Every finding on record at Twin Rivers Rehabilitation and Healthcare Center

Number of residents sampled: Number of residents cited: Based on observation, record review and interview, the facility failed to ensure foods stored in freezers were covered and sealed to maintain freshness and decrease the potential for cross contamination. The facility also failed to ensure the low temperature dishwasher was maintained at proper temperatures to prevent potential contamination of dishware. This failed practice had the potential to affect 67 residents who received meals from the kitchen. The findings include: Incident #1 During the initial tour of the kitchen and concurrent interview with the Dietary Manager (DM) on 02/09/2026 at 10:20 AM, the following were observed: -An opened pie crust that did not have an open date or use by date in the pantry area. The Dietary Manager (DM) verified the pie crust was not labeled with any form of date on them The DM stated it was important to have a date on [food items] that were opened to know if it was still good. -The walk-in freezer contained one box of sheet dough that was opened and not covered or sealed. The DM verified that the box of sheet dough was not covered or sealed. The DM stated it was important for things to be covered and sealed correctly so the food items would not get freezer burn or become cross contaminated. During an interview on 02/12/2026 at 4:07 PM, the Administrator stated if a food item had been opened, it should have an open date and a used by date. Incident #2 Review of an equipment manual titled ES-4000 Dish machine, revealed the wash and sanitizing rinse temperature of the machine should be at a minimum of 120 degrees Fahrenheit (F). Review of an undated facility policy titled Food and Nutrition Services, revealed the dishwasher, should be maintained and run according to manufacturer's instructions. The policy also indicated the dishwasher should be kept above 120 degrees F if using a chemical sanitizer. During an interview on 02/09/2026 at 10:10 AM, the Dietary Manager (DM) stated she had been the DM since December 2025 and had not started classes for dietary certifications yet, but she had been a cook at the facility for the past year. During an interview on 02/09/2026 at 10:45 AM, the DM verified that the facility's dishwasher was a low-temperature model. The DM provided the machine's user manual and log used by the kitchen staff to record the maximum operating temperature achieved by the machine while in use. The DM also provided temperature logs for November 2025, December 2025, and February 2026. The DM was unable to locate a log for January 2026. The following indicates the number of times documented that the dishwasher did not meet the minimum wash and rinse temperatures: December 2025: -Out of 31 Breakfast wash temperatures reviewed, 17 temperatures did not reach 120 degrees F, with one temperature not documented. -Out of 31 Breakfast rinse temperatures, 30 temperatures did not reach 120 degrees F, with one temperature not documented. -Out of 31 Lunch wash temperatures, 21 temperatures did not reach 120 degrees F, with one temperature not documented. -Out of 31 Lunch rinse temperatures, 29 temperatures did not reach 120 degrees F, with one temperature not documented. -Out of 31 Dinner wash temperatures, 27 temperatures did not reach 120 degrees F, with three temperatures not documented. -Out of 31 Dinner rinse temperatures, 22 temperatures did not reach 120 degrees F, with three temperatures not documented. January 2026: -There were no temperatures to review as the DM was unable to locate the temperature log form. February 2026: -Out of 9 Breakfast wash temperatures reviewed, 5 temperatures did not reach 120 degrees F -Out of 9 Breakfast rinse temperatures, 8 temperatures did not reach 120 degrees F -Out of 8 Lunch wash temperatures, 1 temperature did not reach 120 degrees F -Out of 8 Lunch rinse temperatures, 7 temperatures did not reach 120 degrees F -Out of 8 Dinner wash temperatures, 4 temperatures did not reach 120 degrees F, with one temperature not documented. -Out of 8 Dinner rinse temperatures, 5 temperatures did not reach 120 degrees F, with one temperature not documented. During an interview on 02/11/2026 at 12:15 PM the DM stated she was not sure what the dishwasher temperatures should be, but thought it was over 100 degrees F. Review of an outside vendor service report titled Regular Service Call dated 01/29/2026, indicated the Outside Vendor Technician (OVT) #2 checked the machine and dispensers. The report revealed the wash temperature of the dishwasher was, 90 [degrees] Fahrenheit Out of Range – Action Needed. The document also indicated the water temperature needed to be 120 degrees F for best results. During an interview on 02/09/2026 at 3:02 PM, OVT #2 stated when he was last in the facility on 01/29/2026, he noted the water temperature only reached 90 degrees F and notified the dietary staff that was on duty due to the previous dietary manager not being employed at the facility any longer. OVT #3 stated he emailed the report to the Administrator.

Number of residents sampled: Number of residents cited: Based on interviews, observation and record review it was determined the facility failed to ensure a qualified dietary professional served as dietary manager affecting 67 residents that received meals from the facility kitchen. The findings include: Review of a facility document titled, Dietary Manager Job Description, which was signed by the Dietary Manager (DM) on 12/12/2025, indicated the minimum required qualifications were to meet one of the following: Certification as a dietary manager Certification as a food service manager Have similar national certification for food service management and safety from a national certifying body. Have an associate's or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, from an accredited institution of higher learning. Have 2 or more years of experience in the position of food and nutrition services in a nursing facility setting and completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. During an interview on 02/09/2026 at 10:10 AM, the DM stated she had been the DM since December 2025. She also stated she had not started classes for dietary certifications yet, but she had been a cook at the facility for the past year. On 02/09/2026 at 10:34 AM, this surveyor observed the DM attempt to attach a five-gallon bucket to the low temperature dishwasher. The bucket was labeled Laundry Detergent with Bleach. The DM stated the bucket was what the facility always used to sanitize the dishes. At 10:48 AM, the DM and Dietary Staff #1 ran the dishwasher and used a pH strip to test the water. The pH strip indicated no color, which indicated there were no chemicals in the water. This was completed three times with the same result. At 10:50 AM, the DM stated that since the pH strips indicated there was no bleach, she would rewash the same dishes using the same chemicals. The surveyor asked for the DM to clarify, since the dishwasher was not effectively washing the dishes, how would rewashing the dishes in the dishwasher be effective. The DM stated she was unsure what to do if the dishwasher was not properly disinfecting the dishes but thought she could use the three-compartment sink. During a follow up interview on 02/11/2026 at 12:15 PM, the DM stated she was not aware of what the temperatures for the dishwasher should be. During a follow up interview on 02/12/2025 at 3:40 PM, the DM reviewed her signed job description and confirmed she did not meet the required qualifications. During an interview on 02/12/2026 at 4:07 PM, the Administrator confirmed the DM took the position on 12/12/2025. The Administrator stated he thought the Dietary Manger had completed her training. At this time, the Administrator was made aware that the DM had not started the course and did not meet the dietary qualifications.

