MAR documented NO [MEDICATION(S)] HCL was administered. c. The March [DATE] documented, .Blood Pressure 3/15/22 AM 190/96; PM 187/89; 3/18/22 AM 182/70; 3/21/22 PM 178/98 . The March 2022 MAR documented NO [MEDICATION(S)] HCL was administered for the above out of parameters of Blood Pressure readings. d. The April 2022 MAR documented, Blood Pressure 4/5/22 AM 178/88; 4/7/22 AM 177/87; 4/9/22 AM 181/95, PM 181/95; 4/12/22 AM 188/88, PM 188/88; 4/14/22 PM 170/76; 4/15/22 AM 170/76; 4/16/22 PM 186/73; 4/17/22 AM 186/73 . The April 2022 MAR documented NO [MEDICATION(S)] HCL administered. e. On 4/20/22 at 3:00 PM, the Director of Nursing (DON) was shown the resident's [MEDICATION(S)] order and then shown his February, March and April 2022 MARS blood pressure readings and [MEDICATION(S)] given. She was asked, How do you interpret his [MEDICATION(S)] orders? She said, He should get the [MEDICATION(S)] if his blood pressure is greater than 160 Systolic and/or greater than 90 Diastolic. She was then shown all of the Blood Pressure readings on each MARS where the Systolic was greater than 160 or the Diastolic was greater than 90 and then shown each MAR and shown where the [MEDICATION(S)] was given or not given. She was asked, Did he get [MEDICATION(S)] when his Blood Pressure was greater than 160 Systolic and/or greater than 90 Diastolic? She said, Not each time. She was asked, What could the outcome be if he is not given this medication as ordered? She said, It could cause him to have a Stroke, he has a history of Strokes.

Based on observation, interview and record review, the facility failed to ensure that items were labeled and stored accordance with state law and accepted principles of pharmacy laws and regulations; and failed to ensure medication was properly labeled to prevent administration to multiple residents. The findings are: 1. On 04/18/22 at 6:22 AM. A syringe filled with [MEDICATION(S)] was on an overbed table in room [ROOM NUMBER]-A. The resident was lying in the bed while receiving Intravenous (IV) therapy. Licensed Practical Nurse (LPN) #1 was asked What do you see sitting on the overbed table? She said, A [MEDICATION(S)] flush. LPN#1 was asked, Should it be left unattended? She said, No. 2. On 04/19/22 at 2:03 PM, the 300 Hall medication cart was checked with LPN #2. There were 3 bottles in total. One of the was [MEDICATION(S)] eye drops that was not labeled, and the other two bottles were [MEDICATION(S)] ear drops that also were not labeled. 3. On 04/20/22 at 1:00 AM, the Director of Nursing (DON) was asked, Should medications have labels on them? She said, Yes. She was asked why, and she said, So you can't administer to the wrong person. Should a [MEDICATION(S)] flush be left unattended in a resident's room? She said, No. 4. The Medication Storage in the Facility policy provided by the Administrator on 04/20/22 documented, . Policy Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations . The medication supply is accessible only to licensed nursing personnel . 7. Medications labeled for individual resident are stored separately .

Based on observation, record review, and interview, the facility failed to ensure medications and water flushes for a Percutaneous Endoscopies Gastrostomy (PEG) were administered via gravity and hand hygiene and other sanitary conditions were completed to prevent potential infections for 1 (Resident #37) and the bag of formula and water flush were labeled correctly for 3 (Resident #13, #37, #291) of 4 Resident (#7, #13, #37 and #291) sampled residents who had a PEG tube. The findings are: 1. Resident (R) 291 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/26/2022 documented the resident was severely impaired in cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS), was totally dependent on the assistant of one person for eating, received 51% or more calories and 501 milliliters of fluid per day via peg tube. a. A Care Plan dated 7/31/2021 documented, . requires tube feeding r/t [related to] dysphagia .The resident is dependent with tube feeding and water flushes. See MD [Medical Doctor] orders for current feeding orders . b. A Physicians Order date 3/21/2022 documented, Enteral Feed Order every shift [MEDICATION(S)] 1.5 at 50cc [cubic centimeters]/ [per] hr [hour] x [times] 23 hours with 40cc/hr [hour] water flushes. May substitute Vital 1.5. c. On 04/19/22 at 12:01 PM, Resident #291 was lying in bed with around 500 milliliters of liquid infusing by peg tube. The bag containing formula was identified as [MEDICATION(S)] with a date of 04/18/2022. The formula bag did not identify contents properly, there was no time indicating when the formula started, and no flow rate the formula was to infuse at. d. On 4/21/2022 at 10:22 am, Licensed Practical Nurse (LPN)#1 was asked, When hanging formula for a resident receiving feedings by peg tube what information do you write on the bag? LPN #1 stated, You have to put the date, the time, the resident's name, the name of the formula, and the rate on the bag with formula. e. On 4/21/2022 at 10:30 am, the Director of Nursing (DON) was asked, When hanging formula for a resident receiving feedings by peg tube what information do you write on the bag? The DON stated, Resident's name, the current date the bag was hung, the time formula started, the infusion rate, and the kind of formula, f. On 4/21/2022 at 10:35 am, the DON was asked, If any of the information is missing from the bag containing the formula what should the nurse do? The DON stated, The bag should be removed, and a new bag should be hung containing the correct information because you don't know what formula is in the bag. 2. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 2/9/22 documented the resident was totally dependent on one person for eating, received 51% (percent) or more total calories and 501 cc (cubic centimeter)/day or more average fluid intake/day by tube feeding. a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Glucerna 1.5 to run @ [at] 70 cc/hr. [cubic centimeters per hour] via pump continuous. May disconnect prn [as needed] for ADL's, medications, flushes, etc. b. On 4/18/22 at 6:25 PM, R13 Tube Feeding (TF) bag was not labeled (with contents), nor dated or timed when hung. c. On 04/19/22 at 02:37 PM, R13 Tube Feeding bag was not labeled/dated/time. d. On 04/20/22 at 11:12 AM, the Director of Nursing (DON) was asked after showing her the pictures of TF bag, Can you tell by these pictures what is in his TF bag? She stated, No. She was asked, What should this bag look like? She stated, It should have what the feeding is, and date and time it was hung. She was asked, What could the consequences be if none of this was done? She stated, It may have the wrong formula in it, and you can't tell if it is not dated or timed if the correct amount has infused. 3. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/3/22 documented the resident severely impaired in cognitive skills for daily decision making on the Staff Assessment for Mental Status (SAMS), was totally dependent on the assistance of 1 person for eating and received 51% or more calories and 501cc/day or more fluid intake via the PEG tube. a. On 04/18/22 at 06:27 PM, a bag of [MEDICATION(S)] formula was hanging and dated 4/18/22. There was not a label with what type of [MEDICATION(S)], the rate or the start time of the feeding. b. On 04/19/22 at 09:58 AM, a bag of [MEDICATION(S)] hanging dated 04/18/22 but had 04/19/22 written over it. There was not a label with what type of [MEDICATION(S)], the rate or the start time of the feeding. c. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Enteral Feed Order every shift VITAL 1.5 TO CONTINUOUSLY RUN @ 50ML/HR [milliliters per hour] WITH H2O [water] Flush 40ml/hr [hour] . Flush Feeding Tube with 100 cc of water per tube q [every] 3 HOURS May use gravity or slow push every shift related to . May use Osmolyte 1.5 in place of Vital 1.5 . Phone Active 04/14/2022 . d. On 04/20/22 at 08:15 AM, Licensed Practical Nurse (LPN) #1 prepared medications for Administration. She didn't wash or sanitize her hands before she donned on her gloves. LPN#1 disconnected the feeding tube from the pump to the resident. She did not turn off the pump or put it on hold. She did not cap the end of the feeding tube. She placed the feeding tube over the pole of the feeding pump. The feeding tube was dripping formula to the floor. She placed a 60 cc syringe into the gastric port of the feeding tube. She pulled the plunger back to approximately 20 cc without any gastric contents. The LPN pushed the air back into the syringe in the gastric port. She pulled the plunger out of the syringe. She poured 60 cc water into the syringe. The contents would not flow via slow gravity. She then grabbed the plunger and inserted into the syringe. She pushed the water through the syringe with the plunger. She removed the plunger. She picked up the contents of the crushed medication mixed with water and poured into the syringe. The contents would not flow via slow gravity. She then picked up the plunger and inserted into the syringe. She pushed the medications through the syringe with the plunger. She removed the plunger. She poured 60 cc water into the syringe. The contents would not flow via slow gravity. She then picked up the plunger and inserted into the syringe. She pushed the water through the syringe with the plunger. She removed the plunger. She never changed gloves, washed hands, or sanitized hands. She reattached the feeding tube to the gastric port with the formula dripping. e. On 04/20/22 at 10:00 AM, the DON received a photo of the bag with [MEDICATION(S)] dated 4/18/22 written on it. The DON was asked, Is that an appropriate label? She said, No. She was asked, What is ordered for her feeding? She read from the physician orders, Vital if not available can use Osmolyte., She was asked, Is the [MEDICATION(S)] ordered? She said, No, I don't know why they used that. The DON received another picture of a bag with [MEDICATION(S)] dated 4/19/22 written on the bag. The DON was asked, Does it look like they wrote over the 18 to make it a 19? She said, Yes, that bag should have been changed out last night. 4. The Medication Administration . Enteral Tube Medication Administration policy provided by the DON on 04/20/22 at 01:27 PM, documented, . The facility assures the safe and effective administration of enteral formulas and medications. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician . Procedures 1. Enteral formulas, equipment, route of administration and rate of flow are selected based on a Nursing Assessment of the residents' condition and need with physician . A policy documented, Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure/Protocol: 1. Feeding tubes will be utilized according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube): a. Tube placement will be verified before beginning a feeding and before administering medications .

