Every finding on record at The Springs of Pine Bluff

Based on observation, interview, and facility policy review, the facility failed to ensure that the kitchen air vent was cleaned; the kitchen floor was free of chips, debris, dirt, rust, and stains, and floor tiles were replaced; food items stored in the freezer were covered or sealed; the ice machine was maintained in a clean and sanitary condition in one of one kitchen, and dietary staff washed their hands before handling clean equipment or food items for two of two meals observed. The findings include: During a tour of the kitchen on 06/16/2025 at 8:52 AM, this surveyor observed the following: a. A cabinet below the deep fryer had four gas pilot valves, with grease on them. The bottom of the cabinet had a mixture of grease and greasy food crumbs. The Dietary Manager (DM) was asked how often she cleaned the deep fryer and the gas pilot valves, she stated she cleaned them every week, but they had not been cleaned for about a month. b. The ceiling air vent by the steam table, and one by the food preparation counter, had water condensation, rust, and gray stains. The DM stated the vent was sweating and had gray and black residue on them. During an interview on 06/19/2025 at 2:05 PM, the Maintenance Director was asked how often he cleaned the ceiling air vent in the kitchen, and he stated he tried to clean it once a week. During an observation on 06/16/2025 at 9:26 AM, this surveyor observed Dietary [NAME] (DC) #1, without gloves, remove a box of dinner rolls from the freezer and place it on the counter, which contaminated her hands. She then placed gloves on her hands, which contaminated the gloves in the process. Without changing her gloves or washing her hands, DC #1 used her contaminated gloved hands to remove dinner rolls from the bag and place them on the pan to be baked and served for lunch. DC #1 was asked what she should have done after touching dirty objects and before handling food items. She stated she should have washed her hands. During an observation on 06/16/2025 at 10:02 AM, this surveyor observed an opened bag of fish breading on a rack in the storage room. The bag was not sealed, which exposed it to air. The DM confirmed leaving the bag open would allow something to crawl into it. During a concurrent observation and interview on 06/16/2025 at 10:04 AM, the ice machine located in a room facing the dining room, which lead to the 300 Hall, had an accumulation of wet brown residue on the panel and on the area where ice traveled down to the ice collector. There was a wet accumulation of black residue on the inside body of the ice machine that could have fallen onto the ice. The DM stated she cleaned the ice machine once a week. She also verified that the Certified Nursing Assistants used the ice for the water pitchers in the residents' rooms and that it was used to fill beverages served to the residents at mealtimes. The DM confirmed the ice machine was dirty with brown color. During an interview on 06/17/2025 at 10:30 AM, the Maintenance Director stated he cleaned the ice machine weekly, but residue built up fast. During an observation on 06/16/2025 at 11:58 PM, this surveyor observed Dietary Aide (DA) #4 turn on the three-compartment sink faucet to wash the blender bowl, blade, and lid. After sanitizing the equipment, he turned off the faucet with his bare hand, which contaminated his hand. Without washing his hands, he picked up a clean blade and attached it to the blender to puree food items to be served to the residents, who required pureed diets, for lunch. DA #4 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands. During an observation on 06/16/2025 at 12:17 PM, this surveyor observed DC #1 turn on the hand washing sink faucet and wash her hands. After washing her hands, she turned off the faucet with tissue paper, contaminating the tissue. Then, she used the same contaminated tissue to dry her hands. Without rewashing her hands, DC #1 removed slices of cheese from a plastic bag and placed them on a cutting board. DC #1 was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. During a concurrent observation and interview on 06/17/2025 at 11:40 AM, this surveyor observed DC #5 use an empty bread bag to push slices of bread into a blender to be pureed and served to the residents, on pureed diets, for lunch. DC #5 was asked the reason he used a bread bag to push slices of bread into the blender. He stated he should have used a tong. A review of a facility policy titled, Safe Storage of Food indicated all foods would be stored, wrapped, or in covered containers. A review of a facility policy titled, Quick Resource Tool: QRT Handwashing indicated hands should be washed as often as possible, and that it was important to wash hands before starting to work with food, as often as needed during food preparation, and when changing tasks. A review of a facility policy titled Sanitation of Ice Machine indicated the ice machine should be sanitized twice monthly by dietary.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nail care was provided for one (Resident #5) of one resident reviewed for nail care and failed to ensure a bath or shower was provided for one (Resident #386) of one resident reviewed for baths/showers. The findings include: Resident #5 During an observation on 06/17/2025 at 9:01 AM, this surveyor observed Resident #5 lying in bed awake. The resident ' s fingernails, on both hands, were past the tips of the fingers and a dark substance was underneath the nail beds. Resident #5 stated not remembering the last time their fingernails were trimmed. During an observation on 06/18/2025 at 2:41 PM, this surveyor observed Resident #5 sitting up in a Geri-chair in their room, awake. The resident ' s fingernails, on both hands, were past the tips of the fingers and a dark substance was underneath the nail beds During a concurrent observation and interview on 06/19/2025 at 12:12 PM, Certified Nursing Assistant (CNA) #12 stated she had worked at the facility for 19 years. She looked at Resident #5's fingernails and stated the nails were medium length and had stuff underneath their nail beds, which was brown in color. She stated the nurses performed nail care for residents who were diabetic. During a concurrent observation and interview on 06/19/2025 at 2:57 PM, Licensed Practical Nurse (LPN) #13 described Resident #5's fingernails on both hands as too long, brown in color with what appeared to be feces and dirt. LPN #13 stated nail care was randomly provided by the aides, and the Director of Nursing (DON) also provided nail care to residents sometimes. She stated she did not know if residents received nail care on bath days and that Resident #5 had not refused baths. LPN #13 stated CNAs did not provide nail care for residents who had diabetes. A review of Resident #5 ' s admission Record revealed the facility admitted the resident on 12/12/2024, with diagnoses which included diabetes mellitus. A review of Resident #5 ' s Order Summary Report revealed the resident may see a podiatrist, a doctor who treats the foot, ankles and lower legs, every 90 days, and as needed. The Order Summary Report revealed Resident #5 had no orders for weekly nail care. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2025, revealed Resident #5 had a Brief Interview for Mental Status of 07, which indicated severe cognitive impairment. The MDS also revealed Resident #5 had no behaviors, no rejection of care, required moderate assistance with oral and toileting hygiene, and was dependent upon staff for bathing themself and personal hygiene. A review of Resident #5 ' s Care Plan Report, revised 05/19/2025, revealed the resident had an activities of daily living (ADL) self-care performance deficit. The Care Plan included an intervention that directed staff to check nail length, trim, and clean, as necessary. The resident did not express any preference regarding bathing schedule. The Care Plan report also revealed the resident had diabetes mellitus, which included an intervention of diabetic toenail care to be provided by licensed staff. There was not an intervention listed on Resident #5 ' s Care Plan Report for weekly nail care by a licensed staff member. A review of Resident #5 ' s ADL Nail Care Task revealed nail care was last completed on 06/15/2025. A review of Resident #5 ' s ADL Task Bath type revealed the resident ' s bath days were Tuesdays, Thursdays, and Saturdays. According to the ADL Task Bath type, the resident received a shower on 06/14/2025 and a sponge bath on 06/17/2025 and 06/19/2025. A review of the 06/2025 electronic Medication Administration Record (eMAR) for Resident #5 did not indicate an order for nail care. A review of Resident #5 ' s Treatment Record for 06/2025 did not reveal a treatment order for nail care. A review of Resident #5 ' s Progress Notes from 06/01/2025 to 06/19/2025 did not indicate the resident had refused nail care and included documentation of the resident feeding self on 06/14/2025, 06/08/2025, 06/07/2025 and 06/01/2025. During an interview on 06/19/2025 at 3:31 PM, the DON stated any licensed nursing staff could provide nail care to residents who were diabetic, but the facility preferred that CNAs not clean diabetic resident ' s fingernails. She stated Resident #5 was on a schedule to have nails trimmed weekly, and this should have been on the resident's eMAR. The DON stated a licensed nurse needed to clean the residents' fingernails through the week. The DON continued that residents' fingernails should be trimmed and cleaned, because residents eat their food with their hands and so residents did not scratch themselves. A review of a Fingernails/Toenails, Care of policy, revised 02/2018 revealed nail care includes daily cleaning and regular trimming and unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments, and trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The policy indicated the supervisor should be notified if the resident refuses the care. Resident #386 During an interview on 06/16/2025 at 1:23 PM, Resident #386 indicated they had not had a bath since being admitted . A review of Resident #386 ' s ADL/bath record indicated that their showers were scheduled for Monday ' s, Wednesday ' s, and Friday ' s. The ADL/bath record did not indicate that Resident #386 had been given a shower since being admitted . A review of Resident #386 ' s admission Record revealed the facility admitted the resident on 06/10/2025 with a history of falls and a brain bleed. During an observation on 06/16/2025 at 1:25 PM, Lead CNA #8 was heard telling Resident #386 that she would give the resident a shower. A review of Resident #386 Care Plan, initiated 06/10/2025, revealed the resident did not express any bathing preferences, but did require limited assistance with bathing. During an interview on 06/18/2025 at 10:50 AM, CNA #9 indicated that Resident #386 received a shower every week, and the resident had not been informed about their shower days yet. CNA #9 indicated new admissions received their showers as soon as they were admitted . CNA #9 confirmed Resident #386 was admitted on e to two weeks ago. CNA #9 revealed the CNAs were responsible for giving the residents a shower, if there was not a shower aide scheduled. CNA #9 stated he did not know why Resident #386 had not received a shower before yesterday. During an interview on 06/18/2025 at 2:11 PM, Resident #386 indicated only having had three showers since being admitted . The resident indicated they had a shower on 06/16/2025, 06/17/2025, and 06/18/2025, but missed their shower on 06/11/2025, and 06/13/2025. During an interview on 06/18/2025 at 2:17 PM, Lead CNA #8 indicated showers should be documented by the staff after completion, but before the shift was over. Lead CNA #8 stated Resident #386 was cognitive and informed her on Monday that they had not received a shower. Lead CNA #8 indicated that she gave Resident #386 a shower on Monday 06/16/2025. During an interview on 06/19/2025 at 10:40 AM, the DON indicated if a new admit came in after hours, the CNA may not put their task in the computer. The DON stated most of the time, the next morning the department heads made sure the tasks were completed. The DON stated she was not here the week Resident #386 was admitted , and she did not get a chance to look at the task. The DON revealed Resident #386 should have received a bath before 06/16/2025. The DON confirmed Resident #386 received baths on Mondays, Wednesdays, and Fridays. During an interview on 06/19/25 at 2:32 PM, the Administrator stated a new admission should receive a shower whenever they want one, but at least by the next day. She revealed she did not know Resident #386 had not received a shower. A review of a policy titled, Bath, Shower/Tub indicated the purpose of a bath/shower is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on interview and record review, the facility failed to ensure the resident and resident representative were included in care planning meetings for one (Resident #63) of one resident, reviewed for care plan meetings and failed to ensure a care plan was revised to reflect the code status of Do Not Resuscitate (DNR) for a resident under hospice care for one (Resident #63) of one resident reviewed for hospice care. The findings include: A review of Resident #63 ' s modified quarterly Minimum Data Set (MDS), with an Assessment Reference Date of [DATE], revealed the facility re-admitted the resident on [DATE] with a Staff Assessment for Mental Status score of 03, which indicated the resident was severely impaired and never/rarely made decisions. The MDS also revealed the resident was to receive special services from hospice care. A review of Resident #63 ' s Order Summary Report revealed the resident was admitted to local hospice services as of [DATE], and had a code status of DNR, with a start date of [DATE]. The Order Summary Report also indicated Resident #63 had diagnoses which included type 2 diabetes mellitus, paranoid schizophrenia, and Alzheimer's disease. A review of Resident #63 ' s Care Plan Report, last reviewed [DATE], revealed the resident had requested that cardiopulmonary resuscitation (CPR) measures be performed, and that the resident was a full code. The Care Plan revealed an intervention, with an initiation date of [DATE], that directed staff to initiate CPR if found pulseless and breathless and to continue CPR until emergency personnel arrived to take over. The Care Plan also revealed Resident #63 had elected for hospice services. During a phone interview on [DATE] at 2:13 PM, Resident #63 ' s family member stated the facility had not performed a care plan meeting with them since March of 2024, and the last care plan meeting was over the telephone. During a concurrent observation and interview on [DATE] at 3:50 PM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for conducting care plan meetings and updating the residents' care plans. She stated Resident #63's care plan should have been updated to reflect the resident was no longer a full code. The DON reviewed the resident's Electronic Health Record (EHR) and stated there was a DNR order for [DATE]. She reviewed the resident's care plan and stated it reflected, I am a full code. During a concurrent observation and interview on [DATE] at 9:52 AM, the MDS Coordinator stated she was responsible for updating residents' care plans. She stated the care plans were updated per a review schedule, or if she received new orders. She stated the nurse consultant prepared the review schedule for her. The MDS Coordinator revealed she gathered information for updating care plans from the DON, and the aides, or the DON would give her a list of new orders daily. She stated if a resident's full code status was changed to DNR, this should have been reflected on the care plan. The MDS Coordinator stated she completed care plan meetings with the resident, or the resident ' s representative, and the schedule was triggered , alerting her when the meetings were due. The MDS Coordinator provided a copy of the schedule and Resident #63's name was not listed. She stated she sent letters to the resident and resident ' s representative with information regarding when the meeting was scheduled, but sometimes she performed the care plan meetings by phone, due to family not showing up. The MDS Coordinator reviewed the information in the resident's EHR and stated she did not see any documentation to indicate the last care plan meeting had been done. The MDS Coordinator reviewed her current care plan meeting schedule and stated she did not see the resident's name on the list. She stated in the past three months she had not called the family member to provide updates on the resident's care. There were no progress notes in the resident ' s EHR detailing why the care plan meetings were not held. A review of a Care Plans, Comprehensive Person-Centered policy, revised 03/2022, revealed the following: - the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -the resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. -if the participation of the resident and his/her representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record and should include the steps taken to include the resident or representative in the process. -assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the necessary care and services were provided to a resident with a non-pressure related skin issue for one (Resident #1) of two residents reviewed for non-pressure related skin issues. The findings include: During a concurrent observation and interview, on 06/17/2025 at 12:34 PM, this surveyor observed Resident #1 lying in bed on their right side, with a wedge behind their back. There were scabs and bruises, reddish in color, observed on the resident's left arm. When asked what happened, Resident #1 stated the resident and somebody's sister were play scratching and she scratched the resident's arm. The resident was unable to state who the sister was or when this incident happened. The resident's hands were not visible at this time. During an observation on 06/18/2025 at 9:50 AM, this surveyor observed Resident #1 sitting at the dining room table dressed, with both arms covered. During an observation on 06/19/2025 at 11:59 AM, this surveyor observed Resident #1 lying in bed on their right side with eyes closed and their left arm exposed. The left arm was observed with purplish bruising and scabbed over areas. A review of Resident #1 ' s admission record revealed the facility admitted the resident on 06/07/2024, with diagnoses which included dementia, and moderate protein calorie malnutrition. A review of Resident #1 ' s Order Summary Report revealed an order for a left lower leg wound cleanse, with a start date of 06/03/2025. Staff were to apply a dressing to the wound bed, cover with gauze, and secure with tape every shift and as needed (PRN). The Order Summary report also revealed Resident #1 was to receive a low dose delayed release Aspirin tablet one time a day for high blood pressure. A review of Resident #1 Progress Notes from 05/16/2025 to 06/17/2025, did not reveal any documentation of bruising, scabs, or redness to the resident ' s left arm. A review of Resident #1 ' s significant change Minimum Data Set (MDS), with an Assessment Reference Date of 04/23/2025, revealed the resident had a Brief Interview for Mental Status score of 03, which indicated the resident had severely impaired cognition. The MDS also revealed Resident #1 was dependent on staff for oral, personal and toileting hygiene, and transfers. The MDS indicated that the resident had no unhealed pressure ulcers/injuries. A review of Resident #1 ' s Care Plan Report, with a review date of 05/05/2025, indicated the resident had an Activities of Daily Living (ADL) self-care performance deficit with interventions, that directed staff to check nail length, trim, and clean as necessary. Another intervention on Resident #1 ' s Care Plan Report directed staff to inspect skin weekly and PRN, and to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. A review of a Skin Check dated 06/11/2025, revealed Resident #1's skin condition was not clear, and no comments were documented on the form to indicate what the skin condition was. A review of Resident #1 ' s ADL Task Skin Condition revealed from 05/29/2025 to 06/17/2025, no new skin issues were documented. For question two, skin observation, the sections for scratched, red area, discoloration, skin tear, and open area, for 05/29/2025 to 06/17/2025, indicated response not required. For question 3, location of skin concerns, the form indicated response not required. A review of Resident #1 ' s ADL Task - Bathing indicated the residents bath days were Tuesdays, Thursdays, and Saturdays on day shift. The ADL Task Bath Type revealed the resident received a shower on the following days: 06/03/2025 and 06/14/2025, and a sponge bath on 05/31/2025, 06/04/2025, 06/05/2025, 06/07/2025, 06/12/2025, and 06/17/2025. A review of Resident #1 ' s 05/2025 Treatment Record did not indicate any treatment orders for skin issues to the resident ' s left arm. A review of Resident #1 ' s 06/2025 Treatment Record did not indicate any treatment orders for skin issues to the resident ' s left arm. During an interview on 06/18/2025 at 3:58 PM, Licensed Practical Nurse (LPN) #2 stated if she saw a skin issue on a resident such as a laceration, cut, scrape, or bruise that was not there on a previous round, she would have put the observation on an Incident and Accident (I&A) form and would have gotten a treatment order from the provider. LPN #2 stated the family, the Director of Nursing (DON), and Administrator were notified of any I&As completed. During an interview on 06/19/2025 at 10:22 AM, Certified Nursing Assistant (CNA) #17 stated if she saw a skin issue on a resident such as a laceration, cut, scrape, or bruise that was not there on a previous round, she would have gotten the nurse and documented on the chart [the electronic health record]. During an interview on 06/19/2025 at 12:21 PM, CNA #12 stated if she saw a skin issue on a resident such as a laceration, cut, scrape, or bruise that was not there on a previous round, she would have gotten her charge nurse and stated the resident had a cut or bruise. During a concurrent interview and observation on 06/19/2025 at 3:04 PM, LPN #13 stated if she noticed a bruise, scratch, skin tear, sore, open area or scab on a resident's skin that was not previously observed, she would notify the DON, the Assistant Director of Nursing (ADON), and the treatment nurse. She stated she would complete a progress note, if needed. LPN #13 was asked to look at Resident #1's left arm. She described what she observed as old and new bruising on intact skin, some old wounds that were scabbed, healed, and not dressed. She stated there could be old blood on the skin tears. LPN #13 stated she did not know when the resident's left arm became bruised or scabbed. If the CNAs saw bruising or scabs on the resident's skin, they were supposed to let the nurse know. During an interview on 06/19/2025 at 3:41 PM, the DON stated if the CNAs saw any skin issues, they were to notify the charge nurse immediately. She stated it was everyone's responsibility to notify the charge nurse, and the charge nurse would notify the treatment nurse. She stated skin tears were addressed, and CNAs checked the resident's skin every time a resident was checked. A review of a Prevention of Pressure Injuries policy, dated as revised 04/2020, indicated to inspect the skin on a daily basis when performing or assisting with personal care or ADLs and to evaluate, report and document potential changes in the skin. The DON was asked to provide a policy on skin issues and did not provide the policy indicated above instead.

Based on interviews and record review the facility failed to ensure one (Resident #62) of five residents reviewed for medications did not receive an unnecessary medication. The findings include: A review of Resident #62 ' s admission Record indicated the facility admitted the resident on 09/18/2023 with diagnoses that included type 2 diabetes mellitus, without complications. A review of Resident #62 ' s quarterly Minimum Data Set, with an Assessment Reference Date of 05/26/2025, revealed the resident had a Brief Interview for Mental Status score of 07, which indicated severe cognitive impairment. A review of Resident #62 ' s Care Plan, initiated 12/05/2024, revealed the resident had desired to lose weight with a goal weight of 145 pounds (lbs). A review of Resident #62 ' s Order Summary Report revealed Resident #62 had an order for an antidepressant to be given one time a day related to abnormal weight loss ordered on 02/06/2025. The Order Summary Report also revealed the resident had a desire to lose weight with a goal weight of 145 lbs. A review of Resident #62 ' s Weight Summary revealed a weight of 155lbs on 09/02/2024, 148lbs on 12/05/2024, 148lbs on 02/05/2025, 148lbs on 03/04/2025, and 153lbs on 06/02/2025. A review of Resident #62 ' s Weekly Weight Note, dated 09/20/2024 indicated the resident ate what they wanted and was losing weight for their spouse. A review of Resident #62 ' sWeekly Weight Note, dated 09/27/2024, indicated the resident wanted to lose weight. A review of Resident #62 ' s Weekly Weight Note, dated 12/03/2024, indicated orders were received from the Medical Doctor (MD) to start Resident #62 on an anti-depressant medication at bedtime, related to weight loss. During an interview on 06/19/2025 at 9:43 AM, Resident #62 indicated they lost a little weight, and desired to lose a little more. The resident stated they did not eat much at all, because of their desired weight loss. Resident #62 indicated they had not been informed of taking an anti-depressant to gain weight. During an interview on 06/19/2025 at 10:45 AM, the Director of Nursing (DON) confirmed Resident #62 was trying to lose weight. The DON stated Resident #62 informed the Psych Nurse this morning [06/19/2025] that they were too big. The DON indicated that Resident #62 came to her about a year ago and told her they wanted to lose weight. The DON then went to the Care Plan Coordinator and informed her that Resident #62 desired to lose weight and had a goal weight of 145lbs. The DON indicated that she informed Resident # 62 that today the resident had met their weight loss goal. The DON stated Resident #62 received the anti-depressant because they had started losing weight. The DON indicated she would have to check if the anti-depressant was something that the Registered Dietician recommended, and the MD During an interview on 06/19/2025 at 11:02 AM, the MD indicated Resident #62 was receiving an anti-depressant for depression. The MD stated he could not remember if Resident #62 had a diagnosis of depression. The MD indicated he monitored for symptoms and changes, to determine if the anti-depressant was effective. He indicated that side effects and symptoms were monitored to evaluate whether medications should be initiated, continued, reduced, discontinued, or otherwise modified. The MD revealed he was not sure if there was a reason why a gradual dose reduction had not been attempted and could not remember Resident #62 telling him anything concerning their weight. During an interview on 06/19/2025 at 2:34 PM, the Administrator indicated she was not aware Resident #62 wanted to lose weight. A review of a policy titled, Medication Therapy indicated medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to treatment.

Based on record review, interview, and facility policy review, the facility failed to ensure required vaccinations were administered to three (Resident #6, #52, and #63) of five sampled residents reviewed for immunizations. The findings include: A review of Resident #6's Immunization Screen, within the resident ' s Electronic Health Record (EHR), revealed the pneumococcal vaccine was refused, but did not indicate a refusal date. A review of Resident #6's Allergies Screen within the resident ' s EHR indicated the resident had an allergy to penicillin. A review of Resident #6 ' s Order Summary Report revealed the pneumococcal vaccine would be offered, as needed unless contraindicated per the Centers for Disease Control (CDC) guidelines, with an order date of 05/23/2025. A review of Resident #6 ' s significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2025, revealed the facility admitted the resident on 12/11/2024 and re-entered to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. During an interview on 06/19/2025, the Assistant Director of Nursing (ADON), who was also the Infection Preventionist, provided a Release-Pneumococcal Vaccines form, dated 12/11/2024. The Release-Pneumococcal Vaccines form was reviewed and indicated the responsible party signed consenting to Resident #6 ' s receipt of the pneumococcal vaccine. The ADON stated when the nurse attempted to give Resident #6 the vaccine, the resident refused. The ADON stated she could not find documentation of staff informing the Adult Protective Service (APS) worker, who was Resident #6 ' s responsible party, about the resident's refusal of the vaccine or if any education on risks/benefits was provided to Resident #6, or the APS worker. A review of Resident #52's Immunization Screen, within the resident ' s EHR, revealed the pneumococcal vaccine was refused, but did not indicate a refusal date. A review of Resident #52 ' s Order Summary Report revealed the pneumococcal vaccine would be offered per CDC guidelines, with an order date of 11/17/2022. A review of Resident #52 ' s quarterly MDS, with an ARD of 05/07/2025, revealed the facility admitted the resident on 11/17/2022. The MDS also revealed Resident #52 had a BIMS score of 06, which indicated severe cognitive impairment. During an interview on 06/19/2025, the ADON provided a Resident Vaccination Record for Resident #52 which revealed the pneumococcal vaccine was declined on 11/17/2022, but did not specify if any education on the risks/benefits was provided to the resident/responsible party. As of 06/20/2025, the ADON had not provided any further documentation for Resident #52. A review of Resident #63's Immunization Screen, in the resident ' s EHR, revealed the pneumococcal vaccine was refused, but did not indicate a refusal date. A review of Resident #63 ' s Order Summary Report in the resident ' s EHR, revealed the resident had diagnoses which included type 2 diabetes mellitus, paranoid schizophrenia, and Alzheimer's disease. A review of Resident #63 ' s modified quarterly MDS, with an ARD of 03/14/2025, revealed a Staff Assessment for Mental Status score of 03, which indicated the resident was severely impaired and never/rarely made decisions. On 06/19/2025, the ADON provided a copy of an untitled document, dated 12/12/2024 at 9:58 AM, which listed Resident #63's medications. There was an order for pneumococcal vaccine to be given intramuscularly once, with an order date of 12/09/2024, and a discontinue date of 12/09/2025. There was no documentation on this form verifying if Resident #63 received the vaccine. As of 06/20/2025, the ADON had not provided the vaccine information for Resident #63. During an interview on 06/20/2025 at 11:59 AM, the ADON stated she followed up after a resident was admitted to the facility to verify if the resident accepted or declined vaccines. She stated if the resident or resident representative declined vaccines, she would normally put refused but had learned this week to put a note in the EHR. The ADON stated going forward, she would notify the responsible party that the resident declined the vaccine and provide education regarding the risks versus benefits. A review of a Pneumococcal Vaccine policy, dated as revised March 2020, indicated all residents are offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy specified before or on admission, residents were assessed for eligibility to receive the pneumococcal vaccine series and when indicated, offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or had already been vaccinated. The policy indicated residents/representatives had the right to refuse vaccination and appropriate information was documented in the resident's medical record indicating the date of the refusal of the vaccine.