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure residents were free of harm due to improper transferring of residents with a mechanical lift for one (Resident #1) of one resident reviewed for transfers. Resident #1 had a negative outcome which resulted in a right distal third spiral femur fracture (a spiral fracture line caused by twisting forces). The findings include: Review of an “admission Record,” indicated the facility admitted Resident #1 on 07/03/2012 with diagnoses which included brain damage due to lack of oxygen, blocked blood flow to the brain, anxiety disorder, sudden burst of electrical activity in the brain (seizures), weakened bones, cognitive communication deficit, contracture of left hand, brain disorder that affects memory and behavior, high blood pressure, and type 2 diabetes. Review of an “Annual Minimum Data Set” (MDS) with Assessment Reference Date (ARD) of 09/25/2024 and a review of a “Quarterly MDS” with an ARD 06/24/2025, indicated Resident #1 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident had severe cognitive impairment and had long and short-term memory problems. Resident #1 was severely impaired for daily decision making, and no behaviors were exhibited. The residents’ functional abilities were dependent; the helper performed all the effort. Resident #1 was incontinent with bowel and bladder, and a mechanical lift was required. Review of a “Discharge MDS”, with an ARD of 01/02/2025, revealed Resident #1 had a SAMS score of 3, which indicated the resident was severely cognitively impaired for their daily decision making. The MDS also revealed that Resident #1 was dependent on Activities of Daily Living (ADL’s) such as eating, hygiene, transfers, bed mobility, bathing, and dressing. Review of “ADL Transferring” dated 07/31/2025, indicated Resident #1 required total dependence for transferring and was dependent on “full staff performance.” Review of Resident #1’s “Comprehensive Care Plan” dated 06/30/2025, indicated Resident #1 was at risk for fracture due to diagnosis of weakened bones and staff was to provide gentle care while assisting the resident with ADLs. Resident #1 required non-weight bearing assistance with ADLs due to cognitive impairment, required total care and was dependent on two-person assistance with bed mobility, dressing, shower or bathing self, toileting and transfers required two staff with use of a mechanical lift with a green sling. A review of an “Incident by Incident Type” dated March 2025 indicated Resident #1 had an ‘other’ incident on 03/15/2025 at 10:30 PM. A review of a “Progress Note” dated 03/15/2025 at 8:46 PM, indicated Resident #1 had a swollen right knee that was not present the day before and an x-ray was ordered. A review of a “Progress Note” dated 03/16/2025 at 12:09 AM, indicated Resident #1 had a displaced fracture of the right femur. Resident #1 was sent to the emergency room via ambulance. A review of Resident #1’s “Hospital records” revealed Resident #1 obtained a distal third spiral right femur from the pre-operative and post-operative diagnosis. Resident #1 received surgical fixation and stabilization of stated fracture. During an interview on 08/25/2025 at 5:45 PM, Resident #1’s family member stated they arrived to visit the resident on 03/15/2025 when CNA #10 informed them of a swollen knee. When the family member asked the Licensed Practical Nurse (LPN) #4 about the swollen knee and what happened, the LPN asked, “Well what do you want me to do about it?” The family member stated all they wanted to know was what happened and when the nurse “had an attitude,” it upset them without knowing what happened. After the X-ray was completed and it showed a fracture the Administrator was asked by the family member what happened, and the Administrator informed them that “the employee that hurt Resident #1 had been terminated.” When the resident was taken to the hospital for surgery, the hospital personnel came out and wanted to know how the resident got a spiral fracture. The family member stated, “You will have to ask the nursing home because that was where it happened.” The family member stated they had reported concerns about the care that was provided to Resident #1 and the facility had not done anything about their concerns. The family member stated that there were two employees that did not provide good, quality care and it worried them when they were working. The family member stated one was CNA #7 and they did not know the other one’s name. During a telephone interview on 08/25/2025 7:52 PM, CNA #10 stated the reason for her termination was due to improper use of a mechanical lift. She stated she noticed Resident #1 had a swollen knee the morning of 03/15/2025 and she alerted LPN #4. Resident #1 was already up to the Geri-chair when she got to work at 8:00 AM on 03/15/2025. The resident sat in the chair until around 2:30 PM on 03/15/2025. “We had previously been told by the Administrator that we had to do the best we could do when we were working short-staffed and as long as the second staff member was outside the door of the room they counted that as the second staff assist.” CNA #10 stated Resident #1 was like family to her and she did not drop or hit the leg on anything. When she told LPN #4 about the leg and asked if she would come look at it, LPN #4 stated, “Well, you know how the [Resident #1] is.” CNA #10 stated she told LPN #4, “No, something was wrong, the leg was flopping when I turned the resident.” When the family member came to visit the resident she informed them of the knee and that was what started the process for the X-ray. CNA #10 stated she took accountability and admitted she used the mechanical lift by herself. The Administrator informed the CNA that the fracture had happened between Friday 03/14/2025 and Saturday 03/15/2025. CNA #10 stated she did not work on that Friday night and came in on Saturday morning and the knee was already swollen. CNA #10 stated “upper management covered up for someone and I took the fall for it.” During an interview on 08/26/2025 9:46 AM, CNA #1 stated she looked at the Kardex to know how to care for Resident #1. She stated if a resident had a change of condition, she informed the nurse. CNA #1 stated to operate a lift, you had to push it under the bed, lock the wheels and open the legs of the lift, hook up the sling, then the resident would be moved. She stated, “We are required to always use two staff to operate the mechanical lift.” She stated Resident #1 was totally dependent and required two or three staff members to move the resident. CNA #1 stated, “I had seen the lift being used by one person and the last time I saw it was a week ago on the 4-12 shift and it was CNA #7.” During an interview on 08/26/2025 10:01 AM, CNA #2 stated she had never worked the mechanical lift by herself. CNA #2 stated to work the lift, you had to push it under the bed, lock the wheels, hook the sling up and lift the resident up and you had to use a second staff member to help. CNA #2 stated Resident #1 was a total care resident. She stated she had recently seen staff work the lift with just one person on the 12-8 shift. During an interview on 08/26/2025 10:27 AM, CNA #3 stated you had to look every morning at the Kardex to see what you had to do for Resident #1. To work the mechanical lift, you had to get another CNA, get the right size sling, open the legs of the lift and make sure the legs are locked. You had to make sure the legs were opened to balance the resident. When this surveyor asked the reason the incident with Resident #1’s fractured leg occurred, CNA #1 stated “Someone used the mechanical lift by themselves.” During an interview on 08/26/2025 10:43 AM, Licensed Practical Nurse (LPN) #4 stated she had “worked the lift by herself a few months ago due to low staffing.” LPN #4 stated she had received mechanical lift training “a very long time ago.” She stated she was at work the day CNA #10 called her to Resident #1’s room to assess the swollen knee. A family member of the resident walked in, and LPN #4 asked the family member if they wanted me to call the doctor. LPN #4 notified the provider and received an order for a stat x-ray. LPN #4 stated Resident #1’s knee was not swollen on 03/14/2025 and was on 03/15/2025. She stated she felt the incident happened “when they put the resident to bed the night of 03/14/2025 or when they got Resident #1 up early the morning of 03/15/2025.” She also stated, “I do not believe the CNA they terminated was the one that hurt the resident.” During an interview on 08/26/2025 11:31 AM, the CNA Supervisor stated there were ‘always’ to be two staff operating the mechanical lift. If a staff member used the lift by themselves, they would be terminated immediately. The CNA Supervisor stated, “I always made sure there was sufficient staffing, the reason Resident #1 got a fracture was due to an employee that used the lift without assistance and that was why they were terminated.” During an interview on 08/26/2025 2:01 PM, the Advance Practical Registered Nurse (APRN) stated for a resident to get a spiral fracture, there had to be some type of twisting movement. She stated if the lift was not properly used, it could result in a fracture. During an interview on 08/26/2025 2:39 PM, the Medical Director (MD) stated “I would not think a sling would cause this type of injury.” He stated the staff always called to inform him of incidents that happened at the facility. During an interview on 08/26/2025 3:01 PM, the Maintenance Director stated to operate the mechanical lift, you had to roll the lift under the bed, open the legs of the lift, lock the legs, hook the sling up to the lift, then proceed to lift the resident. He also stated, “if a person did not open the legs of the lift and did not lock the wheels, it affected the balance of the lift and resident.” During an interview on 08/26/2025 3:19 PM, LPN #5 stated “you had to look at the care plan to know how to care for a resident.” She stated two staff were required to operate the mechanical lift. LPN #5 stated she worked with Resident #1 on 03/14/2025 and the resident did not appear to be in pain. LPN #5 stated the CNAs that were working had gotten the resident up to the Geri-chair and that was where the resident was when she gave medications. The skin on Resident #1’s legs were not discolored. LPN #5 stated, “when day shift staff came on the next morning 08/15/2025, we noticed the knee was swollen, so the injury had to have happened the night before or early that morning and I do not believe it was done by the employee that got terminated even if that person was operating the lift by themselves.” She stated she had not seen an employee use the lift by themselves. During an interview on 08/26/2025 3:55 PM, CNA #6 stated the process to operating a mechanical lift was to get another staff member to help, open and lock the legs of the lift, lift the resident up, unlock the wheelchair to move it under the lift and to get the right size sling you had to look on the Kardex to see which color to get. CNA #6 stated “I heard Resident #1’s leg was hurt from someone that used the lift wrong, and the resident’s leg was dangling.” During an interview on 08/26/2025 4:25 PM, CNA #7 stated the “online care kiosk told us how to care for a resident, it gives us the care plan.” He stated to operate the mechanical lift “you had to make sure your partner was with you, the resident was placed flat on their back, the sling was placed under the resident, then you rolled the lift under the bed, spread the legs of the lift open, clamp the sling to the lift, work with your partner to move the chair.” He stated that Resident #1 required total, full care. CNA #7 stated he worked on 03/14/2025 on the 4-12 shift. When this surveyor asked if he had worked the lift by himself he responded, “not by myself, or let me say this…the other employee would peek around the door or would stand at the door to watch to make sure everything was okay while lifting the resident but that was when we were shorthanded to get the residents up to dinner.” When the question was reworded by this surveyor, CNA #7 stated he would be the only one that worked the lift, and the nurse would stand in the doorway and looked into the room.” CNA #7 stated “the reason residents were still in bed at that moment was due to being short-staffed tonight (08/26/2025) so he would feed the residents in bed and not get the residents up to a chair to eat.” During an interview on 08/27/2025 6:40 AM, CNA #9 stated she had not used a lift without having another aid helping even when they were short-staffed and that, “you would get terminated if you used it without two staff.” On 08/27/ 8:10 AM, this surveyor called and spoke to an employee with the company that serviced the mechanical lifts at this facility. He stated they checked them every 30-45 days and made sure they worked and did not have broken rubber strips or parts. He stated the facility had not had an issue with batteries not charging. He stated he would email this surveyor the manufacturer guidelines to operate the lift. Review of a “Invacare Reliant 450_600 Patient Lift Manual,” revealed Invacare does not recommend locking the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize when the patient is initially lifted from a chair, bed or any stationary object. During an interview on 08/27/2025 at 9:49 AM, the CNA Supervisor revealed that care plans would indicate two people assist with any mechanical lift. During an interview on 08/27/2025 at 10:38 AM, the Radiologist Medical Director (RMD) indicated the x-ray on 03/15/2025 revealed that Resident #1 had a spiral fracture that did not appear to be pathological. RMD revealed that the type of fracture Resident #1 had does not typically come from osteoporosis (weakened bones). He revealed that this type of fracture could have resulted from a fall or body weight movement. He stated, “It takes a fair amount of force to break a femur. Whatever broke it took some weight behind it. I expect a body weight movement for this type of fracture.” During an interview on 08/27/2025 at 1:24 PM, LPN #11 revealed in reference to the morning of 03/15/2025, that the lift was locked prior to raising Resident #1 off the bed and when lowering the resident to the chair. LPN#11 stated, “We are supposed to lock the lift prior to lifting or lowering the lift.” During an interview on 08/27/2025 at 1:35 PM, CNA #3 verified that the lift was supposed to be locked when raising or lowering a resident. She stated, “It was so the lift wouldn’t tip over.” CNA #3 explained that the last in-service regarding the mechanical lift was 3-4 months ago. During an interview on 08/27/2025 at 1:37 PM, CNA #1 revealed that the mechanical lift was supposed to be locked when raising and lowering a resident. CNA #1 stated, “So the resident isn’t moving around when in the lift.” CNA #1 explained that the last in-service regarding the mechanical lift was 2-3 months ago. During an interview on 08/27/2025 1:45 PM, ADON (Assistant Director of Nursing) revealed that staff would know how to care for a resident by utilizing the care plan which was also reflected on the Kardex. She explained that interventions are determined based on resident cognition and the residents’ fall risk. The ADON explained that the Kardex will tell the staff how many staff would be required, as well as the sling color to use for each resident. The ADON revealed that the facilities’ last training regarding use of the mechanical lifts indicated to lock the wheels with transfers. She referred to the patients’ sling book, stating that the “wheels do not have to be locked.” She stated, “I was always trained to lock the mechanical lift.” This surveyor asked the ADON to read the passage on “Invacare Reliant 450_600 Patient Lift Manual”. After reading the passage, the ADON stated that the staff are “not locking the wheels.” During an interview on 08/27/2025 at 2:15 PM, the Director of Nursing (DON) revealed that the CNA’s and Nurses would know how to care for a resident based upon the care plan and Kardex. The DON revealed the care plan was reviewed every three months. The DON revealed that she was taught to lock the wheels on a mechanical lift when in use but said she was recently taught not to lock the wheels and if a resident swung on the lift pad the mechanical lift could tip over. The DON revealed there was one staff member who admitted to using a mechanical lift by themselves. The time frame CNA #10 used the lift by themselves was in March of 2025. The DON revealed that what she remembers regarding Resident #1’s fracture was that the family member was there, and the family member noticed the resident’s knee was a little swollen. The doctor ordered an x-ray, and the results revealed a fracture and Resident #1 was sent to the hospital. A review of a facility policy titled, “Accident Hazards Prevention”, indicated, “An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address risk and environmental hazards to minimize the likelihood of accidents. A facility with a commitment to safety: 6. Demonstrates a commitment to at all levels of the organization.”

