Every finding on record at Trend Health and Rehab of Brookhaven

Based on record review, facility policy review, and staff and resident interviews, the facility failed to ensure safe transfer practices as evidenced by the facility failed to ensure two (2) staff members were present during a mechanical lift transfer per facility policy for one (1) of (16) sampled residents. (Resident #30). Findings include:Record review of the facility policy, 3/16 revealed Procedure.1. Use of a mechanical lift requires (2) nursing assistants or nurses to perform the procedure each time it is used. A review of a Facility Reported Incident investigation revealed Certified Nursing Assistant (CNA) #1 lifted Resident #30 alone using a mechanical lift on 1/7/26. During the transfer, the lift pad moved and the resident slipped from the lift, falling to the floor. There were no malfunctions identified with the lift or the lift pad.On 02/10/2026 at 12:56 PM, during an interview Resident #30 confirmed only one CNA was present at the time of the fall on 01/07/2026 when she was dropped from the lift. The resident stated the aide had lifted her high in the air when the lift strap slipped, causing her to fall straight onto the ground. She stated she was later informed the CNA would receive refresher training. The resident stated she believed two staff members were supposed to be present during lift transfers so one could observe and attempt to stop or break a fall if equipment failed. She reported she did not sustain bruising or fractures but did sustain a broken fingernail.On 02/10/2026 at 1:23 PM, during an interview CNA #1 confirmed she was alone in the resident's room on 01/07/2026 while transferring the resident using a mechanical lift when the incident occurred. She stated the resident began to slip and slid out of the lift pad, falling to the floor. She reported the facility had changed the lifting method, directing staff to place lift pad straps underneath the legs instead of between the legs. She stated she had attended an in service within the last year related to this change. She further stated the facility reverted to the previous strap placement method after the incident. She confirmed she was alone because other staff were unavailable at the time.On 2/10/26 at 3:10 PM, during an interview, the Director of Nursing (DON) stated an investigation was completed. The DON confirmed CNA #1 transferred the resident alone using a mechanical lift. She stated CNA #1 was suspended for one day and received immediate in-service training with return demonstration. The DON stated CNA #1 had not completed follow up lift training since her hire date in 2021 due to working on an as needed basis. The DON stated facility policy requires two staff members during mechanical lift use to prevent injury, as one staff member serves as a spotter if the lift begins to slip or fall. She confirmed staff are expected to follow facility lifting policy at all times.Record review of the admission Record revealed Resident #30 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation.Record review of the MDS with an Assessment Reference Date (ARD) of 11/11/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, interviews, and record reviews the facility failed to ensure medications were available for administration as ordered for two (2) of (29) medication administration opportunities resulting in a medication error rate of 6.9% that affected Resident #3 and Resident #62.Findings Include:Resident #3On 02/11/26 at 10:46 AM, an observation was made of Licensed Practical Nurse (LPN) #4 preparing medications for Resident #3. During preparation, Flonase 0.05 mg/actuation nasal spray was not available. LPN #4 searched the medication room and was unable to locate the medication.On 02/11/26 at 10:50 AM during an interview, LPN #4 stated the pharmacy delivers medications nightly. She stated the nurse assigned to the medication cart on previous shifts is responsible for reordering medications before depletion. She stated it is important that residents receive medications as ordered.Record review of Resident #3's admission Record revealed an admission date of 02/24/25 with a diagnosis of allergy, unspecified, subsequent encounter.Record review of Resident #3 Physician Orders revealed an order for Flonase Allergy Relief Nasal Suspension, Fluticasone Propionate Nasal, two sprays in both nostrils daily for allergies.Record review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact.Resident #62On 02/11/26 at 9:50 AM, during an observation revealed LPN #4 preparing medications for Resident #62. During preparation, Famotidine 10 milligrams (mg) oral tablet was not available. LPN #4 searched the medication room and was unable to locate the medication.On 02/11/26 at 10:18 AM, during an interview, LPN #4 stated the pharmacy delivers medications nightly. She stated the nurse assigned to the medication cart on previous shifts is responsible for reordering medications before depletion. She confirmed it is important that residents receive medications as ordered.Record review of Resident #62's admission Record revealed an admission date of 02/05/26 with diagnoses that included Gastroesophageal Reflux Disease without esophagitis.Record review of Resident #62's Order Summary Report revealed an order for Famotidine 10 milligrams (mg) oral tablet, one tablet by mouth every morning and at bedtime for Gastroesophageal Reflux Disease without esophagitis.Record review of Resident #62's MDS with an ARD of 2/9/26 revealed a BIMS score of 15 indicating the resident is cognitively intact. On 02/12/26 at 1:53 PM, during an interview, the Director of Nursing (DON) stated nurses are expected to reorder medications when the supply reaches five doses remaining in a blister pack. She stated she places orders for over-the-counter medications every Monday. An order form is maintained in the medication storage room for nursing staff to document needed items. She stated she retrieves over the counter medications weekly and confirmed pharmacy deliveries occur nightly. She stated medications should never be depleted and all systems are in place to prevent shortages. She stated failure to maintain medication supply can be detrimental depending on the medication involved.

Based on record review, facility policy review, and interviews, the facility failed to ensure staff followed the resident's comprehensive care plan and facility mechanical lift policy for safe transfers for one (1) of (1) residents reviewed for accidents involving mechanical lifts. Resident #30. Findings include: Record review of the facility policy, 3/16 revealed : It is the policy of this facility to develop and implement a comprehensive, person centered care plan for each resident, consistent with resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Record review of the Care Plan Report with a date initiated of 2/7/25 revealed .Transferring Hoyer lift with 2 staff assistance for transfer to chair/bed. Record review of the Reportable Incident investigation revealed Certified Nurse Aide (CNA) #1 lifted Resident #30 alone using a mechanical lift. During the transfer, the lift pad moved and the resident slipped out of the lift, falling onto the floor. There were no malfunctions of the lift or sling identified. During an interview on 02/10/2026 at 12:56 PM, Resident #30 confirmed only one CNA was present at the time of the fall on 01/07/2026 when she was dropped from the lift. The resident stated the aide had lifted her high in the air when the lift strap slipped, causing her to fall straight onto the ground. She stated she was later informed the CNA would receive refresher training. The resident stated she believed two staff members were supposed to be present during lift transfers so one could observe and attempt to stop or break a fall if equipment failed. She reported she did not sustain bruising or fractures but did sustain a broken fingernail. During an interview on 02/10/2026 at 1:23 PM, CNA #1 confirmed she was alone in the resident's room on 1/07/2026 while transferring the resident using a mechanical lift when the incident occurred. She stated the resident began to slip and slid out of the lift pad, falling to the floor. She reported the facility had changed the lifting method, directing staff to place lift pad straps underneath the legs instead of between the legs. She stated she had attended an in service within the last year related to this change. She further stated the facility reverted to the previous strap placement method after the incident. During an interview on 02/10/2026 at 3:10 PM, the Director of Nursing (DON) confirmed an investigation was completed and determined CNA #1 transferred the resident alone using the lift. She confirmed the resident's care plan required two staff members for lift transfers, consistent with facility policy requiring two staff when operating a mechanical lift. She stated the purpose of the care plan is to instruct staff on providing safe care. She stated adherence to the 2- person lift requirement prevents resident injury because (1) staff member can stabilize the lift or resident if equipment begins to slip. She confirmed staff are expected to follow both the facility lift policy and resident care plans. During an interview on 02/10/2026 at 3:15 PM, the Minimum Data Set (MDS) and Care Plan Licensed Practical Nurse (LPN) confirmed the care plan identified the resident as a two-person mechanical lift transfer. She stated the purpose of the care plan is to instruct staff on proper transfer techniques to prevent injury. She stated failure to utilize two staff could result in the lift tipping or the resident falling, while a second staff member could intervene to prevent an accident. Record review of the admission Record revealed Resident #30 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation. Record review of the MDS with an Assessment Reference Date (ARD) of 11/11/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on observation, interview, facility policy review and record review, the facility failed to ensure staff performed hand hygiene in accordance with infection prevention standards before donning (putting on) gloves, after glove removal, and after contact with contaminated surfaces during medication administration and enteral feeding for three (3) of (16) sampled residents. Resident #3, Resident #56 and Resident #62.Findings include: Record review of the facility policy Hand Hygiene copyright 2025 revealed .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Resident #3 On 02/11/26 at 10:25 AM, during an observation Licensed Practical Nurse (LPN) #2 performed percutaneous endoscopic gastrostomy (PEG) tube site care for Resident #3. The nurse removed a soiled dressing and failed to perform hand hygiene before retrieving and donning (putting on) new gloves. She cleansed the upper portion of the PEG tube site, removed gloves, and again failed to perform hand hygiene before donning new gloves. She then cleansed the lower portion of the site, removed gloves, and failed to perform hand hygiene prior to applying a new dressing. She changed gloves again without performing hand hygiene and applied tape to secure the dressing before completing care. During an interview on 2/11/26 at 10:30 AM, LPN #2 stated she should have performed hand hygiene between each glove change during care to prevent spread of infection to the site. During an interview on 2/12/26 at 10:18 AM, the Director of Nursing (DON) confirmed hand hygiene should be performed with each glove change to prevent transmission of infection to the PEG tube site and stated staff are expected to follow infection prevention guidelines. Record review of the admission Record revealed Resident #3 was admitted on [DATE] with diagnoses that included sequelae of cerebral infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Resident #56 On 02/10/26 at 12:31 PM, during an observation, LPN #3 provided a bolus enteral feeding to Resident #56. LPN#3 donned gloves then she touched the bed remote control, opened the bathroom door, and turned the water faucet on and off. Licensed Practical Nurse #3 did not perform hand hygiene upon entry and did not remove gloves or perform hand hygiene after touching multiple environmental surfaces prior to administering the feeding. During an interview on 02/10/26 at 12: 48 PM, LPN#3 confirmed she did not wash her hands upon entry and did not change gloves after touching items in the resident room. She stated she should have washed hands upon entry, removed gloves, and washed hands after touching items prior to administering the feeding. She stated the resident could develop an infection. During an interview on 02/10/26 at 1:13 PM, Registered Nurse (RN) #2/Charge Nurse, stated LPN #3 should have her washed hands upon entry to the resident's room. She stated after touching items the nurse should remove gloves, perform hand hygiene, and apply clean gloves before administering the bolus feeding. She stated failure to perform hand hygiene places residents at risk for infection and is an infection control concern. During an interview on 02/10/26 at 3:58 PM, the DON stated that LPN #3 should have washed hands her upon entry prior to donning gloves. She stated the nurse should remove her gloves and wash her hands prior to initiating the feeding due to touching environmental surfaces. She stated this creates cross contamination risk and bacteria on contaminated gloves can be transferred to the resident. During an interview on 02/11/26 at 9:13 AM, RN #1 stated the nurse should have washed her hands before donning gloves and should have removed her gloves and washed her hands before beginning the feeding. She stated failure to do so can spread pathogens to the resident, especially if the resident has open skin areas. During an interview on 2/11/26 at 10:02 AM, the Infection Preventionist/RN #1, stated hand hygiene should be performed each time gloves are changed during wound care because openings in the skin increase susceptibility to infection and contaminated hands can transmit pathogens. Resident #62 On 2/11/26 at 9:50 AM, observed LPN #4 apply a topical Lidocaine patch to Resident #62's lower back. LPN #4 donned gloves upon entering the room but did not perform hand hygiene prior to glove application or prior to applying the patch. During an interview on 2/11/26 at 10:30 AM, LPN #4 confirmed she did not wash hands before donning gloves and applying the patch. She stated she should have washed hands and acknowledged the resident could develop an infection. Record review of the admission Record revealed Resident #62 was admitted on [DATE] with diagnoses including wedge compression fracture of the lumbar vertebra. Record review of the Order Summary Report with active orders of 2/12/26 revealed an order dated 2/5/26 Lidocaine external Patch 5%- Apply to mid back topically in the morning for pain. Record review of the MDS with an ARD of 2/9/26 revealed a BIMS score of 15 indicating the resident was cognitively intact.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were properly dated and labeled in accordance with food storage guidelines for one (1) of four (4) days of survey, which had the potential to result in the use of food beyond recommended time frames.Findings include:Record review of the facility's food storage policy revealed that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.On 02/09/2026 at 10:20 AM, an observation of the kitchen refrigerator revealed two wrapped containers located on the bottom shelf. One container contained oatmeal and the other contained pureed eggs. Both containers were undated.On 02/09/2026 at 10:22 AM, in an interview, the dietary aide stated the items should have been dated so staff would know if the food was fresh. She stated she was in a hurry that morning to get trays out and planned to date them later.On 02/12/2026 at 9:37 AM, in an interview, the Dietary Manager stated that food items are required to be labeled and dated so staff can determine when the food was prepared. He stated regulations require food to be discarded after seven (7) days. He confirmed staff did not follow regulations by failing to date the items.