[NAME] Deputy Based on observation, record review, review of the glucometer manual, review of facility policies, and staff interviews, the facility failed to ensure staff performed proper handwashing, adhered to Enhanced Barrier Precautions (EBP), and correctly disinfected the facility glucometer for two (Resident #2 and #7) of seven residents sampled for infection control. The findings include: On 04/08/2025 at 8:55 AM, during 200 hall observation, Certified Nursing Assistant (CNA) #1 knocked on Resident #2 ' s door, verbalized the resident's name, cleansed her hands with hand sanitizer, donned gloves and a gown, then entered the resident's room, closing the door behind her. Signage on Resident #2's door indicated the resident was on EBP. A caddy with the necessary EBP supplies was located hanging on the outside of Resident #2's door. Upon entering Resident #2's room, this surveyor observed CNA #1, without gloves, applying lotion to Resident #2's legs. CNA #1 did not perform hand hygiene, nor don gloves, for the remainder of care which included placing a clean pad under the resident, repositioning the resident, and removing dirty sheets from the bed. CNA #1 stated that she was old school and usually would don four or five pairs of gloves and take off the dirty gloves as she provided care. No hand sanitizer was within access to CNA #1, while she provided care, but was located in the resident's bathroom. After exiting the room, CNA #1 was observed performing hand hygiene with hand sanitizer, prior to entering another resident's room. A review of Resident #2 Care Plan indicated a diagnosis that included gastrostomy status (indicating a feeding tube). Review of Resident #2's Physician's Orders indicated an order for EBP dated 08/31/2024. On 04/08/2025 at 2:40 PM, a review of facility policy titled Enhanced Barrier Precautions indicated an order for EBP will be obtained for residents with a feeding tube. The policy specified gowns and gloves will be available and alcohol-based hand rub will be present in each resident room. The policy listed high-contact resident care activity included changing linens and providing hygiene. Review of a facility in-service training dated 06/07/2024, revealed Centers for Disease Control (CDC) Enhanced Barrier Precautions, which specified Providers and staff must wear gloves and a gown for high-contact resident care activities, including changing linens and providing hygiene. On 04/08/2025 at 9:30 AM, CNA #1 reported she was not sure if she had received training on Enhanced Barrier Precautions (EBP). She stated she knew if a resident was on EBP, because there were signs on the door and the personal protective equipment (PPE) would be outside of the resident's door. CNA #1 confirmed she should have washed her hands and changed gloves between handling clean and dirty linens. CNA #1 also stated she should have obtained a personal bottle of hand sanitizer, prior to beginning care on Resident #2. She reported she did not wear gloves when applying the lotion and when placing new linen, because she was not touching the feeding tube site nor the area around it. She acknowledged being in-serviced on handwashing. Review of Care Plan dated 06/27/2019, indicated Resident #7 had a diagnosis that included type 2 diabetes mellitus without complications. Resident #7's Physician Orders dated 06/19/2023, indicated Accu checks one time a day every Fri [Friday] related to type 2 diabetes mellitus without complications. Resident #7 was on EBP with an order date of 06/04/2024. On 04/08/2025 at 11:24 AM, Licensed Practical Nurse (LPN) #2 stated she needed to check Resident #7's blood sugar. A review of Resident #7 orders dated 06/04/2024, indicated the resident was on EBP and signage on the door indicated EBP. On 04/08/2025 at 11:24 AM, LPN #2 was observed performing a fingerstick blood sugar on Resident #7. LPN #2 did not perform hand hygiene prior to donning gown and gloves and entering Resident #7's room. After performing the fingerstick blood sugar, LPN #2 washed her hands with soap and water, then picked up the used glucometer and took it back to the medication cart and placed it on top of the cart. On 04/08/2025 at 11:35 AM, LPN #2 stated she thought she washed her hands before and after donning and removing gloves. LPN #2 then stated she needed to clean the glucometer. She utilized an alcohol prep pad to cleanse the glucometer then placed the glucometer back on the medication cart, where it was placed prior to cleaning. LPN #2 reported she would leave it there until it was dry. LPN #2 went on to state that the glucometer should be cleaned with alcohol, before and after it is used for a resident. She indicated some staff used Sani-Cloth wipes and that either one could be used, but that she used alcohol. LPN #2 stated she used an alcohol pad and wiped the glucometer well, then allowed it to air dry. She indicated before providing care to a resident on EBP, she would put on a gown, wash her hands, put on gloves then before leaving the room, she would remove the gloves and gown and wash her hands. On 04/08/2025 at 4:16 PM, LPN #3 denied knowing what EBP meant. She stated she had not had an in-service on that yet. She reported she knew from the computer; it had to do with wearing gloves, gowns, and masks. She indicated to prevent the transmission of infections to residents, she would glove up after washing her hands, wear a mask or whatever was required. LPN #3 stated she had received training on how to don and remove PPE and the facility did have plenty of PPE supplies. She verbalized there was plenty of hand sanitizer in the facility, but she was not sure all staff used it. She reported she was aware if a resident was on precautions, because there would be signage on the door of the resident's room. LPN #3 reported that the facility did have in-service classes on occasion. LPN #3 indicated a nurse/CNA should not apply lotion to a resident, remove dirty linens, or provide personal care with ungloved hands, and stated we have plenty of gloves. She stated, to clean a glucometer in the facility, she cleaned it with alcohol and let it dry. She reported there were two (2) glucometers on the medication carts, so one can be used while the other was allowed to dry. The nurse realized a glucometer was sitting beside her with alcohol prep pads. She picked up the alcohol prep pad, opened it and wiped the glucometer while stating, This is how I clean the glucometer. She reported she cleaned the glucometer each time, before she used it. On 04/08/2025 at 3:50 PM, the Director of Nurses (DON) was interviewed and indicated nurses and CNAs had been trained on EBP. She stated since 04/01/2024, we have in-serviced, we have put up signs and provided verbal explanations of the different kinds of precautions. She could not remember when the last in-service was but stated it had been recent. She indicated a CNA should look for the signs posted regarding EBP or any precautions, remember the education they were taught, and go to their charge nurse and ask if they are unsure or have questions. The DON stated the facility had plenty of PPE supplies and pocket sized hand sanitizers were available on a cart outside of her office for staff to utilize. She stated a CNA should not apply lotion, provide personal care, nor remove dirty linens, without gloves, especially in an EBP room. She reported the facility used multi-use glucometers and that each medication cart had two (2) glucometers so one could be used while the other one dried completely, after disinfection. The DON reported the glucometers should be cleaned after each use. She stated the facility used the manufacture's guidelines to clean the glucometers, using the blue top (canister) alcohol wipes with a ten (10)-minute dry time or an orange top (canister) with bleach. She also indicated a purple top Sani-cloth wipe could be used with a two (2)-minute contact time. After she removed the manual from her desk drawer and reviewed (the name brand) glucometers manual titled, Cleaning and Disinfecting the glucometer, she verified the instructions did not list alcohol as a validated cleaner for the glucometer. She also verified Sani-cloths were listed as a validated cleaner for the glucometer, but only one cleaner may be utilized at a time for the life of the glucometer. On 04/08/2025 at 1:25 PM, a review of the glucometer manufacturers use manual indicated cleaning the glucometer with a bleach based germicidal cleaning cloth or other type of germicidal cleaning wipe. On 04/08/2025 at 1:30 PM, a review of a facility document titled Obtaining a Fingerstick Glucose Level dated as revised October 2011, indicated a disinfected blood glucose meter will be necessary when performing the fingerstick glucose level. The document specified Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. On 04/08/2025 at 3:00 PM, a review of a facility policy Handwashing Hand Hygiene indicated an alcohol-based hand rub or soap and water should be used for hand hygiene before and after direct contact with resident, after contact with a resident's skin, before applying non-sterile gloves, and after removing gloves.

Based on observation and interview, the facility failed to ensure 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; ceiling tiles door frames and floor tiles were free of chips, stains and rust and were maintained in clean sanitary conditions, foods stored in the dry storage area refrigerator and freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods were dated when opened to assure first in, first out usage to prevent potential for food bone illness; 1of 1 ice machine was maintained in clean and sanitary condition to prevent contamination of airborne particles and. These failed practices had the potential to affect 72 residents who received meals from the kitchen, (total census: 74). The findings are: 1. On [DATE] at 08:01 AM, the following observations were made in the kitchen. a. An opened zip lock bag that contained loose coffee filters was on a shelf below the food preparation counter by the steam table. The bag was not sealed. The cover of the light fixture above the 2-door refrigerator in the kitchen was broken. b. The wall below the hand washing sink and the wall above the 3-compartment sink had paint peeling, spillage stains and cement exposed. c. Two poles and regular box attached to the oven had dried brown grease substances on them. d. The cabinet below the deep fryer has 4 pallets which have grease on them. The bottom of the cabinet had a mixture of grease and greasy food crumbs. The Surveyor asked the Dietary Supervisor, How often do you clean the deep fryer and pallets? She stated, It is cleaned every week. e. The wall behind the deep fryer and the floor had grease stains on them. f. The paint on the door frame in the dish washing machine was chipped, exposing the metal frame. g. The floor in the dish washing machine room had a mixture of brown, black and gray stains on it. h. The edges of the vent hood in the dish washing machine had rust stains on it. i. The flat panels on the wall under the counter in the dirty machine area were loose from the wall. j. The ceiling air vent by the steam table and one by the food preparation counter had rust and gray stains. k. There were loose dried food particles on the bottom shelf of the food preparation counter where the cutting board holder and clean pans were located. 2. On [DATE] at 08:20 AM, Dietary Employee (DE) #1 pushed a cart into the kitchen that contained an ice chest from the dining room, contaminated his hands. Without washing his hands, he picked up glasses to be used in serving beverages to the residents for the lunch meal by their rims and set them on the trays. The Surveyor asked DE #1, What you should have done after touching dirty objects or before handling clean Equipment? He stated, I should have washed my hands. 3. On [DATE] at 08:56 AM, the following observations were made: a. A bag of an opened granulated plain salt, on the shelf in the storage room was not sealed. b. An opened box of powdered sugar was on the shelf, in the storage room. The box was not covered or sealed. There was no date on the box as of when it was opened to assure first in first out. c. An opened bag of potato pearl was on a shelf in the storage room. The bag was not sealed. d. An opened box of thickener was on a shelf in the storage room. The box was not covered or sealed. e. There was no date on the box as of when it was opened to ensure first in first out. f. An opened box of graham crumbs with no opening date was on a shelf in the storage room. An opened box cornstarch was on a shelf in the storage room. The box was not covered or sealed. g. The wall behind the door in the storage had paint peeling, exposing the cement. The floor tiles were missing across the dry food storage rack in the storage room. 3. On [DATE] at 09:09 AM, the following observations were made on a shelf in the 1st two door refrigerator: a. There was a gallon of sweet baby barbeque sauce that was closed but had on open date. b. There was a gallon of Caesar dressing that was closed but had no opening date. c. There was a container of honey mustard that was closed but had no opening date. d. An opened box of sausage. The box was not covered or sealed. 4. On [DATE] at 09:18 AM, the following observations were made on a shelf in the 2nd two door refrigerator. There were (5) 32 ounce boxes of vanilla high calorie-high protein nutritional drinks with an expiration date of [DATE]. The Dietary Supervisor removed them and threw them away. 5.On [DATE] at 09:24 AM, the food items in the freezer located in the storage did not have an open date on them: a. An opened box of carrots. The box was not covered or sealed. No open date on it. b. An opened box of green peas. The box was not covered. No open date on the box. c. An opened box of corn. No open date was on the box. d. An opened of lima beans. No open date was on the box. 6. On [DATE] at 09:28 AM, the food items in the second freezer located in the storage room did not have an open date on them: a. An opened box of cinnamon rolls. b. An opened box of broccoli. c. An opened box of French bread. The box was not covered or sealed. 7. On [DATE] at 09:42 AM, the ice machine in a room facing the dining room and or leading to the 300 Hall had wet black residue on the area where ice the ice shot down to the ice collector. There was a wet accumulation of black residue on the inside body of the ice machine that could fall on the ice. The Dietary Supervisor was asked by the Surveyor, How often they cleaned the ice machine and who used the ice from the machine? She stated, We clean it every Monday. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms, and we use it to fill beverages served to the residents at mealtimes. The Dietary Supervisor to describe what was observed in the ice machine. She stated, It's dirty. 8. On [DATE] at 11:22 AM, DE #2 picked up the water hose with bare hand, used it to spray leftover food from inside of the blender bowl, contaminating her hands. She placed it in the dirty rack and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up a clean blade from the rack and attached it to the base of the blender to be used for pureeing food items to be served to the residents on pureed diets. The Surveyor asked DE #2, What should you have done after touching dirty objects or before handling clean equipment? She stated, I should have washed my hands. 9. A facility policy titled, Quick Resource Tool: QRT Hand Washing, documented, .When to wash hands, wash your hands as often as possible. It is important to wash your hands: Before starting to work with food, utensils, or equipment. Before putting on gloves and as often as needed during food preparation and when changing tasks .

Based on observation, interview, and record review, the facility failed to ensure that medications were stored in the med cart with identifiers on the medication cup to identify the resident or to identify the medication. Findings include: During an observation on 03/28/2024 at 12:27 PM, of the medication carts for Halls 400, 500, and 600 revealed two plastic medication cups in the bottom right drawer of the medication cart with multiple different pills with no identifiers on the cups. Plastic medication cup #1 had 10 pills and plastic medication cup #2 had 3 pills in it. During an interview on 03/28/2024 at 12:27 PM, the Licensed Practical Nurse (LPN) #1confirmed that there were 10 pills in cup #1 and 3 pills in cup #2. Also, confirmed there were no identifiers on the cups and that the facility procedure is to waste the pills if the resident is unavailable to take the prescribed pills. The Surveyor asked how the nurse is able to identify the pills in the cup or know who they belong to. LPN #1 responded, I know because I have done this for forever. During an interview on 03/28/2024 at 12:59 PM, the Director of Nurses (DON) confirmed there are multiple pills in the cups without any identifiers. The DON also confirmed that the pills should be wasted if unavailable to identify the pills and that pills should be administered immediately after being prepared in a medication cup. A review of the facility's undated policy titled Storage of Medications, indicated, .Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received .Drug containers that have missing, incomplete, improper, or incorrect labels . are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meal observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the 100 Hall, 8 residents who receive meal trays on the 200 hall, 16 residents who receive meal trays in their room on the 300 hall, 11 residents who receive meal trays in their room on 400 Hall, 8 residents who receive meal trays in their room on 500 Hall. The findings are: 1. Resident #35 had a diagnosis of Type 2 diabetes mellitus with hyperglycemia. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/2024 documented a Brief Interview for Mental Status (BIMS) score of 14 (13-15 indicates cognitively intact). a. A Physician's order dated 02/14/2022 documented Resident #35 had a diet order of NCS (No Concentrated Sweets), regular texture, thin consistency, add large portions. b. On 03/25/2024 at 09:32 AM, the Surveyor asked resident #35 about the temperature of the food and he/she stated, It always be cold. 2. On 03/25/2024 at 01:02 PM, an unheated food cart that contained 11 trays for lunch was delivered to 400 Hall by the Certified Nursing Assistant (CNA) #1. At 01:14 PM, immediately after the last resident was served in their room on 400 hall, temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Baked chicken - 106 degrees Fahrenheit. b. Noodles - 109 degrees Fahrenheit. 3. On 03/25/2024 at 01:09 PM, an unheated food cart that contained 8 trays for lunch was delivered to the 200 Hall by CNA #2. At 01:20 PM, immediately after the last resident was served in their room on 200 Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Noodles - 110 degrees Fahrenheit. 4. On 03/25/2024 at 01:24 PM, an unheated food cart that contained trays for lunch was delivered to the 500 Hall (Unit) by CNA #3. At 01:30 PM, immediately after the last resident was served in the dining room on the 500 Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Noodles - 109 degrees Fahrenheit. b. Pureed carrots - 111 degrees Fahrenheit. 5. On 03/25/2024 at 01:26 PM, an unheated food cart that contained trays for lunch was delivered to the 300 Hall by the CNA #4. At 01:37 PM, immediately after the last resident was served in their room on the 300 Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Ground baked chicken 92 degrees Fahrenheit. b. Noodles 105 degrees Fahrenheit. 6. On 03/26/2024 at 01:26 PM, an unheated food cart that contained trays for lunch was delivered to the 300 Hall (Unit) by CNA #4. At 01:37 PM, immediately after the last resident was served in their room on the 300 Hall, temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Ground baked chicken - 92 degrees Fahrenheit. b. Noodles - 105 degrees Fahrenheit. 7. On 03/26/2024 at 07:43 PM, an unheated food cart that contained trays for breakfast was delivered to 300 Hall (Unit) by CNA #6. At 07:53 PM, immediately after the last resident was served in their room on the 300 Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Sausage - 91degrees Fahrenheit. b. Scrambled eggs - 88 degrees Fahrenheit. 8. On 03/26/2024 at 07:49 AM, an unheated food cart that contained trays for breakfast was delivered to the 100 Hall by CNA #7. At 08:11 AM, immediately after the last resident was served in their room on the 100 Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Pureed sausage - 98 degrees Fahrenheit. b. Pureed scrambled eggs - 106 degrees Fahrenheit. c. Oatmeal - 107 degrees Fahrenheit. d. Regular sausage - 103 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 03/25/2024 at 12:16 PM, Dietary Employee (DE) #3 placed 8 servings of baked chicken into a blender, added chicken broth and pureed. At 12:25 PM, DE #3 poured the pureed chicken into a pan and placed it on the steam. The consistency of the pureed chicken was gritty and not smooth. 2. On 03/25/2024 at 12:32 PM, DE #4 used a 4 ounce spoon to place 8 servings of noodle into a blender, added chicken broth and pureed. At 12:36 PM, DE #4 poured the pureed noodles into a pan and placed it on the steam table. The consistency of the pureed noodles was runny. At 01:30 PM, the surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed chicken was gritty. Pureed noodles were soupy and ground chicken was dried and needed gravy over it. 3. On 03/26/2024 at 07:30 AM, a pan of pureed sausage to be served to the residents on pureed diets was on the steam table. The consistency of the pureed sausage was gritty and not smooth. At 07:54 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed sausage served to the residents for breakfast. She stated, It was gritty. They will buy us a new blade.

Based on observation, interview, and record review, the facility failed to ensure Personal Protective Equipment (PPE) was used before entering a room labeled as contact precautions to decrease the potential for cross contamination for 1 (Resident #172) of 1 sampled resident who had contact isolation precautions in place. The findings are: Resident #172 had a diagnosis of not being able to urinate (Neuromuscular dysfunction of bladder) per the order summary. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/2024 documented a Brief Interview of Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and had an indwelling catheter for bladder and bowel appliances. b. An Order Summary documented, .Contact isolation every shift for MRSA . with an order date of 03/19/2024. c. Resident #172's Hospital Summary, with an admitted [DATE], on page 3 and 4 documented on 03/12/2024 at 10:34 AM, a urine culture was abnormal and contained Methicillin Resistant Staphylococcus Aureus. d. On 03/25/2024 at 08:23 AM, this Surveyor was making rounds on the 600 Hall and observed a white cabinet with three drawers outside Resident #172's room. N95 masks, face shields and yellow disposable stethoscopes were in the top drawer. There was one disposable blue gown in the middle drawer and red biohazard bags and clear melt away bags in bottom drawer. There were no gloves in either drawer, on the wall outside the room or on top of the cabinet. The sign on the door documented, Contact Precautions Everyone Must . Put on gloves before room entry . Put on gown before room entry . The door was partially open, and Resident #172 was in bed with the head of bed up and an oxygen concentrator was in the room. e. On 03/25/2024 at 08:47 AM, Licensed Practical Nurse (LPN) #1 was observed in the room replacing a clear plastic humidifier bottle and tubing with another one and the items were on the resident's bedside table. LPN #2 was not wearing any PPE at this time. This Surveyor stood by the door and at 8:51 AM LPN #1 exited the Resident's room. She was asked, What precautions is [Resident #172] on? She stated, MRSA [Methicillin Resistant Staphylococcus Aureus] (an bacteria that the medication Methicillin will not kill) in urine. When asked if she had put on any isolation equipment before entering the Resident's room, she stated she had already been in [Resident #172]'s room before. She was asked, But the sign says you are to put on those things before going in the room, so did you put on any isolation equipment before entering the room? and she stated she didn't. f. An Infection Control Policy provided by the Director of Nursing on 03/28/2024 documented, .The facility appropriately notifies the physician of possible incidents of communicable disease or infections and administers the most appropriate treatment . implements standard and transmission-based precautions to prevent spread of infection . g. An Isolation-Categories of Transmission-Based Precautions policy documented, .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection . or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door .so that personnel and visitors are aware of the need for and the type of precaution . Contact Precautions . Staff and visitors will wear gloves (clean, non-sterile) when entering the room .Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed .

Based on observation, interview, and record review, the facility failed to ensure medications were not self-administered without a physician order and an interdisciplinary team (IDT) assessment that determined it was safe for 1 (Resident #275) of 1 sampled resident. The findings are: Resident #275 had a diagnosis of Chronic obstructive pulmonary disease with acute exacerbation, and a physician's order documented as intended to treat it for Budesonide-Formoterol Fumarate Inhalation Aerosol. This medication was administered via a nebulizer, a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask. On 03/26/2024 at 10:55 AM, Resident #275 stated to the Surveyor, I am getting ready for my treatment. I can do it on my own. I call for them to bring my stuff and then I do it. On 03/26/24, at 11:00 AM, Resident #275 was observed self-administering the medication utilizing a nebulizer mask. On 03/27/2024 at 11:10 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #275 self-administered their nebulized medication. LPN #1 stated, I'll put the albuterol solution in, or let [Resident #275] do it, the Resident can put the medication in [him/herself]. Then I will leave and let [Resident #275] do it. [Resident #275] will take it off when it is finished. On 03/27/2024 at 11:18 AM, LPN #1 was observed entering Resident #275's room and starting the nebulizer. LPN #1 was then seen leaving Resident #275's room at 11:19 AM, leaving the resident to administer the nebulizer. Resident #275 sat on the bed, holding the nebulizer mask over their nose, and administering the treatment to themselves. On 03/27/2024 at 11:21 AM, the Surveyor asked Resident #275 who put the solution in the nebulizer. Resident #275 stated, I did it. On 03/27/2024 at 11:29 AM, the Surveyor entered Resident #275's room and noted the nebulizer mask in the Resident's right hand. The machine was activated, and the solution was venting into the air. Resident #275 was talking on the telephone while the medication was discharged into the room. This continued until 11:32 AM, when Resident #275 ended the phone call and placed the nebulizer mask back on their face. On 03/28/2024 at 09:30 AM, LPN #1 was asked, How do you document the administration of the albuterol you set up for Resident #275 over the past two days? LPN #1 stated, In progress notes. The Surveyor asked, So, if I went to the progress notes, that is where I can find the documentation? LPN #1 stated, No, I haven't done it for either day. The Surveyor asked, Should it be documented on the MAR [Medication Administration Record]? LPN #1 stated, Yes, but I didn't. The Surveyor asked, How can you ensure the resident is getting the physician ordered amount of the medication if a resident is self-administering the medication alone in their room? LPN #1 stated, [Resident #275] should not. I put it in the cup and all the medicine will come out of the little bowl. The Surveyor asked, Has [Resident #275] been assessed for self-administration of the albuterol or nebulizer? LPN #1 stated, No. The Surveyor asked, What is the importance of a resident being assessed for self-administration? LPN #1 stated, Have a BIMS of 15 and to make sure the resident is capable of doing it. On 03/27/2024 at 02:00 PM, the Director of Nursing (DON) was asked, Do you have anyone who can self-administer their medication? The DON said, No, but we do have some residents that are cognitively able to be, per-say, able to do theirs after you get the medication going. But we do not have anyone here that can self-administer. There are some here who have a BIMS score of 15 high enough they can sit there with their updraft going but the nurse has to set it up. We do not have anyone here that does that or that has been assessed to do that. The Surveyor asked, Have your nurses assessed any residents for self-administration? The DON stated, No. The IDT would have to meet on the assessment for self-administration. The Surveyor asked, Why is it important to have a self-administration assessment? The DON stated, They would be deemed competent and safe to have an updraft until it is finished. They take up to 15-20 minutes to complete. The Surveyor asked, How does the nurse know how much medication the resident receives? The DON stated, They would have to go back and check the residual of the medication that would be in the apparatus of the updraft. On 03/27/2024 at 11:18 AM, the DON provided the facility Self-Administration of Medication policy which documented, residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications are safe and clinically appropriate for the resident . Nursing staff reviews the self-administered medication record for each nursing shift and transfers pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered . On 03/27/2024 at 11:18 AM, the DON was unable to provide a self-administration safety screen for Resident #275.

Based on observation, interview, and record review, the facility failed to ensure fingernails were cleaned to promote good personal hygiene and grooming for 1 (Resident #28) of 1 sampled resident who required assistance with nail care. The findings are: Resident #28 had a diagnosis of Type 2 diabetes mellitus without complications. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/2024 documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and needed partial assistance from another person to complete self-care activities and substantial to maximal assistance with personal hygiene. a. A care plan, last revised 01/10/2024 documented, .[Resident #28] has an ADL [activities of daily living] self-care performance deficit r/t [related to] Amputation (bilateral amputation of lower extremities) . Nail Care: Check nail length and trim and clean as necessary . b. An ADL Task: Nail Care 21 day look back form had a checkmark in the box for 'No' to the question, Task Completed? on 03/17/2024 and 03/24/2024. c. On 03/25/2024 at 09:11 AM, Resident #28's left hand had a dark brown substance underneath them. The resident's right hand was positioned away so this surveyor was unable to see the fingernails. d. On 03/26/2024 at 02:58 PM, Resident #28's left hand was resting on the bed and the fingernails had a dark brown substance underneath. The right hand was positioned away and unable to be seen. e. On 03/27/2024 at 09:58 AM, Resident #28's left hand had a dark brown substance underneath the fingernails. This Surveyor asked Licensed Practical Nurse (LPN) #2 to look at Resident #28's fingernails and describe what was seen. LPN #2 stated, Yes, they need to be cleaned out as she was holding [Resident #28]'s left hand. Resident #28 held out their right hand and the Surveyor observed both hands. There was a dark brown substance underneath the fingernails on both hands. f. On 03/28/2024 at 11:59 AM, Certified Nursing Assistant (CNA) #8 was asked, Who is responsible for nail care to the residents? She stated, All staff members. Only a nurse can do diabetic resident nails. She was asked, When should it [nail care] be performed? CNA #8 stated As often as needed. She was asked, What do you do if a resident refuses nail care? She stated, Report to the charge nurse. g. A policy titled Fingernails/Toenails, Care of provided by the Director of Nursing (DON) on 03/28/2024, documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guideline 1. Nail care included daily cleaning and regular trimming 2. Proper nail care can aid in the prevention of skin problems around the nail bed .