Based on observation and interview, it was determined the facility failed to keep food at a safe temperature prior to serving residents. The findings are: On 8/28/2024 at 7:31 AM, [NAME] #1 checked the temperature of the foods on the steam table using a probe thermometer. The temperature of the pureed eggs was 125 degrees. On 8/28/2024 at 11:52 AM, [NAME] #1 was asked what the temperature of the food held on the steam table should be. [NAME] #1 said between 175 and 185 (degrees Fahrenheit). [NAME] #1 said the steam table hasn't been working correctly and that 2 of the compartments had quit working. On 8/28/2024 at 11:59 AM, the Dietary Manager (DM) was asked what temperature should the food on the steam table be held at prior to serving the residents. The DM said 180 degrees. On 8/29/2024 at 8:05 AM, a policy and in-service on food temperatures was requested from the DM. The DM said that the Administrator keeps all of those documents. On 8/29/2024 at 8:10 AM, the Administrator provided an in-service dated 5/07/2024 that kitchen staff had read and signed. The in-service indicates hot foods are to be served hot and cold foods are to be served cold. Hot food must maintain a temperature of 135 or higher. The facility did not provide a policy on safe food temperatures.

Based on observation, record review, and interview, it was determined that the facility failed to ensure a medication was used only to treat specific diagnosed condition for 1 (Resident #71) sampled resident. The findings are: Review of the Orders portion of Resident #71's electronic health record, it was determined the resident was taking a psychotropic medication. Resident #71's had an order for 15 mg (milligram) of an anti-depressant, 1 tablet by mouth at bedtime for depression. Review of the Medical Diagnosis portion of Resident #71's electronic health record revealed no medical diagnosis for depression listed in the resident's medical record. On 8/29/2024 at 8:59 AM, Licensed Practical Nurse (LPN) #1 was asked what criteria needs to be met before giving a resident a medication. LPN #1 said an order from a physician and a diagnosis. Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/28/2024 revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. On 8/29/2024 at 9:08 AM, LPN #2 was asked what criteria needs to be met prior to giving a resident a medication. LPN #2 said a physician's order and a diagnosis. On 8/29/2024 at 8:15 AM, the Administrator was asked for a policy regarding unnecessary medications. The Administrator said the facility does not have a policy specific to unnecessary medications.

Based on observation, record review, and interviews, the facility failed to provide appropriate treatment and services to prevent complications from an indwelling urinary catheter for 1 (Resident #67) of 1 sampled resident with indwelling catheters. The findings are: A review of the Diagnosis Record indicated Resident #67 had no proper diagnosis for an indwelling urinary catheter. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/2024 revealed Resident #67 had a Brief Interview Mental Status (BIMS) with a score of 14 which indicated the resident was cognitively intact. A review of Resident #67's Care plan, dated 06/21/2024, showed the resident had no diagnosis requiring an indwelling urinary catheter. A review of July 2024 Medication Administration Record, revealed Resident #67 had an indwelling urinary catheter placed on 07/23/2024. A review of Resident #67 Order Summary revealed an order to place indwelling urinary catheter on 07/24/2024. During observation on 08/28/2024 at 9:27 AM, Resident #67 was observed with an indwelling urinary catheter in place attached to the side of the bed. During an interview on 08/29/2024 at 9:18 AM, Licensed Practical Nurse (LPN)#4 said that before an indwelling urinary catheter is placed, there should always be a proper diagnosis to prevent any issues happening to the bladder for unnecessary placement. During an interview on 08/29/2024 at 9:28 AM, Registered Nurse (RN) #5 said there should be a proper diagnosis before ever placing an indwelling urinary catheter to prevent increased risk for urinary tract infections or damage to the bladder. During an interview on 08/29/2024 at 9:46 AM, the Director of Nurses (DON) said there should be a diagnosis present before placing an indwelling catheter to prevent any damage to bladder. At 10:02 AM, the Administrator was asked for a catheter policy, surveyor was informed facility did not have a catheter policy.

Based on observation, record review and interview, the facility failed to ensure foods stored in in the freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; dish washer walls, baseboard, and wallboard were free of stain, debris, dirt, and rust; door frames and baseboards were free of chipped areas; wall tiles and baseboard were replaced, staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination; and hot food items were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who receive meals from the kitchen (Total census:80) as documented on a list provided by Administrator on 10/20/2023 at 08:27 AM. The findings are: On 10/16/23 at 10:00 AM, the following observations were made on a shelf in the walk-in freezer: a. An opened box that contained a bag of biscuits. The box was not covered, and the bag was not sealed. b. An opened box that contained a bag of hamburger patties. The box was not covered, and the bag was not sealed. On 10/18/23 at 4:48 PM, the temperatures of the food items when checked and read on the steam table by Dietary Employee (DE) #1 were as follows: a. Fried okra - 130 degrees Fahrenheit. b. Puree turkey pot pie - 130 degrees Fahrenheit. c. Pureed bread - 115 degrees Fahrenheit. d. Pureed vegetables - 120 degrees Fahrenheit. e. Boiled Okra - 120 degrees Fahrenheit. f. Chicken tenders - 110 degrees Fahrenheit. On 10/18/23 at 4:54 PM, DE #1 used a 6 ounce (3/4 cup) spoon to serve turkey pot pie to the residents on regular diets, instead of one cup of turkey pot pie. On 10/18/23 at 4:56 PM, the following observations were made in the kitchen: a. The baseboard around the area of the steam table leading to the dish washing machine room was chipped exposing the wood. The areas that were chipped had rust and were covered with black residue. b. The wallboard attached to the counter by the steam table where utensils were kept was chipped exposing to the wood. c. The baseboard on the wall leading to the food preparation counter was missing. The areas where the baseboard was missing had dirt on them. d. The door frame leading to the kitchen and the food preparation were chipped. The area that was chipped had rust. e. The baseboard on the wall under the 3 compartment sink was on the floor. The wall below the dish washing machine had sage discoloration on it. On 10/19/23 at 11:07 AM, DE #2 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. When she was ready to place food items into the blender, the Surveyor immediately asked her what she should have done after touching dirty objects or before handling clean equipment. She stated, I should have washed my hands. On 10/19/23 at 11:50 AM, the temperatures of the food items when checked on the steam table by DE #2 were as follows: a. Pureed meatloaf - 113 degrees Fahrenheit. b. Pureed cut green beans - 120 degrees Fahrenheit. c. Meatloaves - 130 degrees Fahrenheit. d. Pureed bread with chicken broth - 109 degrees Fahrenheit. e. Plain meatloaf - 110 degrees Fahrenheit. The above food items were not reheated before being served to the residents.