Based on record review and interview, the facility failed to notify the resident representative in writing of the reason for transfer to hospital for 3 (Resident #31, 13, and 17) of 10 (Resident #31, 13, 17, 24, 40, 23, 11, 38, 93, and 37) sampled residents who transferred to the hospital in the last 6 months. The findings are: 1. Resident (R) #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/14/22 documented a score of 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS). a. A Progress Note dated 3/4/22 documented, . Nursing observations, evaluation, and recommendations are Resident observed sweating. Vital signs reported and were abnormal. Resident blood pressure elevated, increased heart rate. Bilateral lung sounds sounded [NAME] drums. ADON [Assistant Director of Nursing] notified. MD [Medical Doctor] notified and ordered to send resident out to ER [emergency room ] . b. A Notice of Transfer/Bed hold User Defined Assessment (UDA) documented, . Date of Notice: 3/4/22 . To: Hospital . the following reason: The transfer or discharge is necessary for the resident . The UDA form did not document a reason for the transfer to the hospital. c. A Policy titled, Transfer and Discharge provided by the Administrator on 4/20/22 at 1:03 PM documented, . the Social Services Director/Designee will notify the resident and the resident's representative in writing in a language and manner they understand . d. On 04/20/22 at 07:49 AM, the Administrator stated, We QA'd [Quality Assurance] that in February [2022] we realized that no one was assigned to that task. e. A Performance Improvement Plan (PIP), provided by the Administrator on 4/20/22 at 9:22 AM documented, Start sending bed hold notifications for hospital discharge . To ensure that all bed hold notifications are being sent to residents/family when a resident discharges to the hospital . The PIP did not include notifying the resident's representative in writing of the reason for transfer to hospital in a language they understand. f. On 04/20/22 at 10:36 AM, the Administrator was asked to provide a copy of the Notice of Transfer/Discharge that would have been sent to Resident #31's representative with the reason for transfer in writing and in a language they understand. He stated, The UDA form was built by our Corporate and the reason for discharge is a blanket statement that is the same on all of the forms. We will start today filling in a specific reason for discharge. 2. R#13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 documented the resident was Comatose, most Recent Admission/Entry or Reentry into this Facility was 3/9/21; Type of Entry: Reentry from an Acute hospital. a. A Progress Note dated 01/26/22 at 1:00 PM documented, Late Entry: Note Text: Resident throwing up approx. 120 ml [milliliters] of bright red blood, skin cool to touch and diaphoretic. Resident alert. BS [blood sugar] 150. An on-call APRN [Advanced Practice Registered Nurse] was notified. N.O. [New Order] send resident to ER for eval [evaluation]/treatment. The Responsible party was notified, and they requested that the resident be sent to [Medical Center]. The Resident was transported to [Medical Center] via [by] [emergency medical personnel]. b. A Progress Note dated 3/20/22 at 19:28 (7:28 PM) documented, Note Text: Witness resident projectile vomiting. This nurse noticed that the Resident's abdomen was distended and that he was in distress. Transfer by [emergency medical personnel] to [hospital]. Notified wife, daughter . c. On 4/20/22 at 11:00 AM, the Administrator was asked, Do you have written documentation given to his Responsible Party for the reason for resident's hospitalization on [DATE] and 3/20/22? He said, I will check. d. A Notice of Transfer/Bed hold User Defined Assessment (UDA) was received from the Administrator on 4/20/22 at 11:38 AM and signed by the Social Director on 3/22/22 documented, . Date of Notice: 3/20/22 . To: Hospital . For the following reason: The transfer or discharge is necessary for the resident (checked) The safety of individuals in the facility is endangered due to the resident (checked) . The UDA form did not document a reason for the transfer to the hospital. e. On 4/20/22 at 11:40 AM, the Administrator was asked, Do you have the Notice of Transfer/Bed hold for his hospitalization for 1/26/22? He said, No. He was then asked, Do you have written documentation for the reason for transfer to the hospital on 1/26/22 and 3/20/22? He said, No, didn't know we needed to do this until yesterday. This will be added to the Transfer/Bed hold form. 3. Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 2/22/22 documented the resident had a score of 14 (13 - 15 indicates cognitively intact) on the BIMS. a. The Progress Note dated 10/21/21 at 8:00 PM documented, Note Text: resident requested to go to [Medical Center] for left upper extremity swelling. spoke with DON [Director of Nursing] and provider and a stat [immediate] lue [left upper extremity] x-ray was suggested before transporting out to the emergency room . Resident refused stat x-ray and demanded to be sent out to [Medical Center #1]. DON/APRN notified. Resident sent out for evaluation. b. The INTERACT (Interventions to reduce Acute Care Transfers) and the SBAR (Situation, background, assessment and recommendation) Summary for Providers dated 12/6/2021 documented, Situation: The Change in Condition/s reported on this CIC (Change in Condition) Evaluation are/were: Stroke/[CONDITION(S)] [Cerebral Vascular Accident]/TIA [Transient Ischemic Accident]/new neurological signs at the time of evaluation. - SEND RESIDENT OUT FOR OBSERVATION AND EVALUATION c. On 1/3/22 at 2:57 PM, Progress Note documented, Note Text: SEND TO [Medical Center #2] ER [emergency room ] FOR EVAL [evaluation] OF LEFT ARM R/T [related to] swelling one time only related to acute embolism and [CONDITION(S)] of superficial veins of left upper extremity for 1 day send to [Medical Center #2] ER for eval of left arm r/t swelling . [APRN] @ facility with new order: send res. [resident] to [Medical Center #2] ER [emergency room ] for eval of left arm r/t [related to] swelling. notified res. guardian . d. On 4/20/22 at 11:00 AM, the Administrator was asked, Do you have written documentation given to his Responsible Party for the reason for the resident's hospitalization on [DATE], 12/6/21 and 1/3/22? He said, I will check. e. A Notice of Transfer/Bed-hold User Defined Assessment (UDA) received from the Administrator on 4/20/22 at 11:38 AM and was signed by the Social Director on 10/21/22 documented, . Date of Notice: 10/21/22 . To: Hospital . For the following reason: The transfer or discharge is necessary for the resident (checked) . The UDA form did not document a reason for the transfer to the hospital. f. On 4/20/22 at 11:40 AM, the Administrator was asked, Do you have the Notice of Transfer/Bed-hold for his hospitalization for 12/6/21 and 1/3/22? He said, No. He was then asked, Do you have written documentation for the reason for transfer to the hospital on 10/21/21, 12/6/2,1 and 1/3/22? He said, No, didn't know we needed to do this until yesterday. This will be added to the Transfer/Bed-hold form.

Based on record review and interviews the facility failed to ensure care plans were updated for 1 (Resident #6) of 5 (Resident #6, 35, 37, 39 and 241) sampled residents who had orders for updraft treatments and 1 (Resident #24) of 8 (Resident #6 22, 31, 35, 36, 37, 39 and 241) residents who received oxygen. This failed practice had potential to affect 10 residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/18/22 documented the Resident scored 5 (0-7 indicates severe cognitive impairment) on a Brief Interview of Mental Status (BIMS). a. The April 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 05/18/2021 . b. The Resident Plan of Care revised on 4/20/22 did not address the updraft nebulizer respiratory treatment. c. On 04/18/22 at 06:28 PM, Resident #6 was lying in bed, and her on the top drawer of her bed side table, not bagged. d. On 04/19/22 at 10:57 AM, Resident #6 was lying in bed and the Updraft Nebulizer mask was on the top drawer of her bed side table, not bagged. The Resident was asked, Do you get breathing treatments? She stated, Yes. She was asked, How often? She stated, All the time. The resident was asked, Do you give them to yourself? She stated No, the nurses do. e. On 04/20/22 at 11:05 AM, the Director of Nursing (DON) was asked while looking at a photo of Resident #6's unbagged Updraft Nebulizer Mask, Should her Updraft Nebulizer Mask be stored like this? She stated, No. She was asked, How should it be stored? She stated, It should be bagged and dated. She was asked, What might the outcome be being stored like this? She stated, Cross Contamination and possible URI [Upper Respiratory Infection]. She was asked, Should her Updraft Nebulizer Mask be care planned? She stated, Yes. 2. Resident #24 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. 04/18/22 at 06:33 PM, the resident was lying in the bed on her back with oxygen on at 6 liters per minute (lpm) via nasal cannula. The was no humidifier attached to the concentrator. b. 04/19/22 at 10:12 PM, the resident was lying in the bed on her back with oxygen on at 6 lpm via nasal cannula. The was no humidifier attached to the concentrator. c. 04/19/22 at 12:41 PM, the resident was lying in the bed on her back with oxygen on at 6 lpm via nasal cannula. The was no humidifier attached to the concentrator. d. 04/20/22 at 10:00 AM, The Director of Nursing (DON) was asked, Should oxygen be care planned? She said, Yes.

Based on observation, record review, and interview, the facility failed to ensure residents were thoroughly cleansed when performing incontinent care for in accordance with accepted standards of nursing practice for 1 (Residents #37) of 9 (Residents #3, #13, # 14, # 18, #24, # 29, # 31, # 37 and #93) sample residents who were dependent on staff for incontinent care, according to a list provided by the Administrator on 04/21/22. The findings are: Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/3/22 documented the resident was severely impaired in cognitive skills for daily decision making on the Staff Assessment for Mental Status (SAMS) required extensive assistance of 2 plus people for toilet use and required extensive assistance of one person for personal hygiene a. On 04/20/22 at 08:35 AM, Licensed Practical Nurse#1 (LPN) entered the resident's room and noticed the resident had had a bowel movement. LPN # 1 called for Certified Nursing Assistant (CNA) #1 to come assist with changing the resident. LPN # 1 removed the covers off of the resident and wiped down the resident's right side of the peri area using a wipe. She discarded the wipe in the clear bag at the foot of the bed. She said to the CNA, I am going to let you come over here and do this. I don't want to do anything wrong. The CNA walked to the resident's right side and wiped down the right side of the peri area. He discarded the wipe in the clear trash bag. He did this 2 times using a new wipe and each time discarded it in the trash bag. He used a wipe and wiped down the left side of the peri area. He discarded the wipe in the clear trash bag. He did this 2 times using a new wipe each time discarding in the trash bag. He spread the labia apart and wiped down the center and discarded the wipe. There was brown loose feces still on the wipe. They rolled the resident over to her left side. He cleaned each side of buttock area with one wipe and discarded the wipe. He placed a brief under the resident buttock area and rolled her back on her back. LPN # 1 pulled the brief up on the left side and fastened the brief. The CNA pulled up the brief on the resident's right side. He was fastening the brief when he was asked to stop. He was asked to please use a wipe and go down the middle of the resident's labia. He removed the brief and there was loose brown feces on the wipe. He discarded the wipe and retrieved a clean one. He did this 5 times until the resident was clean. The CNA was asked, Was the resident clean as you were putting the brief on the resident? He said, No. b. On 04/20/22 at 10:00 AM, the Director of Nursing (DON) was asked, When providing incontinent care, should all areas of the resident be thoroughly cleansed? She said, Yes. c. The Perineal Care policy provided by the Administrator on 04/20/22 at 10:51 AM documented, . Purpose 1. To promote cleanliness and prevent infection. 2. To remove irritating and odorous secretions. 3. To prevent extended skin exposure to incontinence of urine/feces .

Based on observation, record review and interview the facility failed to ensure meals were prepared and served in accordance with the quantified recipes to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect all 46 residents who resided in the facility. The findings are: 1. On 3/1/22 at 12:30 p.m., the noon meal was observed with the following: On the serving line there was a pan of stew that contained potatoes, carrots, large slices of tomato and ground meat. The liquid was thin in the stew. There was also cornbread, pickled beets (cold) and peach cobbler on the serving line. 2. On 3/1/22 at 1:30 PM, the recipe for the stew was requested and provided by the Administrator at 1:50 PM. The recipe for Classic Beef Stew documented these ingredients: 1.5 ounce of salt, 1 and 2/3 teaspoon of black pepper, 10 1/8 tablespoon Worcestershire sauce, 2.5 pounds of potatoes, 1.5 pounds of carrots, 1 pound of onions, 6.5 ounces celery, 10 ounces of flour and 3 1/3 cup water 3. On 3/1/22 at 1:59 PM, Dietary Employee #1 was asked, Was there any celery or onion in the stew? She stated, No, we didn't have any to put in there. She was asked, Was there any Worcestershire sauce used? She stated, No. She was asked, Did the stew thicken with flour according to the recipe? She stated, No. 4. On 3/1/22 at 3:07 PM, Dietary Employee #2 was asked, Was there any celery or onions in the stew? He stated, No. He was asked, Do you have onions and celery? He stated, I am not sure. He was asked, Should the recipe be followed? He stated, Yes. He was asked, By not following the recipe could this have an effect on the residents? He stated, Yes, they may not eat.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment were completed within 14 calendar days after admission to identify issues needed for comprehensive care plan development for 4 (Residents #1, #2, #4, and #5) of 5 (Residents #1, #2, #3, #4, and #5) sampled residents whose MDS were reviewed. The findings are: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/22 identified the admitted [DATE] and was completed 03/04/22. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Entry MDS with an ARD of 02/18/22 documented admission as 02/18/22. The Admission MDS was not identified with the Medicare 5-day MDS. As of 3/4/22, the MDS had not been completed. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 02/16/22 was incomplete. As of 3/4/22, the MDS had not been completed. 4. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 02/18/22 was incomplete. As of 3/4/22, the MDS had not been completed. 5. On 03/04/22 at 8:43 a.m., the Licensed Practical Nurse, MDS Coordinator was asked, Where is your RAI located? She stated, It's in the MDS section on the computer. She was asked, When does the RAI identify an admission MDS must be completed? She stated, 14 days. She was asked, What identifies an MDS is complete? She stated, When I sign it. Surveyor identified it was when an RN signs and dates it as complete. She was asked, Why wasn't Resident #3 and #4 Admission assessment's tied to the Medicare assessment? She stated, Because our company say's I can't. I have to do two separate assessments. She was asked, Can you tell me what's missing from Resident #2 MDS history? She stated, The admission MDS. She was asked, Were any of these MDS completed timely? She stated, No, they weren't.