Based on observation, interview, and record review, the facility failed to ensure a urinary catheter tube was not directly touching the floor to decrease the potential for contamination or trauma for 1 (Resident #172) of 1 sampled resident who had a urinary catheter in place. The findings are: Resident #172 had diagnoses of poor brain development that affected muscle control (Cerebral Palsy) and inability to urinate (Neuromuscular Dysfunctional of Bladder). a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/2024 documented a Brief Interview of Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and that the Resident had an indwelling catheter for bladder and bowel appliances. b. A Care plan dated 03/12/2024 documented, .[Resident #172] has a Suprapubic cath [catheter] .monitor/document for s/sx [signs/symptoms] of UTI [Urinary Tract Infection] . c. On 03/25/2024 at 11:34 AM, Resident #172 was sitting up in a wheelchair in the dining area with other residents, with the catheter's urine collection bag underneath it and visible from the doorway, not in a privacy bag, and the tubing was resting directly on the floor (Picture taken at 11:36 AM). d. On 03/28/2024 at 11:59 AM, Certified Nursing Assistant (CNA) #8 when asked where a catheter bag should be placed. CNA #8 stated if [the resident] was in bed, the tubing should be looped and clamped to something, and if in a wheelchair, underneath it. She verbalized the tubing should not be on the floor due to cross contamination and infection control concerns. When asked what could happen to the resident if the tubing is on the floor, she stated it could be pulled out, dragged, or stepped on. e. A Catheter Care, Urinary policy provided by the DON documented, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on interview and record review, the facility failed to ensure a physician documented a clinical rationale for the declination of a pharmacist recommended dose reduction or discontinuation of an antipsychotic medication for 1 (Resident #67) of 4 sampled residents who were investigated for antipsychotic medications. The findings are: Resident #67 had a diagnosis of Dementia with behavioral disturbance as listed on the Order Summary. a. An Order Summary documented, Quetiapine Fumarate Oral Tablet 50 MG (milligrams) Give 1 tablet by mouth at bedtime related to .Dementia .ordered 1/25/24; Quetiapine Fumarate Oral Tablet 25 MG .Give 1 tablet by mouth two times a day related to .Dementia .ordered 01/25/2024; Risperidone Oral Tablet 0.25 MG .Give 1 tablet by mouth one time a day related to .Dementia . ordered 1/25/24; Risperdal Oral Tablet 0.5 MG (Risperidone) Give 1 tablet by mouth one time a day related to .Dementia .ordered 1/25/24 . b. A Consultation Report dated 02/22/2024 documented, .[Resident #67] receives two or more antipsychotics: 1. Risperidone 0.25 mg @ [at] 8 am 0.5mg @ 1pm 2. Quetiapine Fumarate 25mg Twice a Day and Quetiapine Fumarate 50mg QHS [every bedtime] Recommendation: Please decrease Risperidone to Risperidone 0.5mg @ 1pm only (D/C [discontinue] AM dose), with the end goal of discontinuation . Evidence for the use of multiple antipsychotics is limited and increases the risk for drug interactions, medication errors, and cumulative side effects . Physician's Response: . I have re-evaluated this therapy and DO NOT wish to implement any changes due to the reasons below. Rationale: Continue POC (plan of care) . c. On 03/28/2024 at 12:19 PM, the Director of Nursing (DON) acknowledged that they educate the providers regarding a rationale should be documented when no gradual dose reduction is performed. When she was asked how this was done, she stated they call them, and she talks to them about looking at the antipsychotics to see about making a reduction. d. An Antipsychotic Medication Use policy provided by the DON documented, .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences .

Surveyor: [NAME], [NAME] Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status at the time of assessment for 2 (Resident #1 and #48) of 25 (Residents #1, #2, #5, #8, #11, #15, #16, #24, #25, #26, #27, #28, #31, #33, #37, #38, #42, #43, #48, #58, #61, #62, #63, #64 and #120) sampled residents whose MDSs were reviewed The findings are: 1. Resident #1 had diagnoses of Generalized Anxiety Disorder, Mood Disorder due to known Physiological Condition, Unspecified, and Unspecified Systolic (Congestive) Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not exhibit wandering behaviors. a. The Annual MDS with an ARD of 12/21/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and did not exhibit wandering behaviors. b. In the Electronic Records a Nurses Note dated 01/05/23 at 11:11 AM documented, Client sitting on side of bed with C/L [call light] in reach, bed in lowest position, client alert and oriented to x3, with episodes of confusion noted. Client went out of 100 back exit door and staff brought her back inside she became very agitated and stated to nurse, I've got to get out of here, ankle alarm bracelet placed on client right ankle, remain on droplet precaution/quarantine r/t positive COVID-19 test results. 43982 2. Resident #48 had diagnoses of Contracture of Muscle, Lower Leg and Adult Failure to Thrive. The Annual MDS with an ARD of 02/15/23 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and required total physical assistance of one person with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing, and had one Pressure Ulcer/Injury Stage 3 Pressure Ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; one unstageable pressure ulcers/injuries due to non-removable dressing/device; and one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. a. A Visit Report dated 02/10/23 documented, .Weeks in Treatment: 20 . presents for f/u [follow up] for Chronic PU [pressure ulcer] to R [right] ischial; L [left] trochanter -chronic wounds present for more than 6 weeks; Stage 3 Pu to Sacral present since 02/03/2023. (Recidivism) Staff reports Pt [patient] does not exhibit pain or voice pain from ulcers . Active Problems . Pressure ulcer of sacral region, stage 3; Pressure ulcer of left hip, stage 4; Pressure ulcer of right buttock, stage 3; .Pressure-Induced deep tissue damage of unspecified site . 3. On 03/24/23 at 9:13 AM, the Surveyor asked the MDS Coordinator to review the Nurses Note for Resident #1 dated 01/05/23 and the Quarterly MDS dated [DATE] Section E0900 Wandering. The Surveyor asked if the MDS was accurate in the response of No. The MDS Coordinator stated, No. Social completes Section E and I sign off on it. The Surveyor asked her to review Resident #48 ' s Visit Report Note dated 02/10/23 and the Annual MDS dated [DATE], Section M. The Surveyor asked if Resident #48 ' s Pressure Ulcers were correctly reflected in the MDS. She stated, No, the Treatment Nurse completes Section M and I sign off on it. 4. The facility policy titled, MDS Accuracy, provided by the Business Office Manager (BOM) on 03/24/23 at 9:57 AM documented, .1. This Interdisciplinary team must conduct all assessments with accurate data . 3. Accuracy means the appropriate health professional has correctly documented the resident's medical, functional, and psychosocial problems and identified strengths to maintain or improve status in these problem areas .

Based on observation, interview, and record review the facility failed ensure care plans were reviewed and revised to include risks, goals, and interventions for 1 (Resident #1) of 2 (Residents #1 and #62) sampled residents who were at risk for elopement and 1 (Resident #48) of 6 (Residents #2, #15, #38, #48, #63 and #120) case mix residents who had pressure ulcers according to the lists provided by the Director of Nursing (DON) on 03/24/23 at 8:51 AM. The findings are: 1. Resident #1 (R#1) had diagnoses of Generalized Anxiety Disorder, Mood Disorder due to known Physiological Condition, Unspecified, and Unspecified Systolic (Congestive) Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not exhibit wandering behaviors. a. The Comprehensive Care Plan with an initiated date of 12/31/21 provided by the DON on 03/21/23 at 4:35 PM contained written revisions completed on 01/04/23 and was described by the DON as the updated Comprehensive Care Plan had not been updated to reflect the findings of the Risk of Elopement/Wandering Review performed 01/06/23. No information was found in the Care Plan regarding the identified risk of elopement. The Care Plan was described by the DON to be the complete current Care Plan for Resident #1 available for staff and found in the Assistant Director of Nursing's (ADON) office. b. In the Electronic Records a Nurses Note dated 01/05/23 at 11:11 AM documented, .Client went out of 100 back exit door and staff brought her back inside she became very agitated and stated to nurse, I've got to get out of here, ankle alarm bracelet placed on client right ankle . c. A Risk of Elopement/Wandering Review, with an assessment completed by the Assistant Director of Nursing (ADON) dated 01/06/23 was provided by Registered Nurse (RN) #1 on 03/21/23 at 3:40 PM. The Review documented, Instructions . Complete upon admission, thirty days after admission, quarterly, and at significant change, or per facility policy. Review Potential Risk Factors and Resident Status and check YES or NO under the appropriate review date. On Side Two, complete the corresponding Summary of Review . Review Dates 1/6/23 . The information for 1/6/23 was entered by the ADON. The Review asked, Does the resident ambulate independently, with or without the use of an assistive device .? The ADON checked No. Is this a new behavior, has there been any changes in the resident's status or routine, i.e. [that is], medications, illness, pain, infection, frustration, personal tragedy? The ADON checked No. In the section titled, Summary of Review 1 .Resident is at risk for elopement/wandering, as evidenced by:, the ADON documented, Attempting to exit facility x 2. Additional Comments, the ADON documented, Res [Resident] wanting to go home. Open 100 Hall door x 2, alarm sounds, et [and] continues to attempt to go out. Becomes combative c [with] staff when redirect. 43982 2. Resident #48 had diagnoses: of Contracture of Muscle, Lower Leg and Adult Failure to Thrive. The Annual MDS with an ARD of 02/15/23 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and required total physical assistance of one person with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing, and had one unhealed Stage 3 pressure ulcer and 2 unhealed unstageable Pressure Ulcers/Injuries. a. The Comprehensive Care Plan with Annual 2/3/2023 handwritten at the top, had an initiated date of 03/02/22. The Care Plan did not address pressure ulcers. This Care Plan was kept in a binder in the ADON's office and was described by the DON to be the Care Plan available to all staff for the care of the residents. b. A Visit Report dated 03/10/23 provided by the DON on 03/24/23 at 3:05 PM documented, .Weeks in Treatment: 24 . presents for f/u [follow up] for Chronic PU [pressure ulcer] to R [right] ischial; L [left] trochanter-chronic wounds present for more than 6 weeks; Stage 3 Pu to Sacral present since 02/03/2023 . (Recidivism) Pt [patient] has a new stage 2 to R trochanter today-resolved; Pt has a new unstageable PU to R foot (lat) [lateral]- present since 03/09/2023. Staff reports Pt does not exhibit pain or voice pain from ulcers . Active Problems Pressure ulcer of other site, unstageable; Pressure ulcer of sacral region, stage 3; Pressure ulcer of left hip, stage 4; Pressure ulcer of right buttock, stage 3 . Plan of Care: .Turn q [every] 2 hours, check feet/toes, redistribution mattress, pad feet/heels/soft boots at all times Factors affecting wound healing, hx [history] anorexia, impaired mobility, anemia, incontinence, LE [lower extremity] contractures- hard to offload New POC [plan of care]/tx[treatment] order as reviewed with tx nurse . c. On 03/22/23 at 2:15 PM, the Surveyor asked the DON who was responsible for updating the Care Plan to reflect a risk for or actual pressure ulcers. The DON stated, Well, anyone can do them, but the Treatment Nurse is primarily responsible because it falls under skin on the Care Plan. The Surveyor asked the DON if a resident with pressure ulcers should be care planned for the pressure ulcers. She stated, Yes they should. The Surveyor asked the DON what should be present on the Care Plan regarding pressure ulcers. She stated, Well, nutrition, supplements, stuff like that. The Surveyor asked the DON what type of interventions should be listed on the Care Plan when you have a resident at risk. The DON stated, Stuff like pressure relieving devices. The Surveyor asked the DON if [Resident #1's] Care Plan should have been updated when the elopement attempt occurred, and she was found to be at risk. The DON stated, Yes, it should have, and should have included the bracelet. The Surveyor asked what the purpose of the Care Plan is. The DON stated, For everyone to be able to know how to care for that patient. 3. The facility policy titled, Care Plans, Comprehensive Person-Centered, provided by the DON on 03/24/23 at 8:15 AM documented, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical , psychosocial and functional needs is developed and implemented for each resident . The Comprehensive, person-centered care plan will: .Incorporate identified problem areas; Incorporate risk factors associated with identified problems . and .The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met .d. At least quarterly, in conjunction with the required quarterly MDS assessment .

Based on interview, and record review, the facility failed to ensure assessments and monitoring were conducted and documented in accordance with accepted standards of nursing practice for 2 (Residents #1 and #48) of 17 (Residents #1, #2, #8, #25, #31, #37, #42, #43, #45, #47, #48, #58, #62, #63, #64, #68 and #120) sampled residents who required quarterly assessments. The findings are: 1. Resident #1 (R#1) had diagnoses of Generalized Anxiety Disorder, Mood Disorder due to known Physiological Condition, Unspecified, and Unspecified Systolic (Congestive) Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not exhibit wandering behaviors. a. The Annual MDS with an ARD of 12/21/22 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a BIMS and did not exhibit wandering behaviors. b. The December 2022 Assessment Calendar provided by the Director of Nursing (DON) documented Resident #1 was scheduled for an annual assessment on 12/12/2022. c. In the Electronic Records a Nurses Note dated 01/05/23 at 11:11 AM documented, .Client sitting on side of bed with C/L [call light] in reach, bed in lowest position, client alert and oriented to x [times] 3, with episodes of confusion noted. Client went out of 100 back exit door and staff brought her back inside she became very agitated and stated to nurse, I've got to get out of here, ankle alarm bracelet placed on client right ankle, remain on droplet precaution/quarantine r/t positive COVID-19 test results. d. A Risk of Elopement/Wandering Review, with an assessment completed by the Assistant Director of Nursing (ADON) dated 01/06/23 was provided by Registered Nurse (RN) #1 on 03/21/23 at 3:40 PM. The Review documented, Instructions . Complete upon admission, thirty days after admission, quarterly, and at significant change, or per facility policy. Review Potential Risk Factors and Resident Status and check YES or NO under the appropriate review date. On Side Two, complete the corresponding Summary of Review . Review Dates 1/6/23 . The information for 1/6/23 was entered by the ADON. The Review asked, Does the resident ambulate independently, with or without the use of an assistive device .? The ADON checked No. Is this a new behavior, has there been any changes in the resident's status or routine, i.e. [that is], medications, illness, pain, infection, frustration, personal tragedy? The ADON checked No. In the section titled, Summary of Review 1 .Resident is at risk for elopement/wandering, as evidenced by: the ADON documented, Attempting to exit facility x 2. Additional Comments, the ADON documented, Res [Resident] wanting to go home. Open 100 Hall door x 2, alarm sounds, et [and] continues to attempt to go out. Becomes combative c [with] staff when redirect. e. On 03/21/23 at 3:55 PM, the Surveyor asked the DON how frequently a Risk of Elopement Assessment/Wandering Review should be performed for Resident #1. She stated, Quarterly. The Surveyor asked when a review should have been performed to follow the one dated 09/15/22. She stated, December is when it should have been done. The DON produced a book she stated referenced, when assessments are due. She stated, An annual, which includes all the assessments was due 12/12/22. The Surveyor asked which assessments would have been included. She stated, Hot liquids, pain, hydration, bed rail, elopement risk. Then DON asked if she could pull up [Facility Computer Software] to identify when the review was performed. She stated, It was done on 1/5/23 at 11:11 AM. The Surveyor asked who was responsible for performing the quarterly assessments. She stated, My ADON, [Name]. The DON called the ADON on her cell phone and activated the speakerphone. The Surveyor asked the ADON to identify herself. She stated, [Name]. The Surveyor asked for her title. She stated, ADON . LPN [Licensed Practical Nurse]. The Surveyor asked the ADON who was responsible for quarterly assessments. She stated, Any nurse can do them. I just do the majority. The Surveyor asked when a review should have been performed to follow the one dated 9/15/2022. She stated, September, October, November, December . In January. The Surveyor asked how frequently a quarterly assessment should be performed. She stated, Every four months. The Surveyor asked the ADON if the twelve months of the year were divided by four, how many months would result. She stated, Four months. The Surveyor asked how she knew when to perform an assessment. She stated, [MDS Coordinator] gives us a calendar. The Surveyor asked when the Wanderguard was placed on Resident #1. She stated, It was placed on her second elopement attempt. She was stopped at the door on her first attempt but made it outside onto the sidewalk the second time. The Surveyor asked the ADON what the answer should have been on the Risk of Elopement/Wandering Review she performed on 01/06/23 when it asked, Does the resident ambulate independently, with or without the use of an assistive device? She stated, It should have been marked Yes. The Surveyor informed the ADON that the question had been marked no. The Surveyor asked the ADON what the answer should have been when it asked, Is this a new behavior, has there been any changes in the resident's status or routine such as medication, illness, pain, infection, frustration, or personal tragedy? She stated, No. The Surveyor asked if she would consider the positive COVID-19 diagnosis the resident received on 01/02/23 to be a change in the resident's status or routine. She stated, No, I don't think so. The Surveyor reiterated, .has there been any changes in the resident's status or routine such as medication, illness, pain, infection, frustration, or personal tragedy . The ADON paused before stating, Yes. The Surveyor informed the ADON that the question had been marked no. The Surveyor asked what could happen if she didn't assess the resident accurately. She stated, I could probably lose my job. The Surveyor asked if the inaccurate assessment could change the way a resident was monitored. She stated, No. 43982 2. Resident #48 had diagnoses of Contracture of Muscle, Lower Leg and Adult Failure to Thrive. The Annual MDS with an ARD of 02/15/23 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a BIMS and required total assistance of one person with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing, one unhealed Stage 3 pressure ulcer and 2 unhealed unstageable Pressure Ulcers/Injuries. a. A Visit Report dated 03/10/23 provided by the DON on 03/24/23 at 3:05 PM documented, .Weeks in Treatment: 24 . presents for f/u [follow up] for Chronic PU [pressure ulcer] to R [right] ischial; L [left] trochanter-chronic wounds present for more than 6 weeks; Stage 3 Pu to Sacral present since 02/03/2023 . (Recidivism) Pt [patient] has a new stage 2 to R trochanter today-resolved; Pt has a new unstageable PU to R foot (lat) [lateral]- present since 03/09/2023. Staff reports Pt does not exhibit pain or voice pain from ulcers . Active Problems Pressure ulcer of other site, unstageable; Pressure ulcer of sacral region, stage 3; Pressure ulcer of left hip, stage 4; Pressure ulcer of right buttock, stage 3 . Plan of Care: .Turn q [every] 2 hours, check feet/toes, redistribution mattress, pad feet/heels/soft boots at all times Factors affecting wound healing, hx [history] anorexia, impaired mobility, anemia, incontinence, LE [lower extremity] contractures- hard to offload New POC [plan of care]/tx [treatment] order as reviewed with tx nurse . b. On 3/22/23 at 3:05pm The Surveyor asked the DON where the Braden Scale Assessments are kept because they were not in the binder in the ADON's office with all the other assessments. The DON stated, In the Treatment Nurses' office probably. She isn't here, she is on vacation this week. The Surveyor accompanied the DON to the Treatment Nurse's office and the DON presented the Surveyor with a binder of the Braden Scale Assessments. She was asked to provide a copy of Resident #48's Braden Scale Assessments. The DON provided a document titled, Braden Scale for Predicting Pressure Sore Risk. The form documented, .To be completed upon admission, weekly x 3, then quarterly and PRN [as needed] . The form had assessments documented and dated 2/25/22, 3/4/22, 6/1/22, 8/31/22, 10/12/22 and 10/22/22. The scores on the assessments ranged from 14 to 18 with the most recent on 10/22/22 with a score of 14, placing Resident #48 at Moderate Risk for pressure sore risk. The form had two blank columns remaining on the document. The Surveyor asked the DON if this was the most recent assessment. The DON stated, Yes, that's the last one that has been done. It looks like there should have been another one done in January. The Surveyor asked how often Braden Scale Assessments should be completed. The DON stated, At least quarterly and as needed if there is a change. The Surveyor asked the DON to look at the Braden Scale Assessment Scores and asked the DON if the Braden Scale Assessments and Scores appeared accurate for this resident who currently has 4 pressure ulcers. The DON looked at the Braden Scale Assessments and stated, Well, let me see. Sensory Perception, yeah, she can do that. Moisture, let me see (while reading), yeah, I'd probably give her a four on that. Activity, yeah that's right a two. Mobility, yeah that's a one. Nutrition, I'd probably give her a two. Friction and Shear, yeah that looks right to me, at least at the time it was done. 3. The facility policy titled, Risk Assessments, provided by the DON on 03/24/23 at 8:15 AM documented, .The nursing staff, in conjunction with the attending physician, consultant pharmacist, consulting dietitian, therapy staff, and others, will seek to identify and document resident risk factors for falls, nutrition deficits, skin breakdown, elopement, smoking safety, and other risks as may be identified . The assessments will be updated at least quarterly and as needed in conjunction with each Resident's MDS schedule or as indicated.

Based on observation, and interview, the facility failed to ensure a clean, homelike environment was maintained for 1 (Resident #28) of 25 (Resident #1, #2, #5, #8, #11, #15, #16, #24, #25, #26, #27, #28, #31, #33, #37, #38, #42, #43, #48, #58, #61, #62, #63, #64 and #120) sampled residents whose rooms were observed. The findings are: 1. Resident #28 had diagnoses of Essential (primary) Hypertension, Unspecified Convulsions, Gastrostomy Status, and Type II Diabetes Mellitus. a. On 03/20/23 a 11:01 AM, Resident #28 was lying in bed. A 2 x 2.5 foot splatter of a dried, thick brown substance was under the resident's bed. An enteral tube feeding pole was at the bedside holding a container of formula and a feeding pump. b. On 03/21/23 at 8:55 AM, Resident #28 was lying in bed. A 2 x 2.5 foot splatter of a dried, thick brown substance was under the resident's bed. A trash can had been moved in front of the spill. c. On 03/22/23 at 7:35 AM, Resident #28 was lying in bed. The large splatter of a dried, thick brown substance remained under the bed. d. On 03/22/23 at 11:12 AM, Housekeeper #1 entered Resident #28's room. Housekeeper #1 returned to the hall for a broom and re-entered the room. She returned to exchange the broom for a mop. e. On 03/22/23 at 11:19 AM, Housekeeper #1 placed a wet floor sign in the doorway of Resident #28's room and proceeded to enter and clean another room. The Surveyor entered the room and the large splatter of brown substance remained on the floor. f. On 03/22/23 at 11:42 AM, the Surveyor asked Housekeeper #1 to accompany the Surveyor to Resident #28's room. The Surveyor asked Housekeeper #1 to describe the substance. She stated, I don't know what that is, it's really stuck on there. I don't want to bother the resident by reaching under the bed. The Surveyor instructed Housekeeper #1 to attempt to remove a portion of the substance. Housekeeper #1 retrieved a small scraper from the cleaning cart in the hallway and returned to the room. She used the scraper to remove a portion of the substance. It came away easily. She stated, I'll have to get maintenance to move the bed so I can get the rest. g. The facility policy titled, Housekeeping, provided by the Business Office Manager (BOM) on 03/24/23 at 11:55 AM documented, Policy Statement .It is the policy of the facility to provide housekeeping services and maintain a clean healthy environment . Policy Interpretation and Implementation l. Cleaning schedules are developed and implemented to assure that each area of our facility is maintained in a safe, clean, and comfortable manner. 2. All floors shall be mopped/cleaned./swept daily in accordance with our established procedures.