Based on observation, record review and interview, the facility failed to ensure residents were assessed to self-administer medications prior to self-administration for 4 (Residents #39 Residents #46, #76 and #60) of 6 (Residents #34, #44, #46, #60, #62 and #76) sampled residents. The findings are: 1. On 10/16/23 at 11:00 AM, 10/17/23 at 9:09 AM, and 10/18/23 at 8:53 AM, observed a tube of Zinc Oxide in a blue mesh bag on Resident #39's overbed table and a tube of Biofreeze on the nightstand. The tubes did not have a pharmacy label. During review of Resident #39's Medical Record there was not an assessment to self-administer medication, there was not Physician Orders for Zinc Oxide, Biofreeze or self-administration of medications and the Care Plan did not address Zinc Oxide, Biofreeze or self-administration of medications. A Package Insert for Zinc Oxide Cream provided by the Director of Nursing (DON) on 10/18/23 at 11:41 AM documented, Tell all of your health care providers that you use zinc oxide cream. This includes your doctors, nurses, pharmacists, and dentist. This medicine may cause harm if swallowed. If . swallowed, call a doctor or poison control center right away . keep all drugs in a safe place . A Package Insert for Biofreeze provided by the DON on 10/18/23 at 11:41 AM documented, .Biofreeze side effects . Biofreeze may cause serious side effects. Stop using Biofreeze and call your doctor at once if you have: severe burning, stinging, redness, or irritation after using this medicine; or pain, swelling, or blistering where the medicine was applied . Use exactly as directed on the label, or as prescribed by your doctor. Do not take by mouth . Do not use on open wounds, broken skin, or irritated skin . An overdose of menthol is not expected to be dangerous. Seek emergency medical attention or call the poison help hotline . if anyone has accidentally swallowed the medication . Avoid using other topical pain medications on the areas you treat with menthol .Remember, keep this and all other medicines out of the reach of children, never share you medicines with others, and use this medication only for the indication prescribed . On 10/17/23 at 1:04 PM, Licensed Practical Nurse (LPN) #3 confirmed there were no residents on the 100 Hall who were assessed to self-administer medications. On 10/18/23 at 9:07 AM, LPN #4 confirmed there were no residents on the 100 Hall who were assessed to self-administer medications. On 10/19/23 at 8:45 AM, the Surveyor asked LPN #4, if you were going to store medications in a resident room, how should they be stored? LPN #4 answered, I never store medications in a resident room. The Surveyor asked if medications should have a pharmacy label LPN #4 answered, Yes, so we would know the directions, the expiration date, and the resident's name. The Surveyor asked if zinc oxide was a medication. LPN #4 answered, Yes, topical. The Surveyor asked if Biofreeze was a medication. The nurse answered, Yes, topical. On 10/19/23 at 9:00 AM, the Surveyor asked the DON if you were going to store medications in a resident's room, how should they be stored. The DON answered, We are not supposed to store medications in a resident's room. The Surveyor asked should medications have a pharmacy label. The DON answered, Yes or at least the opened date and resident's name. The Surveyor asked would you consider zinc oxide a medication. The DON answered, Yes. The Surveyor asked would you consider Biofreeze a medication. The DON answered, Yes. 2. On 10/16/23 at 12:41 PM, Resident #46 was sitting in a wheelchair in the room with a nebulizer mask on and the machine was running without a nurse present. On 10/17/23 at 10:18 AM, the Surveyor asked Resident #46 if he did his own breathing treatments. He answered, Yes. The Surveyor asked if the nurse stays in the room with you when you do them. He answered, No. The nurse does not stay with me. A Physician's Order dated 09/25/23 noted Resident #46 was to receive an Albuterol nebulizer treatment every 4 hours as needed for shortness of breath/wheezing and an Ipratropium-Albuterol nebulizer treatment every 6 hours for shortness of breath while awake There was not a Physicians Order to self-administer medications. On 10/17/23 at 12:51 PM, during review of Resident #46's Medical Record, there was not an assessment to self-administer medication, and the Care Plan did not address self-administration of medications. On 10/19/23 at 8:45 AM, the Surveyor asked LPN #4 what the process is for administering a nebulizer treatment. LPN #4 answered, After you fill the chamber with medication, you explain the procedure and apply the mask or hand them the pipe. Turn it on. I stay with them to make sure they keep the mask on and get all the medication. During an interview on 10/19/23 at 9:00 AM, the DON confirmed the nurse should either stay with the resident or stand right outside the door to monitor the resident. Surveyor: [NAME], [NAME] 3. On 10/16/23 at 10:18 AM, Resident #76 was lying in bed receiving a nebulizer treatment without a nurse present. The reservoir to the nebulizer was dry. Resident #76 asked for the mask to be removed. He stated, It's been on for a long time. On 10/17/23 at 8:40 AM, Resident #76 was lying in bed receiving a nebulizer treatment without a nurse present. At 8:48 AM, observed the Social Services Director enter Resident #76's room, turn off the nebulizer, remove the nebulizer mask and set up Resident #76's breakfast. A Physicians Order dated 08/11/23 noted Resident #76 was to receive Ipratropium-Albuterol nebulizer treatment every 6 hours related to Chronic Obstructive Pulmonary Disease, Unspecified. The Physician orders did not address self-administration of medications. During review of Resident #76's Medical Record there was not an assessment to self-administer medication, and the Care Plan did not address self-administration of medications. On 10/19/23 at 8:32 AM, the Surveyor asked LPN #1 who should administer and discontinue a nebulizer treatment. LPN #1 stated, A nurse. The Surveyor asked if a nurse should stay in eyesight during the administration. LPN #1 stated, Absolutely. Surveyor: [NAME], [NAME] 4. On 10/17/23 at 9:28 AM, Resident #60 was lying in bed receiving a nebulizer treatment without a nurse present. On 10/17/23 at 9:32 AM, observed Resident #60 turn off the nebulizer machine and remove the mask without a nurse present. On 10/18/23 at 8:35 AM, during medication pass Resident #60 requested a nebulizer treatment. LPN #5 started the nebulizer treatment and stated to Resident #60, I will be back in about seven minutes. LPN #5 left the room. On 10/18/23 at 8:49 AM, LPN #5 continued to pass medications without returning to Resident #60's room. During review of Resident #60's Medical Record there was not an assessment for self-administration of medications, and the Care Plan did not address self-administration of medications. A Physicians Order dated 06/01/23 noted Resident #60 was to receive Ipratropium-Albuterol nebulizer treatment every 4 hours as needed for shortness of breath. The Physician orders did not address self-administration of medications. A facility policy titled, Self-Administration of Medications, revised January 2018, provided by the Administrator on 10/18/23 at 11:30 AM documented, .residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. A.an assessment is conducted by the interdisciplinary team of the resident's cognitive .physical, and visual ability to carry out the responsibility during the care planning process . F. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer . A facility policy titled, Medication Administration - General Guidelines, revised January 2018, provided by the DON on 10/19/23 at 3:00 PM documented, .Administration .14. Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold and or hot products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 25 residents who receive meal trays in their rooms on the 300 Hall, 20 residents who receive meal trays in their rooms on the 100 Hall, and 17 residents who received meal trays in their rooms on the 200 Hall, as documented on a list provided by the Administrator on 10/20/23 at 8:27 AM. The findings are: 1. On 10/16/23 at 1:53 PM, the Surveyor asked Resident #16 how the food is, is hot food hot. Resident #16 stated, No, hot food is cold. 2. On 10/19/23 at 7:57 AM, an unheated food cart that contained trays for the breakfast meal was delivered to the 300 Hall by a Certified Nursing Assistant. At 8:16 AM, immediately after the last resident was served in their room on the 300 Hall the temperature of the food items on a tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Milk 58 - degrees Fahrenheit. b. Pancakes - 95 degrees Fahrenheit. c. Pureed scrambled egg - 98.4 6 degrees Fahrenheit. d. Sausage - 90 degrees Fahrenheit. e. Scrambled eggs - 92 degrees Fahrenheit. f. Pureed sausage with biscuit - 99.8 degrees Fahrenheit. 3. On 10/19/23 at 8:10 AM, an unheated food cart that contained trays for the breakfast meal was delivered to the 100 Hall by a Certified Nursing Assistant. At 8:29 AM, immediately after the last resident was served in their room on the 100 Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Milk - 50 degrees Fahrenheit. b. Pureed sausage - 97.7 degrees Fahrenheit. c. Pureed oatmeal - 110 degrees Fahrenheit. d. Pureed eggs - 82.4 degrees Fahrenheit. e. Scrambled eggs - 98.4 degrees Fahrenheit. f. Pancake - 95.6 degrees Fahrenheit. 4. On 10/19/23 at 8:20 AM, an unheated food cart that contained trays for the breakfast meal was delivered to the 200 Hall by a Certified Nursing Assistant. At 8:33 AM, immediately after the last resident was served in their room on the 200 Hall the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Scrambled eggs - 100.2 degrees Fahrenheit. b. Sausage - 93.9 degrees Fahrenheit.

Based on observation, record review and interview, the facility failed to ensure refrigerated scheduled II-V controlled medications were maintained within a separately locked permanently affixed compartment in 1 of 1 medication room. The findings are: On 10/18/23 at 10:16 AM, during observation of the Medication Room with the Director of Nursing (DON), a locked narcotic box, containing narcotics was inside of the refrigerator and was not permanently affixed. On 10/19/23 at 4:10 PM, the DON confirmed the narcotic box was not secured so that it could not be taken. 46868

Based on observation, record review and interview, the facility failed to ensure a Janitor's Closet containing chemicals was locked when not in use to prevent the potential for accidents. This failed practice had the potential to affect 8 residents who resided on the 100 Hall who were independent or supervision/set up with locomotion as documented on a list provided by the Administrator on 10/19/23 at 10:00 AM. The findings are: On 10/16/23 at 10:17 AM, the 100 Hall Janitor's Closet was unlocked. A chemical dispenser labeled Bio Enzymatic Odor Eliminator, Disinfectant Cleanser, Peroxide Multi Surface Cleaner and Disinfectant, and High Performance Ultra Concentrated Neutral Floor Cleaner was on the wall. There were aerosol cans of glass cleaner and furniture polish on the top shelf. On 10/17/23 at 8:30 AM, the 100 Hall Janitor's Closet was unlocked. A spray bottle labeled, Enzyme and 2 other spray bottles were on the floor of the closet near the mop bucket. The Bio Enzymatic Odor Eliminator MSDS (Material Safety Data Sheet) Sheet provided by the Administrator on 10/18/23 at 11:30 AM documented, .SECTION 2. HAZARDS IDENTIFICTATION . Causes serious eye irritation . Wash skin thoroughly after handling. Wear eye protection/face protection . IF IN EYES: Rinse cautiously with water for several minutes If eye irritation persists: Get medical advice/attention . The High Performance Ultra Concentrated Neutral Floor Cleaner MSDS Sheet provided by the Administrator on 10/18/23 at 11:30 AM documented, .SECTION 2. HAZARDS IDENTIFICTATION .Causes eye irritation . IF IN EYES . Rinse cautiously with water for several minutes . If eye irritation persists: Get medical advice/attention . SECTION 4. FIRST AID MEASURES .If swallowed: Rinse mouth. Get medical attention if symptoms occur . The Peroxide Multi-Surface Cleaner and Disinfectant MSDS Sheet provided by the Administrator on 10/18/23 at 11:30 AM documented, .SECTION 2. HAZARDS IDENTIFICTATION .Danger .Harmful if swallowed or in contact with skin. Causes severe burns and eye damage . Toxic if inhaled . IF SWALLOWED: Call a POISON CENTER/doctor if you feel unwell . IF INHALED: .immediately call a POISON CENTER/doctor . The Disinfectant Cleaner MSDS Sheet provided by the Administrator on 10/18/23 at 11:30 AM documented, .SECTION 2. HAZARDS IDENTIFICTATION .Danger - Harmful if swallowed or in contact with skin. Causes severe burns and eye damage . IF SWALLOWED: Call a POISON CENTER or doctor/physician if you feel unwell . On 10/18/23 at 2:03 PM, the Surveyor asked Housekeeping Staff #1 how chemicals were stored inside this building. Housekeeping Staff #1 answered, They should be locked up in the janitor's closet. A facility policy titled, Housekeeping and Maintenance, provided by the Administrator on 10/18/23 at 11:30 AM documented, .All poisons, bleaches, detergents and disinfectants will be kept in a safe place accessible only to employees . A facility policy titled, Accident Hazards Prevention, provided by the Administrator on 10/19/23 at 1:08 PM documented, . Resident Environment. The environment will be free from accident hazards as is possible . It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents .

Based on observation, record review and interview, the facility failed to ensure dietary supplements were provided as ordered for (Resident #76) of 1 Resident reviewed for dietary supplements. The findings are: Resident #76 had a Physicians' order dated 8/11/23 which showed regular diet, mechanical soft texture and a Physician's Order dated 10/6/2023 which showed House Shake two times a day for weight loss supplement. On 10/16/23 at 12:53 PM Resident #76 did not receive a house shake with the noon meal. On 10/17/23 at 08:40 AM, Resident #76 did not receive a house shake with breakfast. On 10/17/23 at 12:34 PM Resident #76 did not receive a house shake with the noon meal. On 10/18/23 at 08:46 AM, Resident #76 did not receive a house shake with the meal. On 10/18/23 at 12:58 PM, Resident #76 did not receive a house shake. Review of a Care Plan dated 08/17/23 with a revision date of 09/09/23 showed Resident #76 had a for nutritional deficits related to stroke with an intervention to obtain food preferences, likes and dislikes. As of 10/19/23 Resident #76's food likes and dislikes had not been updated. On 10/18/23 at 1:05 PM, Certified Nurse Assistant #1 (CNA) said she was not aware Resident #76 had a house shake ordered with meals and confirmed there was not a shake on the noon meal. On 10/18/23 at 1:12 PM, the Surveyor asked Cook #1 if she was aware of Resident #76 having an order for a house shake twice daily. Cook #1 stated. No but I'll take care of it now. During an interview on 10/18/23 at 1:38 PM, the Director of Nursing (DON) said she was not aware Resident #76 had an order for house shake for weight loss. During an interview on 10/19/23 at 11:22AM, the DON said when there is a new diet order, it is entered in the computer and then printed and taken to the dietary department. On 11/19/23 at 11:30 AM, the Dietary Manager confirmed the order for house shakes for Resident #76 was probably missed.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets as provided by the Administrator on 10/20/23 at 8:27 AM. The findings are: 1. On 10/20/23 at 11:51 AM, the following observations were made on the steam table: a. A pan of pureed meatloaf was on the steam table. The consistency of the pureed meatloaf was thick and not smooth. b. A pan of pureed bread was on the steam table. The consistency of the pureed bread was thick and not smooth. 2. On 10/20/23 at 8:30 AM, a pan of pureed oatmeal was on the steam table. The consistency of the oatmeal was runny. There were lumps in the mixture. At 8:32 AM, the Surveyor asked Dietary Employee (DE) #1 to describe the consistency of the pureed oatmeal served to the residents. She stated, It was a little runny and it has little chunks in it.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets and 21 residents who received mechanical soft diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 10/20/23. The findings are: On 10/18/23, the menu for the supper meal documented the residents on regular diets were to receive 8 ounces (1 cup) of turkey pot pie, residents on mechanical soft diets were to receive two #8 scoops (1 cup) of ground turkey pot pie and residents on pureed diets were to receive two #8 scoops of pureed turkey pot pie. On 10/18/23 at 4:54 PM, Dietary Employee (DE) #2 used a 6 ounce (3/4 cup) spoon to serve turkey pot pie to the residents who received regular diets, instead of one cup of turkey pot pie. At 5:37 PM, the Surveyor asked DE #2 what spoon size she used to serve regular pot pie. She stated, I used a 6 ounce spoon. I should have used an 8 ounce spoon. On 10/18/23 at 5:08 PM, DE #2 used a 6 ounce (3/4 cup) spoon to serve regular turkey potpie with diced turkey to the residents on mechanical soft diets, instead of two #8 (1 cup) of ground turkey pot pie. At 5:36 PM, the Surveyor asked DE #2 the reason residents on mechanical soft diets were served regular turkey potpie that contained diced turkey. DE #2 stated, I thought they were supposed to have regular pot pie. On 10/18/23 at 5:11 PM, DE #2 used a #8 scoop (1/2 cup) to serve a single portion of turkey pot pie to the residents on pureed diets, instead of two #8 scoops (1 cup) of pureed turkey potpie. On 10/19/23 at 11:34 AM, the Surveyor asked DE #1 what scoop size she used to serve pureed turkey pot pie to the residents on pureed diets. She stated, I used a #8 scoop. The Surveyor asked how many servings she gave to each resident. She stated, I gave one serving each.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address the use of opioid medication for 1 (Resident #42) of 29 (Residents #3, #5, #7, #9, #11, #12, #16, #26, #27, #28, #30, #34, #38, #39, #42, #44, #45, #46, #47, #48, #49, #51, #60, #61, #62, #64, #69, #72, and #76) sampled residents who had a physician order for pain medication. The findings are: A Physician's Order dated 08/25/23 noted Resident #42 was to receive Hydrocodone-Acetaminophen 1 tablet by mouth every 4 hours as needed for pain. As of 10/18/23 at 10:33 AM, Resident #42's Care Plan did not address pain management and/or opioid (pain) medication. On 10/19/23 at 9:58 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 if Resident #42 had an order for pain medications. LPN #2 responded, Yes. The Surveyor asked, What is the order for? LPN #2 responded, Hydrocodone-Acetaminophen 7.5/325 milligrams every four hours as needed. The Surveyor asked if Resident #42's care plan addressed the pain medication. LPN #2 responded, It's not in the care plan. The Surveyor asked if pain should be addressed on the care plan. LPN #2 responded, If she is taking it. I believe it should be there. It could be put in there. On 10/19/23 at 10:07 AM, the DON confirmed it was put in the chart on 10/19/2023. The Surveyor asked if pain should be documented on the care plan. The DON responded, Yes. On 10/19/23 at 10:09 AM, the Nurse Consultant stated the facility did not have a policy on care planning.

Based on observation and interview the facility failed to ensure food stored in the refrigerator and freezer was tightly sealed, dishes were properly sanitized by immersion in either hot water (at least 171 F) for 30 seconds; or a chemical sanitizing solution (chlorine: ,d+[DATE] ppm minimum 10 seconds contact time), and the ice machine were maintained in clean sanitary condition to minimize the potential the potential food borne illness for residents who receive meals and ice from the kitchen and food items brought in by visitors were monitored for expiration dates for 1 of 1 resident (Resident #39). The failed practices had the potential to affect 61 residents who receive meals from the kitchen (total census 64:), as documented on a list provided by the dietary manager on [DATE]. The findings are: 1. On [DATE] the following observations were made: a. At 10:33 AM, the ice bin's lid had a sticky brownish debris on the inside and there was an unidentified black substance at the top of the internal shield. Dietary Employee #1 took a white towel and wiped the top of the shield and a pinkish substance appeared on the towel. When she wiped the lid, a black color appeared on the towel. b. At 10:40 AM, there was a 2-door reach in refrigerator near the hand sink with a plastic container of 12 eggs covered with foil with no date. c. At 10:42 AM, at the back of the kitchen there was a white homestyle refrigerator/freezer with a bag of steak cut French fries with no date in the freezer compartment. d. At 10:48 AM, Dietary Employee #2 was asked if this dish machine is a low temperature machine or a high temperature machine. She said, I'm not sure. I just know the dishes are real hot and this water [referring to sprayer hose] is real hot. She was asked, When is the temperatures of the dish machine checked? She said, Temperature of water controls itself. The wash cycle was 120 Fahrenheit (F), and the rinse was 125 Fahrenheit according to the temperature gage on the outside of the machine. 1) At 10:50 AM, review of the posted dish machine's temperature log documented no recorded temperatures or Parts per million documented since [DATE]. 2) At 10:52 AM, Dietary Employee #1 was asked, Who is in charge when the dietary manager is not here. Dietary Employee #1 said, [Dietary Employee #3]. 3) At 10:53 AM, Dietary Employee #3 was asked, Can you explain the procedure or steps taken when washing the dishes? She said, You spray them off, then put them in a rack, and it comes on and washes them. She was asked, When are temperatures taken? She said, At the beginning of each time you go to use it. She was asked, If there was anything else that needed to be done? She said, You take a stick and put it in to check the chemical. It's supposed to be a color on the bottle. Dietary employee #3 took a chlorine test strip and placed it in the water of the machine after the rinse cycle and the strip returned with no color. She was asked, What do you do if this happens? Dietary Employee #3 said, I don't know. I will tell Dietary Manager. Dietary Employee #2 continued to use the dish machine to wash the dishes from the breakfast meal. 4) At 10:55 AM, this Surveyor was unable to determine if there was a sanitizer attached to the machine. 5) At 11:17 AM, the Administrator was asked for the manufacturer's guidelines for the dish machine. While in the Administrator's office the Dietary Manager arrived at the facility. The Dietary Manager was asked if the machine was a high temperature or low temperature machine and the Dietary Manager replied, It's low temp. The Dietary Manager, Administrator, and Surveyor went to the kitchen. The Dietary Manager was asked to show me the sanitizer. The Dietary Manager said, This Ultra dry is the wrong product. I was told that it would work until I got another one. Dietary Manager took a chlorine test strip and tested the water, and nothing appeared on the strip. The Dietary Manager stated, I have some [sanitizer] that came on the truck today. 6) At 12:11 PM, the Dietary Manager approached Surveyor and reported the sanitizer has been attached to the machine. She said, It's Ultra San and the Ecolab rep told me this is the right one. We are currently re-washing everything. Will start with this morning's dishes and move from there. The Dietary Manager was asked how long the dish machine had been without sanitizer and the dietary manager said, It was Friday when it was low. She looked at her phone and said, It was 10:54 Friday morning when I called the rep. I ordered more and it came on truck today that's where I got it. 2. On [DATE] at 1:28 PM, Resident #39 was in bed with lunch on the bedside table and an unopened package of peanut butter crackers with an expiration date of 06JUN22. a. On [DATE] at 2:23 PM, CNA#2 was asked, What is the expiration date on the package of peanut butter crackers? CNA #2 stated, [DATE]th, 2022. CNA #2 was asked, Who provided the peanut butter crackers to [Resident #39]? CNA #2 stated, The family. CNA #2 was asked, Who is responsible for ensuring expired food is not given to the residents? CNA #2 stated, We do. 3. On [DATE] at 2:35 PM, there was a box of frozen sugar cookie dough, and a box of pastry sheets that were not tightly closed in the walk-in freezer. The Dietary Manager was asked how food should be store in the freezer and she said, Tied up and closed. 4. On [DATE] at 2:23 PM, the Dietary Manager stated, We have only one dietary policy [policy provided did not address areas of concerns] and we follow the guidelines for Servsafe Manual. 5. On [DATE] at 8:57 AM, CNA #1 was asked, Why should residents ' snacks not be expired? CNA #1 stated, Because it's not healthy. CNA #1 was asked, Who is responsible for ensuring residents snacks are not expired? CNA #1 stated, The kitchen and the CNA's. 6. On [DATE] at 8:59 AM, CNA #7 was asked, Why should resident's snacks not be expired? CNA #7 stated, Because you can't give expired food to people. CNA #7 was asked, Who is responsible for ensuring residents' snacks are not expired? CNA #7 stated, The kitchen and CNA's. 7. On [DATE] at 9:01 AM, the Dietary Manager (DM) was asked, Why should residents' snacks not be expired. The DM stated, Because it's not healthy, we don't want to make them sick. The DM was asked, Who is responsible for ensuring residents snacks are not expired? The DM stated, The kitchen. The DM was asked, Who receives snacks on 400 Hall? The DM stated, All residents receive some kind of snack all day long. 8. On [DATE] at 9:14 AM, the DON was asked, Why should residents' snacks not be expired? The DON stated, Because they go bad. The DON was asked, Who is responsible for ensuring residents snacks are not expired? The DON stated, Everyone. 9. A policy provided by the Administrator on [DATE] at 3:14 PM documented, .Storage of food and beverages brought by visitors .food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination, and safety .