Based on observation, record review and interview, the facility failed to ensure neurological checks and monitoring were completed after a fall to facilitate prompt identification of any potential post-fall neurological deficits and failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #6) of 2 (Resident #6 and #1) residents who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident (R) #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 12/02/21 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required extensive assistance of one person for bed mobility and transfer, extensive assistance of two plus people for dressing and toilet use, and had one fall with injury since admission. a. The Care Plan dated as initiated 01/01/21 documented, [Resident] is a high risk for falls . Check every 2 hrs [hours] for any needs . encourage him to use call light for any assistance such as transfers . Be sure the resident's call light is within reach . Follow facility fall protocol . b. A Nursing General Note dated 10/10/21 at 10:19 AM and completed by Licensed Practical Nurse (LPN) #1 documented Resident fell this morning while attempting to get up unassisted. Large 2x 2 [2-inch by 2-inch] hematoma with 2cm [centimeters] laceration to left head, pupils small, equal and slow to react. NO [new order] for resident to go to ER [emergency room ] for evaluation. No family listed to call. c. An Incident and Accident (I & A) Report dated 10/10/21 at 11:00 AM documented, Resident found sitting on floor naked facing foot of bed with stool all over the floor and a large 2 inch by 2-inch hematoma with 2cm laceration to left side of forehead. This nurse and Director of Nursing (DON) assessed resident and helped him back to bed and cleaned up . sent to ER . d. A Neuro Check form dated 10/10/21 documented a neuro check was completed on 10/10/21 at 12:00 PM. No further neuro checks were documented. The instructions on the form documented, Neurological assessment requires documentation at the following intervals: Q [every] 15 min [minutes] for 1st hour; Q30 minutes X [times] 2; Q hour X 2; Q 4 hours X 2; Q shift for the remaining 72 hours and until stable. e. Hospital Clinical Notes dated 10/10/21 documented, .Hematoma and approximate 0.75cm laceration noted above his left eyebrow. CT Head WO [without] Contrast. Final result: no acute intracranial abnormality. Scalp hematoma over the left frontal calvarium. Laceration Repair Skin closure glue Dressing 4x4 sterile gauze. f. The hospital discharge summary documented the resident was seen at the hospital from 10/10/21 at 12:19 PM to 10/10/21 at 2:00 PM. The hospital After Visit Summary dated 10/10/22 documented, .Laceration Care Adult . Supplies needed: Soap, Water, Hand sanitizer, Bandage (dressing), Antibiotic ointment, Clean towel. If your doctor used skin adhesive strips, keep the wound clean and dry, if you were given a bandage, you should change it at least once a day as told by your doctor . As of 01/31/22, there was no documentation in the resident's medical record of these treatment orders. g. On 02/01/22 at 8:03 AM, the resident was lying in bed on his side after eating breakfast. He was wearing non-skid socks and was asked if he had fallen recently. He stated, Not for a while. h. On 02/01/22 at 9:02 a.m., RN #1 indicated that LPN #1's last day of work was 11/22/21. Former Director of Nursing (DON) #1 was asked, Were you aware of [R #6]'s fall on 10/10/21? She stated, Yes, I was in the building. She was asked, Do you know if the Doctor was notified about the 2cm laceration to the left side of his head? She stated, No I don't. She was asked, Was a treatment obtained? She stated Yes, he went to the ER. She was asked, Were orders for transfer obtained? She stated, I don't know. She was asked Who is supposed to document an order? She stated, It's the responsibility of the floor nurse. She was asked, Can you tell me what the policy for completing neuro checks is for this facility? She stated, It's for 72 hours, it's on the I&A. She was asked, Did you see [R #6's] I&A? She stated, I don't remember reviewing it. She was asked, Whose responsibility was it to review falls/assessments in the medical record? She stated, It's mine and the Administrator, and I had a nursing consultant who was training me. She was asked, Whose responsibility was it to review that neuro checks were completed? She stated, The DON or Assistant Director of Nursing. She was asked, Were [R #6's] neuro checks completed for 72 hours. She stated, No, she [LPN #1] generated the wrong assessment. i. On 02/01/22 at 9:30 a.m., RN #1 was asked, Did [R #6] go to the ER? She stated, Yes, he initially refused but we convinced him to go; the ER completed a CT [computed tomography] and provided treatment. She was asked if the facility could provide the hospital documentation as the electronic medical record did not contain that. The new DON stated she would try to find it. j. On 02/01/22 at 9:55 a.m., the Nurse Consultant (NC) stated, The ER applied a bandage and steri-stripped the laceration. Upon reviewing the hospital After Visit Summary dated 10/10/21, with the laceration care instructions, the NC was asked, Is any of this documented anywhere? She stated, No, it wasn't. k. The Policy and Procedure for Falls Management, provided by the Administrator on 02/01/22 at 10:30 a.m., documented, .Obtain neurological checks (neuro-checks) per policy for any fall with evidence of injury to head. Document in the medical record, including time and person spoken with. If transferred, document transferring agency/responders. Three days for post fall/incident monitoring, including vital signs.

Based on record review and interview, the facility failed to ensure pain management was promptly addressed after admission to the facility, in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #4 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) had not yet been completed at the time of the survey. a. A hospital Discharge Summary dated 9/10/21 at 2:09 PM documented the resident was hospitalized from 8/7/21 to 9/10/21 and, .Hospital Course: [Resident #4] . PMHx [past medical history] notable for recurrent GI [gastrointestinal] bleeding refractory to medical therapy s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . presented to the hospital with J-tube intolerance . During her admission, she developed significant abdominal pain and nausea . decision made to stop J-tube feedings to allow for bowel rest and to start TPN [total [MEDICATION(S)] nutrition] . Patient did develop repeat [CONDITION(S)] on the left upper extremity during admission. It was managed with PO [oral] [MEDICATION(S)] and [MEDICATION(S)]. She will be discharged with these antibiotics for another 7 days . Patient Instructions: START taking these medications . [MEDICATION(S)] 75 mcg/hr [micrograms per hour] patch . Place one patch onto the skin every third day . [MEDICATION(S)] 10 mg/5 mL [10 milligrams per 5 milliliters] solution . 5 mL per J-tube route every 4 hours as needed for pain . [MEDICATION(S)] 50 mg tablet . one tablet by J-tube route at bedtime . b. The Care Plan dated as initiated 09/10/21 did not address the resident's pain management needs. c. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 5ml via J-tube every 4 hours as needed for pain. d. The Narcotics Log documented the first dose of [MEDICATION(S)] was administered to the resident on 09/11/21 at 10:40 PM, more than 24 hours after the resident was admitted to the facility. The log documented the resident received a one-time dose of Oxycodone 5 mg, two tablets, on 09/11/21 at 7:00 PM. e. The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCl [hydrochloride] tablet 50 mg - give 1 tablet at bedtime for [CONDITION(S)] . Start date 9/10/21 . The first dose after admission was documented on 9/10/21 at 8:00 PM. Acetaminophen solution 325 mg/10.15 mL - give 20.3 mL via J-tube every 6 hours as needed for mild pain / fever. This medication was not documented as administered on 9/10/21 or 9/11/21. [MEDICATION(S)] Sulfate solution 10 mg/5 mL - give 5 mL via J-tube every 4 hours as needed for pain. The first dose of this medication was documented as administered on 9/12/21 at 3:52 AM. The resident's pain level at that time was documented as, 8 (on a scale of 0 to 10, with 10 being the most severe). f. On 09/13/21 at 10:28 AM, Resident #4 stated, I got here after 5:00 PM on Friday [09/10/21]. They [facility staff] didn't get me any pain meds [medications] until Saturday night [9/11/21] after 11:00 PM. I kept asking for something for pain, but they just kept saying the pharmacy hadn't sent it yet. The resident was asked if she was given anything for pain prior to leaving the hospital. She stated, They put a new [MEDICATION(S)] patch on me Friday morning. She was asked to describe her pain from Friday night until she received her pain medication Saturday night. She replied, I was in severe pain. g. On 09/13/21 at 2:09 PM, the Assistant Director of Nursing (ADON) was asked if she was aware the resident was in pain over the weekend. She replied, Yes. She was asked what was done for the resident's pain. She replied, We faxed her medications to the pharmacy 5 different times. I got a call from a staff nurse Saturday, and she reported the resident was in pain. She stated she called the MD and the pharmacy again about getting the resident's [MEDICATION(S)] in the building. The doctor said he gave the staff nurse an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . h. On 09/13/21 at 2:35 PM, Resident #4 was asked to rate the severity of the pain she experienced on 09/10/21 and 09/11/21 using a 1 to 10 scale, with 10 being the worst pain. She replied, It was 9 pretty much from the time I got here until I got the [MEDICATION(S)]. i. On 09/14/21 at 1:58 PM, the Medical Director was asked when he was notified that Resident #4's medication had not arrived at the facility. He replied, I believe it was 4 [PM] or so on Saturday [9/11/21]. [ADON] called me and said the pharmacy was going to fax me some scripts [prescriptions] to sign. He was then asked what time he ordered the Oxycodone. He stated, It was probably 7 PM or so. He was asked if he was made aware of the resident's pain scale when the nurse called. He replied, Without remembering the actual words, I can tell you she was really hurting. j. On 09/14/21 at 4:03 PM, a pharmacist from the resident's pharmacy provider was asked when the pharmacy received the prescription for Resident #4's [MEDICATION(S)] Sulfate. He replied, We received the fax from the doctor Saturday [09/11/21] at 5:04 PM. k. On 09/14/21 at 4:18 PM, Licensed Practical Nurse (LPN) #5 was asked if she provided care for Resident #4 on 09/11/21. She replied, I took over her care at 7:00 PM. The resident had a personal request to change nurses. She was asked if the resident reported that she was in pain when LPN #5 assumed her care. She replied, Yes, she was crying in pain when I took over. I'm the one that called the doctor and got a one-time order for the Oxycodone, and then I gave it. l. The facility's policy titled, Pain Management provided by the Administrator on 9/15/21 at 9:34 AM, documented, .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . Recognition . 2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to .d. Signing, groaning, crying, breathing heavily .