Complaint # (AR 480) was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 3 (Residents #1, #2 and #6) case mix residents who were cognitively impaired, at risk for falls and utilized side rails, failed to obtain an informed consent from the resident's family member that included education of the family member on the potential risks associated with side rails use prior to placing the rails on the bed, failed to evaluate falls for causative factors, and failed to identify the potential risks associated with using bed rails for Resident #1, who was confused and consistently attempted to get out of bed with the side rails in the raised position. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to affect 4 residents who were cognitively impaired, at risk for falls and utilized bed rails, according to a list provided by Licensed Practical Nurse (LPN) #3 on [DATE] at 12:03 p.m. The Administrator was informed of the Immediate Jeopardy situation on [DATE] at 9:45 a.m. The findings are: Resident #1 was admitted to the facility [DATE] and had [DIAGNOSES REDACTED]. a. A Temporary Admission Care Plan dated [DATE] documented, Fall mat at bedside, bed in lowest position, has bed pad alarm to alert staff with unassisted transfers. b. A Kardex dated [DATE] documented, Daily decision making severely impaired . chair alarm, bed alarm . keep bed rails up x (times) 2 at all times . c. An Evaluation for use of Side Rails dated [DATE] documented, Why is the use of a side rail(s) being considered? Family requested. For position only . Weakness . History of rolling out of bed. Fear of rolling out of bed. History of sliding to floor . Side rail(s) is/are recommended at this time due to: other. ,[DATE] rails. The section designated for documentation of any alternatives to side rails that were discussed with the resident or family/representative was left blank. The section regarding the resident's cognitive status was also left blank. d. A Physician order [REDACTED]. ASA (Aspirin) 81 mg PO QD. e. A Nurse's Note dated [DATE] at 12:30 p.m. documented, Received res (resident) in room in w/c (wheelchair) with wife present. Patient alert with confusion noted; speech slurred/garbled but can understand some. Noted res very weak, especially on right side. RLL (right lower leg) barely able to pick up foot upon transferring from w/c to bed . Res able to use left side upper and lower ext (extremities); patient constantly trying to get OOB (out of bed) by self . May have bed pad alarm when up in w/c or when in bed to prevent unassisted transfers; wife in agreement. Bed alarm placed on bed and is in proper working order . f. A Nurse's Note dated [DATE] at 11:00 p.m. documented, Rec'd (received) lying awake in bed, resp (respirations) even and unlabored. Appears confused, attempting to get OOB. Talking at random. Unsteady, appears high fall risk . S/R (side rails) up x 2 . g. A Fall Risk Evaluation dated [DATE] documented the resident scored 12 with a score of 10 or higher indicating the resident was at risk for falls. h. A Nurse's Note dated [DATE] at 6:40 a.m., documented, CNA (Certified Nursing Assistant) called nurse to nurse station. Res on floor face down. CNA x (times) 2 helped resident up off the floor, placed resident back in chair. Nurse assess res before picking him off the floor. No injuries noted. CNA took resident back to room and helped resident back in bed . The Incident/Accident (I/A) Report dated [DATE] at 6:40 a.m. for the above incident documented, CNA called nurse to nursing station where I found res down on floor faced down trying to get up off the floor. No injuries. Alert and confused. Placed resident on 15 min (minute) checks, apply non-skid socks . Chair alarm intact to w/c, alarm sounding off, alarmed CNA and came to nurse station, found res on floor. i. A Nurse's Note dated [DATE] at 12:00 p.m. documented, Resident found on floor in room by wife. Per wife, CNA and her had just checked on resident and wife states 'I left the room and when I came back in he was on the floor trying to get up off the floor with blood on the floor and on him from his head. He hit the corner of the night stand in his room above his left eye.' Nurse was called to the room by wife. Nurse found res on floor trying to get up with blood coming from the left side of head above left eye. Res was assessed and helped off the floor . 12:15 p.m. ambulance notified . The I/A Report dated [DATE] at 12:00 p.m. for the above incident documented, Nurse called to resident room by CNA, found resident on floor on knees trying to get off floor with blood on floor coming from his head on the left side above left eye . S/R (side rails) up, bed was in lowest position, call light was on the bed, fall mat was in place when nurse entered the room . bed alarm intact and sounding off that CNA heard . MD (Medical Doctor) notified and advised new order to send resident to (hospital) ER (emergency room ) for evaluation . Summary of investigation . very weak on right side. He needs assistance with transfers and ADLs (activities of daily living). Pt (patient) constantly tries to get up out of bed or w/c without assistance. j. A Computed Tomography (CT) report dated [DATE] from Hospital #1 documented results of a CT of the resident's head as, There is a mixed predominantly hyper dense left subdural hematoma, lateral to the left cerebral hemisphere, thickest overlying the left parietal lobe . There is associated left sided sulcal effacement as well as rightward midline shift by 5 mm (millimeters) . IMPRESSION: Acute left subdural hematoma overlying the left cerebrum with associated rightward midline shift. Old infarctions in the left temporal lobe, left insula, right parietal lobe, and right cerebellum. k. An Emergency Department Physician Record dated [DATE] documented, Subdural hematoma . transfer to (Hospital #2) for neurosurgical evaluation. l. The Emergency Note dated [DATE] from Hospital #2 documented, The patient presents following fall . Left head . risk factors consist of age and anticoagulated . transfer for SDH (subdural hematoma) on Plavix and aspirin for multiple CVA (Cerebrovascular Accidents) . Discussed with wife who is next of kin; she and her family have decided to make patient comfort care only. They would like the patient extubated and kept comfortable but will allow a natural death. m. The History and Physical dated [DATE] from Hospital #2 documented, .recent strokes on dual antiplatelet therapy, presenting with a large acute and hyper-acute subdural hematoma in the left with severe midline shift with no brainstem reflexes at this time. I explained to the family that he is unlikely to survive this . They elected to withhold from surgery and to proceed with palliative care and with terminal extubation . n. On [DATE] at 2:00 p.m., the resident's wife stated the resident died on [DATE]. o. On [DATE] at 11:55 a.m., Licensed Practical Nurse (LPN) #1 was asked about her role in the admission of Resident #1. She stated, I and the nurse go in and assess the skin. I did the initial skin assessment for (Resident #1). She was asked how the resident acted when she was in the room. She stated, He was wanting to walk; trying to get up out of the Geri chair. He was confused. LPN #1's signature was documented on the follow-up portion of the Incident Reports for [DATE], so was asked if she was responsible for investigating the I/As in the facility. She stated, Yes. I do the I/As and the treatments. She was asked why no one was at the nurse's station when the resident fell the first time on [DATE]. She stated, He was in his room when he fell , that I'm aware of. She was shown the Nurse's Note that documented the resident fell at the nurse's station. She stated, Okay, maybe he was put there to be monitored. She was reminded that no one was at the nurse's station when the resident fell . She stated, Well, I can't answer that, then. She was asked if she assessed for causative factors after the first fall. She stated, Is that something that could come up later if he is hurt? She was told that assessing for causative factors meant she would try to determine why the resident fell so the facility could intervene appropriately. She stated, I talk to the people who are involved and ask what happened. p. On [DATE] at 12:45 p.m., CNA #1 was asked about the incident involving Resident #1 on the morning of [DATE]. She stated, That Saturday, when I came in, they had him in a wheelchair at the nurse's station. They said the 10 to 6 (10:00 p.m. to 6:00 a.m. shift) CNA was still here, because the resident had been trying to get out of bed all night and that he had stayed by his door to watch him. I saw him trying to get up while in his wheelchair at the nurse's station. His alarm went off and I sat him down and reminded him not to get up. The nurse said just to leave him there so they could watch him, so I went down the hall to help another resident and then I heard his alarm again and I walked out and saw him on the floor. (LPN #2) was down toward the middle of 100 hall doing something so I yelled for her. I remember her saying, 'I don't know what we are going to do, because he won't stay in his chair'. q. On [DATE] at 1:40 p.m., CNA #2, who was assigned to provide care to Resident #1 on [DATE], was asked how the resident was that day. She stated, I was on his hall that day, but I was down the hall when he fell that first time at the nurse's station. I helped get him off the floor. She was asked if anyone was at the nurse's station when the resident fell . She stated, No one was around the nurse's station when he fell . She was asked why the resident was at the nurse's station and stated, There was a 10 to 6 male CNA who helped me put him in the chair that morning, and we pushed him to the nurse's station so they could help keep an eye on him. He told me the resident was steady trying to get out of bed all night and that he was afraid to leave him because he would fall. But when he fell , I took him back to his bed and I did every 15 minute checks on him. Then his wife came to visit him. The last time I checked him, he was asleep. His wife was not in the room at that time. Maybe 10 minutes went by, and I heard his alarm, so I took off to his room and when I got there, his wife was in the room, the alarm was sounding and he was in the floor bleeding. She was asked if his side rails were in the raised position. She stated, Yes they were. Half rails. r. On [DATE] at 3:20 p.m., LPN #3, who did the side rail assessment for Resident #1 on admission, was asked why side rails would be appropriate for Resident #1. She stated, We were told he was a fall risk. And the nurse told me the wife was asking about him having side rails. She was asked if there was an informed consent for the side rails. She stated, Half rails aren't considered a restraint. We use them for positioning and turning. In all facilities I've ever worked in, half rails aren't considered a restraint. She was asked if it was ever considered that the resident might attempt to crawl over the side rails since he was confused. She stated, He wouldn't crawl over a half rail. The half rail is up by his head. We knew prior to him coming that he was a fall risk, so we would not have full rails for him. He needed half rails to help steady himself if he did get up. s. On [DATE] at 4:20 p.m., LPN #2 was asked what she remembered about the resident's first fall on [DATE]. She stated, I remember he was at the nurse's station, and we were at the dining room getting ready for breakfast. The CNA heard the alarm go off and then she called me. I assessed him and we got him back in his chair. There was no apparent injury so we took him to his room. I implemented every 15 minute checks on him. I filled out the paperwork and called the doctor. When we got through feeding residents, I called his wife to tell her he had had a fall . She was asked if she was at the nurse's station when the resident was brought there. She stated, I can't remember if I was or not. She was asked about the second incident that occurred on [DATE]. She stated, I wasn't at the nurse's station when the second fall happened. (CNA #2) told me she heard the alarm go off, and I think his wife told me that too. She was asked if the resident's side rails were up when she got in the room and she stated, I don't recall. t. On [DATE] at 8:53 a.m., LPN #4 was asked about her Nurse's Note dated [DATE] at 12:30 p.m. She stated, I went in . we had several people in there at the time. He was in a wheelchair drinking water. His wife was helping him. We had the floor mat in place. We implemented the bed alarm. When we got ready to put him in bed, he couldn't really pick up his right leg, so I helped him with that. (LPN #1) did his skin assessment. We went over his diet. He was trying to talk, but he had a slur due to the strokes he had experienced. That was about all I did. She was asked to explain what she meant by him constantly trying to get out of bed. She stated, He kept trying to put his legs over off the side of the bed. He was just really wanting to get up. Constantly trying to get up. His wife was telling him he needed to lay down and rest. She was asked if the resident had side rails on the bed at that time. She stated, Yes, he had side rails at that time. Half rails. And they were up. And he also had a trapeze bar. We knew he was going to be a fall risk. u. On [DATE] at 9:16 a.m., the previous Director of Nursing (DON) of the facility was asked what she remembered about Resident #1. She stated, I read over his paperwork before he came in. I could see he would be a fall risk. I went ahead and put the wheelchair and bed alarm on. I helped do the body audit on him that day. I remember him sitting on the side of the bed, and he couldn't follow commands. He was confused. She was asked if anyone identified that the side rails were a potential danger for him due to his confused state and high fall risk. She stated, No. Not that I know of. Side rails being a problem never entered my mind. v. On [DATE] at 4:15 p.m., CNA #3, who worked the ,[DATE] shift on [DATE], was asked about his experience with Resident #1 that night. He stated, It was a tough night. He would nod off, then wake up and try to get up and walk. His mind . it's like he was trying to go somewhere. I had to pull a chair up close to his doorway to watch him because I was afraid he was coming out of that bed. He was asked if the side rails were in use during that time. He stated, Yes, we had those up. But he could move. When it came time for me to get off, no one had came (sic), so I waited. I told the day shift CNA to keep an eye on him. w. The Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines at F221 and F323 documented, .Although restraints have been traditionally used as a falls prevention approach, they have major, serious drawbacks and can contribute to serious injuries. There is no evidence that the use of physical restraints, including but not limited to side rails, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g. (for example), strangulation, entrapment) . Residents who attempt to exit a bed through, between, over or around side rails are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used . Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement . that may cause them to move about the bed or try to exit from the bed . x. Although the resident had a fall that resulted in death while side rails were in use, there was insufficient evidence to determine that the side rails contributed to the fall or exacerbated the injury that caused his death. The Immediate Jeopardy was removed and the scope and severity lowered to D on [DATE], when the facility implemented the following Plan of Removal: 1.) At 8:30 a.m. on [DATE], the Maintenance Supervisor removed all of the quarter length side rails that were in place on any bed. This will be completed on [DATE] by approximately 3:00 p.m. 2.) On [DATE] at 10:50 a.m., an inservice was initiated by ADON/Designee on our Side Rail Policy, Fall Risk Policy and Regulation F323 - Accidents and Supervision. Any staff member that has not been inserviced on F323, our Side Rail Policy and Fall Risk Policy will not be allowed to return to work until they have been inserviced. 3.) On [DATE] every resident will be assessed to insure the appropriate repositioning and safety device is in use. If a side rail is determined to be the best device for enhancing quality of life, staff will insure a side rail assessment is completed that includes the risk of entrapment or other risk and the benefits of having side rails and a signed informed consent from the responsible party. 4.) On [DATE], ADON/Designee will monitor daily for 4 weeks, then 3 x (times) a week for 4 weeks, then once a week for four weeks and then quarterly thereafter with the MDS schedule and/or with a change of condition to insure the use of side rails is still appropriate for the resident's safety and/or enhancement of quality of life.

Based on observation, record review, and interview, the facility failed to ensure falls were thoroughly and consistently evaluated for causative factors, failed to ensure fall/injury prevention interventions were developed based on those causative factors and failed to ensure planned fall prevention interventions were consistently implemented, to prevent further potential falls and minimize the risk for fall-related injuries for 1 (Resident #8) of 5 (Residents #2, #5, #7, #8 and #10) case mix residents who were at risk for falls. The failed practices resulted in a pattern of actual harm to Resident #8, who fell and sustained a fractured right hip, and had the potential to cause more than minimal harm to 31 residents who had falls from July through December 2016, according to a list provided by the Director of Nursing (DON) on 1/13/17 at 10:35 a.m. The facility also failed to ensure staff avoided lifting a resident under the neck and adequate support was provided to the resident's torso and lower extremities during a manual transfer to minimize the potential for injury for 1 (Resident #11) of 7 (Residents #1, #2, #4, #9, #10, #11 and #13) case mix residents who required assistance for transfers. The failed practice had the potential to affect 19 residents who required assistance with transfers, as documented on a list provided by the Director of Nurses on 1/12/17. The findings are: The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/16 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, required extensive one person physical assistance for bed mobility, transfers, walking in corridor, and locomotion on/off unit, was totally dependent on one person for dressing, toilet use, personal hygiene and bathing, was always incontinent of bladder and bowel and had one fall with major injury since admission. a. A Care Plan dated 11/12/15 documented, .I have had an actual fall with an injury . Check my range of motion every shift . Continue interventions on the at-risk plan . For no apparent acute injury, determine and address causative factors of the fall . PT (Physical Therapy) consult for strength and mobility . All of the interventions on this Care Plan were dated as initiated on 11/12/15. An attached signature sheet documented the Interdisciplinary Team (IDT) reviewed the Care Plan on 11/2/16. b. Nurse's Notes dated 2/24/16 at 8:30 p.m. documented, .upon entering res. (resident) rm (room) noted res. lying on floor in front of w/c on L (left) side. Chair alarm sounding. Body assessment done. Sm. (small) laceration on nose and right cheek bone . Res stated 'chair moved when I stood up'. A Resident Incident / Accident Report dated 2/24/16 at 8:30 p.m. documented, .Res.(resident) stood up et (and) w/c (wheelchair) moved. Sm.(small) laceration on nose et (and) R (right) cheek bone . Tx (treatment) initiated by Charge Nurse . Summary of investigation on 2/29/16 . Resident stated that he stood up from wheel chair and the wheel chair moved backwards. Resident assessed by Charge Nurse, Small laceration noted to bridge of nose and right cheek bone. Physician and family notified . 2/24/16 Brakes on w/c assessed with [REDACTED]. 2/25/16 No problems resident up in w/c with sensor pad in proper working order . 2/29/16 Therapy ordering Anti-Tippers for resident . As of 1/11/17 at 2:48 p.m., the anti-tippers were not addressed on the resident's Care Plan. c. A Kardex Report dated 2/29/16 documented, .Assistive Devices . Anti-tippers . d. Nurses Notes dated 4/21/16 at 5:25 p.m. documented, .Resident found on floor in room at end of bed. Resident complained of right hip pain. Lifted to wheelchair via two CNAs, LPN, and RN. Discoloration noted on right side of eye, chin and right forearm. Lifted to bed . 8:50 p.m. X-ray results received . fracture of right superior and right inferior pubic ramus . transfer to (hospital) 9:30 p.m. Ambulance here . 1.) A Resident Incident / Accident (I&A) Report dated 4/21/16 at 5:25 p.m. documented, Res (resident) lying supine in floor (at) end of bed. Res. turned chair alarm off. Discoloration on R (right) F.A. (forearm) c/o (complain of) R (right) hip px (pain). Lifted to w/c via 2 CNAs (Certified Nursing Assistants) et LPN (Licensed Practical Nurse) et RN ( Registered Nurse) then to bed. X-ray ordered . The section of the I&A form designated for, Additional comments and/or steps taken to prevent recurrence documented, X-ray of Rt (right) hip. The Investigation Follow-Up dated 4/21/16 documented, Resident observed on floor at end of bed. Bed alarm was off, noted that resident is turning off his own alarm, this is care planned. Resident c/o (complained of) hip pain and physician was notified and order given for x-ray . X-ray ordered and obtained, resident transferred to hospital d/t (due to) abnormal x-ray. There was no documentation of any planned intervention to address that the resident turned off his own alarm, nor was this documented on the resident's Care Plan as of 1/11/17. 2.) A Radiology Report dated 4/21/16 at 9:14 p.m. documented, .x-ray hip unilateral with Pelvis, Reason: Pain from fall .Impression: Internal development of right hip acetabular protrusion compared to 11/4/15 . Acute / subacute right superior and right inferior pubic ramus fracture . 3.) A Nurse's Note dated 4/23/16 (not timed) documented the resident returned to the facility from the hospital and, .bruises to chin and arms . c/o pain. Tramadol 50 mg (milligrams) given . There was no documentation of any interventions that were initiated, upon the resident's return to the facility, to address the resident's previously identified ability to turn off his own alarms. e. Nurses Notes dated 6/18/16 at 1:20 a.m. documented, .Pt (patient) found lying on the floor. Denies problems. Pt checked. Assisted to a standing position. No signs of broken bones. Assisted in the wheelchair. Pt. cleaned up and assisted to bed . 1:40 a.m. Pt lying supine . Pt asked if he is okay, states his shoulder is hurt. Shoulders felt, left shoulder pt. grimace . 1.) A Resident Incident/Accident Report dated 6/18/16 at 1:20 a.m. documented, Pt (Patient) found lying on the floor. fell trying to get up. Assisted up after no breaks or problems found . Summary of Investigation . Resident found on floor, attempted to self-transfer out of bed . assisted from floor without incident . Recommendations / New Interventions . 6/18/16 . Refer to Therapy . The I&A Report and Investigation Follow-up form for this incident did not document whether an alarm was in use at the time of the fall and, if so, whether the alarm sounded when the resident stood up. The facility's documentation did not include an evaluation for causative factors (such as asking the resident what he was trying to do at the time of the fall, checking for the presence of alarms and use of wheelchair brakes, et cetera.) No additional fall prevention interventions were documented on the I&A form or added to the resident's Care Plan at this time. 2.) A Radiology Report dated 6/18/16 for an x-ray of the resident's left shoulder documented, Mild degenerative changes seen of the shoulder without acute fracture or dislocation. f. Nurse's Notes dated 6/26/16 at 3:50 a.m. documented, Pt awake. CNA states pt stood and he witnessed pt fall. Left arm where prior bandage was bleeding. Pt alert, sitting on the edge of bed . 0430 (4:30 a.m.) awake, alert, up in the chair. Pt states he fell on L (left) shoulder . 0710 (7:10 a.m.) Called for x-ray . The Incident & Accident Reports for this resident, provided by the DON to the survey team on 1/11/17 at 11:00 a.m., did not include an I&A report for this incident. 1.) A Nurses Note dated 6/26/16 at 4:20 p.m. documented, Sent to ER (emergency room ) for hip fracture. Sent via ambulance . 2.) A Radiology Report dated 6/26/16 at 11:01 a.m. documented, .Impression . Interval development of acute/subacute fracture involving the right hip acetabular protrusion . healed right superior and right inferior pubic ramus fractures . postsurgical changes of the left femur without complication . g. Nurse's Notes dated 8/12/16 at 1:00p.m. documented, .Res has I&A due to found on floor in room at 11:30 a.m. Res has new order for lab and x-ray to Rt. (right) Knee . An Incident/Accident Report dated 8/12/16 at 11:30 a.m. documented, .CNA called nurse to Res. room. Found res. on floor sitting on his buttocks with Rt.(right) knee and) leg up Res. c/o (complains of) Rt. Knee pain, body audit, redness to rt. Knee (with) (no) swelling, (no) bruising . The Additional comments / steps taken to prevent recurrence documented, Advised res. on using call light when needing help to get up or go to bed or in chair . The attached Nurse Fall Investigation Form dated 8/12/16 documented, .Res states, 'I was trying to walk to my chair' . area clean & free from clusters & clutter . Res was lying in bed, Res does ambulate via w/c, self-propel . What alarms did resident have and were they in place and sounding at time of fall? No alarms . The Investigation Follow Up form dated 8/12/16 documented, .Staff to attempt to keep resident's wheelchair close to bed where resident can transfer himself over into the wheelchair . This intervention was not added to the resident's Care Plan. h. A Nurses Note dated 8/27/16 at 9:30 p.m. documented, .Resident up trying to go to bathroom on own. Retrieved by CNAs on hall. Pt asked what he was trying to do. Pt states, 'I was trying to go to bathroom' .Pt had small skin tear to right medial inner thumb . An Incident/Accident Report dated 8/27/16 at 9:30 p.m., documented, .Pt (patient) was found on floor on other side of room next to bathroom door. Pt was asked what he was trying to do. Pt. stated, 'I was trying to go to bathroom'. Pt has skin tear noted to middle inner Rt (right) thumb . The Additional comments / steps taken to prevent recurrence documented, Educated pt to call for help and wait for help . The Investigation Follow Up form dated 8/27/16 documented, .Staff to assist resident to toilet as needed while making rounds . This intervention was not added to the resident's Care Plan. i. A Nurses Note dated 8/29/16 at 10:09 p.m. documented, .Resident found on floor in room on left side with back facing door . Resident assisted to bed by nurse et x 1 (and one) CNA . 1.) An Incident/Accident Report dated 8/29/16 at 10:00 p.m. documented, .Resident found on floor in room on L (left) side (with) back facing door . Resident assisted to bed by nurse and CNA. ROM (range of motion) to BUE (bilateral upper extremities) et (and) BLE (bilateral lower extremities). Alert to person . The Additional comments / steps taken to prevent recurrence section of the form was left blank. 2.) The Nurse Fall Investigation form dated 8/29/16 documented, .Ask resident: what were you trying to do? (Response) Get out of bed . Position of resident when found? On L (left) side (with) back facing the door . surrounding area . free of clutter . tile intact, w/c out of reach . What alarms did resident have and were they in place and sounding at time of fall? Chair alarm . 3.) The Investigation Follow Up form dated 9/3/16 (5 days after the incident) documented, 8/29/16 . Staff to check on resident frequently for the need to get out of bed or to toilet . There was no documentation of any new interventions and no corrective action documented to address the fact that the resident's wheelchair had been left out of his reach (the facility's response to the previous incident on 8/12/16 included that staff would keep the resident's wheelchair within reach of the resident's bed). j. Nurses Notes dated 11/19/16 at 11:30 a.m. documented, .Called to resident's room. Resident sitting on the floor in front of the bathroom. Assisted resident to the bathroom. No injury noted. Encouraged to use call light . The Incident/Accident Report dated 11/19/16 at 11:30 a.m., documented, Called to res. room by HK (house keeper) Res sitting on the floor in front of his bathroom. Assist Res to the bathroom, no injury noted. Encourage to use c/l (call light) for assist. CNA to take to the bathroom (every) 2 (hours) . Intervention . Obtain UA. (urinalysis) No apparent injury . The Investigation Follow Up form dated 11/23/16 documented, 11/22/16 . Urinalysis here, no culture indicated . There was no documentation of any new fall prevention interventions that were to be attempted at this time. k. An Incident/Accident Report dated 12/1/16 at 7:55 a.m. documented, Res (Resident) attempted to amb (ambulate) and sit in floor in rm (room) doorway. Floor dry, good lighting, shoes on feet, w/c (wheelchair) at doorway. Denies px (pain) MAE (moves all extremities) . The Investigation Follow Up form dated 12/5/16 documented, .He was fully dressed, shoes on . Shoes were examined and the soles of his shoes appeared without grip . Another pair of shoes found with grip . Responsible party notified regarding the need for new shoes . l. An Incident/Accident Report dated 12/17/16 at 4:30 p.m. documented, Called to end of 600 Hall (and) Res sitting in front of his w/c at (Room) 609 door. No injury noted. Assisted up to the BR (bathroom) in w/c then to the DR (dining room). Res. was trying to get another Res' (resident's) fan. Interventions have CNA to monitor res. whereabouts when wandering . Sit up by the desk to be monitored when resident is wandering . The Investigation Follow Up form dated 12/21/16 documented, 12/17/16 . Therapy notified of fall . A Nurse Fall Investigation Form dated 12/17/16 at 4:30 p.m. documented, .Ask resident: What were you trying to do? (Response): To get my fan . Was the resident using an assistant device and what type? No . What alarms did resident have and were they in place and sounding at time of fall? No . m. An Incident/Accident Report dated 1/11/17 at 9:30 p.m. documented, CNT (Certified Nurse Technician) in room (with) resident (and) he got (up) out of w/c to get in bed before she could get him he fell in floor and hit his head (L) (left) shoulder and side on the side of the bed. Red scratch to forehead, c/o (left) shoulder pain .X-ray ordered to the left shoulder. Neuro (check) started. (Local x-ray company) notified . A Nurses Note dated 1/11/17 at 9:30 a.m. documented CNT in room cleaning resident from having bowel movement and she put him in his wheelchair to finish cleaning the bed up and linens. CNT (name) stated she walked around to the back of the wheelchair and (Resident) got up to get back in the bed and fell on the floor and hit the left side of his head and left shoulder on the side of the bed. Red mark noted to the top of left forehead. No bleeding noted. Complained of pain to the left shoulder. Old bruises and scabs noted to the left arm from previous fall. (APN) notified and ordered a x-ray to the left shoulder and clean scratch to the top of left forehead .Resident able to perform range of motion to the upper extremities . n. On 1/10/17 at 8:52 a.m. and 4:58 p.m. and 1/11/17 at 8:34 a.m. and 2:20 p.m., the resident was sitting in a wheelchair with no anti-tippers in place. 1.) On 1/11/17 at 2:30 p.m., LPN #5 was asked, What interventions are in place for (Resident#8) to prevent his falls? She stated, I don't really know. I think anti-tippers for the wheelchair, but they are not on his wheelchair. I will go ask the DON. 2.) On 1/11/17 at 2:40 p.m., the DON was asked, Can you tell me if (Resident #8) is supposed to have anti-tippers on his wheelchair? The DON stated, Yes . but CNAs clean the wheelchairs and mixed his wheelchair up with someone else's chair. 3.) On 1/11/17 at 3:48 p.m., LPN #5 stated, They (anti-tippers) are on his wheelchair now. 4.) On 1/12/17 at 2:30 p.m., CNA #16 was asked, Have you ever worked with (Resident#8)? The CNA stated, Yes. She was asked, Have you ever seen anti-tippers on (Resident #8's) wheelchair? CNA #16 stated, Yes, not sure how long. 5.) On 1/12/17 at 2:35 p.m., LPN #6 was asked, Who is responsible for implementing interventions after a fall? LPN #6 stated, The ADON (Assistant Director of Nursing) or the nurse on the hall after they assess him. She was asked, How do you let direct care staff know of interventions and how to implement them? LPN #6 stated, In-service and call all CNAs on the hall to let them know what to do. She was asked, Do you expect a resident with a BIMS (score) of 3 to be aware to call for assistance or help? LPN #6 stated, I'm not sure. LPN #6 was asked, If anti-tippers are ordered for a resident's chair, should they be implemented immediately? LPN #6 stated, Yes, if they are ordered, they should be put in place. She was asked, Have you ever worked with (Resident #8)? LPN #6 stated, Yes, if he has skin issues. 6.) On 1/12/17 at 2:45p.m., CNA #14 was asked, Have you ever worked with (Resident #8)? CNA #14 stated, Yes. She was asked, Have you ever seen anti-tippers on (Resident #8's) wheelchair? CNA #14 stated, No. She was asked, How are you notified of any interventions that are put into place after a fall? CNA # 14 stated, In-service. She was asked, Has (Resident#8) ever put his call light on for assistance? CNA #14 stated, No, we always check on him every 2 hours, and frequently. She was asked, Is (Resident #8) able to make his needs known? CNA #14 stated, No. 7.) On 1/12/17 at 2:45 p.m., LPN #7 was asked, Who is responsible for making an intervention after a fall? LPN #7 stated, The nurse. She was asked, How do you let direct care staff know of interventions, and how to implement them? LPN #7 stated, I tell them, and show them what needs to be done. She was asked, Do you expect a resident with a BIMS of 3 to be aware to call for assistance or help? LPN #7 stated, No, I guess not, check on them regularly, and I don't let them be in the room by themselves. She was asked, If anti-tippers are ordered for a resident's chair, should it be implemented immediately? LPN #7 stated, Yes ma'am, and try to get them. LPN #7 was asked, Have you ever worked with (Resident #8)? LPN #7 stated, Yes, I have worked with him. 8.) On 1/12/17 at 2:45 p.m., LPN #5 was asked, Who is responsible for making an intervention after a fall? LPN #5 stated, I turn the incident/accident over to the DON and Care Nurse, and the DON puts interventions in place. She was asked, How do you let direct care staff know of interventions, and how to implement them? LPN #5 stated, After a resident fall, if there is a new intervention, the CNAs are in-serviced and sign off on the in-service. LPN #5 was asked, Do you expect a resident with a BIMS of 3 to be aware to call for assistance or help? LPN #5 stated, Sometimes, depends on who the resident is. Sometimes they know and don't use the call light. She was asked, If anti-tippers are ordered for a resident's chair, should it be implemented immediately? LPN #5 stated, Yes. She was asked, Did (Resident #8) have an intervention for anti-tippers? She stated, Yes he did. We put them on yesterday, 2/11/17. She was asked, Is that when you first knew he was supposed to have anti-tippers? LPN #5 stated, Well, he was in a room with two wheelchairs, and his wheelchair with anti-tippers was not in the room. I guess when they clean them at night, they put his wheelchair in the wrong room. 9.) On 1/12/17 at 2:48 p.m., CNA #15 was asked, Have you ever worked with (Resident #8)? CNA #15 stated, Yes. She was asked, Have you ever seen anti-tippers on (Resident #8's) wheelchair? CNA #15 stated, No. She was asked, How are you notified of any interventions that are put into place after a fall? CNA #15 stated, In-service. She was asked, Has (Resident #8) ever put his call light on for assistance? CNA #15 replied, No. She was asked, Is (Resident #8) able to make his needs known? CNA #15 stated, He can speak for himself. 10.) On 1/12/17 at 2:50 p.m., CNA #18 was asked, Have you ever worked with (Resident #8)? CNA #18 stated, Yes. She was asked, Have you ever seen anti-tippers on (Resident #8's) wheelchair? CNA #18 stated, No, I have never seen them on. She was asked, How are you notified of any interventions that are put into place after a fall? CNA #18 stated, They don't tell us, I don't know. She was asked, Has (Resident #8) ever put his call light on for assistance? CNA #18 stated, No, never. She was asked, Is (Resident #8) able to make his needs known? CNA 6# stated, You have to ask him first, and he can respond. He doesn't tell me anything first. 2. Resident #11 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 10/25/16 documented the resident scored 0 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required extensive one person physical assistance for bed mobility and transfer. a. The Plan of Care dated as reviewed / revised on 10/25/16 documented, Focus: I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Dementia . Interventions / Tasks: TRANSFER: I require extensive assistance with transfers . b. On 1/13/17 at 10:25 a.m., CNAs (Certified Nursing Assistants) #8 and #9 transferred the resident from the bed to the geri chair. CNA #8 used her left hand and placed it behind the resident's neck to raise resident's upper body off of the bed, in order to place a gait belt underneath the resident's back. The resident was moaning, Oh, oh each time CNA #8 lifted the resident by the neck. The CNA lifted the resident under the neck three times to work the gait belt under the resident's waist. The gait belt was placed around the resident's waist. CNA #8 stated, (The resident) can stand a little bit. CNA #8 put the resident's shoes on her feet and, without lifting the resident's torso from the bed, moved the resident's feet off the side of the bed. The resident was lying across the bed at an angle. CNA #9 placed her right hand at the back of the resident's neck and lifted the resident to a sitting position on the side of the bed. The resident was moaning, Oh, oh, as she was assisted to a sitting position on the side of the bed. The CNAs grasped the gait belt in the front and back and lifted the resident. As they lifted the resident, the gait belt slid up over the resident's chest / rib area. The resident did not bear weight on the lower extremities and her toes dragged on the floor as the CNAs transferred her to the geri-chair. Once the resident was in the geri chair, the CNAs again grasped the gait belt, which was still over the resident's chest/rib area, and repositioned the resident in the geri chair. The CNAs reclined the back of the geri-chair while the foot rest was left angled toward the floor. The lock bar on the right side of the geri chair was approximately one and a half inches higher than the left side. At 10:32 a.m., CNA #8 was asked if the lock bar on the geri chair would lock in place. She stated, No, it is bent on one side. She was asked if the foot rest was operating correctly. She stated, It won't stay up. CNA #8 was asked if the resident's toes always dragged across the floor during transfers. She stated, Not always, she can stand and pivot. CNA #8 was asked if the resident made those moaning noises during all transfers. She stated, Usually.