Based on observation, interviews, record review and facility policy review the facility failed to ensure the emergency medication kit was secured and locked to prevent unauthorized access and to ensure availability of medications for emergency use for one (1) of two (2) medication storage rooms observations.Findings Include:Record review of the facility's Medication Ordering and Receiving from Pharmacy Provider undated revealed, .4. EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS.g. When an emergency or starer dose of medications is needed the nurse breaks the container seal and removes the required medication .On 02/10/2026 at 11:41 AM, during an observation of the medication storage room with Licensed Practical Nurse (LPN) #5 revealed that the Emergency kit was missing a zip lock tie. There were numerous medications in the unlocked kit. LPN #5 confirmed the Emergency kit was not locked. She stated it was supposed to be locked at all times. She stated it contains medications for emergency usage only. She stated the purpose of the kit being locked is so no one can remove medications from the kit unless they sign them out and to ensure they will be available for emergency usage when needed.On 02/10/2026 at 12:07 PM, in an observation and interview with Registered Nurse (RN) #2/Charge Nurse confirmed the kit was not locked. She stated it is supposed to be a zip tag on it. She stated the purpose is to make sure what is in the kit for emergencies is in it when needed for emergencies. She stated it should be always locked. She stated the nurses are responsible for making sure that they place a lock on it if they open it. She stated the nurse can contact pharmacy to get more locks. She stated they are supposed to sign Emergency Box Requisition stating they place a lock on it after opening it to medications out. On 02/10/26 at 3:54 PM, in an interview with Director of Nursing (DON) stated the emergency kit should be locked. She stated the last nurse who got something out of it should make sure it is locked. She stated if they are out of zip locks the nurse should contact pharmacy to get some locks. She stated it important that it stays locked so that no one can get things out of it. She stated it could be dangerous if someone gets things out of it, that they should not have access to the kit.Record review of the Institutional Emergency Medication Kit inventory list confirmed the medications contained in the kit at the time of observation. Narcotics were maintained in a separate locked box.A record review of the Emergency Box Requisitions form revealed there were three nurses who removed medications from the kit but left their initial space blank for replacement lock. The following dates were left blank 2/1/26, 2/6/26 and 2/9/26 on the Emergency Box Requisitions.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices during the provision of care for residents on Enhanced Barrier Precautions (EBP) for two (2) of five (5) care observations. Residents #24 and #40. Findings Include: A review of the facility's procedure titled Procedure for Handwashing, revised 04/15, revealed .When to Wash Hands (at a minimum) . Before and after each resident content After handling any contaminated items (linens, soiled diapers, garbage, etc.) A review of the facility's policy titled, Enhanced Barrier Precautions revised 08/07/24, revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . A review of the facility's policy titled Infection Prevention and Control Program, (undated) revealed It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Resident #24 During an observation on 10/10/24 at 9:07 AM, Licensed Practical Nurse (LPN) #3 entered Resident #24's room to perform PEG tube care and did not perform hand hygiene prior to applying gloves and providing care. During the procedure, the supplies needed for continuation of care fell off the bedside table onto the floor. LPN #3 picked up the dirty supplies, and threw them away, however, when she re-entered the resident's room after securing additional supplies, once again, she did not perform hand hygiene prior to applying her gloves. During an interview on 10/10/24 at 9:41 AM, LPN #3 confirmed she forgot to wash her hands upon entering the room prior to applying gloves and beginning care. The nurse admitted that her actions was against infection control guidelines and could pose a risk for infection. A record review of Resident #24's Order Summary Report, with active orders as of 10/10/24, revealed orders, dated 05/20/24, to clean around the PEG tube site with normal saline gauze, pat dry, apply gentamycin ointment around the stoma, cover with split gauze, and secure with tape twice daily for a gastrostomy infection, until resolved, then discontinue. There was also an order, dated 04/08/24, for Enhanced Barrier Precautions related to PEG tube every day and night shift. A record review of Resident #24's Admission Record revealed the facility admitted the resident on 12/11/19. The resident had diagnoses that included Unspecified Sequelae of Unspecified Cerebrovascular Disease, Epilepsy, and Dysphagia. A record review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/24 revealed that Resident #24's cognitive skills was severely impaired. Section K indicated the presence of a feeding tube. Resident #40 During an observation on 10/09/24 at 9:14 AM, Certified Nursing Assistant (CNA) #1 provided peri care to Resident #40 without wearing the required gown, which was part of the Enhanced Barrier Precautions. During an interview on 10/10/24 at 9:50 AM, CNA #1 confirmed she did not wear the gown as required and acknowledged that not wearing proper PPE could result in the transmission of germs to the resident and others. During an interview on 10/10/24 at 11:23 AM, the Director of Nursing (DON) confirmed that hand hygiene before resident care and when a nurse changes gloves is an important part of infection control. The DON also confirmed that CNA #1 should have worn a gown when providing care to Resident #40, as that is a requirement for Enhanced Barrier Precautions to prevent the risk of cross-contamination. During an interview on 10/10/24 at 11:33 AM, LPN #4 (Infection Preventionist) stated that LPN #3 should have performed hand hygiene prior to providing resident care and when changing gloves. LPN #4 also confirmed that CNA #1 should have worn the required gown while performing care for Resident #40 to decrease the risk of germs being transferred to the CNA's uniform, which could for cross contamination, while providing care to other residents. A record review of Resident #40's Order Summary Report, with active orders as of 10/10/24, revealed an order, dated 04/08/24, for Enhanced Barrier Precautions related to the resident's PEG tube. A record review of Resident #40's Admission Record revealed the facility admitted the resident on 01/23/24. The resident's diagnoses included Alzheimer's Disease, Vascular Dementia, and Dysphagia. A record review of the Quarterly MDS with an ARD of 07/25/24 revealed that Resident #40 was unable to complete the Brief Interview for Mental Status (BIMS) for cognitive status and was scored 99 on the assessment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement care plans interventions regarding wearing all Personal Protective Equipment (PPE) during perineal care and hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube care for two (2) of five (5) residents reviewed for care. Resident #24 and Resident #40. Findings Include: A review of the facility's policy titled Care Plan - Comprehensive, revised October 2016, revealed, An individualized (person-centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident . Policy Interpretation and Implementation . 3. Each resident's comprehensive care plan is designed to: . f. Identify the professional services that are responsible for each element of care . Resident #24 A record review of Resident #24's comprehensive care plan revealed Focus: I am on Enhanced Barrier Precautions .because I have a PEG Tube .Interventions/Task .WASH HANDS BEFORE AND AFTER PROVIDING CARE TO RESIDENT with a dated initiated of 10/2/2024. On 10/10/24 at 9:07 AM, during an observation Licensed Practical Nurse (LPN) #3 entered Resident #24's room to perform PEG tube care and did not perform hand hygiene prior to applying gloves and providing care. During the procedure, LPN #3 had to exit the room. When she re-entered the room, once again, she did not perform hygiene prior to gloving and providing care to the resident. On 10/10/24 at 9:42 AM, during an interview, LPN #3 admitted that she was nervous, forgot to wash her hands, and recognized her actions posed infection control risks. Resident #40 A record review of Resident #40's comprehensive care plan with a date initiated of 4/2/2024 revealed Focus: I am on Enhanced Barrier Precautions .because I have a PEG tube .Interventions/Task .Staff will use PPE (gown and gloves) during high contact resident care activities. During an observation on 10/09/24 at 9:14 AM, Certified Nursing Assistant (CNA) #1 was observed providing perineal care to Resident #40 without wearing the required gown as part of the required PPE for residents on Enhanced Barrier Precautions. During an interview on 10/10/24 at 9:50 AM, CNA #1 confirmed she did not wear a gown and admitted that not wearing proper PPE could spread germs to the resident. During an interview on 10/10/24 at 11:30 AM, the Director of Nursing (DON) confirmed that both Resident #24 and #40 were on Enhanced Barrier Precautions due to a PEG tube. The DON stated that the comprehensive care plans for both residents revealed that they were on Enhanced Barrier Precautions, with interventions that revealed hand washing was required before and after providing care to the residents and staff wearing PPE (gown and gloves) during high contact resident care activities. The DON stated that all staff should follow the comprehensive care plan. During an interview on 10/10/24 at 11:49 AM, LPN #5, the care plan nurse, confirmed that care plans should be followed by both nurses and CNAs and acknowledged that by not wearing a gown, as part of the requirements for Enhanced Barrier Precautions, and washing their hands before providing care to the resident, staff did not follow the care plan when they provided high-contact care for these two (2) residents.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received a physician-ordered salad during the lunch meal for one (1) of eighteen (18) sampled residents. Resident #44 Findings Include: A review of the facility's policy titled Dining and Food Preferences, revised 10/2022, revealed: Individual dining, food, and beverage preferences are identified for all residents/patients. During an interview on 10/07/24 at 10:43 AM, Resident #44 stated that the kitchen does not provide her with food to her liking. She mentioned that she enjoys eating salads daily but has not received them in several months, despite requesting them through the nurses and Certified Nursing Assistants (CNAs). She added that she stopped asking because she became tired of repeating her request. During an observation on 10/07/24 at 12:31 PM, it was noted that Resident #44's lunch tray did not contain a salad. During an interview on 10/07/24 at 2:13 PM, Resident #44's sister expressed her frustration with the facility's failure to honor her sister's food preferences, specifically her desire to receive salads with meals. During an interview on 10/08/24 at 12:11 PM, the Dietary Manager stated that she collects resident food preferences upon admission but had not updated Resident #44's preferences in a while. She acknowledged that it was probably time to reassess the resident's preferences. During an observation on 10/08/24 at 12:17 PM, Resident #44's lunch tray again did not contain a salad. During a follow-up interview on 10/09/24 at 7:02 AM, the Dietary Manager admitted that she stopped purchasing salads a few months ago because of cost concerns. She also revealed that she was unaware of the physician's order requesting that Resident #44 receive a side salad with ranch at every lunch meal. The Dietary Manager stated that she had not received communication from nursing staff about the order. During an interview on 10/09/24 at 2:21 PM, the Director of Nursing (DON) confirmed that the Dietary Department had been notified of the doctor's order. The DON provided a copy of the diet requisition form, which included instructions for diet changes. During an interview on 10/10/24 at 9:21 AM, the Registered Dietician (RD) explained that with every nutritional assessment and recommendation for a resident, she emails a copy to the doctor, DON, and Dietary Manager. She also provides each of them with a hard copy of the diet requisition form, which indicates the same information included in the assessment. A record review of the Admission Record revealed that the facility admitted Resident #44 on 11/22/23 with diagnoses including Hyperlipidemia and Type 2 Diabetes. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/24, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating she was cognitively intact. A record review of the electronic health record Care Profile revealed Resident #44 had an active physician's order, with a start date of 3/19/24, Provide House side salad with Ranch dressing on lunch tray daily . A record review of Resident #44'sRD Assessment & Recommendations, dated 3/13/24, revealed, .Request side salad w/(with) ranch on lunch tray. Will inform dietary . A record review of the Diet Requisition Form, dated 3/18/24, revealed a Request for Services to provide side salad w/ranch on lunch tray daily . The form indicated the requisition was for Resident #44.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, and homelike environment as evidenced by a soiled privacy curtain, missing paint on the walls, strong odors, and flies present in the resident's room for one (1) of fourteen (18) sampled residents. Resident #14 Findings Include: A review of the facility's policy titled Safe and Homelike Environment, undated, revealed, .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . A review of the facility's Residents' Rights document, undated, revealed, .You have the right to live and receive care in a residential setting that is homelike, safe, clean, and comfortable. For example, you are entitled .to housekeeping and related services to keep your living spaces clean, uncluttered, and comfortable . During an observation on 10/07/24 at 12:15 PM, Resident #14's room was observed with a strong smell of urine and mildew. There were four (4) flies flying around the resident's bed, mattress, and pillow. There was paint missing from the wall to the left of the bed, and a spider web with a fly in it was observed behind the door in the upper left-hand corner. The privacy curtain had visible food and other stains. During an interview on 10/07/24 at 1:00 PM, Resident #14 expressed significant concerns regarding her living conditions within the facility. She reported that the persistent strong odor, which she described as moldy, has led her to spend most of her time outside of her room. Resident #14 also reported that recently the presence of flies in her room had increased significantly. During an observation on 10/08/24 at 11:47 AM, in Resident #14's room, there was a strong smell of urine and mildew. Four (4) flies were flying around her bed, mattress, and pillow. The paint was still missing from the wall to the left of the bed, and the spider web was still behind the door. The privacy curtain remained soiled with visible food and other brown, discolored stains. During an observation and interview on 10/08/24 at 12:00 PM, the Facility Administrator confirmed the presence of flies, the odor of mildew, the missing paint on the wall, and the stained privacy curtain in Resident #14's room. The Administrator stated that it was the responsibility of the housekeeping supervisor to ensure the facility, especially resident rooms, was cleaned thoroughly to maintain a homelike environment. He acknowledged that the cleanliness of the resident's room had not been maintained according to the facility's standards. During an observation and interview on 10/08/24 at 12:10 PM, Housekeeping Staff #1 confirmed the presence of flies, the smell of mildew, the stained privacy curtain, and the missing paint in Resident #14's room. He expressed that housekeeping staff are expected to clean resident rooms thoroughly to maintain a homelike environment. A record review of the Admission Record revealed Resident #14 was admitted by the facility on 9/22/2023 with diagnoses including Overactive Bladder. A record review of the Optional State Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 8/29/24, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated her cognition was moderately impaired.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to serve meals to the residents that were palatable for two (2) of three (3) residents reviewed for palatable meals. Residents #2 and #3 Findings include: A record review of the facility's, Food: Quality and Palatability, revised 9/2017, revealed, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served and appetizing temperatures . Resident #2 On 8/28/23 at 4:40 PM, in an interview with Resident #2, she revealed that there are days in which the food is okay, but some days, it has no taste. The resident explained that it depends on who cooked the food. On 8/28/23 at 6:00 PM, in an interview, Resident #2 stated she had corn, rice, and a tortilla with cheese. The resident complained that the corn tasted very bland. Once again, the resident revealed that there are times in which the food has no taste and needs seasoning. However, she noted that the problem with periods of bland tasting food had been brought to the attention of the Dietary Department. On 8/29/23 at 3:30 PM, in an interview, Resident #2 he commented the food tasted better today. A record review of the Order Summary Report, with active orders as of 8/29/23, revealed Resident #2 had orders for a Consistent Carbohydrates diet, Regular texture, Regular liquids consistency, and No Salt Packet with Meals. A record review of Resident #2's Admission Record revealed the facility admitted the resident on 12/25/22, with diagnoses that included Essential (Primary) Hypertension and Type 2 Diabetes Mellitus A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 5/26/23, for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #3 On 08/28/23 at 6:10 PM, in an interview with Resident #3, he stated his supper vegetables had no taste. He stated he ate the barbeque chicken on a bun, and it was okay. The resident revealed that most of the time, the food has no taste. He stated he ate it because he was hungry. On 08/29/23 at 11:50 AM, in an interview with Resident #3, he revealed the grits he was served at breakfast, had no taste. The resident stated he does not like food with no taste. A record review of the Order Summary Report, with active orders as of 8/29/23, revealed Resident #3 had orders for a HSG (limited calorie diet), CCD (carbohydrate-controlled diet), NAS (no added salt), Regular texture, and Regular liquids consistency. A record review of Resident #3's Admission Record, revealed the facility admitted the resident on 4/16/23, with diagnoses that included Essential (Primary) Hypertension, Anemia, and Type 2 Diabetes Mellitus. A record review the MDS with an ARD of 7/20/23, for Resident #3, revealed a BIMS score of 13, which indicates the resident was cognitively Intact. On 08/28/23 at 5:30 PM, in an interview with the Dietary Manager (DM), she stated she there are several different cooks that she must schedule to cook the dinner meals. The DM revealed there has been a high turnover in the dietary department, and she has found that some of the cooks do not taste the food prior to serving the residents. The DM revealed that she believes tasting the food is important, as it helps the cook recognize which foods need additional seasoning. On 08/28/23 at 5:45 PM, during an observation and taste test of the evening meal along with the DM revealed the tray consisted of barbeque pulled chicken on a bun, tater tots, vegetable medley, confetti coleslaw, whole kernel corn, steamed rice, and a cheese quesadilla. The whole kernel corn and vegetable medley tasted very bland. The DM confirmed that they were bland and needed seasoning for taste. She noted that the cook has no salt alternatives for the food and if alternatives were used, it would improve the taste of the food. On 08/29/23 at 4:00 PM, in an interview with Dietary Cook #1, he revealed he uses chicken base to flavor the food when he cooks, as it gives the food a great flavor and is low in sodium.