Complaint # was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure allegations of staff-to-resident mental abuse were immediately reported to the Administrator, failed to promptly initiate an investigation and protective measures to prevent further potential abuse and failed to ensure the allegations were reported to the Office of Long Term Care by 11:00 a.m. the next day after identification, in accordance with State law, for 2 (Residents #1 and #2) of 4 (Residents #1, #2, #4, and #5) case mix residents who were cognitively impaired. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #1 and #2, and had the potential to cause more than minimal harm to 11 residents who were cognitively impaired, according to a list provided by the Administrator on 5/17/17. The facility was informed of the immediate jeopardy condition on 5/16/17 at 5:15 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/17 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was easily annoyed, had verbal behaviors directed toward others, and required extensive assistance with most activities of daily living. The Behavior Management Care Plan dated 3/16/17 documented, .Resident has potential for inappropriate behaviors related to history of yelling at staff, hitting staff. Irritability with direction from others . Redirect when behaviors arise . 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/9/17 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, had verbal behaviors directed toward others, and required extensive assistance with most activities of daily living. 3. During completion of Abuse Investigation Protocol tasks on 5/16/17, there were allegations from staff involving harassment and taunting behaviors exhibited by Nurse Aide (NA) #1 toward Residents #1 and #2, as follows: a. On 5/16/17 at 12:55 p.m., Certified Nursing Assistant (CNA) #2 was asked if she had ever witnessed NA #1 taunting / harassing Resident #2 and stated, I have heard him. He'll be in there changing the roommate and (Resident #2) will be yelling at him, telling him to get out, and he'll say to her, 'Yeah I'm gonna change you next' and then she goes crazy. He does that just to get a rise out of her. Or he will be going down the hall and say to her, 'hey how you doing (Resident #2)', and she'll say, 'don't talk to me!' And he'll say 'okay have a nice day' just to get her riled up. He knows she don't like black men in her room or even talking to her. I don't know why he does that. He knows, everybody knows, she don't like black men. I told him the other day when he was messing with her around the curtain, 'Why you doing that when you know I'm fixing to have to deal with her? The CNA was asked if she reported this to anyone and stated, No I didn't. The CNA was asked why, and stated, I don't know. The CNA was asked if she thought it was abuse and stated, I didn't really look at it like that. The CNA was asked if she had observed or heard that NA #1 had allegedly gone up behind Resident #1's wheelchair, grabbed the back of it and held it while the resident was trying to propel herself and laughed at her and stated, No, but I wouldn't put it past him. He's a clown. b. On 5/16/17 at 1:36 p.m., Employee #1 was asked if she had ever witnessed NA #1 being inappropriate with a resident and stated, Yes I have. (Resident #2). She's demented and she lashes out at Blacks. I was walking by her room a couple of weeks ago, and he (NA #1) was arguing with her (Resident #2). I went in there and said, 'you're not gonna talk to her that way!' So I brought her out of her room, and while I was pushing her in her wheelchair, he kept following us as we were going down the hall saying, 'I'm not gonna have her shooting allegations at me!' She was saying, 'keep him out of my room!' I told him she didn't even understand what he was saying. I told (Administrator) that it wasn't right that we just chart it as her having behaviors. Then a few days later, I walk by, and he's standing at the edge of her curtain saying things to antagonize her! The next morning in stand-up (meeting), I brought it up and told them it was inappropriate and I also brought up an incident that happened in the food area where he was talking with some students. Then the Employee #3, (Administrator's) son, said, 'I also saw him mistreat (Resident #1). He grabbed the back of her wheelchair when she was trying to go down the hall and he was laughing when she was jerking hard trying to keep going. All of the department heads heard it! Employee #1 was asked if she felt his actions were abusive toward the residents and stated, Yes I did. Him antagonizing her and getting her worked up . that's abuse. If he would not have done that, she would be fine! If he grabbed (Resident #1's) wheelchair and she jolted forward . what if she would have fallen and hit her head? c. On 5/16/17 at 2:25 p.m., Employee #3 was asked if a discussion took place 2-3 weeks ago in stand-up meeting regarding NA #1 taunting or harassing Resident #2 by making comments to her to agitate her when he knows she doesn't like him, and grabbing the back of Resident #1's wheelchair and holding it where she couldn't propel herself and then laughing at her. The employee stated, I remember hearing those stories. The employee was asked if this discussion took place in the morning stand-up meeting. The employee stated, I don't remember that. I remember his name coming up in meetings, like he's hard to find because he's out socializing. MDS Coor was asked if the discussions involving these two residents were presented as allegations of abuse. The employee stated, Yes. They were put out there as abuse allegations, but I don't know if or what was done about it. d. On 5/16/17 at 2:46 p.m., Employee #4 was asked if a discussion took place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2 and stated, I do remember a conversation. It was kind of like . he eggs her on. (Employee #1) was passing by, and she heard him with (Resident #2) and she told him he couldn't do that. Then someone mentioned (Resident #1). They said they would bring him up and talk to him. Later on that morning, I saw him come out of HR (Human Resources), so I assumed it was taken care of. PTA Director of Rehabilitation was asked, based on what she had heard, if she interpreted the comments as allegations of abuse and stated, I interpreted it as egging the resident on. PTA Director of Rehabilitation was asked what it meant to egg someone on and stated, To antagonize. The employee was asked if it was okay to antagonize a resident and stated, No. The employee was asked if antagonizing a resident was abuse and stated, Yes, it is. e. On 5/16/17 at 3:43 p.m., Employee #5 was asked if a discussion had taken place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2 and stated, They mentioned that he agitates (Resident #2). I don't know if the word was 'agitates' or 'eggs on'. I do remember that it was mentioned, but I don't remember any details about it. I remember (BOM) saying something like, 'that's unacceptable'. It is unacceptable, if he's doing it to agitate residents or aggravate them. The way it was said, I gathered he was doing it to get a rise out of her. Laundry Supervisor was asked if anything was said by Maintenance Man about NA #1 going up behind Resident #1 and grabbing her wheelchair while she was trying to propel herself and laughing at her and stated, Oh, yes. He did say that. The employee was asked, based on what she heard, if these were allegations of abuse and stated, Yes, and if he really did that - any of this - it's not funny. f. On 5/16/17 at 4:04 p.m., Employee #6 was asked if a discussion had taken place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2 and stated, Yes it did. The employee was asked if she remembered any details about what was said and stated, It was said that it was abuse and that it was disrespectful and that he was antagonizing her. The Admissions Coordinator was asked if any other resident was discussed and stated, Yes, (Resident #1). They said he was holding onto her wheelchair so she couldn't move it. The employee was asked if Maintenance Man said that and stated, Both (BOM and Maintenance Man) were speaking up, so I can't really remember which one said it. 4. The following observations / interviews were conducted on 5/15/17 through 5/17/17 to investigate the facility's knowledge and handling of the allegations against NA #1: a. On 5/15/17 at 4:35 p.m., the Administrator was asked if any allegations or complaints had been reported to her involving Nurse Aide (NA) #1, Resident #1 or Resident #2. The Administrator stated, No. He's here every day and he's fairly new. (Resident #2) has [MEDICAL CONDITION], and he (NA #1) usually works on that hall. He takes care of her (Resident #2's) roommate, but even if (Resident #2) sees him in the room, she screams to get him out. She hates all black males. The only thing I have heard is that he was talking to some students and was using the wrong word when he was explaining something. I haven't heard anything at all about (Resident #1). The Administrator was informed of the specific allegations, to enable her to initiate an investigation and protective measures. As of 5:00 p.m., NA #1 was continuing to work in the facility, providing care for residents, with no additional supervision of his interactions with them. b. On 5/15/17 at 5:00 p.m., NA #1 was informed of the allegations against him, concerning Resident #2 and was asked for his comment. He stated, Are you serious? It's been 2 to 3 weeks since I have even worked on that hall. I don't even talk to (Resident #2) unless she talks to me first. (Note: Just prior to this interview, at 4:55 p.m., the Surveyor observed NA #1 talking to another employee while standing just outside Resident #2's door. Resident #2 was coming out of her room at that time). And, I'm way too busy to be messing with someone, and no one has even been in there with me providing care. I always pull the curtain and I ask (Resident #2) to leave the room when I take care of the roommate. You know what? As a matter of fact, a nurse told me I need to watch what I'm doing, because some folks feel that I am taunting (Resident #2). I couldn't believe it. They said it could be psychological abuse. I have no idea what I supposedly did to cause that statement, so I said okay, why don't I go talk to (Administrator). So, I did. I told her exactly what the nurse said and she told me not to worry about it. I requested to be pulled off that hall and I haven't worked on it since then. I can be just standing by (Resident #2) door and she yells at me to get away from her door. NA #1 was asked who told him that what he was doing could be considered taunting and possible psychological abuse and stated, You know, that doesn't even matter. I was told there was a meeting about it and that was brought up. NA #1 was asked about the allegation involving Resident #1 and stated, What? I cannot believe this. No. I have never done that. c. On 5/16/17 at 3:00 p.m., the Director of Nursing (DON) was asked if a discussion had taken place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2. The DON stated, I don't remember anything like that. I do remember a discussion about (NA #1) talking to some students. Now, I was late getting here one day, and I don't think (Administrator) was here that day. I got here, and the meeting was already over. No one mentioned anything like that to me. d. On 5/16/17 at 4:30 p.m., the Administrator was asked again if any allegations had been received in the past concerning NA #1 and Residents #1 and #2 and if these allegations had been discussed in a morning stand-up meeting. The Administrator stated, I just don't remember that being brought up and I have looked through all the meeting notes from April and May, and I don't see anything about that documented. The Administrator was asked who documents the notes during the meetings and stated, I do if I'm here, but I was gone some during that time. e. On 5/17/17 at 11:46 a.m., Maintenance Man, the Administrator's son, was asked what he knew about any allegations involving NA #1 and Residents #1 and #2 and stated, I know there are accusations with (Resident #2). I have never seen (NA #1) be inappropriate with (Resident #2) at all. (Resident #2) is very old school, very racist . (NA #1's) performance was being discussed in stand-up . Him grabbing the handles of (Resident #1) wheelchair, I was the person who saw that . Approximately 3 weeks ago, (Resident #1), who is very combative, was wheeling down the hall. (NA #1) grabbed her wheelchair and was trying to calm her down. He got down on his knees to try to calm her. I approached (NA #1) and told him how to deal with her. I told him he did good by getting down on her level, but to not get in her face. (NA #1) is new and I was trying to help . He was corrected by a senior staff member, being myself. He was asked if this was discussed in the morning stand-up meeting and stated, No. Me and (Employee #1) had a personal conversation about (Resident #1), not in the meeting. I told her what I saw and she said, 'I think that's abuse' and I said, 'I do not.' There was a conversation about (Resident #2) in the meeting. It was that she had become agitated and was using the 'N' word and we felt (NA #1) needed to be moved off the hall. Abuse was never mentioned. That had to have been a side conversation amongst a group. 5. The immediate jeopardy was removed and the scope and severity lowered to E, on 5/17/17 at 11:15 a.m. when the facility implemented the following plan of removal: 1.) Upon notification from surveyor that 2 allegations of abuse were made by staff that had not been reported to the Administrator, the Administrator immediately completed the DMS (Division of Medical Services)-7734 OLTC (Office of Long Term Care) Incident and Accident Reports, submitted to OLTC via fax with confirmations obtained and suspended accused CNA. a. Allegation #1: (Resident #2) was submitted at 5:17 p.m. on 5/15/17. BIM score of 10 on last MDS dated [DATE] - resident unable to provide statement. b. Allegation #2: (Resident #1) was submitted at 5:29 p.m. on 5/15/17. BIM score of 99 (unable to complete) on last MDS - resident unable to provide a statement. c. (NA #1) was suspended pending investigation on 5/15/17 at 5:55 p.m. d. A statement was taken from (NA #1) prior to his suspension. e. Involved staff will be interviewed pertaining to the above allegations. 2.) Current residents who reside in the facility have the potential to be affected. a. 57 residents reside as of 5/17/17. b. Residents with a BIM score greater than 13 are being interviewed (17) currently residing in the facility will be interviewed on 5/17/17 to ensure that they had not been abused or neglected. The Social Worker will conduct the interviews. Questions asked are: Has a staff member mistreated you since you've been a resident here? Are you fearful of any staff members here? Do you feel safe? c. Of current employee personnel files were reviewed by the facility Human Resources Director on 5/15/17 to ensure that the files were complete with the Criminal Background Check, Registry Checks and Abuse and Neglect training was present. No discrepancies were identified. 3.) 63 current facility staff and all contract staff across all departments are being re-educated starting 5/16/17 and will continue shift to shift until completed on the facility's policy and procedure on Abuse and Neglect (N-1265) by the Director of Clinical Services/designee to be completed by 5/19/17. Currently there are 2 staff members on suspension, one on FMLA (Family Medical Leave Act), one on personal leave of absence who will be re-educated on facility policy on abuse and neglect prior to returning to work. 4.) Quality Assurance/Performance Improvement Committee consisting of the Director of Clinical Services, Medical Director, and Social Services Director reviewed the facility's policy on Abuse and Neglect and adopted the policy without any changes or revisions. As per facility policy: 'All incidents of resident abuse are to be reported immediately to the Clinical nurse in charge, the Director or Assistant Director of Clinical Services and the Executive Director (ED). Once reported to one of those three officials, an investigation will begin immediately. The ED/Abuse Coordinator is responsible for reporting to appropriate officials in accordance with General and State Regulations. a. The Social Services Director/designee will conduct Quality Improvement (QI) monitoring of regulation F-225 by conducting interviews with interviewable residents and staff to determine if any instances of abuse and/or neglect have occurred. QI monitoring will occur 5 times a week randomly across all shifts using a sample size of 5 interviewable residents and 5 interviewable staff. Any issues identified will be addressed immediately. b. The facility Executive Director, Director of Clinical Services/Nurse Manager/designee will conduct Quality Improvement Monitoring on abuse and neglect in the facility using: Resident and Staff interviews, chart reviews, facility concern process, employee personnel files. c. QI monitoring will be conducted 5 times weekly for 4 weeks, then 3 times weekly for 4 weeks, then weekly for a month. Any issues identified will be immediately addressed.