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize respiratory complications for 1 (Residents #39) of 2 (Residents #39 and #42) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #39 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Modified Significant 5 -day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/22, documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assist of 2 staff for bed mobility, was totally dependent on staff for transfer, and required limited assist of 1 staff for dressing, eating and personal care, and received oxygen therapy. a. The care plan with a revision date of 5/18/22 documented, .has [CONDITION(S)] [[CONDITION(S)]] and other disorders of the lung . Oxygen at 2 liters per nasal cannula . b. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Apply oxygen at 2 liters per minute via nasal cannula prn [as needed] every shift . c. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .change out oxygen tubing and humidifier . every day shift every Friday . d. On 07/11/22 at 12:19 PM, 1:33 PM and on 07/12/22 at 9:42 AM, Resident #39 was in bed receiving oxygen at 3 liters per minute via nasal cannula. e. On 07/12/22 at 9:50 AM, Licensed Practical Nurse (LPN) #2 was asked, What is [Resident #39's] oxygen running at? LPN #2 stated, 3 liters per minute. LPN #2 was asked, What is it supposed to be on? LPN #2 stated, I'd have to look. LPN #2 was asked, Who is responsible for ensuring resident's oxygen is running per the physician orders? LPN #2 stated, The nurse. f. On 07/14/22 at 9:01 AM, Registered Nurse (RN) #1 was asked, Who is responsible for ensuring resident's oxygen is running per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? RN #1 stated, Nurses and respiratory therapist. RN #1 was asked, Why should physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? RN #1 stated, Because that's an order, it's the law, it's part of your license. RN #1 was asked, Why should care plans be followed? RN #1 stated, It's an order, it's part of their plan of care and you have to follow and ensure residents safety. g. On 07/14/22 at 9:46 AM, the Director of Nursing (DON) was asked, Who is responsible for ensuring resident's oxygen is running per physician orders? The DON stated, Nurses. The DON was asked, Why should physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, Because it's the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked, Why should care plans be followed? The DON stated, So you know how to care for the resident because they are resident centered. h. A policy provided by LPN #1 on 713/22 at 12:25 PM documented, .Lippincott Manual of Nursing Practice .10th edition .Administering Oxygen by Nasal Cannula .Very correct patient .make sure the humidifier is filled to the appropriated mark .attach the connecting tube from the nasal cannula to the humidifier outlet .set the flow rate at the prescribed liters per minute .place the tips of the cannula in the patient's nose and adjust straps around ears for snug, comfortable fit .

Based on observation, record review and interview, the facility to ensure a bottle of normal saline was securely stored for 1of 1 (Resident #165) sampled resident who required the use of normal saline. The facility failed to a gait belt was used during a transfer to prevent the potential for injury for 1 (Resident #9) of 4 (Residents #9, #39, #51, and #42) sampled residents who required 2 person assist for transfers. The findings are: 1. Resident #165 had a diagnosis of Alzheimer's, Type 2 Diabetes Mellitus, and a Percutaneous Endoscopic Gastronomy (PEG) tube. The Significant Change 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/22 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS), required extensive assist of 1 staff for dressing, and personal hygiene, and required extensive assist of 2 for transfer, and dressing. a. A physician order with a start date of 5/21/22 documented, .catheter flush . every day and night shift . flush with 30 ml (milliliters) of normal saline . b. On 07/11/22 at 01:33 PM, 02:04 PM, and on 07/12/22 09:43 AM there was an opened, half full bottle of normal saline with a date of 7/5/22 on the resident's nightstand. c. On 07/12/22 at 10:02 AM, Licensed Practical Nurse (LPN) #2 was asked, What is that bottle of normal saline used for? LPN #2 stated, The wound care nurse uses that. LPN #2 was asked, Why should the normal saline not be left out? LPN #2 stated, Because any resident could get it and open it and drink or anything. d. On 07/14/22 at 09:01 AM, Registered Nurse (RN) #1 was asked, What is normal saline used for in the facility? RN#1 stated, For cleaning wounds, and to flush foley catheters. RN#1 was asked, Is normal saline a medication? RN#1 stated, Yes. RN#1 was asked, Do you need a physician order to use normal saline on a resident? RN#1 stated, Yes. RN#1 was asked, Where should normal saline be stored when not in use? RN#1 stated, Stored on a locked cart. RN#1 was asked, Why should normal saline not be left out in the resident's room. RN#1 stated, Because it's a medication. RN#1 was asked, Why could an accident occur if a cognitively impaired resident were to obtain the bottle of normal saline? RN #1 stated, They could drink it. e. On 07/14/22 at 09:46 AM, the Director of Nursing (DON) was asked, What is normal saline used for in the facility? The DON stated, To clean wounds. The DON was asked, Is normal saline a medication? The DON stated, Yes. The DON was asked, Do you need a physician order to use normal saline on a resident? The DON stated, Yes. The DON was asked, Where should normal saline be stored when not in use? The DON stated, In the med [medication] room, treatment cart or somewhere locked up. The DON was asked, Why should normal saline not be left out in the resident's room? The DON stated, Because they might get to it and not need to. The DON was asked, Why could an accident occur if a cognitively impaired resident were to obtain the bottle of normal saline? The DON stated, Because they have impaired cognition and wouldn't understand. f. A policy received on 7/13/22 at 12:57 PM from the DON documented .Pharmaceutical Services . Storage of drugs . All drugs and biologicals are stored in locked compartments under proper temperature controls . Only authorized personnel are permitted to have access to the medication keys . 2. Resident #9 had a diagnosis of Dementia, [CONDITION(S)], and Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/22 documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, required extensive assist of 1 staff for bed mobility, dressing, toilet use, and personal hygiene, and extensive assist of 2 staff for transfers, and for surface-to-surface transfers, not steady, only able to stabilize with staff assistance. a. The care plan with an initiated date of 8/19/21 documented, .The resident has an ADL [activity daily living] self-care performance deficit r/t [related to] confusion, impaired balance, limited ROM (range of motion) . extensive 2 assist with transfers . b. On 07/11/22 at 01:17 PM, Resident # 9 was sitting in a lift chair outside the 400 Hall dining room. Certified Nursing Assistant (CNA) #1 and CNA #2 were assisted the resident from the lift chair to the wheelchair without using a gait belt. CNA #1 raised the lift chair up using the remote control. CNA #1 used her right arm and cupped under R#9's right arm, and CNA #2 grabbed the resident's left arm at the elbow and raised the resident out of the recliner and into the wheelchair. c. On 07/14/22 at 09:01 AM, Registered Nurse (RN) #1 was asked, How do you transfer a resident who is dependent on staff for a 2 person transfer from a recliner to a wheelchair? RN #1 stated, Use a gait belt. RN #1 was asked, Why should gait belts be used when transferring a dependent resident from a recliner to a wheelchair? RN #1 stated, To prevent injury to joints, twisting of the knees or injury. d. On 07/14/22 at 02:47 PM, CNA #3 was asked, How do you transfer a resident who is dependent on staff for a 2-person transfer from a recliner to a wheelchair? CNA #3 stated, We put the gait belt around the resident, get on each side of the resident, stand up the resident, then pivot the resident to sit. CNA #3 was asked, Why should gait belts be used when transferring a dependent resident from a recliner to a wheelchair? CNA #3 stated, Don't want to tug on their arms, it could cause fractures or bruising. e. On 07/14/22 at 03:05 PM, CNA #4 was asked, How do you transfer a resident who is dependent on staff for a 2-person transfer from a recliner to a wheelchair? CNA #4 stated, We use a gait belt. CNA #4 was asked, Why should gait belts be used when transferring a dependent resident from a recliner to a wheelchair?' CNA #4 stated, So they won't get skin tears and you're not supposed to chicken wing them. CNA #4 was asked, What do you mean by chicken wing? CNA #4 stated, When you go up under the resident's arm without a gait belt and lift them up. f. On 07/14/22 at 03:07 PM, CNA #5 was asked, How do you transfer a resident who is dependent on staff for a 2 person transfer from a recliner to a wheelchair? CNA #5 stated, 2 CNA's and a gait belt. CNA #5 was asked, Why should gait belts be used when transferring a dependent resident from a recliner to a wheelchair? CNA #5 stated, It's safer for the residents and staff. CNA #5 was asked, Why shouldn't residents be lifted under the arms when being transferred from a recliner to a wheelchair? CNA #5 stated, It causes skin tears and pulling on them is not safe. g. On 07/14/22 09:46 AM, the Director of Nursing (DON) was asked, How do you transfer a resident who is dependent on staff for a 2-person transfer? The DON stated, Use a gait belt and watch the affected side. The DON was asked, Why should gait belts be used when transferring a dependent resident from a recliner to a wheelchair? The DON stated, For safety. The DON was asked, Why shouldn't a resident be lifted under the arms when being transferred from a recliner to a wheelchair? The DON stated, Because of damage to nerves under the arm, it's not a good safety practice. h. On 07/14/22 at 03:53 PM, the DON stated, We do not have a policy on gait belts or 2 assist transfers, we go by standard of practice for transfers with a gait belt.