Based on interview, record review, and facility policy review, the facility failed to resolve repeated group dietary complaints voiced by residents during Resident Council Meetings for five (5) of six (6) months of resident council meeting minutes reviewed. Findings include: Review of the Healthcare Services Group (HCSG) policy titled, Food: Quality and Palatability, revised 9/2017, revealed, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Foods and liquids are prepared and served in a manner, form, and texture to meet resident's needs . Review of the Healthcare Services Group (HCSG) policy titled Meal Distribution: Infection Control Consideration, revised 9/2017, revealed . All food items will be transported promptly for appropriate temperature maintenance . Record review of the Resident Council Meeting Minutes reviewed for the past six (6) months revealed varied dietary complaints of food being salty at times, and bland at other times. However, there were repeated complaints of cold food during five (5) of the six (6) months reviewed. Meeting minutes revealed residents complained of cold food during the meetings held on 9/27/22, 10/25/22, 12/20/22, 1/24/23, and 2/21/23. An interview and observation of a test tray with the Dietary Consultant on 3/06/23 at 12:14 PM, revealed the pork loin had a good taste and was warm, the collard greens were warm and extremely salty, and the rice pilaf was warm and bland with no taste. During a meeting on 3/7/23 at 10:00 AM, with 13 Resident Council Members, they revealed that have complained about the food for months during their monthly meetings. The members also stated that they have met with the Administrator and Dietary Manager to voice their concerns. During an interview on 3/9/23 at 10:09 AM, with the Activity Director, she revealed she records the Resident Council Meeting minutes. She stated the residents continue to complain every month that the food is cold and bland. The Activity Director confirmed she had forwarded the complaints to the Administrator and Dietary Director. During an interview on 3/9/23 at 11:18 AM, the District Manager confirmed the residents had complained several months in resident council meetings about the food being cold, salty, and bland. The District Manager also confirmed the collard greens were salty and the rice pilaf was bland on the test tray. During an interview on 3/9/23, at 11:26 AM, with the Administrator she confirmed the residents had complained for several months about the food, however, she had talked to the Regional Managers about the food complaints, as the kitchen staff is contracted through a private company. An interview on 3/9/23 at 12:30 PM, with the Dietary Manager, revealed she was aware of the food complaints. The Dietary Manager confirmed there had been some improvements in dietary, but they are still trying to find ways to keep the food warm and improve the taste.

Based on observation, interviews, and facility policy review, the facility failed to prevent the possible spread of infection by leaving an unattended ice chest in the hallway for one (1) of four (4) days of observation. Findings include: A review of the facility policy, titled Infection Prevention and Control Program, dated 6/6/22, revealed, It is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections . All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . An observation on 3/7/23 at 9:30 AM, revealed Resident #35 getting ice out of the ice chest left unattended in the hallway. The resident scooped ice and water out of the ice chest into his personal mug, then poured the excess out of his mug back into the ice chest. During an interview on 3/7/23 at 9:40 AM, with Registered Nurse (RN) #3/IP (Infection Preventionist), she confirmed the ice chest was left on the hallway unattended but should have been taken to the kitchen after the nurse aides filled the resident's mugs with ice. The IP confirmed this was an infection control issue, as other residents could be exposed to infectious substances if they received ice from the contaminated ice chest. During an interview on 3/9/23 at 11:29 AM, with the Director of Nursing (DON), she confirmed the Certified Nurse Aide (CNA) should have removed the ice chest from the hallway after passing out ice to the residents. The DON confirmed the actions of Resident #35 contaminated the ice chest and the remaining ice could lead to cross contamination and be a potential source of infection. 41680

Based on observation, interviews, and facility policy review, the facility failed to remove expired, refrigerated medications from the medication storage room for one (1) of two (2) observations. Findings include: A record review of the facility's policy titled, Checking Stock Medication for Manufacturer Expiration Dates, with a revision date of 4/17, revealed, It is the policy of this facility to check for medication expiration dates monthly for manufacturer's expiration dates and as needed prior to dispensing to residents . During the process, if any medication is found to be expired, it will immediately be removed from the med cart or stock room and given to the Director of Nursing for proper disposal . On 3/9/23 at 10:02 AM, in an observation of the medication room, with Registered Nurse #2 (RN), revealed a refrigerated bottle of labeled Influenza Vaccine Flucelvax Quadrivalent 2021-2022 Formula, with an opened date of 12/17/21, and an expiration date of June 30, 2022. The opened vaccine bottle was half full. On 3/9/23 at 10:12 AM, in an interview with RN #2, she explained it is the responsibility of the Charge Nurse to dispose of the expired medications. She stated expired vaccines could be less effective. On 3/9/23 at 1:00 PM, in an interview with the Director of Nursing (DON), she revealed the Charge Nurse should check for expired medications in the medication refrigerator, as she monitors the refrigerator temperature. She confirmed expired Influenza vaccine could potentially be less effective in protecting the residents from influenza.