Complaint # was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure the facility abuse prohibition policies and procedures were implemented, as evidenced by failure to ensure allegations of staff-to-resident mental abuse were immediately reported to the Administrator, failure to promptly initiate an investigation and protective measures to prevent further potential abuse and failure to ensure the allegations were reported to the Office of Long Term Care by 11:00 a.m. the next day after identification for 2 (Residents #1 and #2) of 4 (Residents #1, #2, #4, and #5) case mix residents who were cognitively impaired. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #1 and #2, and had the potential to cause more than minimal harm to 11 residents who were cognitively impaired, according to a list provided by the Administrator on 5/17/17. The facility was informed of the immediate jeopardy condition on 5/16/17 at 5:15 p.m. The findings are: 1. The facility's, Policies and Procedures for Resident Abuse, revised 9/1/16, documented, .It is inherent in the nature and dignity of each resident at (facility) that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property . Employees of (facility) are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident . Psychological/Emotional Abuse: Humiliation. Harassment, malicious teasing, threats of punishment or deprivation. Not giving reasonable consideration to a resident's wishes . Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological or emotional harm . Acts such as teasing, humiliation, degrading, or intentionally ignoring a resident may constitute abuse . Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of [REDACTED]. Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations . Immediately upon an allegation of abuse or neglect, the suspect(s) shall be segregated from residents pending the investigation . Any suspect(s) who is an employee, once he/she has been identified, will be suspended pending the investigation . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/17 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was easily annoyed, had verbal behaviors directed toward others, and required extensive assistance with most activities of daily living. The Behavior Management Care Plan dated 3/16/17 documented, .Resident has potential for inappropriate behaviors related to history of yelling at staff, hitting staff. Irritability with direction from others . Redirect when behaviors arise . 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/9/17 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, had verbal behaviors directed toward others, and required extensive assistance with most activities of daily living. 4. During completion of Abuse Investigation Protocol tasks on 5/16/17, there were allegations from staff involving harassment and taunting behaviors exhibited by Nurse Aide (NA) #1 toward Residents #1 and #2, as follows: a. On 5/16/17 at 12:55 p.m., Certified Nursing Assistant (CNA) #2 was asked if she had ever witnessed NA #1 taunting / harassing Resident #2 and stated, I have heard him. He'll be in there changing the roommate and (Resident #2) will be yelling at him, telling him to get out, and he'll say to her, 'Yeah I'm gonna change you next' and then she goes crazy. He does that just to get a rise out of her. Or he will be going down the hall and say to her, 'hey how you doing (Resident #2)', and she'll say, 'don't talk to me!' And he'll say 'okay have a nice day' just to get her riled up. He knows she don't like black men in her room or even talking to her. I don't know why he does that. He knows, everybody knows, she don't like black men. I told him the other day when he was messing with her around the curtain, 'Why you doing that when you know I'm fixing to have to deal with her? The CNA was asked if she reported this to anyone and stated, No I didn't. The CNA was asked why, and stated, I don't know. The CNA was asked if she thought it was abuse and stated, I didn't really look at it like that. The CNA was asked if she had observed or heard that NA #1 had allegedly gone up behind Resident #1's wheelchair, grabbed the back of it and held it while the resident was trying to propel herself and laughed at her and stated, No, but I wouldn't put it past him. He's a clown. b. On 5/16/17 at 1:36 p.m., Employee #1 was asked if she had ever witnessed NA #1 being inappropriate with a resident and stated, Yes I have. (Resident #2). She's demented and she lashes out at Blacks. I was walking by her room a couple of weeks ago, and he (NA #1) was arguing with her (Resident #2). I went in there and said, 'you're not gonna talk to her that way!' So I brought her out of her room, and while I was pushing her in her wheelchair, he kept following us as we were going down the hall saying, 'I'm not gonna have her shooting allegations at me!' She was saying, 'keep him out of my room!' I told him she didn't even understand what he was saying. I told (Administrator) that it wasn't right that we just chart it as her having behaviors. Then a few days later, I walk by, and he's standing at the edge of her curtain saying things to antagonize her! The next morning in stand-up (meeting), I brought it up and told them it was inappropriate and I also brought up an incident that happened in the food area where he was talking with some students. Then the Maintenance Man, (Administrator's) son, said, 'I also saw him mistreat (Resident #1). He grabbed the back of her wheelchair when she was trying to go down the hall and he was laughing when she was jerking hard trying to keep going. All of the department heads heard it! Employee #1 was asked if she felt his actions were abusive toward the residents and stated, Yes I did. Him antagonizing her and getting her worked up . that's abuse. If he would not have done that, she would be fine! If he grabbed (Resident #1's) wheelchair and she jolted forward . what if she would have fallen and hit her head? c. On 5/16/17 at 2:25 p.m., Employee #3 was asked if a discussion took place 2-3 weeks ago in stand-up meeting regarding NA #1 taunting or harassing Resident #2 by making comments to her to agitate her when he knows she doesn't like him, and grabbing the back of Resident #1's wheelchair and holding it where she couldn't propel herself and then laughing at her. The employee stated, I remember hearing those stories. The employee was asked if this discussion took place in the morning stand-up meeting. The employee stated, I don't remember that. I remember his name coming up in meetings, like he's hard to find because he's out socializing. MDS Coor was asked if the discussions involving these two residents were presented as allegations of abuse. The employee stated, Yes. They were put out there as abuse allegations, but I don't know if or what was done about it. d. On 5/16/17 at 2:46 p.m., Employee #4 was asked if a discussion took place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2 and stated, I do remember a conversation. It was kind of like . he eggs her on. (Employee #1) was passing by, and she heard him with (Resident #2) and she told him he couldn't do that. Then someone mentioned (Resident #1). They said they would bring him up and talk to him. Later on that morning, I saw him come out of HR (Human Resources), so I assumed it was taken care of. PTA Director of Rehabilitation was asked, based on what she had heard, if she interpreted the comments as allegations of abuse and stated, I interpreted it as egging the resident on. PTA Director of Rehabilitation was asked what it meant to egg someone on and stated, To antagonize. The employee was asked if it was okay to antagonize a resident and stated, No. The employee was asked if antagonizing a resident was abuse and stated, Yes, it is. e. On 5/16/17 at 3:43 p.m., Employee #5 was asked if a discussion had taken place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2 and stated, They mentioned that he agitates (Resident #2). I don't know if the word was 'agitates' or 'eggs on'. I do remember that it was mentioned, but I don't remember any details about it. I remember (BOM) saying something like, 'that's unacceptable'. It is unacceptable, if he's doing it to agitate residents or aggravate them. The way it was said, I gathered he was doing it to get a rise out of her. Laundry Supervisor was asked if anything was said by Maintenance Man about NA #1 going up behind Resident #1 and grabbing her wheelchair while she was trying to propel herself and laughing at her and stated, Oh, yes. He did say that. The employee was asked, based on what she heard, if these were allegations of abuse and stated, Yes, and if he really did that - any of this - it's not funny. f. On 5/16/17 at 4:04 p.m., Employee #6 was asked if a discussion had taken place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2 and stated, Yes it did. The employee was asked if she remembered any details about what was said and stated, It was said that it was abuse and that it was disrespectful and that he was antagonizing her. The Admissions Coordinator was asked if any other resident was discussed and stated, Yes, (Resident #1). They said he was holding onto her wheelchair so she couldn't move it. The employee was asked if Maintenance Man said that and stated, Both (BOM and Maintenance Man) were speaking up, so I can't really remember which one said it. 5. The following observations / interviews were conducted on 5/15/17 through 5/17/17 to investigate the facility's knowledge and handling of the allegations against NA #1: a. On 5/15/17 at 4:35 p.m., the Administrator was asked if any allegations or complaints had been reported to her involving Nurse Aide (NA) #1, Resident #1 or Resident #2. The Administrator stated, No. He's here every day and he's fairly new. (Resident #2) has [MEDICAL CONDITION], and he (NA #1) usually works on that hall. He takes care of her (Resident #2's) roommate, but even if (Resident #2) sees him in the room, she screams to get him out. She hates all black males. The only thing I have heard is that he was talking to some students and was using the wrong word when he was explaining something. I haven't heard anything at all about (Resident #1). The Administrator was informed of the specific allegations, to enable her to initiate an investigation and protective measures. As of 5:00 p.m., NA #1 was continuing to work in the facility, providing care for residents, with no additional supervision of his interactions with them. b. On 5/15/17 at 5:00 p.m., NA #1 was informed of the allegations against him, concerning Resident #2 and was asked for his comment. He stated, Are you serious? It's been 2 to 3 weeks since I have even worked on that hall. I don't even talk to (Resident #2) unless she talks to me first. (Note: Just prior to this interview, at 4:55 p.m., the Surveyor observed NA #1 talking to another employee while standing just outside Resident #2's door. Resident #2 was coming out of her room at that time). And, I'm way too busy to be messing with someone, and no one has even been in there with me providing care. I always pull the curtain and I ask (Resident #2) to leave the room when I take care of the roommate. You know what? As a matter of fact, a nurse told me I need to watch what I'm doing, because some folks feel that I am taunting (Resident #2). I couldn't believe it. They said it could be psychological abuse. I have no idea what I supposedly did to cause that statement, so I said okay, why don't I go talk to (Administrator). So, I did. I told her exactly what the nurse said and she told me not to worry about it. I requested to be pulled off that hall and I haven't worked on it since then. I can be just standing by (Resident #2) door and she yells at me to get away from her door. NA #1 was asked who told him that what he was doing could be considered taunting and possible psychological abuse and stated, You know, that doesn't even matter. I was told there was a meeting about it and that was brought up. NA #1 was asked about the allegation involving Resident #1 and stated, What? I cannot believe this. No. I have never done that. c. On 5/16/17 at 3:00 p.m., the Director of Nursing (DON) was asked if a discussion had taken place in the morning stand-up meeting 2-3 