Complaint # (AR 793), Complaint # (AR 805) and Complaint # (AR 825) were substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to promote the healing of pressure ulcers for Residents #1, #3, #7 and #8: The facility failed to ensure pressure ulcer treatments were promptly initiated and were provided at the frequency ordered by the physician to promote healing and prevent potential deterioration for 2 (Residents #3 and #8). The facility failed to ensure the physician was promptly consulted regarding newly identified pressure ulcers or deterioration of existing pressure ulcers to allow the physician to determine if a change in treatment was needed for 2 (Residents #3 and #8) of 7 (Residents #1, #3 and #5 through #9) case mix residents who had pressure ulcers. The facility failed to conduct and document thorough pressure ulcer assessments on at least a weekly basis, to include measurements, staging and condition of the wound and surrounding tissue to facilitate the ability to track healing progress or deterioration of pressure ulcers for 2 (Resident #3 and 8) of 7 (Residents #1, #3 and #5 through #9) case mix residents who had pressure ulcers. The facility failed to ensure planned pressure relief interventions were consistently implemented to decrease the potential for development of new pressure ulcers and to prevent deterioration in existing pressure ulcers for 2 (Residents #1 and #3) of 7 (Residents #1, #3 and #5 through #9) case mix residents who had pressure ulcers of 7 (Residents #1, #3 and #5 through #9) case mix residents who had pressure ulcers. These failed practices resulted in patterns of actual harm to Residents #3 and #8, who experienced deterioration in existing pressure ulcers and development of new pressure ulcers, and had the potential to cause more than minimal harm to 4 residents who had pressure ulcers, as documented on a list provided by the Director of Nursing on 11/17/15. The facility also failed to ensure a [DEVICE] (vac) was applied as ordered by the physician to promote healing for 1of 1 (Resident #7) case mix residents who had pressure ulcers and physician orders [REDACTED]. This failed practice had the potential to cause more than minimal harm for 1 residents with pressure ulcers and physician orders [REDACTED]. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/15 documented the resident scored 2 (0-7 indicates severely impaired) on the brief interview for mental status, was totally dependent on 2-plus persons for bed mobility and transfers, was incontinent of bowel and bladder, was at risk for developing pressure ulcers and had 1 Stage 3 and one Stage 4 pressure sore. a. The Braden Scale for Predicting Pressure Ulcer Risk form dated 8/21/15 documented the resident's total pressure ulcer risk score was 15, with a score of 15-16 indicating a mild risk for pressure ulcers. The categories on the form that contributed to this score documented the following: 1) Scored 3 for Sensory Perception: Ability to respond meaningfully to pressure-related discomfort slightly limited responds to verbal commands, but cannot always communicate discomfort or need to be turned or has some sensory impairment which limits ability to feel pain discomfort in 1 or 2 extremities. 2) Scored 3 for Moisture: Degree to which skin is exposed to moisture - occasionally moist - skin is occasionally moist, requiring an extra linen change approximately once a day. 3) Scored 2 for Activity: Chair fast - ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 4) Scored 3 for Mobility: Ability to change and control body, slightly limited - makes frequent though slight changes in body or extremity position independently. 5) Scored 3 for Nutrition: Usual food intake pattern: Adequate - Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, or is on a tube feeding or TPN (Total [MEDICATION NAME] Nutrition) regimen, which probably meets most of nutritional needs. 6) Scored 1 for Friction and Shearing: Problem - Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requires frequent repositioning with maximum assistance. Spastic contrarieties or agitation leads to almost constant friction. b. The Comprehensive Care Plan dated 9/10/15 documented, .I have a Pressure Ulcer . date initiated 9/10/15. Goal - My Pressure Ulcer will show signs of healing and remain free from s/sx (signs and symptoms) of infection through review date . Intervention/Task - Assess/record/monitor healing weekly. Measure length, width and depth; where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvement and declines to the MD (Medical Doctor) . Monitor/document/report to MD PRN (as needed) changes in skin status; appearance, color wound healing, s/sx of infection, wound size (length x (times) width x depth), stage. Administer treatments as ordered and monitor for effectiveness. The November Physician order [REDACTED].Positioning Devices . The order was dated 5/30/14. c. A physician order [REDACTED]. The Wound Center Progress Note dated 10/6/15 documented, Integumentary . Wound #17 Left Heel is a Stage III Pressure Ulcer and has received a status of not healed. Sequela wound encounter measurements are 1.3 cm (centimeters) length x 1.1 cm width x 0.1 cm depth with an area 1.43 sq (square) cm and a volume of 0.143. There is a small amount of sero-sanguineous drainage noted which has no odor. The wound margin is flat and intact. Wound bed is 1-25% adherent, yellow slough, 76-100% red granulation . Physical exam notes; His heel wound continues to improve it is presently 97% closed. He is wearing the protective boot 24/7 . Wound orders, Wound #17 cleanse wound and peri-wound with soap and water. [MEDICATION NAME] - apply [MEDICATION NAME] Cream in wound/bed. Cover and secure with dressings of choice. Change as directed - change BID (two times per day). Change Dressing BID and PRN (as needed) for excessive drainage. Off Loading. Follow up Appointment, Return appointment in 3 weeks. 1) The facility's Weekly Pressure Ulcer Record documented measurements obtained by the Treatment Nurse on 10/9/15 and 10/29/15 as follows: 10/15/15: 1.2 centimeter (cm) by (x) 1 cm x 0 cm 10/22/15: 1.3 cm x 2 cm x 0 cm 10/29/15: 3.8 cm x 2.5 cm x 0.1 cm 2) On 11/13/15 at 12:20 p.m., the Treatment Nurse was asked, When you obtain your measurements of the wounds, when do you do your documentation? The Treatment Nurse stated she obtained her measurements and then documented them, .later in the week or when I get a chance . 3) The October 2015 Treatment Administration Record (TAR) documented, Cleanse Left Heel with Normal Saline and apply [MEDICATION NAME] and cover with 4 x 4 dressing, pad with ABD (abdominal) pad and secure with Kerlix and tape order date: 12/17/14 first shift 7-3 (7:00 a.m. - 3:00 p.m.) every day. The TAR documented nurses' initials to indicate the treatment was provided once daily from 10/1/15 through 10/24/15 and 10/26/15 through 10/30/15. There were no initials to indicate that the dressing change was provided on 10/25/15 and 10/31/15. The October 2015 TAR did not document the physician order [REDACTED]. d. The Wound Center Progress Note dated 10/27/15 documented, Integumentary . Wound #17 Left Heel is a Stage 3 Pressure Ulcer and has received a Status of not healed. Sequela wound encounter measurements are 4.9 cm length 7 cm width x 0.1 cm depth with an area of 34.3 sq (square) cm . There is a large amount of Sero-sanguineous drainage noted which has no odor. The wound margins are flat and intact. Wound bed is 26-50% adherent, yellow slough. 26%-50% adherent, yellow slough, 26-50% bright red granulation . Physical Exam: .Today the wound is larger. It is obvious that the NH (Nursing Home) is not keeping pressure off of the heel . Wound Orders . Wound #17 Wound cleansing & Dressing Cleanse wound and peri-wound with soap and water. [MEDICATION NAME] - Apply [MEDICATION NAME] Cream to wound bed. Cover and secure with dressing of choice. Change as directed. Change dressing BID (two times daily) for excessive drainage . Off Loading; Mattress Overlay/Specialty Bed Mattress - Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degree tilt. Limit HOB (head of bed) elevation to 30 degrees in bed. Use/wear Heel Lift for offloading as directed - wear at all times . Wound #21 Left Lateral Ankle . Stage II Pressure Ulcer . has received a status of not healed. Initial wound encounter measurements are 1 cm length x 0.8 cm width x 0.1 cm depth with an area of 0.8 sq cm. There is a small amount of Sero-Sanguieous drainage noted which has no odor. The wound margins are flat and intact. Wound bed is 26%-50% adherent, yellow slough, 26%-50% bright red granulation .Wound #21 Left Lateral Ankle, Wound cleansing & Dressing Cleanse wound and peri-wound with soap and water. [MEDICATION NAME]- Apply [MEDICATION NAME] Cream to wound bed. Cover and secure with dressing of Choice. Change as directed. Change dressing BID (two times daily) for excessive drainage . Return appointment in 3 weeks. Nurse visit as needed. Follow wound care orders for nurse only visits. Contact panel Physician with any significant changes . There was no documentation in the facility clinical record of an assessment or physician consultation regarding a pressure ulcer to the left lateral ankle, prior to the Wound Center encounter on 10/27/15. e. The November 2015 Physician order [REDACTED]. Pad and secure with Kerlix and tape 7-3 every day. The physician order [REDACTED]. f. The November 2015 Treatment Administration Record documented, Cleanse Left Heel with Normal Saline and apply [MEDICATION NAME] and cover with 4 x 4 dressing, pad with ABD, pad and secure with Kerlix and tape order dated 12/17/14 first shift every day. As of 11/10/15, the TAR documented nurses' initials to indicate the treatment was provided once daily from 11/2/15 through 11/10/15, instead of twice daily as ordered by the physician. There were no initials to indicate the treatment was provided on 11/1/15. The November 2015 TAR also documented 2 handwritten orders dated 11/11/15 as follows: 1) Cleanse Lt (left) heel (with) NS (Normal Saline) apply [MEDICATION NAME] cover with 4 x 4s apply ABD pad secure with Kerlix, tape, q (every) day . 2) Cleanse Lt (left) lateral ankle (with) NS apply [MEDICATION NAME] cover with 4 x 4s, ABD pad, wrap (with) Kerlix tape, q day. g. On 11/9/15 at 2:54 p.m., the resident was lying in bed with the head of bed elevated to approximately 30 degrees. The resident had a heel lift boot on the left foot with the heel of the boot resting directly on the bed. h. On 11/10/15 at 8:40 a.m., 12:10 p.m. and 3:10 p.m., the resident was lying in bed with a heel lift boot on the left foot, with the heel of the boot resting on the bed. The resident's right foot was resting directly on the bed, not offloaded. i. As of11/6/15 at 5:25 p.m., the MDS Kardex Report utilized by the facility's Certified Nursing Assistants did not document instructions for offloading the resident's heels, and the Comprehensive Care Plan dated 9/10/15 had not been updated to include the use of heel lift boots to relieve pressure to the resident's heels. j. On 11/11/15 at 2:50 p.m., the resident was in bed. The Treatment Nurse provided wound care for the resident. The resident was in bed and had a heel lift boot on the left foot. When the Treatment Nurse began removing the heel lift boot, the resident's heel was resting directly on the inner foam lining of the boot and was not suspended in the heel lift boot to prevent pressure to the left heel wound. The left lateral ankle was also in direct contact with the solid foam lining of the boot. The foam edges of the boot were torn. The Treatment Nurse measured the heel wound as approximately 5 cm in length x 7 cm in width x 0.1 cm in depth. The wound bed was red with yellow slough, and there was a moderate amount of serosanguinous drainage on the dressing. The left lateral ankle measurements were approximately 2 cm in length x 2 cm in width x 0.1 depth, and the wound bed had a reddish appearance with a scant amount of reddish drainage. The Treatment Nurse stated, The boot has torn foam and needs to be replaced. 1) On 11/12/15 at 12:50 p.m., the Treatment Nurse provided the manufacturer's instructions for the Heellift AFO (ankle-foot orthosis) boot and stated this was the type of boot that was in use on Resident #3's left lower extremity. The instructions documented, .Application & (and) Fitting Guide . Each boot comes with a spare elevation pad that can be trimmed to further ensure a customized fit . Place the foot inside the boot with the heel positioned above the heel suspension opening. The heel should hang over the bottom elevation pad . Test for the proper fit. You should be able to fit your fingers between the heel opening and the bed . Customizing the Fit, Malleolar Decubitus, cut away the bumps surrounding the ankle. Cut a portion of the fixed pad if necessary . 2) On 11/13/15 at 11:45 a.m., the Treatment Nurse was asked who was responsible for ensuring the resident's heels were properly off loaded and that the resident's foot was positioned correctly inside the heel lift boot. The Treatment Nurse stated, I am, along with the Nurses and CNAs (Certified Nursing Assistants), to ensure that pillows are placed on the bed so the heels are off loaded. The Treatment Nurse was asked what type of boot the resident was wearing and stated, I don't know; it starts with H. It has foam inside the boot. He had the same boot on in September (2015) . I got out of school in May (2015). I'm a new nurse. The Treatment Nurse was asked if she had received any wound training. The Treatment Nurse stated, No, people have come in, and the DON and ADON (Assistant Director of Nursing) have helped me. The Treatment Nurse was asked if the resident's heel should be resting directly on the foam inside the heel lift boot. The Treatment Nurse stated, Yes, it is foam inside the boot. The Treatment Nurse was asked if this would cause increased pressure on the heel. The Treatment Nurse stated, I guess. The Treatment Nurse was asked, With a heel lift suspension boot, should the heel be suspended inside the boot? The Treatment Nurse stated, Yes, I changed his boot this morning; the other boot had been washed and the foam was tearing off. The Treatment Nurse also stated the resident's wife had informed her in October 2015 that the resident's feet / heels were not being properly positioned and, .I did another in-service. 3) The Treatment Nurse provided the survey team with in-service documentation dated 10/2/15 through 10/4/15, which documented that the ADL (Activity of Daily Living) book would contain the turn schedule for residents that had suspension boots. A return demonstration of proper positioning was documented, including how to bridge residents' heels with pillows. There was no documentation that staff were instructed on properly positioning residents' feet in heel lift boots to prevent pressure to the heels. The Treatment Nurse was asked, How did you ensure (residents') heels were off loaded and the heel suspension boots were applied correctly? The Treatment Nurse stated, I documented the monitoring in my notes. 4) The Nurses Note dated 10/5/15 and signed by the Treatment Nurse documented, Rounds were made on hall to make sure heels were being bridged properly. Will continue to observe. k. On 11/11/15 at 3:55 p.m., the Treatment Nurse was asked, Do you read the documentation when the resident returns from the Wound Clinic? The resident went to the Wound Clinic on 10/27/15 and there was an increase in the size of the pressure ulcer to the left heel. The Treatment Nurse stated, The CNAs are not keeping the resident's heel bridged properly on the hall, and the resident has gained weight. The Treatment Nurse was asked about the Wound Clinic Physician order [REDACTED]. The Treatment Nurse stated she had called the wound clinic and did not receive the orders on 11/4/15 and, I went over and picked up the orders. The Treatment Nurse stated she wrote a clarification order on 11/11/15. The Treatment Nurse and this surveyor reviewed the telephone order dated 11/11/15, which documented the same once-daily treatment with normal saline and [MEDICATION NAME] that had been in place since December 2014. The order did not document the name of the person who provided the order to the Treatment Nurse. The Treatment Nurse was then asked who she had spoken with at the wound clinic to obtain this order. The Treatment Nurse provided 2 different names. The Treatment Nurse was asked if she knew the person's title and stated, No. l. On 11/12/15 at 12:50 p.m., during a telephone interview, the Clinical Manager of the Wound Clinic was asked if the facility had called her regarding Resident #3. The Clinical Manager stated she had spoken with them. The Clinical Manager was asked if the facility had called regarding the frequency of the dressing changes to the resident's left heel. The Clinical Manger stated she would check the computer and the paper documentation. After review of the documentation, the Clinical Manger stated, The dressings are to be changed BID (twice daily). The Clinical Manager was asked if she had spoken to anyone at the facility to decrease the frequency of the dressing changes back to daily. The Clinical Manager stated, I don't recall that or have documentation of that . to my knowledge, the dressing is to be changed BID. m. On 11/12/15 at 1:40 p.m., the Director of Nursing (DON) and this surveyor observed the positioning of the resident's foot in the heel lift boot. The DON was asked if the heel of the resident's foot was resting directly on the foam. The DON stated, Yes, it's partly lying on the foam. The DON was asked if the heel was properly suspended in the heel lift boot. The DON stated, No. The DON was asked who was responsible for ensuring that the heel lift boots were properly applied and the heels were properly positioned. The DON stated. The Nurses. The DON was asked if the improper positioning of the resident's heel in the boot would increase pressure on the resident's heel. The DON stated, Yes. The DON was shown the Wound Clinic measurements for 10/6/15 and 10/27/15, which also documented Physician order [REDACTED]. The DON was then shown the facility's October and November 2015 TARs, which documented the wound care to the left heel had been provided once daily. The DON was asked if the treatments should have been provided BID. The DON stated, Yes, that's what it (physician order) says. The DON was asked if the treatments had been provided BID and stated, It doesn't look like it was done. The DON was then asked to review the Comprehensive Care Plan and MDS Kardex to determine if they addressed the need for the heel lift boot and offloading of the resident's heels. The DON reviewed the Care Plan and Kardex and stated, No, it's not documented. The DON was asked who was responsible for updating the Comprehensive Care Plan and MDS Kardex and stated, The Care Plan Coordinator. There has been a problem with getting the Care Plans and Kardex to contain all information that is related to the resident; we are working on that. n. On 11/12/15 at 2:25 p.m., the Assistant Director of Nursing (ADON) was asked how long she had been the ADON. The ADON stated, One year. The ADON was asked, What are your job duties? The ADON stated, A little bit of everything; I oversee the wounds, staffing, stuff like that. The ADON was asked, When a resident goes to the Wound Clinic, how long does it take for the orders to be received from the wound clinic? The ADON stated, Sometimes a couple of days. When I was Treatment Nurse, I had to call them and ask them to fax the orders. The ADON was asked if she had spoken with the Director of Nursing about the timeframes for the orders being sent, received and processed from the Wound Clinic. The ADON stated, No. The ADON was asked who checked the documentation received from the Wound Clinic for new orders. The ADON stated, The Treatment Nurse. The ADON was asked, What is the expected timeframe for transcribing a Physician Order? The ADON stated, Immediately. The ADON was asked how often Resident #3 went to the Wound Clinic. The ADON stated, Every 3 weeks. The ADON was asked, Did you call the Wound Clinic on 11/11/15? The ADON stated Yes, I called because the orders documented clean with soap and water and had it changed to Normal Saline. The ADON was asked if she called about anything else. The ADON stated, No. The ADON was asked who she spoke with and stated, (Clinical Manager.) The ADON was asked if the Treatment Nurse had called the Wound Clinic and stated, If she did, I wasn't in there. The ADON was asked if she was aware of the increase in size of the pressure ulcer to the resident's left heel. The ADON stated, She (Treatment Nurse) told me that it had gotten bigger and we're trying to keep it offloaded. The ADON was asked if she had checked the resident or checked the positioning, removed the boot and checked the positioning of the resident's foot in the boot. The ADON stated, The first part of October, I did. The ADON was asked if she saw a problem with the positioning of the foot in the heel lift boot at that time. The ADON stated, No. The ADON was asked if she was aware the Treatment Nurse had stated she picked up the Wound Clinic Orders on 11/4/15 for the Wound Clinic appointment dated 10/27/15, and that those orders were not processed until 11/11/15. The ADON stated, I don't know. The ADON was asked about the Wound Clinic Physician order [REDACTED]. The ADON stated, I didn't check the wound clinic orders; the Treatment Nurse did. o. On 11/13/15 at 11:52 a.m. the DON was asked to review the October and November 2015 Treatment Administration Record and to verify the frequency of the dressing changes to the resident's left heel from 10/6/15 -11/11/15. The DON stated, Only daily. The DON was informed the Treatment Nurse stated that she had called the Wound Clinic on 11/11/15 for clarification of the Wound Orders that she had received on 11/4/15, and had documented a Physician order [REDACTED]. The DON was informed there was no documentation on the order of who she had received the Physician order [REDACTED]. The DON was also informed that the wound clinic was called by the surveyor on 11/12/15 and the Clinical Manager had stated that, although she had spoken with staff from the facility, she had no knowledge of the dressing order being changed back to daily. The DON stated, I see the order for BID. The DON was informed that the Treatment Nurse stated that she had received the orders on 11/4/15 from the Wound Clinic, and according to the documentation in the clinical record and the Treatment Administration Record, there was a delay in processing and implementing the orders until 11/11/15. This was 35 days the resident did not receive the treatments BID as ordered. The DON stated, I see that. p. On 11/13/15 at 12:20 p.m., the Treatment Nurse, with the DON present, was asked if she had completed the treatments for the resident that morning. The Treatment Nurse stated she changed the dressings just before lunch, around 12 noon. The Treatment Nurse stated she had from 6:00 a.m. until 2:00 p.m. to change the dressing for her shift. The Treatment Nurse was asked, If a treatment is BID, should there be specific time (scheduled)? The Treatment Nurse stated, No, we don't put a time frame; its 6 to 2 (6:00 a.m. to 2:00 p.m.) and 2 to 10 (2:00 p.m. to 10:00 p.m.). The Treatment Nurse was asked, If you change the dressing at noon, and the 2 to 10 shift comes on and changes the dressing at 3:00 p.m., that would be 3 hours between dressing changes. The Treatment Nurse stated, The treatment is BID. The DON stated, That's something we are going to have to work on. The Treatment Nurse was asked, Regarding the pressure ulcer on the left lateral ankle, when was the onset date of this the pressure ulcer? The Treatment Nurse stated, It occurred a few days before he went to the Wound Clinic; he was going on 10/27/15. The area was at first just bleeding and then it got a little bit larger. The Treatment Nurse was asked if she had called the Physician upon identification of this pressure ulcer. The Treatment Nurse stated, No, he was scheduled for the wound clinic. The Treatment Nurse was asked if she had performed a treatment to this wound and stated she had used a previous order to provide treatment to the left lateral ankle wound. The Treatment Nurse was asked if she had obtained measurements of the pressure ulcer when it was discovered. The Treatment Nurse stated, No, he was scheduled to go to the wound clinic in a few days. The Treatment Nurse was asked, You did not notify the Physician of a new Pressure Ulcer, did not obtain measurements when you discovered the Pressure Ulcer, (you) performed a treatment without a Physician order [REDACTED].? The Treatment Nurse stated, He (resident) was going to the Wound Clinic in a few days. The Treatment Nurse was asked, When the area started on the left ankle, did you assess to determine what could have been causing the pressure on the left lateral ankle? The Treatment Nurse stated, There was an in-service on offloading and positioning the first part of October. The Treatment Nurse was asked if she had assessed the heel lift boot for pressure points on the ankle. The Treatment Nurse stated, No. 2. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/5/15 documented the resident scored 15 (13-15 indicates cognitively intact) on the brief interview for mental status, required total assistance for bed mobility and transfers, was at risk for Pressure Ulcers and had 1 Stage II, 1 Stage III and 1 Stage IV pressure ulcer. a. A physician's orders [REDACTED]. The record documented the wound care was provided to the resident once daily on the 6:00 a.m. to 2:00 p.m. shift from 10/9/15 through 10/30/15, as indicated by the nurses' initials. b. The Weekly Pressure Ulcer Record dated 10/29/15 documented the resident had 1 Abrasion, 1 Stage II pressure ulcer, 3 Stage III pressure ulcers, one of which had increased to Stage IV and 2 Stage IV pressure ulcers. c. The November 2015 Physician order [REDACTED]. Apply [MEDICATION NAME] to bil (bilateral) buttocks BID (two times daily) and PRN (as needed). Twice daily every day. Date 6/1/15 . Clean Scrotum with soap and water apply protective ointment BID and PRN. Treatment twice daily every day. Date-8/27/15 . Cleanse right heel with Dakin's apply Santyl and cover with 4x4s and kerlix with heel foam QD (every day) and PRN. Date 8/27/15 . Cleanse Right Lateral Heel with Dakins apply Santyl and cover with 4 x 4's and Kerlix QD and PRN. Date 8/27/15 . Cleanse Right Lower Anterior Leg with Dakins, apply TAO (Triple Antibiotic Ointment) and cover with 4 x 4's and Keri QD and PRN Contact Isolation for Wound Infection. Date - 8/27/15 . d. The Wound Clinic Records dated 11/2/15 documented the following: 1) Wound #15, L (Left) heel, is chronic Stage 2 Pressure Ulcer and has a status of not healed, measurements 2 cm length x 1 cm width x 1 cm depth. Small amount of Serous Drainage. 2) Wound #16, Left Lateral Foot is Chronic Necrotic Tissue (unstageable) Pressure Ulcer and received a status of not healed, measurements 1.2 cm length x 5.5 cm width x 0.1 cm depth, no drainage. Wound is 76%-100% black eschar, none granulation. 3) Wound #17, Right Anterior Ankle is chronic stage II Pressure Ulcer and has received status of not healed. Measurements are 1 cm length x 0.8 cm width x 0.1 cm depth. Small amount of serous drainage. Wound bed is 26-50% adherent yellow slough. 26-50% bright red granulation. 4) Wound #18 Right Medial Heel is a chronic Stage II Pressure Ulcer and has received a status of not healed. Measurements are 0.3 cm length x 0.3 cm width x 0.3 cm depth. Small amount of serous drainage. The wound bed is 76-100% bright red granulation. 5) Wound #19 Right Lateral Heel is a chronic Stage II Pressure Ulcer and has received a status of not healed. Measurements are 0.2 cm length x 0.3 cm width x 0.1 cm depth. There is a small amount of serous drainage. The wound bed is 76-100% bright red granulation. 6) Wound #20 Right Lateral Foot is a chronic Stage II Pressure Ulcer and has received a status of not healed. The Measurements are 2 cm length x 4.7 cm width x 0.8 cm depth. The margin is thickened, the wound bed is 26-50% adherent yellow slough and 26-50% bright red granulation. 7) Wound #21 Right Lateral Lower Leg is a chronic Stage II Pressure Ulcer and has received a status of not healed. The Measurements are 1.5 cm length x 1.5 cm width x 0.2 cm depth. The wound margin is undefined, the wound bed is 51-75% adherent yellow slough. 1-25% bright red granulation. 8) Wound #22 Left Buttocks is a chronic Stage III Pressure Ulcer and has received status of not healed. The wound margin is thickened, the wound bed is 51-75% adherent yellow slough with 1-25% bright red granulation. 9) Wound #23 Right Buttocks is a chronic Stage IV Pressure Ulcer and has received status of not healed. The Measurements are 1 cm length x 1 cm width x 0.1 cm depth. There is a small amount of serous drainage. The wound bed is 51-75% adherent yellow slough with 1-25% bright red granulation. 10) Wound #24 is a chronic Stage II Pressure Ulcer and has received the status of not healed. The measurements are 1.0 cm length x 1.5 cm width x 0.1 cm depth. There is a moderate amount of serous drainage. The wound bed is 26-50% adherent yellow slough with 26-50% pink granulation. 11) Wound #25 Sacral is a chronic Stage II Pressure Ulcer and has received a status of not healed. There is small amount of serous drainage. The wound bed is 76-100% bright red granulation. 12) Wound #22 Left Buttocks, The ulcer base is biofilm. There was an incisional debridement preformed. Post abridgement measurements 8 cm length, x 6.5 cm width x