Based on observation, staff intervention, record review, Manufacturer's Instructions for Digital Thermometer Calibration and facility policy review, the facility failed to prevent the possibility for the spread of food borne illness during tray line temperature checks and wet stacking of juice glasses, for one (1) of three (3) kitchen observations. Findings include: A review of facility's policy titled, Infection Prevention Program Overview dated 2/2018, revealed The goals of the infection control prevention program are to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by; decreasing the risk of infection to residents and personnel, identifying and correcting problems relating to infection prevention practices and maintaining compliance with state and federal regulations relating to infection prevention. Prevention of spread of infection is accomplished by use of hand hygiene, standard precautions, transmission based precautions, as indicated, and other barrier. A review of a typed document on the facility's letterhead, signed and dated (MONTH) 8, 2019 by the Administrator, revealed, Countrybrook Living Center contracts with (Name of Healthcare Business) to provide dietary services, and thermometer calibration is to be done prior to each meal with the standard of use following manufacturers' instruction manual. A review of the Waterproof Digital Thermometer Instructions Manual provided by the facility revealed, If recalibration is necessary, for best results, calibrate within the temperature range most commonly used. Always utilize a reliable source as a benchmark when calibrating. If a verified reference temperature cannot be achieved in the usage range, then calibrate in an ice bath. An observation, on 8/5/19 at 3:53 PM, revealed 18 Juice glasses, were wet and stacked on top of each other, sitting on a rack with other clean dishes. A review of the Lippincott's Nursing Procedures titled, Hand Hygiene, dated (MONTH) 14,2019, revealed, The hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. This information was provided by the Administrator she obtained from the Lippincott website. An observation, on 8/6/19 at 11:50 PM, revealed the Dietary Cook came from an area in the back of the kitchen wearing gloves and holding a metal pan containing food. The Dietary Cook approached the holding table where the food warms until it is served and sat the pan in the holding table. The Dietary Cook did not change gloves or wash her hands. The Dietary Manager handed the Dietary Cook a thermometer that he had been holding in his bare hand. The Dietary Manager went to the back of the kitchen, washed his hands and then returned to watch the Dietary Cook check the temperatures of the different food. The Dietary Cook began to check the temperature of the foods on the holding line without washing hands or changing gloves after brining the pan of food from the back of the kitchen. Neither the Dietary Cook nor the Dietary Manager calibrated the thermometer. The Dietary Cook wiped the thermometer probe with an alcohol prep pad and checked the temperature of the pork tenderloin (temp 169 degrees). The Dietary Cook wiped the thermometer probe with an alcohol prep pad and checked the temperature of the zucchini with onions (tempted 185 degrees). The Dietary Cook wiped the thermometer probe with an alcohol prep pad and checked the temperature of the potatoes (173 degrees). The Dietary Cook checked the temperature of the [MEDICATION NAME] garlic chicken (149 degrees) and then wiped the thermometer probe with an alcohol prep pad. The Dietary Manager then checked the temperature of the green beans (168 degrees). The Dietary Cook then wiped the probe of the thermometer with an alcohol prep pad and checked the temperature of the pureed pork tenderloin (143 degrees., The Dietary Cook wiped the thermometer probe with an alcohol prep pad and checked the temperature of the pureed chicken (141 degrees). The Dietary Cook wiped the probe and then tempted the green beans at 150 degrees. The Dietary Cook wiped the probe with an alcohol prep pad and checked the temperature of the mechanical soft pork tender loin (134 degrees). The Dietary Manager took the metal pan with the pork loin in it over to a preparation surface behind the holding table. The Dietary Manager gloved, took a spoon and poured the mechanical soft pork loin into a plastic container, and placed the plastic container containing the pork loin into the microwave to reheat. The Dietary Manager removed the plastic container containing the pork loin from out of the microwave and took a different digital thermometer, which he did not calibrate and the probe had not been cleaned, and began to stir the pork loin with the thermometer. The handle of the thermometer went into the pork loin touching the meat. The Dietary Manager checked the temperature of the pork loin at 193 degrees and then covers the pork loin and replaces it in the holding table to serve. The Dietary Cook checked the temperature of the buttered noodles at 134 degrees and could not obtain the desired temperature. The Dietary Manger, without changing gloves or doing hand hygiene, takes the digital thermometer from the Dietary Cook and stirs the noodles with the thermometer again getting the handle of the thermometer into the noodles. The Dietary Manager covered the pan of noodles and places them on the holding table to be served. The contaminated noodles and mechanical soft pork loin were observed being served. An interview, on 8/6/19 at 12:10 PM, with the Dietary Manager revealed, I did stir the mechanical pork loin and buttered noodles with the thermometer but I don't remember the handle getting into the mechanical soft pork loin or the buttered noodles. When asked if the thermometer had been calibrated the Dietary Manager stated the thermometer is digital it doesn't need calibrating. Do you really have to do it every day? I do think that if I touched the food with the handle it would be an infection control issue. This was my first survey and I was nervous. Not calibrating the thermometer could cause the temperature of the foods to be inaccurate. An interview, on 8/6/19 at 12:12 PM, with the Dietary Cook revealed, I saw the Dietary Manager stir the buttered noodles with the thermometer, but I didn't see the handle in the food. I also saw him stir the pork with the thermometer, but I didn't see the handle in the food. If he did touch the food with the handle of the thermometer then it would be an infection control issue. I didn't calibrate the thermometer before using it. I did wear my gloves from the back of the kitchen. I should have changed my gloves before starting to do the temperatures. I just didn't think about it. An interview, on 8/7/19 on 11:14 AM, with the Dietary Manager revealed, I did not throw the food away yesterday after we discussed that I stirred it with the thermometer, and it was said the handle touched the food. I served it. We did not calibrate the thermometer. An interview, on 08/07/19 at 03:50 PM with the Director of Nursing (DON), revealed not calibrating the thermometer could have allowed the food to be too hot or too cold. The Dietary manager stirring the food with the thermometer and allowing the handle of the thermometer to get into the food is an infection control issue. Stacking the wet glasses is an infection control issue. An interview, on 8/7/19 at 3:51 PM, with the Administrator revealed, Food is contaminated with the handle getting into the food. The Dietary Manager should have thrown it away. It was a Infection Control Issue.