Based on observation, interviews and record review, the facility failed to ensure nail care was provided for 2 (Residents #36 and #48) and baths were given for (Resident #36) for 20 (Residents #36, 48, 60, 16, 24, 165, 14, 6, 54, 30, 22, 2, 53, 51, 29, 41, 1, 9, 215 and 42) sampled residents who were dependent on staff for personal hygiene and oral care was provided to promote good personal hygiene for 1 (Resident #165) of 7 (Residents #165, 39, 11, 51, 41, 9 and 42) sampled residents who required oral care. The findings are: 1. Resident #36 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/22 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive physical help with the bathing activity. a. The Care Plan with an initiated date 09/10/2018 of and revised on: 05/31/2022 documented the resident has an ADL (activities of Daily Living) self-care performance deficit due to limited Mobility, deconditioning, scoliosis, chronic low back pain, orthopnea, and hx [history] of T-spine compression fracture with an interventions of PERSONAL HYGIENE: The resident is able to wash face and hands if given wash cloth and needs assist of one staff to complete care. BATHING/SHOWERING: The resident requires total assist of one staff with, showering 3 times a week and has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 07/11/22 at 10:44 AM, Resident #36 in her room. The resident's nails were greater than 1/2 inch in length. She was asked if she wanted her nails trimmed and she stated yes. c. On 07/12/22 at 12:33 PM, the resident stated she had not had a bath since Monday 7/4/22. 2. Resident #48 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 06/01/2022 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status (SAMS), and was totally dependent on staff for bed mobility, transfer, toileting, and bathing activity. a. The Care Plan with an initiated 09/27/2018 documented the resident has an ADL self-care performance deficit r/t (related to) disease process [CONDITION(S)], with a review date of 06/30/2022 documented, . PERSONAL HYGIENE: The resident requires total assistance with personal hygiene. BATHING/SHOWERING PERSONAL HYGIENE: requires assistance of one staff with bathing/showering. b. On 07/12/22 at 12:57 PM, the resident's nails were greater than 1/4 in length with brown debris under nails. The resident's toenails were greater than 1/4 inch in length. 3. On 07/13/22 at 11:40 AM, the Director of Nursing (DON) was asked, Who does nail care? She stated, CNA's [Certified Nursing Assistants]do, and the nurses do the diabetics. a. On 07/14/22 at 11:45 AM, CNA #4 was asked who performed nail care on residents. CNA #4 stated, CNAs don't do diabetics, the nurses or treatment nurse do the diabetics. The CNA was asked when nail care was done and CNA #4 stated, When they need it, usually done on bath days b. On 07/14/22 at 2:56 PM, CNA #3 was asked who was responsible for nail care and he stated, The CNA's do the non-diabetic residents and Nurses do the diabetic residents. He was asked how often nail care was done and he answered, It depends, I personally have to do my nails about every week, so when they need it. He was asked what he does if he notices any substance or debris under nails and he stated, I use these little wooden sticks we have, with an angled end to get it out from under there. 4. Resident #165 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change 5-day MDS with an ARD of 5/23/22 documented the resident was severely impaired in cognitive skills per a SAMS and required extensive assistance of 1 staff for dressing, and personal hygiene, and required extensive assistance of 2 for transfer, and dressing. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .NPO [nothing by mouth] diet .enteral feed consistency . b. The care plan with a revision date of 1/23/22 documented, .has an ADL self-care performance deficit related to fatigue, impaired balance, limited mobility, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .grooming .extensive 1 assist . c. On 07/11/22 at 12:22 PM, 1:33 PM, and 2:02 PM, and on 07/12/22 at 9:43 AM, Resident #165 was in bed. The resident's lips were dry, cracked and flaking. d. On 07/12/22 at 10:02 AM, Licensed Practical Nurse (LPN) #2 was asked, to describe Resident #165's lips. LPN #2 stated, They are dry, crusty and cracked and definitely need oral care. LPN #2 was asked, Who is responsible for the resident's oral care? LPN #2 stated, All of us. e. On 07/14/22 at 9:01 AM, Registered Nurse (RN) #1 was asked, Who is responsible for the resident's oral care? RN #1 stated, The nurse and Certified Nursing Assistants. RN #1 was asked, How do you perform oral care on a resident who has a peg tube? RN 1 stated, Use lemon swabs and pink spongy swabs. RN #1 was asked, What should a resident's lips look like if they are receiving oral care on a regular basis? RN #1 stated, Moisturized, pink, and not cracked. RN #1 was asked, Why shouldn't a resident's lips be cracked, crusty, dry and flaky? RN #1 stated, That could cause wounds or infections, and discomfort. f. On 07/14/22 at 9:46 AM, the Director of Nursing (DON) was asked, Who is responsible for residents' oral care? The DON stated, CNAs and nursing. The DON was asked, How do you perform oral care on a resident who has a peg tube? The DON stated, Lemon [MEDICATION(S)] swabs. The DON was asked, What should a resident's lips look like if they are receiving oral care on a regular basis? The DON stated, Not cracked, but moist with some lip balm. The DON was asked, Why shouldn't resident's lips be cracked, crusty, dry and flaky? The DON stated, Because that's poor oral care hygiene. g. On 07/14/22 at 2:47 PM, CNA #3 was asked, Who is responsible for residents' oral care? CNA #3 stated, CNA's. CNA #3 was asked, How do you perform oral care on a resident who has a peg tube? CNA #3 stated, Use pink sponges with water or mouth rinse, and lemon swabs. CNA #3 was asked, Why shouldn't residents' lips be cracked, crusty, dry, and flaky? CNA #3 stated, Painful and dignity. h. On 07/14/22 at 3:05 PM, CNA #4 was asked, Who is responsible for residents' oral care? CNA #4 stated, Everyone. CNA #4 was asked, How do you perform oral care on a resident who has a peg tube? CNA #4 stated, Pink swabs and Listerine, and lemon [MEDICATION(S)] swabs. CNA #4 was asked, Why shouldn't residents' lips be cracked, crusty, dry, and flaky? CNA #4 stated, They should be moisturized because we have lip balm. i. On 07/14/22 at 3:07 PM, CNA #5 was asked, Who is responsible for residents' oral care. CNA #5 stated, CNA's and nursing. CNA #5 was asked, How do you perform oral care on a resident who has a peg tube? CNA #5 stated, Lemon swabs, pink swabs and Listerine. CNA #5 was asked, Why shouldn't residents' lips be cracked, crusty, dry, and flaky? CNA #5 stated, It probably hurts, and it's dignity. j. On7/15/22 at 7:40 AM, the Administrator stated, We don't have a policy on oral care, we follow standards of practice. 3. On 07/13/22 at 11:40 AM, the Director of Nursing (DON) was asked, Who does nail care? She stated, CNA's do, and the nurses do the diabetics a. On 07/14/22 at 11:45 AM, CNA #4 when asked who performed nail care on residents. The CNA stated, CNAs don't do diabetics, the nurses or treatment nurse do the diabetics. The CNA was asked when nail care was done and the CNA stated, When they need it, usually done on bath days b. On 07/14/22 at 2:56 PM, CNA #3 was asked who was responsible for nail care and he stated, The CNA's do the non-diabetic residents and Nurses do the diabetic residents. He was asked when asked how often nail care was done and he answered, It depends, I personally have to do my nails about every week, so when they need it. He was asked what he does if he notices any substance or debris under nails and he stated, I use these little wooden sticks we have, with an angled end to get it out from under there.