Complaint # (AR 132) was substantiated, all or in part, in these findings Based on observation, record review and interview, the facility failed to ensure a mechanical lift was utilized for transfers, as care planned, to prevent injury and failed to ensure prompt consultation with the physician and treatment after the resident stated her leg was broken during the transfer, to prevent delays in treatment and for 1 of 1 (Resident #1) case mix resident who was care planned for the use of a mechanical lift for transfers. The failed practices resulted in actual harm to Resident #1, who sustained a fracture of the leg and had the potential to cause more than minimal harm 26 residents who were care planned for the use of a mechanical lift for transfers according to the list provided by the Director of Nursing (DON) on 4/24/15. The findings are: 1. The facility Policy and Procedure for Transfer Technique (Bed to Chair) received on 4/24/15 from the Certified Nursing Assistant (CNA) #1 documented, "Policy, Transfer activity is performed by nursing personnel based upon the resident's needs or a Physician order [REDACTED]. This procedure insures using the safest and most effective means of moving a resident with diminished or absent lower body sensation or weakness, immobility or injury. Transfer Safety, Clinician and patient safety must never be compromised. Whenever in doubt about the level of assistance required to transfer a patient safely, obtain additional assistance..." 2. Policy and Procedure for Condition Change of the Resident received from the DON on 4/24/15 documented, "Purpose, To observe, record and report any condition change to the attending physician so proper treatment will be implemented." 3. Resident #1 was admitted to the facility on [DATE] at approximately 12:00 p.m. with [DIAGNOSES REDACTED]. The Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/15 documented the resident was independent in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required extensive assistance with bed mobility, transfers, and dressing; and was totally dependent for toilet use. a. The Interim Plan of Care dated 4/6/15 documented, "Mobility Ambulation devices W/C (wheelchair). Transfer assist Lift bed, chair 2 person." b. The Fall Risk Evaluation dated 4/6/15 documented, "Mobility confined to chair, uses bed rails, balance - evaluate resident's balance while standing, siting and during transitions, not able to attempt without physical help." The total fall risk score was 16, with a score greater than 10 indicating a high risk for falls. c. Nurses Notes dated 4/6/15 at 12:00 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, "R (Resident) arrived via facility van (with) facility staff... Requires Hoyer lift for transfers...." Nurses Notes dated 4/6/15 and signed by LPN #1 documented, "(At) 1900 (7:00 p.m.) I was asked to come to resident's room because they were getting ready to put resident to bed. On entry to room they were three male CNA (Certified Nursing Assistants). The CNA entered the room. Resident up in w/c (wheelchair) at bedside... was uncooperative with staff. The male CNA's lifted resident to a standing position. Turned & (and) sit on the bed. I heard the bed frame pop. When the bed popped, resident said, "Y'all broke my leg, I heard it pop." After positioning resident on bed I explained to resident that the sound she heard was not her leg the sound was the bed frame popping after she was seated on it... I palpated resident legs... Resident continued expressing dislike for facility and not wanting to stay here. Ask resident if she could feel me touching her leg. She stated, "Yes... My leg is broke and I need to go to the hospital. I'm calling my sister to call a ambulance to take me to the hospital... 2110 (9:10 p.m.) Ambulance personnel passed Nursing Station with resident on stretcher. One of the paramedic asked if I had paper work. I said no I was holding on the phone for the physician. No return call. I could get the copy. The male paramedic stated that alright we can get information from the patient." d. The EMS (Emergency Medical System) Record documented, "Date 4/6/15 Time 21:22 (9:22 p.m.). Narrative, [AGE] year old female patient lying in bed at (facility name), patient alert and oriented to person, place, time and event. Patient complains of pain to the right lower leg upon palpation and ROM (range of motion), patient states that she was being moved by nursing home staff. When she felt a "pop" in her right leg followed by severe pain. Patient states she can no longer move her right leg very well due to the pain. No deformity or swelling noted... Patient states that she is unable to stand or walk, patient rates her pain level 7/10 NH (Nursing Home) staff present." e. The hospital History and Physical dated 4/6/15 documented, "In talking with the patient, she indicates that she has been non-ambulatory for about a year. She tells me she had history of fractures of both the right and left legs/ankles, which were treated non-operatively with casts. The patient tells me that she never regained the ability to ambulate... The X-rays AP (anteroposterior) and lateral view of the right tibia and fibula taken in the emergency roiagnom on [DATE] are reviewed. The patient has an oblique fracture of the right mid tibia, which is non-displaced in the AP projection and minimally displaced on the lateral projection. The patient also has a non-placed fracture of the right fibula at about the junction of the middle and distal one third of the right fibula." f. On 4/23/14 at 4:30 p.m., LPN #1 was asked, "When a resident is admitted to the facility, how do the staff know how to care for the resident?" The LPN stated, "By the Licensed Nurse, after the assessment has been done." The LPN was asked, "Who determines how the resident is to be transferred?" The LPN stated, "The admitting Nurse, by our assessment; the family if with them; and the resident." The LPN was asked if she cared for Resident #1. The LPN stated, "Yes." The LPN checked the resident's clinical record then stated, "She was already here she was sitting up in the wheelchair in the doorway." The LPN was asked, "When was the resident transferred to bed?" The LPN stated, "It was around 1900 (7:00 p.m.). I was asked to come to the room and observe the resident being put to bed; they (CNA's) were having a problem. There were 3 male CNA's in the resident's room, (CNA's #5, #6 and #7) and 1 female, (CNA #3). The resident was ready to go to bed. They transferred her with a gait belt; she was reluctant. She had stated that they used a stand up lift and we don't have a stand up lift. But there was no other way we could get her to bed without a lift pad under her. We talked to her, and she finally agreed. They lifted her up and sat her on the bed and the bed frame popped. She said, 'ya broke my leg.' I told her that the bed frame had popped, not her leg. She immediately got her phone and she wasn't paying attention to me. I checked her legs and she kept saying her leg was broke." The LPN was asked, "When the resident was transferred, were her feet flat on the floor and did the feet move?" The LPN stated, "The feet were on the floor, but I didn't see her feet." The LPN was asked, "When did the resident first complain about her leg?" The LPN stated, "When she sat on the bed and the bed frame popped, and she said 'Ya broke my leg.' The LPN was asked if she assessed the resident. The LPN stated, "The legs were both pretty swollen when she came in. I asked her if she could feel me touching her legs and she stated, 'Yes.' She moved her right foot slightly. Different family members kept calling me, and she was upset. She had called them telling them that her leg was broke and needed an ambulance to take her to the hospital. I told her I was trying to examine her to find out, explained the ordeal of the transfer. She was still on the phone. I was called to the phone every 15 minutes to talk to the family, she wanted to go to the hospital." g. On 4/24/15 at 10:06 a.m., CNA #5 was asked if he had cared for Resident #1. The CNA stated, "Yes." The CNA was asked when the resident was transferred. The CNA stated, "The first time meeting her was around 6:30 p.m." The CNA was asked who transferred her. The CNA stated, "Myself and (CNA #6). The CNA was asked, "How did you transfer the resident?" The CNA stated, "We took a flat sheet and tied 2 knots in the sheet, because the gait belt we had wasn't large enough. We put the sheet around her. She didn't bear any weight." The CNA was asked, "Did the resident bear any weight on her feet?" The CNA stated, "No." The CNA stated, "When we were transferring her, the guy working with me fell on the bed, not on the resident... it took every bit of our strength, but we made it, because she said she couldn't bear weight on her feet." The CNA was asked if the resident complained of anything. The CNA stated, "No." h. On 4/24/15 at 10:33 a.m., CNA #6 was asked if he assisted with transferring Resident #1. The CNA stated, "Yes." The CNA was asked, "Who determines how a resident is to be transferred?" The CNA stated, "I'm not sure." The CNA was asked, "How did you transfer (Resident #1)?" The CNA stated, "We put a sheet around her, the gait belt was not big enough. We pulled her up with the sheet." The CNA was asked "How many staff assisted with the transfer?" The CNA stated, "2." The CNA was asked if the resident stood. The CNA stated, "We stood her up, but she couldn't stand but for a few seconds. The CNA was asked if her feet touched the floor. The CNA stated, "Yes." The CNA was asked if her knees buckled. The CNA stated, "I don't recall." The CNA was asked, "Where was the sheet located on the resident?" The CNA stated, "It was under her arms." The CNA was asked if he lost his balance. The CNA stated, "I slipped a little and onto the bed." The CNA was asked if the resident was on the bed. The CNA stated, "No, she was still standing. I slipped and fell on the bed." The CNA was asked if the resident's feet were on the floor. The CNA stated, "Yes, feet were on the floor." The CNA was asked if the resident's feet moved. The CNA stated, "No, she didn't really - couldn't move them. We put her on the bed and we left the room. I really don't know what she said. I wasn't working on that hall; I was just called to help. We transferred her and left." i. On 4/24/15 at 10:33 p.m., CNA #7 was asked, "Who determines how the resident is to be transferred?" The CNA stated, "Nurses." The CNA was asked if he assisted with transferring Resident #1. The CNA stated, "I was in the room, but I didn't do the transfer. I moved the chair." The CNA was asked "When was the resident transferred?" The CNA stated, "It was after supper about 6:30 p.m." The CNA was asked about the transfer. The CNA stated, "I held the chair, and (CNA #5 and #6) transferred the resident." The CNA was asked what was used to transfer the resident. The CNA stated, "A sheet." The CNA was asked where the sheet was located. The CNA stated, "Around her (resident's) waist." The CNA was asked if the resident was able to stand and stated, "She stood a little, but she really couldn't stand for the most part." The CNA was asked if the resident's feet were on the floor. The CNA stated, "Yes, her feet were on the floor." The CNA was asked if there was anything that happened during the transfer. The CNA stated, "She said something about her leg hurt after the transfer. She said she heard her leg pop. I didn't hear her leg pop. After that, I went back to my hall." The CNA was asked if the resident's knees buckled during the transfer. The CNA stated, "Not that I know of." The CNA was asked if anything else happened. The CNA stated, "One person lost his balance and fell on the bed. But no one fell on her. He caught himself with his hand on the bed." The CNA was asked who lost their balance. The CNA stated, (CNA #6)." The CNA was asked if the resident fell . The CNA stated, "No, she remained upright." j. On 4/24/15 at 1:08 p.m., CNA #1 (Lead CNA) was asked to describe his job duties. The CNA stated, "Training..." The CNA was asked who trained the staff on the transfers. The CNA stated that he was trained by physical therapy and then he trains the staff. The CNA was asked what type of lifts does the facility have and the CNA stated, "Hoyer lift (mechanical lift)." The CNA was asked, "If a resident has to be transferred with the Hoyer lift and there is no lift pad under the resident, what would you do?" The CNA stated, "If physical therapy is in the building, they would say how to proceed. We can use the U-sling and place that pad under the resident and behind the resident's legs and criss-cross the straps." The CNA was asked, "Who determines how a resident is to be transferred?" The CNA stated, "Where the residents are transferred from, the family and consult with therapy." k. On 4/24/15 at 2:10 p.m., CNA #8 stated, "The facility had 2 sizes of a gait belt. The standard gait belt was 60 inches and the bariatric gait belt was 80 inches." l. On 4/24/15 at 2:15 p.m., LPN #1 was asked what time the resident was transferred. The LPN stated, "It was around 7:00 p.m., because I hadn't started my medications yet." The LPN was asked what they used to transfer the resident. The LPN stated, "We didn't have a stand up lift and had to use a gait belt. We didn't have any other means. She was disagreeing, but she finally agreed." The LPN was asked, "What time did you call the DON?" The LPN stated, "I talked to her 2 or 3 times; I really don't know." The LPN was asked what time she called the physician. The LPN stated, "It was around 9:00 p.m. I kept working with her and answering the phone." The LPN was asked, "What were you trying to accomplish?" The LPN stated, "The resident wouldn't cooperate with me." The LPN was asked, "What did you want the resident to do?" The LPN stated, "She (resident) stayed on the phone and ignored me." The LPN was asked, "If the resident had a change in condition, when should the physician be called?" The LPN stated, "As soon as possible." The LPN was asked, "When the resident had told you that her leg was broken, what was the delay in calling the physician?" The LPN stated, "I was trying to handle the situation and get that resolved." The LPN was asked what she was trying to resolve. The LPN stated, "I went back to her room and she was talking on her phone and ignoring me... I was on the phone with the Physician at a little after 9:00 p.m. and the ambulance was here." The LPN was asked, "Did you call the ambulance?" The LPN stated, "No, the family did." The LPN was asked, "Do you feel that waiting until approximately 2 hours after the incident was a delay in the resident receiving treatment?" The LPN stated, "Yes." m. On 4/24/15 at 2:47 p.m., the ADON was asked if she performed interviews with the CNA's after the transfer involving Resident #1. The ADON stated, "Yes, there was 3 guys, 1 girl and the nurse in the room. The transfer was a smooth transfer. She heard a pop and she thought it was her leg, but the bed popped. (LPN #1) was in the room and the ambulance came." The ADON was asked what time the ambulance arrived at the facility. The ADON stated, "I don't know when the ambulance came." The ADON was asked, "Did you state that the transfer went smoothly?" The ADON stated, "Yes." The ADON was asked what was used to transfer the resident. The ADON stated, "They couldn't get the gait belt around her, so they used a sheet." The ADON was asked, "If the resident was sitting up in the wheelchair, could the staff have put a transfer sling under the resident?" The ADON stated, "She was a hefty woman and was tight in the wheelchair that she came to the facility in from another facility." The ADON was asked if there were any issues that occurred during the transfer with a staff member losing their balance. The ADON stated, "No, during the transfer, they heard a pop; I didn't hear of anything else." The ADON was asked if the staff said anything about what happened during the transfer or what the resident said. The ADON stated, "The resident just complained that she had a fracture in both of her legs in the past. She never complained of pain during the transfer." The ADON was asked, "Did the staff tell you about anything that the resident said during or after the transfer?" The ADON stated, "No." The ADON was asked if she read the Nurses Notes related to this incident. The ADON stated, "No, I have difficulty reading (LPN #1's) handwriting. (LPN #1) was on the phone to the physician when the ambulance was here to pick her up." The ADON was asked if she knew how much time elapsed from the time of the transfer to bed and the time the ambulance arrived. The ADON stated, "No." The ADON was asked if the LPN had reported to her that the resident said she heard a pop and that her leg was, "broke". The ADON stated, "She didn't really complain of pain." The ADON was asked if she was aware of the resident saying anything to the staff regarding her leg popping and her leg being broken. The ADON stated, "There was a pop; she didn't complain of any pain, but she had broken her leg before and knew what it sounded like." n. On 4/24/15 at 2:55 p.m. the DON was asked who interviewed the staff regarding the incident with the transfer for Resident #1. The DON stated, "ADON (Assistant Director of Nursing)." The DON was asked if she was aware of how the resident was transferred. The DON stated, "I was told it was a gait belt, but I know now it wasn't." The DON was asked, "When did the LPN call you?" The DON stated, "I'm not sure of the time, but the ambulance arrived at the facility while I was talking to her (LPN)." The DON was asked if she knew what the timeframe was between the incident with the transfer and the time the ambulance arrived. The DON stated, "No." o. On 4/24/14 at 4:10 p.m., the DON was asked if it was appropriate to transfer a resident with a sheet. The DON stated, "Not typically, I was not aware that they used a sheet at that time, I am now." The DON was asked if the CNA's should use a sheet to transfer the resident. The DON stated, "No." p. On 4/24/14 at 4:25 p.m., the DON brought the survey team a gait belt. The surveyors, measured the gait belt identified by the DON as a bariatric gait belt that measured 70.5 inches in length from buckle to tip. The DON was asked, "Was there a bariatric belt in the building on 4/6/15?" The DON stated, "I don't know if there was one; we couldn't find one. I got 2 in last week."