Based on observation, staff interview, record review and facility policy review, the facility failed to implement the Comprehensive Care Plan for Resident #16's suprapubic catheter care, Resident #207's Percutaneous Endoscopic Gastrostomy (PEG) tube site care, and to develop a Care Plan for Resident #54's coagulant medication therapy. This concern was identified for three (3) of 20 resident care plans reviewed. Findings include: A review of the facility's policy titled, Comprehensive Care Plan, revised (MONTH) (YEAR), revealed the facility would develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental and psychosocial needs. The care plan is developed with the resident goals, wishes, and preferences. The plan includes measurable objectives and timetables agreed to by the resident to meet such objectives. The purpose of the Comprehensive Care Plan is to provide effective and person-centered care. Review of the Lippincott's Nursing Procedures, obtained from the Lippincott website by the Administrator, revealed: Hand Hygiene, dated (MONTH) 14,2019, the hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. Resident #54 A review of Resident #54's Order Summary of Physician Orders, dated 8/9/19 at 10:50 AM, revealed an order, dated 07/17/19, for Xarelto (Anticoagulant/Blood Thinner) 15 milligrams (mg) one (1) by mouth in the evening related to [MEDICAL CONDITION] Fibrillation. A review of the Admission Minimum Data Set (MDS), with an Assessment Reference date of 7/24/19, revealed Resident #54 was on anticoagulant medication for seven (7) days of the seven (7) day look back period. A review of Resident #54's Comprehensive Care Plan revealed a care plan was not developed related to anticoagulant therapy. An interview, on 08/08/19 at 9:45 AM, revealed Registered Nurse (RN) #1/MDS Coordinator, said the care plan should be developed for the anticoagulant use by Resident #54 because it was one of the medications that is closely monitored. She said Xarelto was a high risk medication and was monitored daily by the nurses. An interview, on 08/08/19 at 11:03 AM, revealed the Director of Nursing (DON) said she expected the care plan to be specific to the resident and Resident # 54 should have a care plan related to Xarelto use and concerns. Resident #16 Record review of Resident #16's Comprehensive Care Plan revealed a Focus for a Suprapubic Catheter, with a revision date of 10/05/18. The Interventions included: Clean suprapubic tube site every shift as ordered and suprapubic catheter care with soap and water as ordered. An observation, on 08/07/19 at 8:40 AM, revealed Registered Nurse (RN) #3 entered Resident #16's room to perform catheter care. RN #3 had already placed the catheter care supplies on the over bed table using a towel as a barrier. RN #3 washed and dried her hands. RN #3 obtained a basin and filled the basin with warm water. RN #3 obtained DermaVera skin and hair soap from a shelf and put the soap into the water in the basin. RN #3 used her anterior wrist area to turn the faucet off. RN #3 left the rest room, but returned to wash her hands again stating, I touched the faucet with my wrist. RN #3 returned to the bedside and picked up a red biohazard bag and a clear bag that were lying on the foot of Resident #16's bed. RN #3 opened the bags and then placed them at the foot of Resident #16's bed. RN #3 gloved without washing her hands and removed the dirty dressing from around Resident #16's suprapubic stoma site and discarded the dressing in the red bag. RN #3 washed her hands, gloved and took a wash cloth and put it into the basin containing the water and soap. RN 3 squeezed the cloth out and wadded the cloth up in her right gloved hand. RN #3 wiped the catheter stoma site in a circular motion with one wipe and discarded the cloth into the clear bag. RN #3 obtained a second cloth, wet the cloth in the basin and wiped the catheter stoma site in a circular motion and discarded the cloth into the clear bag. RN #3 obtained a third cloth, wet the cloth in the basin, took the tubing into her left gloved hand and begin to clean the tubing with the cloth in her gloved right hand starting at the catheter stoma site. RN #3 stated, there is something on the tubing and she wiped the tubing in the same area for several moments in a circular motion using the same spot on the cloth and then continued upwards on the tubing using the same cloth. RN #3 discarded the cloth into the clear bag. RN #3 washed her hands, gloved, opened a split gauze dressing and applied it to the stoma site. RN #3 took a piece of cloth tape and applied the tape to the dressing and skin stating, this is to hold the dressing in place. RN #3 did not date or initial the clean dressing. RN #3 removed her gloves, applied new gloves without washing her hands, picked up the basin and discarded the water into the toilet. RN #3 washed her hands, gloved and tied the red bag up and placed it back on the foot of the bed. RN #3 removed the towel used as a barrier and placed it into the red bag and tied the bag up leaving it on the foot of the bed. RN #3 removed her gloves and placed Resident #16's things back onto the over bed table without washing her hands or cleaning the over bed table with sanitizer. RN #3 picked up the red biohazard bag and exited the room without washing her hands. RN #3 stated after exiting the room, I didn't wash my hands when I took my gloves off and before leaving the room. An interview, on 08/07/19 at 12:06 PM, revealed Registered Nurse (RN) #1/Minimum Data Set (MDS)/Care Plan Nurse stated, the care plan is created for staff to care for a resident. My expectations is for staff to follow the care plan. The care plan is used as a guide in the care of the resident. RN #1 revealed the Care Plan was not followed if correct care was not provided. An interview, on 08/08/19 at 9:43 AM, with the Director of Nursing (DON)/Interim Infection Control Nurse revealed the care plan should have been followed to provide proper catheter care for Resident #16. An interview, on 08/08/19 at 10:06 AM, revealed RN #1 stated, What I mean by providing suprapubic care on the care plan is that I expect staff to follow the catheter care policy and procedure to help prevent the spread of infection. The nurse should not have used the same cloth to rub the tubing and then continue up the tubing. The nurse should follow what she knows is infection prevention. Resident #207 Record review of Resident #207's Comprehensive Care Plan revealed a Focus for a Percutaneous Endoscopic Gastrostomy (PEG) tube, with a revision date of 8/06/19. The Interventions included: PEG tube care daily as ordered. An observation, on 08/07/19 at 9:00 AM, revealed Registered Nurse (RN) #3 gathered supplies from the wound care cart, obtained a towel from the linen cart to use as a barrier and entered Resident #207's room to perform Percutaneous Endoscopic Gastrostomy (PEG) tube care. RN #3 placed a towel on the over bed table, without cleaning the over bed table, and laid the unopened bottle of normal saline, unopened gauze and a drain gauze on the barrier. RN #3 moved the over bed table, containing the supplies, with her foot to the side of the bed. RN #3 washed her hands, turned the lights on in the room and then left the room to obtain a red biohazard bag. RN #3 entered Resident #207's room with the red bag and placed the unopened red bag on the foot of the bed. RN #3 removed her gloves and left the room stating she had to go to the linen cart and get some gloves. RN #3 removed an open box of gloves from the linen cart and returned to the room taking several pair of gloves out of the box and placing them on the barrier. RN #3 put the remaining box of gloves in the bracket on the wall. RN #3 washed her hands, gloved, turned off Resident #207's feeding pump and then unhooked the tubing from the stoma site. RN #3 removed her gloves, washed her hands, gloved and let the head of the bed down. RN #3 attempted to turn Resident #207 over as he was lying on his left side. RN #3 voiced that the red unopened biohazard bag had fallen onto the floor and she reached down, picked it up and opened it at the foot of the bed. RN #3 reached over Resident # 207's right side and removed the dirty dressing from the stoma site. RN #3 discarded the soiled dressing into the red biohazard bag. RN #3 removed her gloves, washed hands, re-gloved, opened the normal saline bottle and sat it on the barrier and then opened the gauze. RN #3 picked up the gauze, the bottle of normal saline, and then touched the gauze to the opening of the normal saline bottle to wet the gauze. RN #3 took the gauze and wiped the PEG stoma area in a circular motion going all the way around the stoma twice and then folded the gauze and continued to wipe the stoma area in a circular motion. RN #3 discarded the dirty gauze into the red bag, removed her gloves and washed her hands. RN #3 gloved and took a dry gauze and dried the stoma area in a circular motion wiping twice with the same gauze without lifting the gauze. RN #3 removed her gloves, washed her hands and applied clean gloves. RN #3 opened the drain sponge and applied the sponge to the stoma securing it with paper tape. RN #3 did not date or initial the clean bandage. RN #3 pulled the covers up on Resident #207 without removing her gloves or providing hand hygiene. RN #3 tied the red biohazard bag up and placed it on top of the towel that was used as a barrier. RN #3 removed her gloves, washed her hands and picked up the red bag leaving the towel on the over bed table. RN #3 left the room, walked down the hall to the biohazard room and discarded the red bag. RN #3 washed her hands and returned to the room. RN #3 opened a clear bag and placed the towel used as a barrier into the bag and tied the bag up. RN #3 washed her hands, picked up the clear bag and exited the room without cleaning the over bed table and stated I'm finished and I'm going down the hall to discard the dirty linen. An interview, on 08/07/19 at 12:06 PM, with RN #1/MDS/Care Plan Nurse, revealed The care plan is created for staff to care for a resident. My expectations is for staff to follow the care plan. The care plan is used as a guide in the care of the resident. RN #1 revealed the Care Plan was not followed if proper care was not provided. An interview, on 08/08/19 at 9:43 AM, with the Director of Nursing (DON)/Interim Infection Control Nurse, revealed the care plan should have been followed to provide proper PEG tube care for Resident #207. An interview, on 08/08/19 10:12 AM, with RN #1 revealed What I mean by providing Enteral Feeding care on the care plan is that I expect the staff to follow the care plan for Enteral Feeding care for Resident #207. The nurse should first look at the physicians orders, the care plan, and policy and procedure of doing the care before beginning care.

Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to discharge and accurately code the comprehensive MDS assessment related to hospice services for two (2) of 20 MDS assessments reviewed, Resident #57 and Resident #58. Findings include: A review of the facility's policy titled, Resident Assessment Instrument (RAI) Process, dated (MONTH) (YEAR), revealed the RAI was used at the facility to provide the caregiving staff with ongoing assessment information necessary to develop a resident care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The MDS provides a core set of screening, clinical, and functional status elements that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare or Medicaid. The RAI is completed by an interdisciplinary team that includes facility staff with varied backgrounds. Each interdisciplinary team member completes his/her assigned sections of the MDS within the designated time frame. The Resident Assessment Coordinator is required to sign the MDS certifying the assessment is complete. Resident #57 Review of the physician's orders [REDACTED].#57 was admitted to hospice care. Review of the most recent Significant Change MD assessment, dated 7/2/19 with a completion date of 7/16/19, revealed hospice was checked in the Special Treatments, Procedures, and Programs section. On 8/6/19 at 12:07 PM, an interview with the Director of Nurses (DON), revealed she would expect the MDS to reflect the condition of the resident at the time the MDS was completed. On 8/6/19 at 12:10 PM, an interview with Registered Nurse (RN) #2/Care Plan Nurse, revealed Resident #57 was admitted to hospice services on 6/24/19 and the MDS assessment with an ARD of 7/2/19 was not coded to include hospice services. RN #2 stated the MDS should have been coded to include hospice. A review of the facility's Face Sheet revealed, the facility admitted Resident #57 on 4/8/19. Resident #58 Review of the most current Minimum Data Sheet (MDS) revealed Resident #58 was admitted on [DATE], and discharged on [DATE] to an Acute Hospital. Review of Resident #58's Physician Orders, dated 07/23/2019, revealed the resident was discharged to home with home health services. Review of Resident #58's Progress Notes-Nursing, dated 07/23/2019, revealed the resident was being discharged at this time. The Nurses Notes revealed Resident #58's daughter was with her and understood all that needed to be done and taken care of, the resident ambulated to a private vehicle. On 08/06/19 at 12:06 PM, an interview with the Director of Nursing (DON), revealed the resident was discharge to home. On 08/06/19 at 12:11 PM, an interview with Registered Nurse #2/MDS Coordinator, revealed the MDS was coded incorrectly.

Based on staff interview, record review, and facility policy review, the facility failed to revise the Resident #48's Comprehensive Care Plan related to weight loss for one (1) of 20 resident care plans reviewed. Findings include: A review of the facility's policy titled, Comprehensive Care Plan, with a revision date of (MONTH) (YEAR), revealed the care plan was to be reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or change in condition. A review of Resident #48's Comprehensive Care Plan revealed the resident had a care plan Focus of, I have a nutritional problem of weight loss. Further review of the care plan revealed there was no diagnoses or risks documented related to the weight loss. The Goal stated the resident would maintain adequate nutritional status as evidenced by no signs/symptoms (s/s) of malnutrition, consuming 50% of at least three meals daily through review date, 9/11/19. The Interventions included: Administer medications as ordered. Determine individual like and dislikes. IDT (Interdisciplinary Team) referral as needed. Provide supplements/snacks as ordered. Attend activities that promote additional intake. Provide and serve diet as ordered and observe intake and record every (q) meal. RD evaluate as needed. Weigh as ordered. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of (MONTH) 03, 2019, revealed the Swallowing/Nutritional Section K. K0300 was coded a 2, which indicated Resident # 48 had weight loss not on a physician's prescribed weight loss regimen. A review of Resident #48's Nurse Practitioner's Progress Note, dated 7/22/19, revealed the resident had a [DIAGNOSES REDACTED]. Resident #48 was with significant weight loss upon return from the hospital, on 6/23/19. Resident #48 was admitted to the hospital on [DATE], and per Computerized [NAME]ography (CT) scan, on 6/20/19, calcified [DIAGNOSES REDACTED]s, pleural effusion and possible metastatic disease were found. On 08/07/19 at 9:22 AM, an interview revealed the Registered Dietician (RD) said she was aware of the weight loss and it was addressed in her notes with the resident's [DIAGNOSES REDACTED]. The RD said she did not do the care plans and the care plans were the responsibility of the MDS/Care Plan Nurses. A review of the RD note for Resident #48 titled, Nutrition Data Collection, dated 6/25/19, revealed Resident #48 had a weight loss of 14.6% and the resident had been [MEDICATION NAME] in the hospital and the weight loss was likely related to the resident's [DIAGNOSES REDACTED]. A review of the [DIAGNOSES REDACTED].# 48 revealed Malignant neoplasm of the sigmoid colon and chronic [MEDICAL CONDITION]. Both were dated 5/29/19. An interview with the Administrator (ADM), on 08/07/19 at 3:12 PM, revealed information from the initial hospitalization for Resident #48 did not mention [MEDICAL CONDITION], but they were trying to find information from the Onocologist. An interview, on 08/08/19 at 9:31 AM, with Registered Nurse (RN) #1/MDS Coordinator/ Care Plan Nurse, revealed the care plans would be updated for the residents as status changes occur. The information would come from the orders and daily meetings. She said she was responsible to update the care plans in the computer and that the facility had no paper care plans in the charts. RN #1 also said that Resident #48's care plan did not address the weight loss related to [MEDICAL CONDITION] [DIAGNOSES REDACTED].#1 said the thought process was because she was so swollen when she came from the hospital initially that the weight loss was from lose of the fluid. She said the care plan should have been specific to the resident'[MEDICAL CONDITION] and [MEDICAL CONDITION]. An interview, on 08/08/19 at 11:05 AM, with the Director of Nursing (DON) revealed she expected the care plan to be specific to Resident #48's needs and concerns and the care plan should have listed the weight loss related to the severe [MEDICAL CONDITION] and her [DIAGNOSES REDACTED].