weeks ago about NA #1 harassing/taunting Resident #2. The DON stated, I don't remember anything like that. I do remember a discussion about (NA #1) talking to some students. Now, I was late getting here one day, and I don't think (Administrator) was here that day. I got here, and the meeting was already over. No one mentioned anything like that to me. d. On 5/16/17 at 4:30 p.m., the Administrator was asked again if any allegations had been received in the past concerning NA #1 and Residents #1 and #2 and if these allegations had been discussed in a morning stand-up meeting. The Administrator stated, I just don't remember that being brought up and I have looked through all the meeting notes from April and May, and I don't see anything about that documented. The Administrator was asked who documents the notes during the meetings and stated, I do if I'm here, but I was gone some during that time. e. On 5/17/17 at 11:46 a.m., Employee #2 was asked what he knew about any allegations involving NA #1 and Residents #1 and #2 and stated, I know there are accusations with (Resident #2). I have never seen (NA #1) be inappropriate with (Resident #2) at all. (Resident #2) is very old school, very racist . (NA #1's) performance was being discussed in stand-up . Him grabbing the handles of (Resident #1) wheelchair, I was the person who saw that . Approximately 3 weeks ago, (Resident #1), who is very combative, was wheeling down the hall. (NA #1) grabbed her wheelchair and was trying to calm her down. He got down on his knees to try to calm her. I approached (NA #1) and told him how to deal with her. I told him he did good by getting down on her level, but to not get in her face. (NA #1) is new and I was trying to help . He was corrected by a senior staff member, being myself. He was asked if this was discussed in the morning stand-up meeting and stated, No. Me and (Employee #1) had a personal conversation about (Resident #1), not in the meeting. I told her what I saw and she said, 'I think that's abuse' and I said, 'I do not.' There was a conversation about (Resident #2) in the meeting. It was that she had become agitated and was using the 'N' word and we felt (NA #1) needed to be moved off the hall. Abuse was never mentioned. That had to have been a side conversation amongst a group. 6. The immediate jeopardy was removed and the scope and severity lowered to E, on 5/17/17 at 11:15 a.m. when the facility implemented the following plan of removal: 1.) Upon notification from surveyor that 2 allegations of abuse were made by staff that had not been reported to the Administrator, the Administrator immediately completed the DMS (Division of Medical Services)-7734 OLTC (Office of Long Term Care) Incident and Accident Reports, submitted to OLTC via fax with confirmations obtained and suspended accused CNA. a. Allegation #1: (Resident #2) was submitted at 5:17 p.m. on 5/15/17. BIM score of 10 on last MDS dated [DATE] - resident unable to provide statement. b. Allegation #2: (Resident #1) was submitted at 5:29 p.m. on 5/15/17. BIM score of 99 (unable to complete) on last MDS - resident unable to provide a statement. c. (NA #1) was suspended pending investigation on 5/15/17 at 5:55 p.m. d. A statement was taken from (NA #1) prior to his suspension. e. Involved staff will be interviewed pertaining to the above allegations. 2.) Current residents who reside in the facility have the potential to be affected. a. 57 residents reside as of 5/17/17. b. Residents with a BIM score greater than 13 are being interviewed (17) currently residing in the facility will be interviewed on 5/17/17 to ensure that they had not been abused or neglected. The Social Worker will conduct the interviews. Questions asked are: Has a staff member mistreated you since you've been a resident here? Are you fearful of any staff members here? Do you feel safe? c. Of current employee personnel files were reviewed by the facility Human Resources Director on 5/15/17 to ensure that the files were complete with the Criminal Background Check, Registry Checks and Abuse and Neglect training was present. No discrepancies were identified. 3.) 63 current facility staff and all contract staff across all departments are being re-educated starting 5/16/17 and will continue shift to shift until completed on the facility's policy and procedure on Abuse and Neglect (N-1265) by the Director of Clinical Services/designee to be completed by 5/19/17. Currently there are 2 staff members on suspension, one on FMLA (Family Medical Leave Act), one on personal leave of absence who will be re-educated on facility policy on abuse and neglect prior to returning to work. 4.) Quality Assurance/Performance Improvement Committee consisting of the Director of Clinical Services, Medical Director, and Social Services Director reviewed the facility's policy on Abuse and Neglect and adopted the policy without any changes or revisions. As per facility policy: 'All incidents of resident abuse are to be reported immediately to the Clinical nurse in charge, the Director or Assistant Director of Clinical Services and the Executive Director (ED). Once reported to one of those three officials, an investigation will begin immediately. The ED/Abuse Coordinator is responsible for reporting to appropriate officials in accordance with General and State Regulations. a. The Social Services Director/designee will conduct Quality Improvement (QI) monitoring of regulation F-225 by conducting interviews with interviewable residents and staff to determine if any instances of abuse and/or neglect have occurred. QI monitoring will occur 5 times a week randomly across all shifts using a sample size of 5 interviewable residents and 5 interviewable staff. Any issues identified will be addressed immediately. b. The facility Executive Director, Director of Clinical Services/Nurse Manager/designee will conduct Quality Improvement Monitoring on abuse and neglect in the facility using: Resident and Staff interviews, chart reviews, facility concern process, employee personnel files. c. QI monitoring will be conducted 5 times weekly for 4 weeks, then 3 times weekly for 4 weeks, then weekly for a month. Any issues identified will be immediately addressed.

Complaint # (AR 610) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure a mechanical lift and 2 staff were utilized for transfers in accordance with the resident's assessed transfer needs to prevent accidents / injuries for 1 (Resident #1) of 4 (Residents #1, #3, #6 and #7) case mix residents who required mechanical lift transfers. This failed practice resulted in actual harm to Resident #1, who was transferred manually by 1 Certified Nursing Assistant (CNA), fell to the floor and sustained a complex comminuted distal femur fracture. The CNA failed to immediately report the incident to a licensed nurse, to allow an assessment to be conducted before moving the resident, and failed to obtain assistance from trained nursing personnel to assist the resident off of the floor, which could result in further injury. The facility also failed to ensure staff avoided the use of residents' clothing as a lifting device during transfers, to prevent potential accidents / injuries or 2 (Residents #2 and #5) and failed to ensure the wheelchair brakes were locked prior to conducting a manual transfer to prevent potential falls for 1 (Resident #5) of 3 (Residents #2, #4 and #5) case mix residents who required manual transfers with a gait belt. The facility also failed to ensure chair alarms were maintained in proper working order to alert staff of unassisted transfer attempts in accordance with the plan of care for 1 (Resident #2) of 1 case mix resident who was care planned for the use of a wheelchair alarm. These failed practices had the potential to cause more than minimal harm for 8 residents who required mechanical lift transfers, 30 residents who required manual transfers with a gait belt and 4 residents who were care planned for alarms, as documented on lists provided by the Administrator on 8/28/15. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/15 documented the resident was severely impaired cognitive skills for daily decision making per a staff assessment of mental status, weighed 161 pounds, was totally dependent on the assistance of 2 persons for bed mobility and transfers, had no functional limitation in range of motion, had no complaints of pain in the past 5 days and had no falls since admission, re-entry or prior assessment. a. The Transfer/Mobility Status Criteria dated 5/12/14 documented, .Transfer Status: 4 (total dependence) .Totally non-weight bearing . Total lift with full body sling. Lift required: Yes . b. The Comprehensive Care Plan dated 6/7/15 documented, Fall Prevention Care Plan Problem: At risk for falls r/t (related to) cognition status, dependent mobility . Transfer using total lift assist (assistance) of two. High back w/c (wheelchair) with pommel cushion for positioning . c. Nurses' Notes dated 8/23/15 at 1:30 p.m. documented, Resident was Hoyer lift to bed, pain noted during transfer. R (resident) holding L (left) leg administered 2 Tylenol arthritis at 12:55 p.m. Abrasions to L side of face noted, (no) bleeding noted, also redness to L upper clavicle, L leg above knee. Swelling noted (and) bent inwards. Awaiting (name) for x-rays . 1650 (4:50 p.m.) (name) x-ray technician arrives for x-rays, stated resident had a femur break from looking at screen. (Physician) notified awaiting call back. 1830 (6:30 p.m.) N.O. (New Order) to send out to (Hospital) ER (emergency room ). Ambulance notified. d. The Accident/Incident Report Form dated 8/23/15 documented, .Date 8/23/15 at 12:10 p.m . Status: Resident (Resident #1) Witness (Certified Nursing Assistant (CNA) #1), Falls . Transfer from bed to w/c (wheelchair) . Factors related to fall: (Resident) Alert (at time of accident) - Injuries observed: (blank) . Range of motion limited ROM (range of motion) . e. The Situation / Background Assessment / Request (SBAR) Communication form dated 8/23/15 1:15 p.m., documented, .Situation: Fall with signs of hip L (left) leg pain. This condition, symptom or sign has occurred before: No 8. Skin evaluation: Describe symptoms or signs: Lt (left) leg appears swollen and lt knee appears swollen and slightly turned inward. 9. Pain Evaluation: Does the resident have pain: Yes . Is the pain new: Yes . Does the resident show non-verbal signs of pain (for residents with dementia describe restless, pacing, grimacing, new change in behavior): Resident grimacing with movement and holding Lt leg . Appearance: Lt leg edematous and knee is slightly turned inward . Recommendations: Stat X-ray of Lt hip, upper leg and knee . f. The Fall Root Cause Investigation Report dated 8/23/15 documented, .Resident description or statement regarding the cause: Improper transfer of resident from bed to wc (wheelchair) by CNA . External/Environmental Contributing Factors . Transfer Status: Assist x (times) 2 - Devices used for transfer: Lift. Other: Transfer from bed to wc . Summary: Improper transfer at resident from bed to wc by CNA. Employee received disciplinary actions . g. The Radiology Report dated 8/23/15 documented, .Conclusion: Complex comminuted acute distal femur fracture . h. A Physician order [REDACTED]. Bedrest . 5. Immobilizer on at all times 6. Tylenol arthritis strength 650 mg po TID (three times daily) . 9. Contact (orthopedic specialty clinic) R/T (related to) follow up. L femur fx (fracture). i. The Office of Long Term Care (OLTC) Witness Statement form dated 8/23/15 at 12:20 p.m. documented, Witness Full Name: (Housekeeper #1). State in your own words what you witnessed (be very descriptive) and sign below: 'I was doing my daily routine. I was asked by a CNA worker to help a patient off the floor. Personally, I wasn't aware of what was going on. I admitted ly help the CNA worker with the lady . (Housekeeper #1) . j. The OLTC Witness Statement form dated 8/23/15 at 12:57 p.m. documented, Witness Full Name: (CNA #1) . State in your own words what you witnessed (be very descriptive) and sign below: 'I pulled her legs (Resident #1) around to the edge of the bed so they would dangle. I lifted her and placed her on the seat. I got weak. Sat her on the chair and she slid out of the chair .