Based on observation, record review and interview, the facility failed to ensure staff were trained in the safe operation of the van lift and the lift was operated according to the manufacturer recommendations for 1 (Resident #7) of 11 (Residents #3 and #5 through #14) case mix residents who used the transport van lift. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death to Resident #7, who suffered a head injury as a result of a fall from the transport van lift, and had the potential to affect 57 other residents who used the transport van lift, as documented on a list provided by the Administrator on 10/19/12 at 11:07 a.m. The facility was informed of the Immediate Jeopardy on 10/17/12 at 4:00 p.m. The findings are: 1. The Van Lift Manufacturer's Instructions (The Braun Corporation Reference Material Information/Usage Guide) received from the Administrator on 10/17/12 at 2:08 p.m. documented, "...Lift Operation Safety: ...Familiarity with proper operation instructions as well as proper maintenance procedures are necessary to ensure safe, troublefree operation. Safety precautions are provided to identify potentially hazardous situations and provide instruction on how to avoid them. ...Warning: Read manual and supplement(s) before operating lift. Read and become familiar with all safety precautions, operation notes and details, operating instructions and manual operating instructions before operating the lift. ...Operation notes and Details: Lift Passengers: If you are an attendant operating the lift, it is your responsibility to perform safe loading and unloading procedures. Wheelchair lift attendants should be instructed on any special needs and/or procedures required for safe transport of wheelchair passengers. The lift operator and bystanders must keep clear of the area in which the lift operates. Observe your passenger at all times during lift operation. ...The lift attendant should not ride on the platform with the passenger. ...Wheelchair-Equipped Occupant Seat Belts; The Braun Corporation recommends wheelchair passengers position and buckle their wheelchair-equipped seat belt (torso restraint) before loading onto a wheelchair lift. Different types of disabilities require different types of wheelchairs and different types of wheelchair-equipped occupant restraint belt systems (torso restraints). It is the responsibility of the wheelchair passenger to have his or her wheelchair equipped with an occupant restraint (seat belt) under the direction of their health care professional. Wheelchair lift attendants should be instructed on any special needs and/or procedures required for safe transport of wheelchair passengers. The Braun Corporation recommends that transit agency supervisors and wheelchair lift attendants review the safety precautions and operation procedures appearing in this manual and on lift-posted decals with your wheelchair lift sales representative (dealer), before attempting lift operation. ...Failure to follow these rules may result in serious bodily injury and/or property damage..." 2. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/1/12 documented the resident scored 5 (0-7 severe cognitive impairment) on the Brief Interview for Mental Status, was totally dependent on the physical assistance of two people for transfers and locomotion on and off the unit, did not move from a seated to a standing position, did not walk, did not perform surface-to-surface transfers, had functional limitation in range of motion of an upper extremity on one side and of both lower extremities, used a wheelchair for mobility, had active [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 5/1/12 documented, "...(Focus) I am at risk for falls r/t (related to) unaware of safety needs, confusion at times, deconditioning, psychoactive drug use ...(Goal) I will not sustain serious injury through the review date ...(Interventions) Anticipate and meet my needs and ensure that I am transferred by 2 staff to maintain my safety and provide me with wheelchair for locomotion..." b. On 10/17/12 at 11:50 p.m., the surveyor heard over the facility loud speaker, "Nurse to parking lot STAT (immediately)." Out in the parking lot, the resident was lying on his back beside the facility van, in front of the lift. Multiple staff members were around the resident and one staff member had a towel with ice on the resident's head and forehead. Blood was on the towel. There was some blood on the platform lift of the van and on the cement. The platform lift was in the lowest position and the outer flap was down. The wheelchair was at the left side of the lift, towards the back of the van. No straps or belts were visible on the wheelchair or on the lift. The Director of Nursing (DON) and the Treatment Nurse were attending to the resident with other staff. The Administrator asked Certified Nursing Assistant (CNA) #1 (the Van Driver) and Licensed Practical Nurse (LPN) #1 to write statements about what happened. An ambulance arrived at the facility at 12:00 p.m. The resident left in the ambulance. c. The Incident/Accident Report (I and A) dated 10/17/12 documented, "(Resident #7)... Time of Accident / Incident: 11:40 a.m. ...Van driver reported that after lift was in lowest position, (Resident) leaned forward and fell (with) w/c (wheelchair) on top of him. W/C was removed. (Resident) assessed by nurses on duty immediately ... Additional Comments and/or steps taken to prevent recurrence: Seatbelt applied to van lift...Description of Situation: informed by van driver that (Resident) leaned forward when lift stopped in lowest position and fell out of W/C. Summary of Investigation: Van driver states after lift made it to the ground. The (Resident) leaned forward and fell out of W/C. (Resident) was immediately assessed by on-duty nurses ... Recommendations / New Interventions: Seat belt attachment to van lift. Inservice van drivers..." 1) An OLTC (Office of Long Term Care) Witness Statement Form dated 10/17/12 documented, "Time: 11:50 a.m. Witness Full Name: (CNA #1) ...Job Title: Transport. I (CNA #1) transported (Resident #7) from (Wound Clinic). Once we arrived back to (the facility), I lowered (Resident #7) on the lift. Immediately when the lift stopped, (Resident #7) lean(ed) forward and fell . I couldn't get to him fast enough and support him." 2) A statement dated 10/17/12 and signed by LPN #1 documented, "At approximately 11:50, I was parked in the south parking lot facing North toward the transportation van. As I began to start my car I heard a loud yell, "Oh." I saw two male CNAs, (CNA #2 and CNA #3) running toward the transportation van. At this time I also saw the transportation aide (CNA #1) trying to recover he and (Resident #7) from the accident. I told them not to move him and to go get help. The lift was completely on the ground and the wheelchair turned over. (Resident #7) was alert and bleeding from his nose, head, and hands and feet. The DON was (at) the scene applying pressure to his head wound. The Administrator notified and on the scene as well." On 10/17/12 at 1:55 p.m., LPN #1 stated, "At 11:50 a.m. I was in my car with the windows down, getting things ready...(CNAs #3 and #2) came from the side of the building. I then saw (Resident #7) on the ground trying to get up. (CNA #1) at the side. I told them not to get him up...I saw a gash on his forehead, at that time a scant amount of blood, but after the resident tried to get up, it started gushing. I told (CNAs #3 and #2) to get help and call the ambulance." The LPN stated that other staff including the DON came out and attended to the resident. d. On 10/17/12 at 1:35 p.m., the Administrator stated, "(Resident #7) had been brought back from the wound clinic. When the van driver had gotten the lift on the ground, the resident was in the wheelchair on the lift floor. The resident leaned forward and the wheel(chair) toppled over (with) him." e. On 10/17/12 at 2:45 p.m., CNA #1 stated, "I had just arrived back at the facility. I had unstrapped all of his seat belts. We both got on the lift. I was standing directly behind him on the lift and he leaned forward and I couldn't stop it... I put them on the lift backwards facing out, lock wheels, you're supposed to hook the seat belt but it wasn't on there ...(CNA #4) trained me and told me there is usually a seat belt... I've done a return demonstration in front of (CNA #4) and the Maintenance man. I've never seen a video or read an instruction manual." The CNA named three other Van Drivers: Van Driver #2, Van Driver #6 and Van Driver #5. At 3:00 p.m., CNA #1 demonstrated how he had operated the van lift. The CNA pushed the wheelchair onto the lift platform and he was standing directly behind the wheelchair. The platform was lowered to the ground and as the platform touched the ground, he stated, "The resident leaned forward and fell to the ground and the wheelchair flipped on top of the resident's back." f. On 10/17/12 at 3:04 p.m., CNA #2 stated, "The only thing I saw was (Resident #7) was laying face down with the wheelchair on his back. I ran to the nurse's desk and told them there was an emergency in the parking lot and to call 911. I went back and helped apply pressure to his head and they applied ice and stayed until the ambulance came." The CNA was asked if he had ever used the van lift. He stated, "Yes, the way I was trained is to come off of the van and stand in front of them, pull them forward, lock the wheelchair wheels and then put the lift down to prevent something like this from happening." The CNA stated that the Maintenance Supervisor had trained him. g. On 10/18/12 at 10:27 a.m., the Administrator provided a list titled, "Approved Van Drivers", which included 7 drivers. The Administrator was asked to provide copies of documentation of the in-services for these drivers on the use of the van lift. h. On 10/18/12 at 12:03 p.m., the Administrator provided two in-service signature sheets that documented the following: 1) "Inservice Training... Presented by: (Approved Van Driver #6) LCNA (Lead Certified Nursing Assistant)... Employee Signature... (Approved Van Driver #4)... Summary of in-service: Securing Resident on the lift (van) for transport. Date 11/29/10... Signature of Department Head (Approved Van Driver #6) LCNA" There was another staff member's signature on the in-service sheet, however that staff member was no longer on the Approved Van Driver list. 2) "Inservice Training... Presented by: Administrator... Employee Signature... (Approved Van Driver #1)... Summary of in-service: Proper use of van lift (and) securing w/c (and) (resident) inside van. Date 7/18/12... Signature of Department Head (Administrator)." At this time, the Administrator stated this was all the documentation on van lift training she could locate. i. The Immediate Jeopardy was removed on 10/18/12 at 9:30 a.m. and the scope/severity reduced to a "G" when the facility implemented the following Plan of Removal: Effective immediately the facility will not use the van lift or transport any resident requiring use of the van lift until retraining of all staff who are on the insurance to drive the van. All staff who drive the van and the DON / management staff will be retrained on 10/18/12 via video at http://www.braunability.com/commercial/customer-support who is the manufacturer, which includes loading resident on the lift in a wheelchair, securing the resident and wheelchair inside the van, securing resident and wheelchair on platform before lowering resident down on lift platform, transport staff not standing on the platform while lifting or lowering a resident on the lift, and the transport staff standing beside the lift while lift is in use. Each driver will do a return demonstration and be checked off by management staff for competency. The DON / management staff will ride on the van when the lift is to be utilized during transportation to monitor van transport staff to ensure the deficient practice does not recur and transport staff knows how to use the lift. Monitoring will continue 1 time a week for 6 weeks. Any negative findings will be corrected immediately. Random monitoring will be on-going quarterly. No one will be allowed to operate the van lift until trained. In addition, the facility will equip 2 wheelchairs with seat belts to be used as transport wheelchairs. The wheelchair seat belts will be ordered on [DATE] and installed upon delivery."

Based on observation, record review and interview, the facility Administration failed to develop and implement a system that would ensure transport staff were proficient in use of the van lift per manufacturer instructions for 1 (Resident #7) of 11 (Residents #3 and #5 through #14) case mix residents who used the transport van lift. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death to Resident #7, who suffered a head injury as a result of a fall from the transport van lift, and had the potential to affect 57 other residents who used the transport van lift, as documented on a list provided by the Administrator on 10/19/12 at 11:07 a.m. The facility was informed of the Immediate Jeopardy on 10/17/12 at 4:00 p.m. The findings are: 1. The Administrator job description was provided by the Administrator on 10/18/12 at 11:40 a.m. and documented, "Job Summary... The Administrator directs and coordinates all activities of the nursing home in carrying out its objective of provided the best possible care for each resident, in striving to recreate a sense of security... for the residents... Qualifications... 1. Must have thorough knowledge of fundamentals of nursing home organization and administration, standards and regulations of nursing homes and laws applicable to nursing home operations... 2. Must have working knowledge of personnel... functions of all departments... 5. Willingness to accept responsibility for activities of the nursing home... 8. Considerable initiative and judgment involved in formulating policies and regulations, delegating responsibility... planning and analyzing nursing home activities... Responsibilities... 1. Efficient functioning and coordination of all departments. 2. Meets and maintains standard in the home for licensure of accreditation for the total operation of the facility... 5. Adopts and enforces rules and regulations for the health care and safety of recipient - residents and others..." 2. The Van Lift Manufacturer's Instructions (The Braun Corporation Reference Material Information/Usage Guide) received from the Administrator on 10/17/12 at 2:08 p.m. documented, "...Lift Operation Safety: ...Familiarity with proper operation instructions as well as proper maintenance procedures are necessary to ensure safe, troublefree operation. Safety precautions are provided to identify potentially hazardous situations and provide instruction on how to avoid them. ...Warning: Read manual and supplement(s) before operating lift. Read and become familiar with all safety precautions, operation notes and details, operating instructions and manual operating instructions before operating the lift. ...Operation notes and Details: Lift Passengers: If you are an attendant operating the lift, it is your responsibility to perform safe loading and unloading procedures. Wheelchair lift attendants should be instructed on any special needs and/or procedures required for safe transport of wheelchair passengers. The lift operator and bystanders must keep clear of the area in which the lift operates. Observe your passenger at all times during lift operation. ...The lift attendant should not ride on the platform with the passenger. ...Wheelchair-Equipped Occupant Seat Belts; The Braun Corporation recommends wheelchair passengers position and buckle their wheelchair-equipped seat belt (torso restraint) before loading onto a wheelchair lift. Different types of disabilities require different types of wheelchairs and different types of wheelchair-equipped occupant restraint belt systems (torso restraints). It is the responsibility of the wheelchair passenger to have his or her wheelchair equipped with an occupant restraint (seat belt) under the direction of their health care professional. Wheelchair lift attendants should be instructed on any special needs and/or procedures required for safe transport of wheelchair passengers. The Braun Corporation recommends that transit agency supervisors and wheelchair lift attendants review the safety precautions and operation procedures appearing in this manual and on lift-posted decals with your wheelchair lift sales representative (dealer), before attempting lift operation. ...Failure to follow these rules may result in serious bodily injury and/or property damage..." 3. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 8/1/12 documented the resident scored 5 (0-7 severe cognitive impairment) on the Brief Interview for Mental Status, was totally dependent on the physical assistance of two people for transfers and locomotion on and off the unit, did not move from a seated to a standing position, did not walk, did not perform surface-to-surface transfers, had functional limitation in range of motion of an upper extremity on one side and of both lower extremities, used a wheelchair for mobility, had active [DIAGNOSES REDACTED]. a. The Resident Plan of Care dated 5/1/12 documented, "...(Focus) I am at risk for falls r/t (related to) unaware of safety needs, confusion at times, deconditioning, psychoactive drug use ...(Goal) I will not sustain serious injury through the review date ...(Interventions) Anticipate and meet my needs and ensure that I am transferred by 2 staff to maintain my safety and provide me with wheelchair for locomotion..." b. On 10/17/12 at 11:50 p.m., the surveyor heard over the facility loud speaker, "Nurse to parking lot STAT (immediately)." Out in the parking lot, the resident was lying on his back beside the facility van, in front of the lift. Multiple staff members were around the resident and one staff member had a towel with ice on the resident's head and forehead. Blood was on the towel. There was some blood on the platform lift of the van and on the cement. The platform lift was in the lowest position and the outer flap was down. The wheelchair was at the left side of the lift, towards the back of the van. No straps or belts were visible on the wheelchair or on the lift. The Director of Nursing (DON) and the Treatment Nurse were attending to the resident with other staff. The Administrator asked Certified Nursing Assistant (CNA) #1 (the Van Driver) and Licensed Practical Nurse (LPN) #1 to write statements about what happened. An ambulance arrived at the facility at 12:00 p.m. The resident left in the ambulance. c. The Incident/Accident Report (I and A) dated 10/17/12 documented, "(Resident #7)... Time of Accident / Incident: 11:40 a.m. ...Van driver reported that after lift was in lowest position, (Resident) leaned forward and fell (with) w/c (wheelchair) on top of him. W/C was removed. (Resident) assessed by nurses on duty immediately ... Additional Comments and/or steps taken to prevent recurrence: Seatbelt applied to van lift...Description of Situation: informed by van driver that (Resident) leaned forward when lift stopped in lowest position and fell out of W/C. Summary of Investigation: Van driver states after lift made it to the ground. The (Resident) leaned forward and fell out of W/C. (Resident) was immediately assessed by on-duty nurses ... Recommendations / New Interventions: Seat belt attachment to van lift. Inservice van drivers..." 1) An OLTC (Office of Long Term Care) Witness Statement Form dated 10/17/12 documented, "Time: 11:50 a.m. Witness Full Name: (CNA #1) ...Job Title: Transport. I (CNA #1) transported (Resident #7) from (Wound Clinic). Once we arrived back to (the facility), I lowered (Resident #7) on the lift. Immediately when the lift stopped, (Resident #7) lean(ed) forward and fell . I couldn't get to him fast enough and support him." 2) A statement dated 10/17/12 and signed by LPN #1 documented, "At approximately 11:50, I was parked in the south parking lot facing North toward the transportation van. As I began to start my car I heard a loud yell, "Oh." I saw two male CNAs, (CNA #2 and CNA #3) running toward the transportation van. At this time I also saw the transportation aide (CNA #1) trying to recover he and (Resident #7) from the accident. I told them not to move him and to go get help. The lift was completely on the ground and the wheelchair turned over. (Resident #7) was alert and bleeding from his nose, head, and hands and feet. The DON was (at) the scene applying pressure to his head wound. The Administrator notified and on the scene as well." On 10/17/12 at 1:55 p.m., LPN #1 stated, "At 11:50 a.m. I was in my car with the windows down, getting things ready...(CNAs #3 and #2) came from the side of the building. I then saw (Resident #7) on the ground trying to get up. (CNA #1) at the side. I told them not to get him up...I saw a gash on his forehead, at that time a scant amount of blood, but after the resident tried to get up, it started gushing. I told (CNAs #3 and #2) to get help and call the ambulance." The LPN stated that other staff including the DON came out and attended to the resident. d. On 10/17/12 at 1:35 p.m., the Administrator stated, "(Resident #7) had been brought back from the wound clinic. When the van driver had gotten the lift on the ground, the resident was in the wheelchair on the lift floor. The resident leaned forward and the wheel(chair) toppled over (with) him." e. On 10/17/12 at 2:45 p.m., CNA #1 stated, "I had just arrived back at the facility. I had unstrapped all of his seat belts. We both got on the lift. I was standing directly behind him on the lift and he leaned forward and I couldn't stop it... I put them on the lift backwards facing out, lock wheels, you're supposed to hook the seat belt but it wasn't on there ...(CNA #4) trained me and told me there is usually a seat belt... I've done a return demonstration in front of (CNA #4) and the Maintenance man. I've never seen a video or read an instruction manual." The CNA named three other Van Drivers: Van Driver #2, Van Driver #6 and Van Driver #5. At 3:00 p.m., CNA #1 demonstrated how he had operated the van lift. The CNA pushed the wheelchair onto the lift platform and he was standing directly behind the wheelchair. The platform was lowered to the ground and as the platform touched the ground, he stated, "The resident leaned forward and fell to the ground and the wheelchair flipped on top of the resident's back." f. On 10/17/12 at 3:04 p.m., CNA #2 stated, "The only thing I saw was (Resident #7) was laying face down with the wheelchair on his back. I ran to the nurse's desk and told them there was an emergency in the parking lot and to call 911. I went back and helped apply pressure to his head and they applied ice and stayed until the ambulance came." The CNA was asked if he had ever used the van lift. He stated, "Yes, the way I was trained is to come off of the van and stand in front of them, pull them forward, lock the wheelchair wheels and then put the lift down to prevent something like this from happening." The CNA stated that the Maintenance Supervisor had trained him. g. On 10/18/12 at 10:27 a.m., the Administrator provided a list titled, "Approved Van Drivers", which included 7 drivers. The Administrator was asked to provide copies of documentation of the in-services for these drivers on the use of the van lift. h. On 10/18/12 at 12:03 p.m., the Administrator provided two in-service signature sheets that documented the following: 1) "Inservice Training... Presented by: (Approved Van Driver #6) LCNA (Lead Certified Nursing Assistant)... Employee Signature... (Approved Van Driver #4)... Summary of in-service: Securing Resident on the lift (van) for transport. Date 11/29/10... Signature of Department Head (Approved Van Driver #6) LCNA" There was another staff member's signature on the in-service sheet, however that staff member was no longer on the Approved Van Driver list. 2) "Inservice Training... Presented by: Administrator... Employee Signature... (Approved Van Driver #1)... Summary of in-service: Proper use of van lift (and) securing w/c (and) (resident) inside van. Date 7/18/12... Signature of Department Head (Administrator)." At this time, the Administrator stated this was all the documentation on van lift training she could locate. i. The Immediate Jeopardy was removed on 10/18/12 at 9:30 a.m. and the scope/severity reduced to a "G" when the facility implemented the following Plan of Removal: Effective immediately the facility will not use the van lift or transport any resident requiring use of the van lift until retraining of all staff who are on the insurance to drive the van. All staff who drive the van and the DON / management staff will be retrained on 10/18/12 via video at http://www.braunability.com/commercial/customer-support who is the manufacturer, which includes loading resident on the lift in a wheelchair, securing the resident and wheelchair inside the van, securing resident and wheelchair on platform before lowering resident down on lift platform, transport staff not standing on the platform while lifting or lowering a resident on the lift, and the transport staff standing beside the lift while lift is in use. Each driver will do a return demonstration and be checked off by management staff for competency. The DON / management staff will ride on the van when the lift is to be utilized during transportation to monitor van transport staff to ensure the deficient practice does not recur and transport staff knows how to use the lift. Monitoring will continue 1 time a week for 6 weeks. Any negative findings will be corrected immediately. Random monitoring will be on-going quarterly. No one will be allowed to operate the van lift until trained. In addition, the facility will equip 2 wheelchairs with seat belts to be used as transport wheelchairs. The wheelchair seat belts will be ordered on [DATE] and installed upon delivery."

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure Resident #1 received the necessary care and services to attain or maintain the highest practicable physical well-being while receiving anticoagulant therapy. The facility failed to ensure [MEDICATION NAME]/International Normalized Ratio (PT/INR) testing was obtained as ordered by the Physician, failed to ensure abnormal PT/INR values were promptly followed-up on when there was no response from the Physician and failed to immediately consult the Physician upon becoming aware of rectal bleeding for 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who received [MEDICATION NAME] therapy. The failed practices resulted in a delay in treatment and a pattern of harm for Resident #1 who received [MEDICATION NAME] therapy and expired at the hospital related to [MEDICAL CONDITION] on [DATE] and had the potential to cause more than minimal harm for 3 residents who received [MEDICATION NAME] therapy, according to the Administrator on [DATE] at 1:45 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 2 (,[DATE] severe cognitive impairment) on the brief interview for mental status, required supervision with transfers and ambulation and was independent in bed mobility. The Incident and Accident (I/A) report dated [DATE] at 9:00 a.m. documented, "Resident stated I roll out of bed and got myself back up. Unable to move (right) leg d/t (due to) pain. Notify (physician) order x-ray (right) hip... Was person involved taken to a hospital? Yes... x-ray sent... [DATE] 1300 (1:00 p.m.)..." The x-ray report dated [DATE] documented, "...Results: There is a recent fracture involving the right femoral neck with lateral displacement..." a. The Nurse's Notes dated [DATE] at 2:20 p.m. documented, "Admit to Medicare Part A, received back to (nursing home)..." b. A Physician telephone order dated [DATE] documented, "...PT/INR ([MEDICATION NAME]/International Normalized Ratio) Q (every) 2 day (times) 1 week, [MEDICATION NAME] 2.5 mg (milligram) PO (by mouth) Q day (times) 1 week." c. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. A laboratory report documented, "Specimen Collected: ([DATE]) 7:30 a.m. Specimen Resulted: ([DATE]) 2:42 p.m. [MEDICATION NAME] Time (and) INR... [MEDICATION NAME] Time 35.40 (High)... (Reference Range) 9.45 - 13... INR 3.20 (High)... (Reference Range: 2 - 3). Handwriting on the bottom of the laboratory report documented, "[DATE] 1656 (4:56 p.m.) Faxed to doctor's office." The handwritten entry was signed by Licensed Practical Nurse (LPN) #1. 1) As of [DATE], the Daily Skilled Nurse's Note form dated [DATE] (for the Day, Evening and Night shifts) contained no documentation of any attempt to consult the resident's Physician regarding the [DATE] elevated PT/INR lab report and no documentation the resident was monitored for signs and symptoms of bleeding. 2) On [DATE] at 4:44 p.m., LPN #1 was asked, " What do you do when you receive abnormal lab results on a resident? " The LPN stated, "Call the doctor. When they have a panic lab, the lab is going to call us. Then we are going to call the doctor." LPN #1 was asked why the doctor was not called on [DATE] concerning the resident's elevated [MEDICATION NAME] Time and elevated PT/INR. LPN #1 stated, "I thought I did. I know I called about pain medicine." As the LPN reviewed her note dated [DATE], she was asked if she documented in the nurse's notes when she called the doctor. She stated, "Yes, I normally do." e. As of [DATE], there was no PT/INR laboratory report in the resident's clinical record for [DATE], as ordered by the Physician. At 5:00 p.m., the Director of Nursing (DON) was asked if the facility determined why the resident's PT/INR was not obtained every 2 days, as per the physician's orders [REDACTED]." She was then asked, what about STAT orders. The DON stated, "We have to have an order for [REDACTED].? The DON stated, "Yes..." f. The next available laboratory report documented, "Specimen Collected: ([DATE]) 6:40 a.m. Specimen Resulted: ([DATE]) 3:39 p.m. [MEDICATION NAME] Time (and) INR... Daily Order *Panic* ...phone results on [DATE] at (3:39 p.m.) Panic Value called to Nurse: (LPN #1)... [MEDICATION NAME] Time 56.8 (High)... (Reference Range) 9.45 - 13... INR 5.09 (very high)... (Reference Range) ,[DATE]. Handwriting on the bottom of the laboratory report documented, "[DATE] 1550 (3:50 p.m.) Call to (Physician) lab results. New order to hold [MEDICATION NAME] 2.5 mg until [DATE] Friday. Recheck PT (and) INR on [DATE] (Friday)..." The handwritten entry was signed by LPN #1. 1) The Daily Skilled Nurse's Note form dated [DATE] documented, "(untimed entry) ...Evening Shift ...Rec'd (received) lab results of PT 56.8 and INR 5.09. (Physician name) on call notified of lab results. New order noted to hold [MEDICATION NAME] 2.5 mg until [DATE] Friday. Recheck PT (and) INT on Friday [DATE]. Will continue to monitor..." The Daily Skilled Nurse's Note form entries for the [DATE] Day, Evening and Night shifts contained no documentation the resident was monitored for signs and symptoms of bleeding. 2) The Physician telephone order form documented, "[DATE] Hold [MEDICATION NAME] 2.5 mg until Friday ([DATE]). Recheck PT (and) INR on Friday ([DATE])... Signature of Nurse Receiving Order - (LPN #1)... Time 1550 (3:50 p.m.)" 3) The resident's [DATE] MAR indicated Hold" was written on the MAR by the resident's [MEDICATION NAME] for [DATE], [DATE] and [DATE]. g. The next available laboratory report documented, "Specimen Collected: ([DATE]) 7:05 a.m. Specimen Resulted: ([DATE]) 2:32 p.m. [MEDICATION NAME] Time (and) INR... [MEDICATION NAME] Time 39.40 (High)... (Reference Range) 9.45 - 13... INR 3.55 (High) (Reference Range) ,[DATE]." Handwriting on the bottom of the laboratory report documented, "[DATE] 1630 (4:30 p.m.) Called in lab results to (Physician). New order noted to (discontinue) [MEDICATION NAME]." The handwritten entry was signed by LPN #1. 1) The Nurse's Notes dated [DATE] documented, "...Comments / Concerns Evening Shift... Called lab results of PT 39.40 (and) INR 3.55. New order noted to D/C (discontinue) [MEDICATION NAME] from (Physician), will continue to monitor." The Daily Skilled Nurse's Note form entries for the [DATE] Day, Evening and Night shifts contained no documentation the resident was monitored for signs and symptoms of bleeding. 2) The Physician telephone order form documented, "[DATE] ...D/C [MEDICATION NAME] Signature of Nurse Receiving Order (LPN #1)... Time 1630 (4:30 p.m.)" 3) The resident's [DATE] MAR indicated [REDACTED]." h. The Daily Skilled Nurse's Notes dated [DATE] documented, "0830 (8:30 a.m.) While making rounds, (resident) was noted on floor, lying on (right) hip facing the wall. (Resident) checked for injuries, (none) noted. (Resident) c/o (complained of) pain to (right) hip upon movement of (right) hip. 0845 (8:45 a.m.) (Physician) notified order given to x-ray (right) hip ASAP (as soon as possible)... 1530 (3:30 p.m.) (resident) c/o pain to (right) hip, (resident) given [MEDICATION NAME] 1640 (4:40 p.m.) (no) further complaints voiced (resident) moved to ICU 2 for extended bed rails for safety. will cont (continue) to observe." The entries were signed by LPN #4. i. The Nurse's Notes dated [DATE] were signed by LPN #3 and documented the following: "0600 (6:00 a.m.) (Through)out the noc (night) the (resident) has had 2 stools (with) blood noted. Dark red (with) foul odor..." "0725 (7:25 a.m.) Noted the (resident) has had another episode of blood (rectal bleeding) noted on the pad. Still has a foul odor, dark red (and) small clots noted. Called (hospital) paging (and) spoke (with) (Physician). She states to do an INR (and) if it is high then send the (resident) to the hosp (hospital)..." On [DATE] at 2:40 p.m., LPN #3 was asked about the resident's bleeding. The LPN stated, "I couldn't see any blood the first time, there was more poop than anything. I couldn't tell. The second time she (Resident #1) let it go. I could see it then I could tell it was blood. That's when I called the doctor. Before I could get to the phone to call the doctor they (Certified Nursing Assistants) called me again to (Resident #1)'s room because she had one again." She was asked, " Do you know anything about her [MEDICATION NAME]? " LPN #3 stated, "I don't have a clue about her [MEDICATION NAME]." She was asked, " Do you have any idea what was going on, why you didn't call her doctor after the second episode? " LPN #3 stated, "I had Halls 1, 2 and 3. I had on 300 Hall a resident (non case mix resident), she wasn't breathing good. I left out of her room to go to the Nurse's station to call the doctor about (Resident #1) when they called me back to (Resident #1)'s room. She had another episode of rectal bleeding and then it wasn't that long between episodes. Maybe 5 minutes, I called the doctor ...about 7:30 a.m. ..." "0736 (7:36 a.m.) INR drawn and sent to (hospital) lab for stat results...." j. A laboratory report processed by a local hospital documented, "...Collected: [DATE] (at) 07:36 (7:36 a.m.)... First Reported: [DATE] (at) 08:41 (8:41 a.m.)... [MEDICATION NAME] 29.0 ...(Normal Range) 12.4 - 15.0 ...INR for [MEDICATION NAME] 2.7" Handwriting on the bottom of the laboratory report documented, "[DATE] 11:00 (a.m.) send to ER (emergency room )." This was approximately 5 hours after the facility became aware of the resident's rectal bleeding. 1) An untimed Daily Skilled Nurse's Note dated [DATE] documented, "...Comments / Concerns DAY Shift ...Observe dark red blood with foul odor on pad around her buttock area. Continue to observe... Received result from PT INR. Call (physician). Stated to send to (hospital) ER for eval... Abduction pillow had blood on it... have a pillow between legs..." 2) A Physician telephone order dated [DATE] documented, "Send to (hospital) ER to eval (evaluate). (blood in stool)." k. The hospital ER Flowsheet documented, "..XXX[DATE] (at) 12:12 p.m. ...Presenting Complaint: GI (gastrointestinal ) Complaints... " 1) The hospital PT/INR results dated [DATE] at 12:17 p.m. documented, "[MEDICATION NAME] 29.3 (normal range: 12.4 - 15) ... INR for [MEDICATION NAME] 2.8." 2) The hospital ER Flowsheet documented, "..XXX[DATE] (at) 12:30 (p.m.) ...patient was sent from (nursing home) for GI bleed, bright red blood, noticed this a.m. Unsure when it was started... Gastrointestinal ...Stools Moderate amount of stool, Stool bright red in color, Stool liquid consistency... 3) The hospital report dated [DATE] at 12:41 p.m. documented, "...Rectal exam - stool exam... Stool Color - bright red blood... Stool Characteristics - soft, Stool Heme Test - positive. ...Treatment and Plan: One (liter) IV (intravenous) NS (normal saline), 2.5 mg Vitamin K in ER. Will admit to hospital for serial h&h (hemoglobin and hematocrit) monitoring..." 4) The hospital PT/INR results dated [DATE] at 4:12 p.m. documented, [MEDICATION NAME] 39.6 (normal range: 12.4 - 15)... INR for [MEDICATION NAME] 4.1." 5) The hospital Record of Death dated [DATE] documented, "Patient was pronounced by (Physician) on 23-May-2012 02:39 (2:39 a.m.)... Preliminary Cause of Death GI Bleed..."