Based on record review, staff interview, and facility policy review, the facility failed to protect the resident from misappropriation of funds for one (1) of four (4) resident records reviewed for Trust Fund accounts, Resident #51. Findings include: A review of the facility's policy titled, Abuse and Neglect Prohibition, dated (MONTH) (YEAR), revealed each resident has the right to be free from abuse and misappropriation of resident property. A record review of the Facility Reported Incident (FRI) revealed Resident #51 stated Housekeeper #1 had borrowed $20.00 from him until payday, but had not paid the $20.00 back. The report showed the Administrator completed an investigation by interviewing the resident, staff members, and the Resident Representative. The FRI also indicated the Administrator replaced the $20.00 to the resident. The Administrator also indicated, misappropriation of Resident #51's funds was substantiated with the funds replaced, and Housekeeper #1 was suspended and terminated. On 8/5/19 at 10:45 AM, an interview with Resident #51, revealed he does not remember letting anybody have any money. He stated he has not let anyone have any money, and if he did he would remember. On 8/5/19 at 2:15 PM, an interview with Resident #51's Resident Representative (RR) revealed, she does not recall the resident loaning an employee any money. She stated the facility told her not to give the resident large sums of money. The RR also stated the facility has been doing good with taking care of the resident. On 8/05/19 at 2:26 PM, an interview with the Administrator, revealed Resident #51 was the person who reported his money was missing and she informed the RR. She stated the employee does not work at the facility any longer and has termination papers in the investigation packet. She stated his name was (Name of Housekeeper #1). She stated the previous employee did admit to borrowing the money and the facility paid the money back. On 8/06/19 at 8:18 AM, the surveyor attempted to call the previous employee, Housekeeper #1 with no answer received. On 8/06/19 at 8:36 AM, an interview with the Housekeeper #2, revealed he was not aware of the previous employee borrowing money from the resident. He stated he was notified at home and came to the facility upon notification. He also stated he first placed Housekeeper #1 on suspension and after a couple of days he let the employee go. On 8/07/19 at 3:42 PM, an interview with the Director of Nurses (DON), revealed she became aware of the resident loaning Housekeeper #1 money after it was reported to the Administrator. She stated she helped to in-service staff on abuse, but the Administrator handled the investigation for Housekeeper #1 borrowing the money from Resident #51. On 8/08/19 at 10:32 AM, the surveyor attempted to call Housekeeper #1 and no answer was received.

Based on staff interview, record review, and facility policy review, the facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of determining the resident had a significant change for one (1) of 20 resident Minimum Data Set (MDS) assessments reviewed, Resident #57. Findings include: A review of the facility's policy titled, Resident Assessment Instrument (RAI) Process, dated (MONTH) (YEAR), revealed the RAI was used at the facility to provide the caregiving staff with ongoing assessment information necessary to develop a resident care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The MDS provides a core set of screening, clinical, and functional status elements that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare or Medicaid. The RAI is completed by an interdisciplinary team that includes facility staff with varied backgrounds. Each interdisciplinary team member completes his/her assigned sections of the MDS within the designated time frame. The Resident Assessment Coordinator is required to sign the MDS certifying the assessment is complete. Resident #57 Review of the physician's orders [REDACTED].#57 was admitted to hospice care. Review of Resident #57's Progress Notes-Nursing Note, dated 6/25/19 at 1:10 PM, revealed the IDT (Interdisciplinary Team) Risk Meeting was held. Resident #57's recent hospital return, on 6/24/19, was discussed. Hospice services had been elected, peg (PEG-Percutaneous Endoscopic Gastrostomy) feedings, and [MEDICAL CONDITION] medication use. [MEDICAL CONDITION] meds monitoring in place. Recent weight loss s/p (status [REDACTED]. Upcoming Significant Change MDS scheduled for 7/1/19. The MDS Coordinator's electronic signature was identified as the author of the note. Review of the most recent Significant Change MD revealed the assessment was dated 7/2/19. Further review of the MDS revealed the MDS Coordinator's signature to confirm completion of the MDS was dated 7/16/19, which was 22 days after the MD order was written for Hospice. On 8/6/19 at 12:07 PM, an interview with the Director of Nurses (DON), revealed she would expect the MDS to be completed timely, within the time period that is expected for the MDS to be completed. On 8/6/19 at 12:10 PM, an interview with Registered Nurse (RN) #2/MDS Coordinator, revealed Resident #57's MDS should have been completed within 14 days of determining that the resident had been admitted to hospice services. RN #2 stated the MDS was not completed within the 14 day window. A review of the facility's Face Sheet revealed, the facility admitted Resident #57 on 4/8/19.

Based on interview, record review, facility kardex review, and facility policy review, the facility failed to follow the plan of care for Resident #1 for one (1) of three (3) resident care plans reviewed for use of a Hoyer Lift as evidenced by CNA #1 transferred Resident #1 alone using a Hoyer Lift resulting in a fall with major closed head injury and a rib fracture. The facility's failure to follow the care plan for two (2) person assistance with the Hoyer Lift for Resident #1's transfer resulted in Resident #1's fall with harm, a G level deficiency. Based on the facility's implementation of corrective action, initiated on 7/7/16 and completed on 7/15/16, prior to the State Agency's entrance on 7/20/16, the SA determined the G to be Past Non-Compliance and removed as of 7/16/16. Findings Include: Review of the facility's policy entitled, Resident Care Management-Module 4: Care Planning/Care Conference, dated 2008, revealed the structure of the Care Planing Process includes Implementation, applying the plan of care, which is developed as a guide for charting and care. Review of the facility's Kardex which provides Certified Nursing Assistants (CNAs) care instructions for the care of Resident #1 revealed the resident required a Mechanical Lift/Full body lift with two (2) staff assistance for transfers. Review of the Care Plan potential for injury related to impaired ability to self-transfer with an onset date of 12/16/16 and updated 3/8/16 and 7/12/16 revealed Resident #1 requires the use of a Mechanical lift with two (2) person assist at all times for transfers. A telephone interview on 7/20/16 at 2:40 PM with Certified Nursing Assistant (CNA) #1 confirmed the care plan was not followed because she attempted to transfer the resident alone. CNA #1 stated she was aware that Resident #1 was a two (2) person assist for use of the Hoyer Lift by looking at the Kardex and care plan but she attempted to transfer Resident #1 alone which resulted in the resident falling to the floor. CNA #1 explained she pushed Resident #1 into the hallway in the sling alone. CNA #1 said when she positioned the resident in the sling over the wheelchair and began to open the legs to the lift, Resident #1 leaned forward and to the right and fell from the sling to the floor. In an interview with the Minimum Data Set (MDS) Coordinator on 7/21/16 at 12:15 PM revealed when asked the risk of not following the plan of care for a resident Care Planned for two (2) person assist, the CNA responded it puts the resident in danger and at risk for harm. The MDS Coordinator stated the Kardex is an extension of the care plan for each resident and lists if they are a two (2) person assist or Mechanical Lift so the CNAs will know. In an interview on 7/20/16 at 10:00 AM with the Director of Nursing (DON) revealed during the investigation, CNA #1 lifted Resident #1 without assistance with the Hoyer Lift resulting in a fall to the floor as a result of not following Resident #1's Plan of Care. The DON confirmed Resident #1 sustained major injury as a result of this fall and CNA #1 was terminated from employment (7/11/16)after she failed to follow the resident's care plan and the facility's policy. In an interview with the Medical Director on 7/20/16 at 2:42 PM confirmed all staff would need to be in-serviced prior to working on following each resident's plan of care for transfers and the use of the lift. The Face Sheet indicated the facility admitted Resident #1 on 8/5/10 with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 5/24/16 revealed Resident #1 scored fifteen (15) on the Brief Interview for Mental Status (BIMS) and was cognitively intact. Based on these findings, it was determined that the actual harm occurred to Resident #1 as a result of the facility's staff failure to follow the care plan. Based on the facility's corrective actions initiated and completed as of 07/15/16 prior to the State Agency's entrance on 07/20/16, the State Agency determined this actual harm at a scope and severity of G as Past Non-Compliance at F282. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 07/20/16, and alleged correction was completed as of 07/15/16. 1. The facility determined the fall (for Resident #1) from the lift occurred on 07/07/16 at approximately 11:15 AM. Resident #1 was assessed and EMS (Emergency Medical Services) activated. Resident #1 was transferred to the ER at Hospital #1 for evaluation via ambulance on 07/07/16. The facility self-reported the incident to the State Survey Agency via hotline on 07/07/16 and the Attorney General's Office, with written report of 07/12/16. The SA reviewed the disciplinary action taken against CNA #1 and determined CNA #1 was suspended on 07/07/16 and was terminated on 07/11/16 for failure to follow Resident #1's care plan and the facility's policy. 2. The lift and lift pad were removed from use on 7/7/16; and the lift and the sling (lift pad) were observed for proper working order by the Director of Nurses (DoN) and the Maintenance Director on 07/07/16. 3. The Maintenance Director conducted an immediate evaluation of four (4) of four (4) Hoyer lifts to ensure that all were functioning properly on 07/07/16, and they were functioning properly. 4. A Quality Assurance and Assessment (QA) meeting occurred on 07/07/16, at approximately 5:00 PM, with the DoN, Administrator, and Assistant DoN, RN Charge Nurse and the Medical Director (via teleconference) and the Maintenance Director regarding the incident involving Resident #1. Policies and procedures regarding Hoyer lifts were reviewed and there were no changes needed to the policies/procedures. The plan of care/kardex, maintenance and use of the Hoyer lift and pads were also reviewed. A performance improvement plan (PIP) was initiated on 7/7/16, which included education to all nursing staff regarding the use of lifts, lift pads, the plan of care, and following the Kardex. No nursing staff will be allowed to work until in-serviced. 5. All 12 of 12 Lift slings were evaluated on 07/07/16. All slings were determined to be in proper working condition with no observed evidence of wear or required replacement. These evaluations were completed by the DON/ADON and the Housekeeping staff. 6. An in-service was initiated by the DON and ADON on 7/7/16 through 7/15/16 for all Nurses (9 Registered Nurses (RNs) and 11 Licensed Practical Nurses (LPNs)) and 22 Resident Care Specialists/Certified Nurse Aides (CNAs). The in-service included the use of the Hoyer Lift and the use of two (2) person assist with skills check validation, the Kardex, and following the plan of care, and battery care with the exception of the PRN staff, who have not worked since the incident and will not be allowed to work prior to being in-serviced with a skills check validation. 7. The MDS Coordinator reviewed all 77 residents with transfer needs, their care plans, and Kardexes for accuracy and determined all were accurate on 7/8/16. 8. The DON/ADON/RN Charge Nurse observed transfers with Hoyer Lifts beginning on 07/07/16 to ensure plans of care were followed. These observations will continue five (5) times weekly for four (4) weeks to ensure Hoyer Lifts and assistance of two (2) persons are implemented per assessment/care plan. 9. The facility alleged their corrective action plan was completed by 7/15/16, when the Hoyer Lift supplier visited the facility and checked the Hoyer Lifts for proper working order. This supplier representative reviewed lift operation for staff on all shifts on 7/15/16. The State Agency surveyor validated the facility's corrective action on 7/20/16 and 7/21/16 as follows: 1. The SA verified the facility's investigation and self-report to the State Agency regarding the incident that occurred on 07/07/16 at approximately 11:15 AM through staff interviews, written reports and computer submitted reports. The SA verified through interview and termination report that CNA #1 was terminated on 7/11/16 for failure to follow the care plan. The SA validated by interviews on 07/20/16 and 07/21/16 with the DoN and ADoN and review of documents, the incident occurred regarding the use of the Hoyer Lift/Transfer of Resident #1, which resulted in the injury. 2 . The SA validated by staff interview on 07/21/16 at 11:25 AM, with the Maintenance Director, that the Lift and Lift pad were checked after the incident with Resident #1 removed from use on 07/07/16. This interview confirmed that the Maintenance Director had been reviewing and checking lifts weekly. 3. The SA validated by staff interview on 07/21/16 at 11:25 AM, with the Maintenance Director, that four (4) of four (4) Hoyer lifts were checked for proper functioning on 07/07/16 and found without concerns, in good working condition. 4. The SA validated by interview with the DoN on 7/20/16 at 2:30 PM, and the Medical Director on 7/20/16 at 2:42 PM, and review of the sign-in sheet that the facility initiated a Quality Assurance and Performance Improvement Meeting on 07/07/16. The Medical Director was present by phone on 07/07/16 and signed the QA sheet on 07/08/16. Interviews revealed policy was reviewed with no revisions and in-services would be conducted with all nursing staff for following the care plan and using two (2) persons for transfer with the Hoyer lift. Review of the Performance Improvement Plan (PIP) dated 7/7/16 revealed the plan included in-service for nursing staff for the use of two (2) person assist with Hoyer transfers and following the care plan. The SA validated through staff interview and review of the policy and procedure regarding the use of the Hoyer lift that no changes in policy were made and/or needed, as a result of the incident that occurred on 07/07/16. 6.The SA validated on 07/20/16 and 07/21/16 through nursing staff and resident interviews, sign in sheets, and observation of resident transfers, that the facility initiated and in-serviced all RNs, LPNs, and CNAs on the policy/procedure for use of two (2) persons assist with all transfers and skill check validation beginning 7/7/16-7/15/16, with the exception of PRN staff who had not worked per schedule since the incident. In-service included lift/transfers, battery care, lift sling inspection and care, following Kardex and access of plan of care, and documenting or care. Interview with the DON on 7/20/16 at 2:30 PM, revealed in-services were initiated with skills check offs on all nursing staff on 7/7/16 and completed by 7/15/16 with the exception of those PRN and no staff had been allowed to work until they had those in-services. Review of incident logs and interview with the DON on 7/20/16 at 10:00 AM, revealed no other incidents had occurred as the result of improper transfer with the lift. 7. The SA validated through staff interview with the DON and MDS Coordinator on 7/21/16 at 11:06 AM, and record review of assessments and care plans, that 77 residents who were assessed for transfer needs following the incident on 07/07/16, and that Kardexes, care plans were reviewed for accuracy for type of lift and reviewed, and all were determined accurate. This was initiated on 7/7/16 and completed on 7/8/16. 8.The SA validated through staff interview that random audits were conducted beginning on 07/07/16-7/15/16, and reviewed to determine that lifts were used correctly, that two (2) person assist were being done as care planned, and all were found to be accurate. These audits were documented on a calendar and continued five (5) times weekly. 9. The SA validated through review of a signed document, dated 7/15/16, that the Hoyer lift supplier visited the facility on 07/15/16 and checked the hoyer lifts and found no concerns. The SA observed all lift pads on 7/20/16 and found no concerns.