(CNA #1) . k. Nurses Notes dated 8/24/15 at 1:10 a.m. documented, R (Resident) returned to facility via (ambulance service) on stretcher . S/S (signs and symptoms) of pain observed. Given Tylenol 650 mg (milligrams) po (by mouth) as ordered. Abrasion to L (left) cheek and neck observed as previously noted. Immobilizer brace in place to LLE (left lower extremity). Foley Cath (catheter) inserted using sterile technique size 16 fr.(French) 10 cc (cubic centimeters) bulb . R to remain on bedrest . L Distal Femur Fx (Fracture) . l. The Physician order [REDACTED]. m. Nurses Notes dated 8/24/15 at 12:15 p.m. documented, Spoke with (Physician's Nurse). Res (Resident) needs surgery but family does not (sic) & (and) refused surgical repair . Daughter at facility & stated she does not want to do surgery & just keep her comfortable at facility & palliative care . n. On 8/27/15 at 5:29 p.m., CNA #1 was interviewed as follows: The CNA was asked how long she had been employed by the facility and stated, One month; I finished CNA classes one month ago. The CNA stated she was on her second round of orientation. The CNA was asked how Resident #1 was supposed to be transferred and stated, (Resident #1) was a total lift, 2-person transfer. The CNA was asked, Why did you (manually) transfer the resident, who was supposed to be a total lift? The CNA stated, I was late from lunch and I was in a hurry. I just wanted to get her in her chair, to go to the lunch room. They wanted all the CNAs in the dining room to pass lunch trays. I didn't want to get in trouble. The CNA was asked, So, you transferred the resident by yourself? The CNA stated, Yes, there was nobody to help me. I couldn't find the nurse. I was the only one assigned to that hall. I sat her (Resident #1) up on the side of the bed. I got weak and sat her down, and she slid out of the wheelchair. I went to the hall, and the Housekeeper was there and she helped me get her back in the wheelchair, and I took her to the dining room. The CNA was asked, You got the resident out of the floor before you told the nurse? The CNA stated, Yes. The CNA was asked, If a resident has a fall, are you supposed to move the resident before the resident is assessed by a nurse? The CNA stated, No. The CNA was asked, Is a housekeeper supposed to be assisting you with patient care? The CNA stated, I was too weak to pick the resident up; I didn't know at that time that she (Housekeeper #1) wasn't supposed to help. I told the nurse when we got to the dining room. The CNA was asked if it was appropriate to transfer Resident #1 via manual transfer when the resident was assessed to require a mechanical lift. The CNA stated, No. o. On 8/28/15 at 2:20 p.m., Housekeeper (HK) #1 was interviewed as follows: The Housekeeper was asked how long she had been employed by the facility and stated, Three months. The housekeeper was asked about her training and stated that she had 1 day of training. The Housekeeper was asked if she had worked in a nursing home before and stated, No. The Housekeeper was asked if she had assisted with any resident care. The Housekeeper stated, When the situation happened last week, I helped a CNA get her (Resident #1) off the floor; she didn't appear hurt at that time. The Housekeeper was asked, What position were her (Resident #1) legs in (while on the floor). The Housekeeper stated, Her (Resident #1) legs were crossed, Indian-style. The Housekeeper was asked, How did you pick the resident up? The Housekeeper stated, We put one arm under her arms and one hand under her legs (pointing to the upper thigh area) and we lifted her and sat her in the wheelchair. The Housekeeper was asked if she was supposed to be assisting with resident care. The Housekeeper stated, I was informed after that situation that I was not. The Housekeeper was asked, Were you told during your orientation that you were not to assist with any resident care. The Housekeeper stated, No. p. On 8/28/15 at 12:45 p.m., CNA #2 was asked her job title. The CNA stated, Lead CNA, when I am able, but I have been working on the hall for the last week. I am Lead CNA every other week. I watch them do transfers, make sure they do peri-care, help them out on the halls, the 300 and 400 halls, because there's 1 person for that hall, and whatever needs to be done. There's no specific job description for Lead CNA. The CNA was asked specifically about CNA #1's training and stated she had worked with CNA #1 for 2 days while CNA #1 was a student, then after she started her employment with the facility, I worked with her 1 day, then she rotated one day on each hall. The CNA was asked who checked CNA #1 off on transfers. The CNA stated, I did not . I stress that lifts, you don't do by yourself, you get another person; everybody knows that. q. On 8/28/15 at 1:22 p.m., the Director of Nursing (DON) was asked, When the CNAs are in training, who checks the CNAs off to ensure they have the ability to perform their job duties? The DON stated, The Lead CNA orientates the new CNAs until they feel they are competent. The DON was asked, But who checks off the new CNAs to ensure that the CNA is competent in their tasks? The DON stated, The Lead CNA. The DON was asked about the incident involving Resident #1. The DON stated, About (Resident #1), the CNA did an improper transfer. It was reported to me that the CNA did a manual transfer and then picked the resident up off the floor. That resulted in a femur fracture. The DON was asked, What steps have you taken to ensure that this does not happen again? The DON stated, We did a 4 step plan . The resident was placed on bedrest, close monitoring, a leg brace and air mattress. The family has elected not to have surgery, secondary to her age. The facility's '4 Point Plan' developed 8/23/15 documented, .2.Curent residents will have updated transfer/ mobility assessments completed by 8/24/15 .3) current staff will be re-educated by 8/25/15 .a. immediate post fall interventions .c. re-education on lift procedures .d. identification of transfers .4) fall investigations will be reviewed during the morning meeting .weekly audit by mock survey x (times) 3months . The DON was asked if the housekeeper was trained as a CNA. The DON stated, No. The DON was asked if it was appropriate for the Housekeeper to assist with lifting a resident. The DON stated, No. 2. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an ARD of 6/5/15 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), required extensive assistance of 1 person for transfers and personal hygiene and extensive assistance of 2 persons for bed mobility and utilized a wheelchair for mobility. a. The Resident Transfer/Mobility Status Criteria dated 6/11/14 documented, .Transfer Status: (2), Limited assistance: Resident highly involved in activity; receives physical help in guided maneuvering of limbs or other non-weight bearing assistance . Lifting Aide to be used. Gait belt with assist of one if support of individual is unreliable, then use two person support . gait belt assist of 1. b. The Screening of Resident Falls form dated 3/30/15 documented, .Nursing Intervention: Alarms checked (and) functioning properly. Safety mat properly placed . c. The August 2015 Alarm Monitoring Log documented, 8/1/15 - 8/27/15: .Physician order [REDACTED]. Alarm on bed, body or wheelchair? Y . Alarm positioned correctly? Y . Alarm batteries working? Y . Alarms needed repair? N (no) . The form was initialed by the Restorative CNA. d. On 8/27/15 at 1:50 p.m., the resident was sitting in a wheelchair with an alarm on the left side of the wheelchair. The light was not flashing to indicate the alarm was functioning. e. On 8/27/15 at 2:17 p.m., CNA #1 and #2 assisted the resident to her room via wheelchair. The wheelchair alarm was on the back left side of the resident's wheelchair and was not flashing to indicate the alarm was functioning. The CNAs combed the resident's hair as the resident was trying to leave the room. The CNAs took the resident back to the day room area and the resident propelled herself back to the table and laid her head on the table. The CNAs did not check to ensure that the wheelchair alarm was functioning. f. On 8/27/15 at 3:09 p.m., Registered Nurse (RN) #1 was asked to check the resident's alarm. The RN checked the alarm. She stated, There are no batteries in the alarm. The RN put new batteries in the alarm, and a constant beeping started to sound, although the resident was positioned properly in the chair. CNA #1 and #2 took the resident to her room. The CNAs assisted the resident to stand using a gait belt and changed out the seat alarm pad for one that functioned properly. During the process of standing the resident up, the CNAs placed the gait belt around the resident's waist and grasped the gait belt with one hand and the waistband of the resident's pants with their other hand. They used the gait belt and the resident's pants to pull the resident up out of the wheelchair and hold the resident in an upright position while the cushion and alarm pad were changed in the wheelchair. After the procedure was completed, CNA #2 was asked how often the batteries in the chair alarms were checked. The CNA stated, Weekly. CNA #1 was asked, How often are the placement and functioning of the alarms checked? The CNA stated, I don't know. g. On 8/28/15 at 11:03 a.m., Licensed Practical Nurse (LPN) #1 was asked who was responsible for checking the placement and functioning of the wheelchair alarms. The LPN stated, The Restorative CNA (CNA #3). h. On 8/28/15 at 11:30 a.m., CNA #3 was asked about her job duties. The CNA stated, I check all bed and wheelchair alarms, fix drinks in the dining room for breakfast and lunch, apply splints for residents after discharge from therapy, perform range of motion for resident on the Restorative Nursing Program, perform weights on all new residents, Monday weights for weekly weights and monthly weights. The CNA was asked if she had checked the alarms on the wheelchairs on Thursday 8/27/15. The CNA stated, Yes. The CNA was asked if there were any issues related to the alarms. The CNA stated, Yes, on occasion, they are unplugged. CNA #3 was asked, Did you check (Resident #2's) wheelchair alarm on 8/27/15. The CNA stated, Yes. When asked if the chair alarm was functioning properly, she stated, Yes. The CNA was asked when she checked the alarm and stated, When I first get to work and before I leave at 3 (3:00 p.m.). CNA #3 was asked, Did you check the alarm for (Resident #2) before you left on 8/27/15? The CNA stated, No. i. On 8/28/15 at 1:22 p.m., the Director of Nursing (DON) confirmed that CNA #3 was supposed to check the alarms when she arrived at work and again before she left for the day. The DON stated the Restorative CNA (CNA #3) did not check the alarms before she left on 8/27/15. 3. Resident #5 had [DIAGNOSES REDACTED]. a. The Transfer /Mobility Status Criteria dated for 5/12/14 documented, .Transfer Status: 2 (limited assistance) . receives physical help in guided maneuvering of limbs or other non-weight bearing assistance . Lifting Aid to be used. Gait belt with assist of one; If support of individual in unreliable, then use two-person support . b. The Comprehensive Care Plan dated 2/5/15 documented, .Problem, Self-Care Deficit, ambulation related to impaired balance, generalized weakness. Hx (history) fear of falling . Lt (left) Hemiparesis, non-ambulatory . Goal: Resident will continue to transfer with assist of one. Interventions/Approaches: Provide assistance as needed with transfers . Transfer with assist of one for toileting . c. On 8/27/15 at 1:37 p.m., the resident stated she was wet. CNA #2 assisted her to the bathroom. The CNA placed a gait belt around the resident's waist, then assisted the resident to stand by grasping the gait belt and the waistband of the resident's pants and pulling in an upward motion. The CNA did not lock the wheelchair brakes during the transfer. After the resident finished toileting, she asked to go to bed. The CNA took the resident to the bed in the wheelchair and positioned the wheelchair at the foot of the bed. The CNA again grasped the gait belt and the resident's pants and pivoted the resident to the bed. The CNA did not lock the wheelchair brakes during the transfer.