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure that 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who received [MEDICATION NAME] therapy was free of significant medication errors, due to failure to ensure the resident's [MEDICATION NAME] was held and discontinued as ordered. An additional 2 doses of [MEDICATION NAME] 2.5 mg daily were administered to Resident #1 after receiving a physician's orders [REDACTED]. The failed practice resulted a pattern of harm for Resident #1 whose [MEDICATION NAME] (PT) and International Normalized Ratio (INR) became critically high, after which she expired on [DATE] at 2:39 a.m. related to [MEDICAL CONDITION]. The failed practice had the potential to cause more than minimal harm for 3 residents who received [MEDICATION NAME] therapy, according to the Administrator on [DATE] at 1:45 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 2 (,[DATE] severe cognitive impairment) on the brief interview for mental status, required supervision with transfers and ambulation and was independent in bed mobility. a. A Physician telephone order dated [DATE] documented, "...PT/INR Q (every) 2 day (times) 1 week, [MEDICATION NAME] 2.5 mg (milligram) PO (by mouth) Q day (times) 1 week." 1) The pharmacy medication delivery form dated [DATE] at 6:54 p.m. documented the pharmacy delivered 6 pills of [MEDICATION NAME] Sodium ([MEDICATION NAME]) 2.5 mg. 2) The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. b. A laboratory report documented, "Specimen Collected: ([DATE]) 7:30 a.m. Specimen Resulted: ([DATE]) 2:42 p.m. [MEDICATION NAME] Time (and) INR... [MEDICATION NAME] Time 35.40 (High)... (Reference Range) 9.45 - 13... INR 3.20 (High)... (Reference Range: 2 - 3). Handwriting on the bottom of the laboratory report documented, "[DATE] 1656 (4:56 p.m.) Faxed to doctor's office." c. The resident's [DATE] MAR indicated [REDACTED]. d. The next available laboratory report documented, "Specimen Collected: ([DATE]) 6:40 a.m. Specimen Resulted: ([DATE]) 3:39 p.m. [MEDICATION NAME] Time (and) INR... Daily Order *Panic* ...phone results on [DATE] at (3:39 p.m.) Panic Value called to Nurse: (LPN #1)... [MEDICATION NAME] Time 56.8 (High)... (Reference Range) 9.45 - 13... INR 5.09 (very high)... (Reference Range) ,[DATE]. Handwriting on the bottom of the laboratory report documented, "[DATE] 1550 (3:50 p.m.) Call to (Physician) lab results. New order to hold [MEDICATION NAME] 2.5 mg until [DATE] Friday. Recheck PT (and) INR on [DATE] (Friday)..." 1) The Physician telephone order form documented, "[DATE] Hold [MEDICATION NAME] 2.5 mg until Friday ([DATE]). Recheck PT (and) INR on Friday ([DATE])... Signature of Nurse Receiving Order - (LPN #1)... Time 1550 (3:50 p.m.)" 2) The resident's [DATE] MAR indicated Hold" was written on the MAR by the resident's [MEDICATION NAME] for [DATE], [DATE] and [DATE]. e. The pharmacy medication delivery form dated [DATE] at 7:00 p.m. documented the pharmacy delivered 12 pills of [MEDICATION NAME] Sodium ([MEDICATION NAME]) 2.5 mg, resulting in a remaining supply of 14 [MEDICATION NAME] pills. f. The next available laboratory report documented, "Specimen Collected: ([DATE]) 7:05 a.m. Specimen Resulted: ([DATE]) 2:32 p.m. [MEDICATION NAME] Time (and) INR... [MEDICATION NAME] Time 39.40 (High)... (Reference Range) 9.45 - 13... INR 3.55 (High) (Reference Range) ,[DATE]." Handwriting on the bottom of the laboratory report documented, "[DATE] 1630 (4:30 p.m.) Called in lab results to (Physician). New order noted to (discontinue) [MEDICATION NAME]." 1) The Nurse's Notes dated [DATE] documented, "...Comments / Concerns Evening Shift... Called lab results of PT 39.40 (and) INR 3.55. New order noted to D/C (discontinue) [MEDICATION NAME] from (Physician), will continue to monitor." 2) The Physician telephone order form documented, "[DATE] ...D/C [MEDICATION NAME] Signature of Nurse Receiving Order (LPN #1)... Time 1630 (4:30 p.m.)" 3) The resident's [DATE] MAR indicated [REDACTED]." g. The Nurse's Notes dated [DATE] were signed by LPN #3 and documented the following: "0600 (6:00 a.m.) (Through)out the noc (night) the (resident) has had 2 stools (with) blood noted. Dark red (with) foul odor..." "0725 (7:25 a.m.) Noted the (resident) has had another episode of blood (rectal bleeding) noted on the pad. Still has a foul odor, dark red (and) small clots noted. Called (hospital) paging (and) spoke (with) (Physician). She states to do an INR (and) if it is high then send the (resident) to the hosp (hospital)..." "0736 (7:36 a.m.) INR drawn and sent to (hospital) lab for stat results...." On [DATE] at 2:40 p.m., LPN #3 was asked, " Do you know anything about her [MEDICATION NAME]? " LPN #3 stated, "I don't have a clue about her [MEDICATION NAME]." She was asked, " Do you have any idea what was going on, why you didn't call her doctor after the second episode? " LPN #3 stated, "I had Halls 1, 2 and 3. I had on 300 Hall a resident (non case mix resident), she wasn't breathing good. I left out of her room to go to the Nurse's station to call the doctor about (Resident #1) when they called me back to (Resident #1)'s room. She had another episode of rectal bleeding and then it wasn't that long between episodes. Maybe 5 minutes, I called the doctor ...about 7:30 a.m. ..." h. A laboratory report processed by a local hospital documented, "...Collected: [DATE] (at) 07:36 (7:36 a.m.)... First Reported: [DATE] (at) 08:41 (8:41 a.m.)... [MEDICATION NAME] 29.0 ...(Normal Range) 12.4 - 15.0 ...INR for [MEDICATION NAME] 2.7" Handwriting on the bottom of the laboratory report documented, "[DATE] 11:00 (a.m.) send to ER (emergency room )." 1) An untimed Daily Skilled Nurse's Note dated [DATE] documented, "...Comments / Concerns DAY Shift ...Observe dark red blood with foul odor on pad around her buttock area. Continue to observe... Received result from PT INR. Call (physician). Stated to send to (hospital) ER for eval... Abduction pillow had blood on it... have a pillow between legs..." 2) A Physician telephone order dated [DATE] documented, "Send to (hospital) ER to eval (evaluate). (blood in stool)." i. The hospital ER Flowsheet documented, "..XXX[DATE] (at) 12:30 (p.m.) ...patient was sent from (nursing home) for GI bleed, bright red blood, noticed this a.m. Unsure when it was started... Gastrointestinal ...Stools Moderate amount of stool, Stool bright red in color, Stool liquid consistency... The hospital report dated [DATE] at 12:41 p.m. documented, "...Rectal exam - stool exam... Stool Color - bright red blood... Stool Characteristics - soft, Stool Heme Test - positive. ...Treatment and Plan: One (liter) IV (intravenous) NS (normal saline), 2.5 mg Vitamin K in ER. Will admit to hospital for serial h&h (hemoglobin and hematocrit) monitoring..." The hospital Record of Death dated [DATE] documented, "Patient was pronounced by (Physician) on 23-May-2012 02:39 (2:39 a.m.)... Preliminary Cause of Death GI Bleed..." j. The hospital PT/INR results dated [DATE] at 12:17 p.m. documented, "[MEDICATION NAME] 29.3 (normal range: 12.4 - 15) ... INR for [MEDICATION NAME] 2.8." The hospital PT/INR results dated [DATE] at 4:12 p.m. documented, [MEDICATION NAME] 39.6 (normal range: 12.4 - 15)... INR for [MEDICATION NAME] 4.1." As of [DATE], the resident's hospital records contained no documentation that the resident was administered [MEDICATION NAME] in the hospital. k. The Nursing 2010 Drug Handbook, page 505 for [MEDICATION NAME] Sodium documents: " Action ...Route ...Onset ...Peak ...Duration ...(Route) PO (by mouth) (Onset) within 24 hr (hours) (Peak) 4 hrs (Duration) ,[DATE] days ...half life ,[DATE] hours. " l. On [DATE] at 1:05 p.m., LPN #4 was asked, "Do you know anything about (Resident #1)'s [MEDICATION NAME]? " The LPN stated, "If I'm not mistaken, seems like they had put a hold on her [MEDICATION NAME]." The LPN was asked, "Do you know whether you gave the [MEDICATION NAME] on the 19th ([DATE]) and 20th ([DATE]) (weekend on 3:00 to 11:00 p.m. shift) at 4:00 p.m.? " LPN #4 stated, "I sure don't. I'd have to check the chart. I don't know." She was asked, " Do you remember whether someone reported to you about the [MEDICATION NAME] being on hold or was it by reading the 'hold' on the MAR? " LPN #4 stated, "I'm not sure. I can't really be definite about that." m. The facility's Record of Destruction of Medications Book dated [DATE] was signed by LPN #2 and the Pharmacy Consultant. The book documented they destroyed 12 pills, not 14 pills. 1) On [DATE] at 10:10 a.m., LPN #5 searched the medication room and at 11:45 the LPN searched the medication cart. The facility could not account for 2 of the pills from the card delivered on [DATE]. 2) On [DATE] at 4:08 p.m., the Pharmacy Consultant was asked if he counted the pills before punching then out of the card to be destroyed. He stated, "No, I may spot check. It's too time consuming to do that. We try to get through it as fast as we can. It wastes so much time." He was asked if he could recall the resident's [MEDICATION NAME] and if he could recall how many he destroyed. The Pharmacy Consultant stated, " I don't recall. I can't remember..."

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure residents were provided sufficient fluid volume to prevent dehydration for 3 (Residents #1, #4 and #5) of 5 case mix residents (Residents #1-5) who were at risk for dehydration and failed to promptly intervene when Resident #1's fluid intake declined. The failed practices resulted in actual harm to Resident #1, who was hospitalized with Dehydration and [MEDICAL CONDITION], and had the potential to affect 42 residents who were at risk for dehydration, according to the Administrator on 10/12/10 at 3:37 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented the resident had short and long term memory problems, moderately impaired cognitive skills for daily decision making and required the extensive assistance of one person with eating. a. The Nutritional Evaluation dated 7/5/10 documented the resident's estimated fluid needs were calculated to be 1622.7 cubic centimeters (cc) per day. b. The most recent Dietary Progress Record was dated 7/28/10 and documented, "Referred to RD (Registered Dietician) due to wt (weight) loss. 119# (pounds) down from 124#. Diet Puree, Labs: Hgb (Hemoglobin) -12.9, Hct (Hematocrit) -40.9, BS (Blood Sugar) -72, BUN (Blood Urea Nitrogen) -12, Na (Sodium) -146, K+ (Potassium) -3.9, Alb.([MEDICATION NAME]) - 3.4. Dietary provides Fortified Foods and Ice cream at L&S (Lunch and Supper). Recommend adding whole milk at meals Appetite fair to good. Continue other food fortification to increase Kcal (kilocalories)". c. The Nurses Notes dated 8/13/10 at 1:10 p.m. documented, "Call to room via CNA (Certified Nursing Assistant) observe dark red blood in resident's diaper. Appear to be coming from her rectum area. Call Dr. (name) stated to send to ER (emergency room ) for eval (evaluation)..." At 6:00 p.m., "return back to (name of facility)... [DIAGNOSES REDACTED]. d. The hospital lab results dated 8/13/10 at 2:08 p.m. documented, "WBC (white blood cells) - 12.1, RBC (red blood cells) - 4.29, Hgb - 14.5, Hct - 43.5, Sodium - 144, Potassium - 3.8, Chloride - 110, BUN - 17, Creatinine - 1.1..." e. The Care Plan updated on 8/16/10 documented, "Hx (History) of Abnormal Weight Loss at risk for poor nutritional intake which makes her at risk for wt. loss. Interventions: monitor for wt loss report changes to physician, ...To DR (dining room) at feeder table for meals, staff to feed resident at meals...". A handwritten entry dated 9/15/10 documented, "Goals Provide adequate nutrition/hydration ..." but documented no interventions for hydration. f. The September 2010 ADL (activities of daily living) Flow sheet indicated the resident had a decline in food consumption from 9/23/10 through 9/27/10. The flow sheet did not document the volume of fluids the resident consumed and documented the resident's meal consumption as: 9/22/10 75% for breakfast, 100% for lunch and 100% for supper; 9/23/10 - 25% for breakfast and 50% for lunch, 9/24/10 - 25% for breakfast and lunch, 9/25/10 25% for breakfast and refused lunch and supper; 9/26/10 - refused breakfast and lunch and consumed 15% for supper; 9/27/10 25% for breakfast and lunch. g. The Nurses Notes dated 9/27/10 at 4:50 p.m. and signed by Registered Nurse (RN) #1, documented, "Resident noted nonresponsive to verbal stimuli, BP (blood pressure) 108/60, Pulse 90, O2 Sat (blood oxygen saturation) 83%, Resp. (respirations) 36, notified Dr. (name), received T.O. (telephone order) send to (name of hospital) E.R. to eval. and treat". h. The hospital ER (emergency room ) Flowsheet dated 9/27/10 at 6:40 p.m. documented, "...Chief Complaint: Pt (patient) unresponsive; per daughter, she is exhibiting a decreased LOC (level of consciousness) since this a.m. She usually garbles her speech and will respond/resist when nursing draws blood or changes her; this a.m., she would not respond to nursing, nor would she resist when nursing tried to examine her". i. The hospital lab results dated 9/27/10 at 6:07 p.m. documented, " WBC - 20.3, RBC - 3.76, Hgb - 12.5, Hct - 39.4, Sodium - 184, Potassium - 3.3, Chloride - 150, BUN - 60, Creatinine - 2.2... " The ER Flowsheet documented, " Clinical Impression: ... Dehydration ... Elevated WBC's, Renal Function, suggestive of dehydration, elevated blood sugar, Hypokalemia, [MEDICAL CONDITION], Macrocytic, [MEDICAL CONDITION] left shift with 98% segs; Hypermagnesemia; increase chloride... Diagnosis/Clinical Impression: ...Severe [MEDICAL CONDITION], Dehydration [MEDICAL CONDITION] treatment plan: j. On 10/12/10 at 11:30 a.m., Licensed Practical Nurse (LPN) #1, the MDS/Care Plan (CP) Coordinator, was asked what would place a resident at risk for dehydration. She stated, "According to the MDS, anyone on diuretics, tube feeding or history of UTIs (Urinary Tract Infections) and if residents are dependent on staff for drinking". Resident #1's RAP (Resident Assessment Protocol) trigger sheet dated 7/5/10 did not address dehydration/maintenance fluid needs. LPN #1 was asked if, since Resident #1 required staff to feed her, that placed her at risk for dehydration. The LPN stated, "Yes... we rely on staff to encourage and offer fluids and they are to let me know if they (residents) don't drink". The LPN was asked how the facility monitored fluid intake to ensure the residents were consuming sufficient fluids as recommended by the Registered Dietician (RD) to prevent dehydration and she stated, "We've had a lead CNA in the past that monitored that (fluids consumed) prior to cutting staff, that just messed us up". She said they were supposed to have restarted the lead CNA position, but was uncertain if it had been 100% implemented now. She also added the facility had not had a Dietary Manager since September 24th, (approximately 18 days). LPN #1 stated, "But the CNAs on the halls, it's their responsibility to report to the charge nurse that the resident is not eating. They should look for a pattern of not eating. In my opinion, 50% or less should definitely be reported". She said that during meal service, if they see the resident is not eating they should take the initiative to get something else for the resident, by telling the nurse or getting it themselves, to offer the resident more. LPN #1 was shown the ADL Flow sheet for Resident #1 from 9/23/10 through 9/27/10 that documented the resident had a decline in consumption and was refusing her meals. She stated, "I was training for the MDS 3.0 on 9/21/10, 9/22/10 and 9/24/10. The resident was sent to the hospital on [DATE] " . She was asked if she was aware Resident #1 had a decline in meal consumption on those days, according to the ADL Flow sheet. She stated, "I just didn't know, no one reported to me". She was asked who her backup was when she was not there. She stated, "I don't have a backup". She was asked why. She stated, "They tell me I don't need a backup because the census is too low". k. On 10/12/10 at 12:05 p.m., the Director of Nursing (DON) was asked how the facility monitored fluid intake to ensure the residents were consuming sufficient fluids, as recommended by the RD, to prevent dehydration. She stated, "...the restorative aide documents... besides documenting for breakfast, lunch and dinner, she passes snacks at 10 a.m., 2 p.m. and 8 p.m. and gives fluids. She stands there with the resident and writes down the amount of fluids the resident took in..." She was asked where the restorative aide documented this information and she stated, "...in the ADL book. The form "Between Meals Hydration" was initiated on 10/8/10." The DON was asked who monitored these forms to ensure staff documented residents' consumptions of fluids to prevent dehydration. She stated, " (LPN #2) does". The DON was asked if she was aware Resident #1 had a decline in consumption the week prior to being admitted to the hospital on [DATE]. She stated, "When she went to the hospital, I made it a point to review her chart. Something was going on ... her decline. I suspended two nurses because when I looked at her chart, I noticed there was no documentation between 9/23/10 and 9/27/10. When I looked and saw she had been eating 15% and was refusing meals, they (nurses) just didn't look at the resident. I thought, "You're (nurses) not paying attention to the resident or the CNAs... When a resident goes to the hospital, if you've been paying attention to your resident, your documentation should reflect the condition of your resident". The DON was asked if she became aware of Resident #1's decline in fluid consumption before or after she was sent to the hospital. She stated, "...After". The DON provided a book which included a form titled "Between Meals Hydration". According to the ADL book, the form was initiated 10/8/10, 11 days after Resident #1 was sent to the hospital. l. On 10/12/10 at 1:15 p.m., CNA #1 (Restorative Aide) stated she did the weights, passed snacks and fed residents at the restorative table. She was asked to refer to the "Between Meal Hydration" form. She stated, "To be honest, I was just given this form today, because I was off Friday (10/8/10) and yesterday. I didn't come into the facility until 12 noon yesterday (10/11/10). m. On 10/12/10 at 2:15 p.m., the meeting minutes titled "Daily QA (Quality Assurance) Meeting", dated 9/30/10 and provided by the Administrator, documented, "Family said res. (resident) transported to hospital dehydrated and skin and bones - *directed Lead CNA to provide list of res unable to hydrate selves - begin providing hydration regularly. *directed Lead CNA to review all ADL Care Plan cover sheets to ensure accuracy - the attached cover sheets were updated". The QA meeting minutes documented the family reported their concerns about the resident to the facility. The forms that were initiated on 10/8/10 for monitoring hydration did not document the resident's fluid consumption was monitored consistently. n. On 10/12/10 at 2:40 p.m., LPN #2 was asked if she was responsible for monitoring the ADL sheets for hydration. She stated, "No ma'am. We had a lead CNA that was monitoring that and every time we get a new Administrator they go and change it up. We don't have anyone to monitor. We dropped the ball". o. On 10/12/10 at 2:50 p.m., CNA #2 stated, "I was Lead CNA. They took it away from me in July (2010). They gave it back to me Wednesday (10/6/10). She was asked what the Lead CNA was supposed to do. She stated, "Orient other CNAs, check charting, ADLs, snacks ...round every 2 hours, check foley catheters..." She was asked why the position was taken away from her and she stated, "Because he (Administrator) didn't feel like a CNA should be over CNAs. I wasn't doing the monitoring because I was on the floor". She was asked if anyone was monitoring the hydration sheets. She stated, "Not that I know of". p. On 10/12/10 at 3:20 p.m., RN #1 was shown the September 2010 ADL Flowsheet for Resident #1, specifically 9/23/10 through 9/27/10, that documented the resident's decline in consumption and refusal of meals. She was asked if any CNA reported to her that Resident #1 had not been eating well. She stated, "Not that I remember". She was asked, "Nothing clued you to do an assessment for dehydration such as checking for skin turgor or dry mucus membranes?" She stated, "No, she was just her normal self". There was no documentation of hydration assessments, skin turgor or mucous membrane status. 2. Resident #5 had [DIAGNOSES REDACTED]. The quarterly MDS with an assessment reference date of 7/21/10 documented the resident was severely impaired in cognitive skills for daily decision making, required the limited assistance of one person with eating and was incontinent. a. The most current Dietary Assessment was dated 4/23/10 and documented the resident's estimated fluid needs for a 24 hour period were 2760 cc. b. The Care Plan last updated 7/21/10 documented, "Problem 11/24/08 - At risk for fluid volume deficit, potential for dehydration related to diuretic therapy due to [MEDICAL CONDITION] of bilateral lower extremities ... Approach: Observe consumption. Notify charge nurse if consumption of fluids decreases from her normal". c. On 10/12/10 at 1:35 p.m., the DON provided forms titled "Between Meals Hydration" to document the fluid consumption of residents who were at risk for dehydration. Resident #5 was documented on the form, however, the forms dated 10/8/10 and 10/9/10 were blank in the spaces provided for 10:00 a.m. and 2:00 p.m. The form dated 10/10/10 was completely blank. d. The October 2010 ADL sheet documented meal consumption percentages for Resident #5, but did not document fluid intake. 3. Resident #4 had [DIAGNOSES REDACTED]. The most recent Resident Assessment Protocol Summary (RAPS) trigger sheet dated 5/7/10 triggered in the area of dehydration/fluid maintenance, however, the Care Plan dated 8/3/10 did not address hydration needs. a. On 10/11/10 at 12:27 p.m., the resident's lunch tray was delivered with a 4 ounce (120 cc) glass of tea and a 4 ounce glass of water. The resident consumed 100% of the tea and 50% of the water for a total of 180 cc. No other fluids were provided or offered during the meal. b. On 10/11/10 at 5:12 p.m., the resident received his dinner tray with a 4 ounce glass of cranberry juice. The resident consumed 100% of the juice for a total of 120 cc. No other fluids were provided or offered during the meal. At this time CNA #3 was asked why the resident did not receive more fluids with his meal. The CNA stated, "He's not a drinker. He will eat all his food, but not any more fluids". c. On 10/12/10 at 11:50 a.m., the Care Plan Coordinator was asked why Resident #2 received only small amounts of fluids with meals. She stated, "I don't know. They dropped the ball when they didn't offer him more. Prior to staff being cut, we had the juices on a cart that went around to each table, but we've had no Dietary Manager since the 24th. I just became aware last Friday that they weren't doing that". d. On 10/12/10 at 12:40 p.m., the resident was fed lunch by CNA #4. The resident was served a 12 ounce glass of punch. CNA #4 was asked if the resident drank only small amounts with meals. She stated, "He'll drink whatever I give him". The resident consumed 100% of the punch, a total of 360 cc. e. On 10/12/10 at 1:35 p.m., the form titled "Between Meals Hydration" for Resident #4 dated 10/8/10, 10/9/10 and 10/10/10 were blank in the spaces provided for 10:00 a.m., 2:00 p.m. and 8:00 p.m. The form dated 10/11/10 was blank in the space provided for 8:00 p.m. f. The October 2010 ADL sheet documented meal percentages for Resident #4, but did not document fluid intake.