Based on observation, interview, record review, facility investigation review, and facility policy review, the facility failed to use two (2) persons while lifting Resident #1 with a Hoyer Lift resulting in a fall with major injuries for one (1) of three (3) residents reviewed for use of Hoyer Lift/Two (2) person assist. The failure to use two (2) person assistance with the Hoyer lift resulted in harm to Resident #1 due to a fall with major injury to the head and fractured ribs. This was deemed a G level deficiency. Based on the facility's implementation of corrective action, initiated on 7/7/16 and completed on 7/15/16, prior to the State Agency's entrance on 7/20/16, the SA determined the G to be Past Non-Compliance and removed as of 7/16/16. Findings Include: Review of the facility's policy, entitled Lift, Transfer, and Repositioning Policy, dated 2010, revealed facility policy requires two (2) staff members to assist when lifting with mechanical lifting devices. On 7/20/16 at 2:40 PM a telephone interview with Certified Nursing Assistant (CNA) #1 revealed she was aware that Resident #1 was a two (2) person assist for use of the Hoyer Lift. CNA #1 stated on 7/7/16 she pushed Resident #1 into the hallway and over the wheelchair alone. She explained that when she began to open the legs to the lift, Resident #1 leaned forward and to the right and fell from the sling to the floor. CNA #1 confirmed when she lifted Resident #1 from the bed by the Hoyer Lift alone, this put Resident #1 at risk for harm. CNA #1 confirmed she was aware of the proper procedures and stated she knew it was her fault when she did not get another person to assist her when transferring Resident #1. CNA #1 confirmed the facility terminated her after the incident. Review of the facility's investigation revealed Resident #1 was sent to the ER for evaluation and treatment on 7/7/16 at approximately 11:15 AM after falling about 2-3 feet to the floor. Interview with Resident #1 on 7/20/16 at 4:10 PM revealed the resident stated, The lift just came down on me. It dropped me. Resident #1 stated the facility staff were caring and denied abuse. Observation revealed Resident #1 was sitting in her wheelchair in her room watching television. An interview on 7/20/16 at 4:25 PM with the Assistant Director of Nursing (ADON) revealed on 7/7/16, after Resident #1 fell from the lift, she observed the lift in the up position with the lift sling fully connected and Resident #1 lying on the floor. In an interview on 7/20/16 at 10:00 AM with the Director of Nursing (DON) revealed the facility's investigation revealed CNA #1 transferred Resident #1 without assistance with the Hoyer Lift resulting in a fall to the floor. The DON confirmed Resident #1 sustained a major head injury as a result of this fall. The DON stated the facility terminated CNA #1 from employment after she failed to follow the facility's policy for proper use of the lift. The DON stated any resident that required a lift was automatically a two (2) person assist. Interview with the DON on 7/20/16 at 2:30 PM, revealed a Quality Assurance meeting was held with the Medical Director and other staff on 7/7/16 after Resident #1's incident and policy was reviewed without changes and in-services were provided to nursing staff on the use of the Hoyer with two (2) person assistance and following the care plan. In an interview with the Medical Director on 7/20/16 at 2:42 PM revealed the facility notified him of Resident #1's fall as a result of the improper use of the lift. The Medical Director confirmed the Quality Assurance committee determined lift policies were in place, but CNA #1 failed to follow the policies. An interview with the facility's Administrator on 7/20/16 at 1:25 PM revealed CNA #1 has been an employee for seventeen (17) years and had only one (1) write up related to punching the time-card for lunch. The Administrator stated there had never been a concern related to CNA #1 and resident abuse or neglect. Record review of the Nurses Notes dated 7/7/16 at 11:15 AM revealed Licensed Practical Nurse (LPN) #1 documented, Looked up and saw resident falling forward from lift leaning to the right side. Prior to sending to the local emergency room (ER) at approximately 11:35 AM. On 7/21/16 at 9:32 AM, the State Agency surveyor attempted to call LPN #1 but the LPN was unavailable. In a review of the local emergency room Note dated 7/7/16 revealed Resident #1 had a Major Closed Head Injury, Right Cerebral Hemorrhage, Right Sided Subarachnoid Hemorrhage, Small Right Tempero-Parietal Hemorrhage, and Left 11th Rib Hairline Fracture and was transferred to a higher level of care hospital. The Face Sheet indicated the facility admitted Resident #1 on 8/5/10 with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 5/24/16 revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) and was cognitively intact. Based on these findings, it was determined that the actual harm occurred to Resident #1 as a result of the facility's failure to use two (2) persons when lifting Resident #1 with a Hoyer lift resulting in a fall with a major closed head injury and a rib fracture. Based on the facility's corrective actions initiated and completed as of 07/15/16 prior to the State Agency's entrance on 07/20/16, the State Agency determined that this actual harm at a scope and severity of G as Past Non-Compliance at F323. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 07/20/16, and alleged correction was completed as of 07/15/16. 1. The facility determined the fall (for Resident #1) from the lift occurred on 07/07/16 at approximately 11:15 AM. Resident #1 was assessed and EMS (Emergency Medical Services) activated. Resident #1 was transferred to the ER at Hospital #1 for evaluation via ambulance on 07/07/16. The facility self-reported the incident to the State Survey Agency via hotline on 07/07/16 and the Attorney General's Office, with written report of 07/12/16. The SA reviewed the disciplinary action taken against CNA #1 and determined CNA #1 was suspended on 07/07/16 and was terminated on 07/11/16 for failure to follow Resident #1's care plan and the facility's policy. 2. The lift and lift pad were removed from use on 7/7/16; and the lift and the sling (lift pad) were observed for proper working order by the Director of Nurses (DoN) and the Maintenance Director on 07/07/16. 3. The Maintenance Director conducted an immediate evaluation of four (4) of four (4) Hoyer lifts to ensure that all were functioning properly on 07/07/16, and they were functioning properly. 4. A Quality Assurance and Assessment (QA) meeting occurred on 07/07/16, at approximately 5:00 PM, with the DoN, Administrator, and Assistant DoN, RN Charge Nurse and the Medical Director (via teleconference) and the Maintenance Director regarding the incident involving Resident #1. Policies and procedures regarding Hoyer lifts were reviewed and there were no changes needed to the policies/procedures. The plan of care/kardex, maintenance and use of the Hoyer lift and pads were also reviewed. A performance improvement plan (PIP) was initiated on 7/7/16, which included education to all nursing staff regarding the use of lifts, lift pads, the plan of care, and following the Kardex. No nursing staff will be allowed to work until in-serviced. 5. All 12 of 12 Lift slings were evaluated on 07/07/16. All slings were determined to be in proper working condition with no observed evidence of wear or required replacement. These evaluations were completed by the DON/ADON and the Housekeeping staff. 6. An in-service was initiated by the DON and ADON on 7/7/16 through 7/15/16 for all Nurses (9 Registered Nurses (RNs) and 11 Licensed Practical Nurses (LPNs)) and 22 Resident Care Specialists/Certified Nurse Aides (CNAs). The in-service included the use of the Hoyer Lift and the use of two (2) person assist with skills check validation, the Kardex, and following the plan of care, and battery care with the exception of the PRN staff, who have not worked since the incident and will not be allowed to work prior to being in-serviced with a skills check validation. 7. The MDS Coordinator reviewed all 77 residents with transfer needs, their care plans, and Kardexes for accuracy and determined all were accurate on 7/8/16. 8. The DON/ADON/RN Charge Nurse observed transfers with Hoyer Lifts beginning on 07/07/16 to ensure plans of care were followed. These observations will continue five (5) times weekly for four (4) weeks to ensure Hoyer Lifts and assistance of two (2) persons are implemented per assessment/care plan. 9. The facility alleged their corrective action plan was completed by 7/15/16, when the Hoyer Lift supplier visited the facility and checked the Hoyer Lifts for proper working order. This supplier representative reviewed lift operation for staff on all shifts on 7/15/16. The State Agency surveyor validated the facility's corrective action on 7/20/16 and 7/21/16 as follows: 1. The SA verified the facility's investigation and self-report to the State Agency regarding the incident that occurred on 07/07/16 at approximately 11:15 AM through staff interviews, written reports and computer submitted reports. The SA verified through interview and termination report that CNA #1 was terminated on 7/11/16 for failure to follow the care plan. The SA validated by interviews on 07/20/16 and 07/21/16 with the DoN and ADoN and review of documents, the incident occurred regarding the use of the Hoyer Lift/Transfer of Resident #1, which resulted in the injury. 2 . The SA validated by staff interview on 07/21/16 at 11:25 AM, with the Maintenance Director, that the Lift and Lift pad were checked after the incident with Resident #1 removed from use on 07/07/16. This interview confirmed that the Maintenance Director had been reviewing and checking lifts weekly. 3. The SA validated by staff interview on 07/21/16 at 11:25 AM, with the Maintenance Director, that four (4) of four (4) Hoyer lifts were checked for proper functioning on 07/07/16 and found without concerns, in good working condition. 4. The SA validated by interview with the DoN on 7/20/16 at 2:30 PM, and the Medical Director on 7/20/16 at 2:42 PM, and review of the sign-in sheet that the facility initiated a Quality Assurance and Performance Improvement Meeting on 07/07/16. The Medical Director was present by phone on 07/07/16 and signed the QA sheet on 07/08/16. Interviews revealed policy was reviewed with no revisions and in-services would be conducted with all nursing staff for following the care plan and using two (2) persons for transfer with the Hoyer lift. Review of the Performance Improvement Plan (PIP) dated 7/7/16 revealed the plan included in-service for nursing staff for the use of two (2) person assist with Hoyer transfers and following the care plan. The SA validated through staff interview and review of the policy and procedure regarding the use of the Hoyer lift that no changes in policy were made and/or needed, as a result of the incident that occurred on 07/07/16. 6.The SA validated on 07/20/16 and 07/21/16 through nursing staff and resident interviews, sign in sheets, and observation of resident transfers, that the facility initiated and in-serviced all RNs, LPNs, and CNAs on the policy/procedure for use of two (2) persons assist with all transfers and skill check validation beginning 7/7/16-7/15/16, with the exception of PRN staff who had not worked per schedule since the incident. In-service included lift/transfers, battery care, lift sling inspection and care, following Kardex and access of plan of care, and documenting or care. Interview with the DON on 7/20/16 at 2:30 PM, revealed in-services were initiated with skills check offs on all nursing staff on 7/7/16 and completed by 7/15/16 with the exception of those PRN and no staff had been allowed to work until they had those in-services. Review of incident logs and interview with the DON on 7/20/16 at 10:00 AM, revealed no other incidents had occurred as the result of improper transfer with the lift. 7. The SA validated through staff interview with the DON and MDS Coordinator on 7/21/16 at 11:06 AM, and record review of assessments and care plans, that 77 residents who were assessed for transfer needs following the incident on 07/07/16, and that Kardexes, care plans were reviewed for accuracy for type of lift and reviewed, and all were determined accurate. This was initiated on 7/7/16 and completed on 7/8/16. 8.The SA validated through staff interview that random audits were conducted beginning on 07/07/16-7/15/16, and reviewed to determine that lifts were used correctly, that two (2) person assist were being done as care planned, and all were found to be accurate. These audits were documented on a calendar and continued five (5) times weekly. 9. The SA validated through review of a signed document, dated 7/15/16, that the Hoyer lift supplier visited the facility on 07/15/16 and checked the hoyer lifts and found no concerns. The SA observed all lift pads on 7/20/16 and found no concerns.