Complaint # (AR 610) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) were able to demonstrate competency in properly transferring residents in accordance with their assessed and care planned needs, as evidenced by: Failure to ensure a mechanical lift and 2 staff were utilized for transfers in accordance with the resident's assessed transfer needs to prevent accidents / injuries for 1 (Resident #1) of 4 (Residents #1, #3, #6 and #7) case mix residents who required mechanical lift transfers. This failed practice resulted in actual harm to Resident #1, who was transferred manually by 1 Certified Nursing Assistant (CNA), fell to the floor and sustained a complex comminuted distal femur fracture. The CNA then failed to immediately report the incident to a licensed nurse, to allow an assessment to be conducted before moving the resident, and failed to obtain assistance from trained nursing personnel to assist the resident off of the floor, which could result in additional injury; Failure to ensure CNAs avoided the use of residents' clothing as a lifting device during transfers, to prevent potential accidents / injuries for 2 (Residents #2 and #5) and failed to ensure the wheelchair brakes were locked prior to conducting a manual transfer to prevent potential falls for 1 (Resident #5) of 3 (Residents #2, #4 and #5) case mix residents who required manual transfers with a gait belt. These failed practices had the potential to cause more than minimal harm for 8 residents who required mechanical lift transfers and 30 residents who required manual transfers with a gait belt, as documented on lists provided by the Administrator on 8/28/15. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/15 documented the resident was severely impaired cognitive skills for daily decision making per a staff assessment of mental status, weighed 161 pounds, was totally dependent on the assistance of 2 persons for bed mobility and transfers, had no functional limitation in range of motion, had no complaints of pain in the past 5 days and had no falls since admission, re-entry or prior assessment. a. The Transfer/Mobility Status Criteria dated 5/12/14 documented, .Transfer Status: 4 (total dependence) . Totally non-weight bearing . Total lift with full body sling. Lift required: Yes . b. The Comprehensive Care Plan dated 6/7/15 documented, Fall Prevention Care Plan Problem: At risk for falls r/t (related to) cognition status, dependent mobility . Transfer using total lift assist (assistance) of two. High back w/c (wheelchair) with pommel cushion for positioning . c. Nurses' Notes dated 8/23/15 at 1:30 p.m. documented, Resident was Hoyer lift to bed, pain noted during transfer. R (resident) holding L (left) leg administered 2 Tylenol arthritis at 12:55 p.m. Abrasions to L side of face noted, (no) bleeding noted, also redness to L upper clavicle, L leg above knee. Swelling noted (and) bent inwards. Awaiting (name) for x-rays . 1650 (4:50 p.m.) (name) x-ray technician arrives for x-rays, stated resident had a femur break from looking at screen. (Physician) notified awaiting call back. 1830 (6:30 p.m.) N.O. (New Order) to send out to (Hospital) ER (emergency room ). Ambulance notified. d. The Accident/Incident Report Form dated 8/23/15 documented, .Date 8/23/15 at 12:10 p.m . Status: Resident (Resident #1) Witness (Certified Nursing Assistant (CNA) #1), Falls . Transfer from bed to w/c (wheelchair) . Factors related to fall: (Resident) Alert (at time of accident) - Injuries observed: (blank) . Range of motion limited ROM (range of motion) . e. The Situation / Background Assessment / Request (SBAR) Communication form dated 8/23/15 at 1:15 p.m. documented, .Situation: Fall with signs of hip L (left) leg pain. This condition, symptom or sign has occurred before: No 8. Skin evaluation: Describe symptoms or signs: Lt (left) leg appears swollen and lt knee appears swollen and slightly turned inward. 9. Pain Evaluation: Does the resident have pain: Yes . Is the pain new: Yes . Does the resident show non-verbal signs of pain (for residents with dementia describe restless, pacing, grimacing, new change in behavior): Resident grimacing with movement and holding Lt leg . Appearance: Lt leg [MEDICAL CONDITION] and knee is slightly turned inward . Recommendations: Stat X-ray of Lt hip, upper leg and knee . f. The Fall Root Cause Investigation Report dated 8/23/15 documented, .Resident description or statement regarding the cause: Improper transfer of resident from bed to wc (wheelchair) by CNA . External/Environmental Contributing Factors . Transfer Status: Assist x (times) 2 - Devices used for transfer: Lift. Other: Transfer from bed to wc . Summary: Improper transfer at resident from bed to wc by CNA. Employee received disciplinary actions . g. The Radiology Report dated 8/23/15 documented, .Conclusion: Complex comminuted acute distal femur fracture . h. A Physician order [REDACTED]. Bedrest . 5. Immobilizer on at all times 6. Tylenol arthritis strength 650 mg po TID (three times daily) . 9. Contact (orthopedic specialty clinic) R/T (related to) follow up. L femur fx (fracture). i. The Office of Long Term Care (OLTC) Witness Statement form dated 8/23/15 at 12:20 p.m. documented, Witness Full Name: (Housekeeper #1). State in your own words what you witnessed (be very descriptive) and sign below: 'I was doing my daily routine. I was asked by a CNA worker to help a patient off the floor. Personally, I wasn't aware of what was going on. I admitted ly help the CNA worker with the lady . (Housekeeper #1) . j. The OLTC Witness Statement form dated 8/23/15 at 12:57 p.m. documented, Witness Full Name: (CNA #1) . State in your own words what you witnessed (be very descriptive) and sign below: 'I pulled her legs (Resident #1) around to the edge of the bed so they would dangle. I lifted her and placed her on the seat. I got weak. Sat her on the chair and she slid out of the chair .(CNA #1) . k. Nurses Notes dated 8/24/15 at 1:10 a.m. documented, R (Resident) returned to facility via (ambulance service) on stretcher . S/S (signs and symptoms) of pain observed. Given Tylenol 650 mg (milligrams) po (by mouth) as ordered. Abrasion to L (left) cheek and neck observed as previously noted. Immobilizer brace in place to LLE (left lower extremity). Foley Cath (catheter) inserted using sterile technique size 16 fr.(French) 10 cc (cubic centimeters) bulb . R to remain on bedrest . L Distal Femur Fx (Fracture) . l. The Physician order [REDACTED]. m. Nurses Notes dated 8/24/15 at 12:15 p.m. documented, Spoke with (Physician's Nurse). Res (Resident) needs surgery but family does not (sic) & (and) refused surgical repair . Daughter at facility & stated she does not want to do surgery & just keep her comfortable at facility & palliative care . n. On 8/27/15 at 5:29 p.m., CNA #1 was interviewed as follows: The CNA was asked how long she had been employed by the facility and stated, One month; I finished CNA classes one month ago. The CNA stated she was on her second round of orientation. The CNA was asked how Resident #1 was supposed to be transferred and stated, (Resident #1) was a total lift, 2-person transfer. The CNA was asked, Why did you (manually) transfer the resident, who was supposed to be a total lift? The CNA stated, I was late from lunch and I was in a hurry. I just wanted to get her in her chair, to go to the lunch room. They wanted all the CNAs in the dining room to pass lunch trays. I didn't want to get in trouble. The CNA was asked, So, you transferred the resident by yourself? The CNA stated, Yes, there was nobody to help me. I couldn't find the nurse. I was the only one assigned to that hall. I sat her (Resident #1) up on the side of the bed. I got weak and sat her down, and she slid out of the wheelchair. I went to the hall, and the Housekeeper was there and she helped me get her back in the wheelchair, and I took her to the dining room. The CNA was asked, You got the resident out of the floor before you told the nurse? The CNA stated, Yes. The CNA was asked, If a resident has a fall, are you supposed to move the resident before the resident is assessed by a nurse? The CNA stated, No. The CNA was asked, Is a housekeeper supposed to be assisting you with patient care? The CNA stated, I was too weak to pick the resident up; I didn't know at that time that she (Housekeeper #1) wasn't supposed to help. I told the nurse when we got to the dining room. The CNA was asked if she was off of orientation at the time of the incident and stated, Yes, I was the only CNA that was assigned to that hall. The CNA was asked, How do you determine how a resident is to be transferred? The CNA stated, It's documented on the sheet on the resident's closet door, the sticker outside the resident's room and the ADL book that we document in at the nurses station. The CNA was asked what the sticker outside Resident #1's door indicated. The CNA stated, TL - that is a total lift. The CNA was asked, If a resident is a total lift / mechanical lift, should the resident be transferred without the lift? The CNA stated she had worked with some staff who did transfer the resident without the lift, but with 2-person assistance, during her orientation, but did not provide the names or dates/times that occurred. The CNA was asked if it was appropriate to transfer Resident #1 via manual transfer when the resident was assessed to require a mechanical lift. The CNA stated, No. o. On 8/28/15 at 2:20 p.m., Housekeeper (HK) #1 was interviewed as follows: The Housekeeper was asked if she had assisted with any resident care. The Housekeeper stated, When the situation happened last week, I helped a CNA get her (Resident #1) off the floor; she didn't appear hurt at that time. The Housekeeper was asked, What position were her (Resident #1) legs in (while on the floor). The Housekeeper stated, Her (Resident #1) legs were crossed, Indian-style. The Housekeeper was asked, How did you pick the resident up? The Housekeeper stated, We put one arm under her arms and one hand under her legs (pointing to the upper thigh area) and we lifted her and sat her in the wheelchair. p. On 8/28/15 at 12:45 p.m., CNA #2 was asked her job title. The CNA stated, Lead CNA, when I am able, but I have been working on the hall for the last week. I am Lead CNA every other week. I watch them do transfers, make sure they do peri-care, help them out on the halls, the 300 and 400 halls, because there's 1 person for that hall, and whatever needs to be done. There's no specific job description for Lead CNA. The CNA was asked what she did with new CNAs. The CNA stated, For new CNAs, I'm on the hall; they orientate with me for 1 day before they move to another hall. The CNA was asked, They (new hires) only work with you for 1 day? The CNA stated, Yes, then they work on another hall with another CNA and they rotate through the halls and job duties. The CNA was asked specifically about CNA #1's training and stated she had worked with CNA #1 for 2 days while CNA #1 was a student, then after she started her employment with the facility, I worked with her 1 day, then she rotated one day on each hall. The CNA was asked who checked CNA #1 off on transfers. The CNA stated, I did not . I stress that lifts, you don't do by yourself, you get another person; everybody knows that. The CNA was asked how the staff knew how a resident was to be transferred. The CNA stated, There is a sticker on the door, a care plan on the closet door and the ADL book. If that is not available, you can check with the nurse. q. On 8/28/15 at 1:22 p.m., the Director of Nursing (DON) was asked about the facility's orientation for CNAs. The DON stated, The Lead CNA does the training. The DON was asked who completed the assessments to determine how the residents should be transferred. The DON stated, The ADON (Assistant Director of Nursing). The DON was asked, When the CNAs are in training, who checks the CNAs off to ensure they have the ability to perform their job duties? The DON stated the, Lead CNA orientates the new CNAs until they feel they are competent. The DON was asked, But who checks off the new CNAs to ensure that the CNA is competent in their tasks? The DON stated, The Lead CNA. The DON was asked about the incident involving Resident #1. The DON stated, About (Resident #1), the CNA did an improper transfer. It was reported to me that the CNA did a manual transfer and then picked the resident up off the floor. That resulted in a femur fracture. The DON was asked, What steps have you taken to ensure that this does not happen again? The DON stated, We did a 4 step plan . The resident was placed on bedrest, close monitoring, a leg brace and air mattress. The family has elected not to have surgery, secondary to her age. The facility's '4 Point Plan' developed 8/23/15 documented, .2.Curent residents will have updated transfer/ mobility assessments completed by 8/24/15 .3) current staff will be re-educated by 8/25/15 .a. immediate post fall interventions .c. re-education on lift procedures .d. identification of transfers .4) fall investigations will be reviewed during the morning meeting .weekly audit by mock survey x (times) 3months . The DON was asked if there had been other residents who had been injured related to improper transfers. The DON stated, No. The DON was asked if the housekeeper was trained as a CNA. The DON stated, No. 2. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an ARD of 6/5/15 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), required extensive assistance of 1 person for transfers and personal hygiene and extensive assistance of 2 persons for bed mobility and utilized a wheelchair for mobility. a. The Resident Transfer/Mobility Status Criteria dated 6/11/14 documented, .Transfer Status: (2), Limited assistance: Resident highly involved in activity; receives physical help in guided maneuvering of limbs or other non-weight bearing assistance . Lifting Aide to be used. Gait belt with assist of one if support of individual is unreliable, then use two person support . gait belt assist of 1. b. On 8/27/15 at 3:09 p.m., CNA #1 and #2 took the resident to her room in a wheelchair to change out the wheelchair alarm pad, which was not functioning. During the process of standing the resident up for the alarm pad change-out, the CNAs placed the gait belt around the resident's waist and grasped the gait belt with one hand and the waistband of the resident's pants with their other hand. They used the gait belt and the resident's pants to pull the resident up out of the wheelchair and to hold the resident in an upright position while the cushion and alarm pad were changed in the wheelchair. 3. Resident #5 had [DIAGNOSES REDACTED]. a. The Transfer /Mobility Status Criteria dated for 5/12/14 documented, .Transfer Status: 2 (limited assistance) . receives physical help in guided maneuvering of limbs or other non-weight bearing assistance . Lifting Aid to be used. Gait belt with assist of one; If support of individual in unreliable, then use two-person support . b. The Comprehensive Care Plan dated 2/5/15 documented, .Problem, Self-Care Deficit, ambulation related to impaired balance, generalized weakness. Hx (history) fear of falling . Lt (left) [MEDICAL CONDITION], non-ambulatory . Goal: Resident will continue to transfer with assist of one. Interventions/Approaches: Provide assistance as needed with transfers . Transfer with assist of one for toileting . c. On 8/27/15 at 1:37 p.m., the resident stated she was wet. CNA #2 assisted her to the bathroom. The CNA placed a gait belt around the resident's waist, then assisted the resident to stand by grasping the gait belt and the waistband of the resident's pants and pulling in an upward motion. The CNA did not lock the wheelchair brakes during the transfer. After the resident finished toileting, she asked to go to bed. The CNA took the resident to the bed in the wheelchair and positioned the wheelchair at the foot of the bed. The CNA again grasped the gait belt and the resident's pants and pivoted the resident to the bed. The CNA did not lock the wheelchair brakes during the transfer.