Complaint #MS8266 Based on observation, record review, staff interview and policy review, the facility failed to ensure an environment free from accident hazards by providing proper supervision to prevent injuries for two (2) of 19 residents reviewed (Residents #1 and #7). Resident #1 was fell from the wheelchair on 4/27/20 and sustained a laceration to the forehead and a fracture to the right tibia shaft and distal fibia fracture of the right tibia. Resident #1 was supposed to have a seat belt in place to the wheelchair. The seat belt was not in place which resulted in an avoidable accident. Resident #7 had falls on 2/13/10, 2/16/10, 3/31/10 and 4/27/10. The facility did not implement effective measures and follow recommendations regarding assessing Resident #7 for the appropriate wheelchair and assistive devices in a timely manner to prevent falls. Findings include: Observation on 7/14/10 at 10:25 a.m. revealed that Resident #1 was seated in a wheelchair with a red cast to his/her right leg and a seat belt in place. Record review revealed that Resident #1 moved into the home on 3/14/10 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed that Resident #1 was severely impaired with cognitive skills for daily decision making. Resident #1 required extensive assistance of two (2) or more persons with transfers. Review of the physician's telephone orders dated 3/22/10 revealed an order for [REDACTED]. Review of the Resident #1's care plan for "Restraints" revealed that Resident #1 was at risk for a fall and the self release seat belt was noted on 3/22/10 with an update completed on 4/23/10. Review of the nurse's notes dated 4/27/10 at 11:55 a.m. revealed: "While passing meds on C Hall I heard a noise in (Room number). Upon arriving in rm (room) I saw Resident in doorway body in rm (room) facing down and head turn to (r). Resident was bleeding. Front of head was cleaned with NS (normal saline). VS (vital signs) taken and WNL (within normal limits). RP (responsible party) was left mess (message) and MD notified. Resident was sent out to (Name of hospital) for evaluation per ambulance." Review of the Incident/Accident Report dated 4/27/10 revealed that Resident #1 had a fall at 12:30 p.m. from a wheelchair with no seat belt attached. Review of the facility's investigation report revealed an interview with the Certified Nurse Aide (CNA) #1 acknowledged that he/she was taking care of Resident #1 on 4/27/10 and that a bath was provided. CNA #1 stated he/she went in the bathroom and saw the resident's new wheelchair wrapped in plastic. The wheelchair was unwrapped by CNA #1 and the resident was placed in the wheelchair. Resident #1 was then placed by the nurse's station and the DON (Director of Nursing) was informed of the resident's placement in the new wheelchair. The DON proceeded to radio the Maintenance Supervisor to move the self release belt from the old chair to the new chair. Review of the facility investigation revealed an interview with the Maintenance Supervisor where he/she acknowledged that around 11:30 a.m. the Director of Nursing paged and asked that the seat belt for Resident #1 be removed from the old wheelchair and placed on the new wheelchair. The Maintenance Supervisor was unable to locate the old wheelchair or the CNA to find the wheelchair, so he/she left for lunch. Resident #1 fell from the wheelchair on 4/27/10 at 11:55 a.m. and was transported to the hospital for evaluation and treatment. Resident #1 returned from the hospital on [DATE] with steri-strips in place to the center of the forehead. On 4/29/10 at 9:15 a.m. Resident #1 was grimacing when he/she touched his/her leg. The physician was notified and Resident #1 was sent out for an x-ray. At that time it was determined that Resident #1 had sustained a fracture to the right tibial fibia shaft and distal tibia fracture and fracture of the right tibia. A leg splint was applied. On 4/29/10 at 3:30 p.m. "based on the investigation staff were suspended pending investigation." (An attempt to interview CNA #1 about the typed statement revealed all of the numbers in the personal record had been disconnected and a contact with a family member provided rejected the call.) (An attempt to interview the Maintenance Supervisor with the numbers provided revealed the numbers were disconnected.) An interview on 7/14/10 at 9:15 a.m.. with the Director of Nursing revealed that the CNA and the Maintenance Supervisor were both terminated. An interview with Licensed Practical Nurse (LPN) #1 on 7/14/10 at 12:30 p.m. revealed that he/she was administering medications on the hall and that Resident #1 followed him/her to another hall. Around 12:30 p.m. Resident #1 was at another resident's door when a loud noise was heard. LPN #1 reported running to the door to see Resident #1 on the floor face down with a laceration to the forehead and his/her right leg unusually resting beneath his/her body. It was then noticed by LPN #1 that the seat belt was not on the wheelchair. An interview with Registered Nurse (RN) #1 and the current Director of Nursing (DON) revealed that the DON that was present during the fall was no longer employed at the facility. Review of the nurse's notes dated 4/29/10 at 9:15 a.m. noted: "Was summon to resident rm (room) per RCA, while getting Resident up RCA noticed Resident opening (his/her) mouth wide when (he/she) moved (r) leg. Resident was observed and leg touch (touched) and Resident opened mouth wide. (Name of physician) called and giving observation, xray ordered per MD." Review of the x-ray report dated 4/29/10 stated that there was a spiral fracture involving the distal fibula just above the lateral malleolus. A spiral fracture through the proximal fibula is present. An oblique fracture also extends through the distal tibia 5 cm (centimeters) above the joint. An interview with the Administrator and the Director of Nursing on 4/16/10 at 1:33 p.m. acknowledged that the events of the investigations were as provided and documented. Record review revealed that Resident #7 moved into the hoe on 2/24/10 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed that Resident #7 was moderately impaired in cognitive skills for daily decision making 4/14/10 as having poor decision making skills and impaired short and long term memory problems. Observation on 7/14/10 at 12:00 noon revealed that Resident #7 was bed fast and was not interviewable. Record review revealed that Resident #7 had five (5) unwitnessed falls/incidents from 2/13/10 - 4/6/10. Record review revealed that Resident #7 complained of pain to the left side as a result of the unwitnessed fall out of bed on 3/31/10. Resident #7 rolled out of the bed on to the floor and was found by a Certified Nurse Aide (CNA). Resident complained of pain and was sent by ambulance to the hospital for evaluation. Resident #7 was given routine Lortab for pain as prescribed by the physician. Review of the care plan interventions related to the fall/incident on 3/31/10 revealed: "Fall on 3/31/10 contusion to R (right) hip ...change out mattress." The care plan had no new interventions to prevent potential for future falls. Record review revealed that on 2/13/10 that Resident #7 fell out of his/her wheel chair to the floor. The incident was not witnessed. The facility documented that Resident #7 wheel chair was to be evaluated for appropriateness by the physical therapy. There were no documents to indicate that Resident #7's wheel chair was evaluated by the Physical Therapy department until 2/16/10 (after a second fall). Resident #7 was sitting in the same wheel chair on 2/16/10 and he/she fell out of the same wheel chair on 2/16/10. The 2/16/10 fall was not care planned and no new interventions were implemented after that fall. The facility did not follow the recommendations that was on the care plan after the fall on 2/13/10. Review of the Incident and Accident Report dated 4/6/10 for Resident #7 revealed: "Fall - unwitnessed transfer-sat down on floor no injury." There were no statements attached to the 4/6/10 incident report and there were no details of any assessments and/or evaluations of Resident #7 after the unwitnessed fall. The care plan did not contain any new interventions after the fall on 4/6/10. There were no assessments of Resident #7 documented after the fall on 4/6/10. Resident #7 fell from a wheel chair on 4/6/10. The care plan dated 2/13/10 stated that Resident #7 was to be placed in a Geri-chair in the reclined position with a tab alarm. The incident report did not document that Resident #7 was in a Geri-chair on 4/6/10. An interview on 7/13/10 at 3:30 p.m. with the Director of Nursing (DON) revealed that Resident #7's falls all occurred prior to his/her employment at the facility and prior to his/her becoming the DON. The DON stated that the above information was obtained by the prior Director of Nursing. Review of the home's "Fall Management" policy, revised March 2008, noted: "... Fall Event ... 3. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form. The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. 4. The nurse will communicate via the 24 -hour report to the IDT (interdisciplinary team) team of the resident fall. 5. The IDT team will review all resident falls within 24 -72 hours at the interdisciplinary team meeting to evaluate circumstances and probable cause for the fall. 6. The IDT then modifies and implements a care plan and treatment approach to minimize repeat falls. The care plan is to be reviewed/revised as indicated... Each facility is responsible for implementing individualized interventions related to/for each resident's fall risk."