Based on observation, record review, and interview, the facility failed to ensure the privacy curtain was completed pulled around the bed and door to the resident ' s room was closed to provide privacy during incontinent care for 1 (Resident #29) of 11 (Residents #54, 30, 22, 215, 16, 2, 48, 1, 6, 165, 41 and 42) sampled residents who were dependent for incontinent care. The findings are: Resident #29 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2022 documented the resident scored 14 (13-15 cognitively intact) on a Brief Interview for Mental Status, required two-person assist with bed mobility, transfers, and extensive assistance with personal hygiene. a. On 07/11/22 at 11:10 PM, Resident #29 was in bed having his brief changed by physical therapy, without curtain pulled or the door closed b. On 07/12/22 at 11:45 AM, the resident stated he did not like being changed without the privacy curtain pulled all the way and the door closed. c. On 07/13/22 at 8:07 AM, Occupational Therapist #1 was asked about privacy while assisting the resident on 7/12/2022. He stated he should have pulled the curtain. He was asked if he should have pulled the curtain all the way around and he stated, Yes. He was asked about closing the resident ' s room door when providing care and he again stated he should have closed the door. He stated, [Resident #44] comes and goes in and out of the room and that was why I probably didn't close it. I probably should have closed the door during [Resident #29's] care.

Complaint # (AR 976) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure an effective fall prevention program that included adequate supervision and assistance for residents who were at risk for falls was developed and consistently implemented, as evidenced by: failure to ensure planned interventions were consistently implemented to prevent falls to the extent possible and reduce the potential for injury from falls that did occur for 2 (Residents #2 and #4); of 8 (Residents #1 thru #8) case mix residents who were at risk for falls, failure to ensure falls were thoroughly investigated for causative factors and interventions were developed and implemented based on those causative factors to decrease the potential for further falls / injuries for 2 (Residents #2 and #3) of 8 (Residents #1 through #8) case mix residents who were at risk for falls; failure to ensure the necessary precautions were taken after falls until thorough assessments or diagnostic procedures were completed to determine if any serious injury was present and prevent potential exacerbation of any fall-related pain or injuries for 3 (Residents #2, #3, and #4) of 4 (Resident #2, #3, #4, and #7) case mix residents who had sustained fractures; failure to ensure a resident at risk for falls received adequate supervision during a shower to prevent a fall for 1 (Resident #1) of 8 (Residents #1 thru #8) case mix residents who were at risk for falls. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #2, #3, and #4, who experienced falls that resulted in a fractures, and had the potential to cause more than minimal harm to 72 residents who were at risk for falls, as documented on a list provided by the Director of Nursing (DON) on 2/8/18. The Administrator was informed of the Immediate Jeopardy condition on 2/7/18 at 10:00 p.m. The findings are: 1. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/26/17 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance with transfers, did not walk in room, was not steady when moving from seated to standing position, had functional limitation in range of motion to the lower extremity on one side, and had 2 or more falls prior to admission. a. A hospital Emergency Department (ED) Note dated 9/14/17 at 1:29 a.m., prior to the resident's admission to the facility, documented, .History Chief Complaint . Patient presents with Fall .This [AGE] year old male has fallen twice earlier today and presents with complaint of left thigh pain . CT (computed tomography) hip left WO (without) contrast . Final Result 1. There's a mildly displaced [MEDICAL CONDITION] greater trochanteric region with approximately 2 to 3 mm (millimeter) of distraction similar to the plain radiographic findings. 2. There's no [MEDICAL CONDITION] femoral neck. Femoral head remains approximated in the acetabulum as above. 3. Mild [MEDICAL CONDITION] across the load bearing joint . Assessment/Plan After confirmation via CT scan, we consult (Orthopedist) who comes and evaluates (Resident #3) in the ED. After working with case management and (long term care facility) we arrange for (Resident #3) to be sent to (long term care facility) for rehab (rehabilitation) . Final Diagnoses: [REDACTED]. b. A facility Nursing Note dated 9/14/17 at 5:56 p.m. documented, .had fall several days ago, x-ray completed . CT scan completed next day showed Lt (left) superior greater trochanter mild displacement . c. A Fall Risk Evaluation (not dated or signed, but attached to an Unusual Occurrence Report dated 9/19/17) documented, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan . Total Score 11 . d. A Nurse Aide's Information Sheet dated 12/20/17 in the resident's clinical record documented, .Comments: .Eyes on Resident (facility monitoring program) . d. An Unusual Occurrence Report dated 1/22/18 at 3:35 p.m. and signed by the Assistant Director of Nursing (ADON) documented, .Type of Unusual Occurrence: .Found on Floor . Describe exactly what was observed: (Resident) was found on floor in front of closet. Laying (sic) on back (with) arms at bilateral sides, legs straight out in front of body. Skin tear noted to (left) hand (times) 2, one on wrist (and) one on top of hand between pinky (and) 3rd finger. (Resident) stated was trying to get out of wc (wheelchair) (and) into his bed. R's (Resident's) crash mat is down beside bed preventing him to be able to pull wc up to bed . f. The Unusual Occurrence Investigation Report dated 1/22/18 also documented, .1. Date of Investigation: 1/22/18. Time of Unusual Occurrence (3:35) p.m. 3. Is caregiver(s) staff known? Yes. If yes, Name(s) (Certified Nursing Assistant (CNA) #4). 4. Is this a repeat occurrence? Yes . If yes, in the last 30 days? Yes . 7. Summarize factors that contributed to this unusual occurrence: a. Based on the gathered facts, what may have caused the event to occur? (i.e. (such as) if a resident fell , what caused the resident to fall?) R (Resident) tried to transfer self but could not get wc all the way to bedside due to crash mat on floor . c. Who was involved in the event? R only. d. Include any other information that is pertinent to this incident such as patterns or trends. Resident has had many falls, uses knees as mode of transportation. 8. What immediate interventions have you initiated to prevent this event from occurring again? R is not to be left unattended in room while sitting up in wc. WC to be moved out of sight while laying (sic) in bed or sitting up in recliner . A Fall Risk Evaluation form attached to the Unusual Occurrence Report dated 1/22/18 documented, .Total Score 20 . A score of 10 or greater indicates high risk for falls . A Nursing Note dated 1/22/18 at 4:54 p.m. documented, Nursing Note: res (resident) found on floor on his back, arm bilateral with legs stretched out. Skin tear to lt (left) hand, with treatment in place. Fall attributed to crash mat. Crash mat changed, aids (CNAs) changed, aids educated on the need to assist res (resident) into wheelchair and brought to common area while in wheelchair. Res plan of care updated to Res needs . g. The Resident Plan of Care updated 1/22/18 documented, Risk for falls R/T (related to) unsteady gait, weakness, and Hx (history) of falls . Wheelchair out of site (sight) while in bed (and) recliner. Do not leave in room unattended while (up) in wc (wheelchair) . h. An Unusual Occurrence Report dated 1/28/18 at 6:20 p.m. documented, .Type of Unusual Occurrence: Fall/Slip . Location of Unusual Occurrence: Resident Room . Physician Notified? Yes . Date 1/28/18. Time: (6:21 p.m.). Response: x-ray (left) hip . Describe exactly what was observed: Pt (Patient) found sitting on floor by bed. States he was trying to get from his w/c to his recliner. No redness or swelling c/o (complains of) pain to (left) hip 3/10 (severity of 3 on a scale of 1 to 10, with 1 indicating mild pain and 10 indicating severe pain) . X-ray to be done . The Unusual Occurrence Investigation Report also documented, .1. Date of Investigation: 1/28/18. Investigator: (blank). Date of Unusual Occurrence 1/28/18. Time of Unusual Occurrence (6:20 p.m.). 3. Is caregiver(s) staff known? Yes . 4. Is this a repeat occurrence? Yes If yes in the last 30 days? Yes . 5. Contributing Factors: Unsafe position / posture / transfer . 6. Environmental Contributing Factors: check all that apply and any additional factors: (no check marks were documented for any of the available factors on the form) . 7. Summarize factors that contributed to this unusual occurrence: .Based on the gathered facts, what may have caused the event to occur? (the response area for this question was blank) b. What other information is needed before a conclusion can be made? (the response area for this question was blank). c. Who was involved in the event? (blank) d. Include any other information that is pertinent to this incident such as patterns or trends. (blank). 8. What immediate interventions have you initiated to prevent this event from occurring again? Sending R (resident) out for x-ray from radiology, sent straight to ER (emergency room ) d/t (due to) new Fx (fracture). Staff to assist R to room (after) each meal r/t (related to) safety . 9. Conclusion: (check one). Cause unknown (or) Probable Cause known (no check mark was documented next to either option) . Charge Nurse to begin investigation by completing Sections 1-9 at time of Unusual Occurrence . There was no documentation of any further effort to determine the causative factors of this fall and there was no indication that the investigation identified the failure to implement the previously planned intervention to not leave the resident unattended in the wheelchair. A Fall Risk Evaluation form (not dated or signed, but attached to the 1/28/18 Unusual Occurrence Report) documented the resident's fall risk score was 20, which indicated a high risk for falls. A form titled, 10 Questions at the time a Resident Falls was attached to the Unusual Occurrence form dated 1/28/18. This form documented .2. Ask resident: What were you trying to do? Transfer from w/c to recliner . 4. Position of Resident? Sitting on floor with head resting on side of bed . 10. Who was in the area when the resident fell ? CNA . An Office of Long Term Care (OLTC) Witness Statement form dated 1/28/18 at 6:20 p.m. and signed by Certified Nursing Assistant (CNA) #5 documented, State in your own words what you witnessed (be very descriptive) and sign below . Coming out of another resident's room going into another, heard (Resident #3) yell, went to room (Resident #3) was on floor laughing saying he slipped out his wheelchair trying to get in recliner. A Physician's Telephone Order dated 1/28/18 at 6:25 p.m. documented, X-ray (left) hip. A Nursing Note dated 1/28/18 at 7:26 p.m. and signed by Licensed Practical Nurse (LPN) #3 documented, Nursing Note: fall documentation (6:20 p.m.) CNA found patient sitting on floor beside bed states he was trying to get from his wheelchair to the recliner. Complains of pain 3/10 (severity 3 on a scale of 1 to 10) to left hip . (6:21 p.m.) new order received from (Advanced Practice Nurse) to get x-ray l (left) hip . There was no documentation that indicated any efforts to make arrangements for the x-ray to be completed. i. The January 2018 Medication, Treatment and Task Administration Record Report dated documented [MEDICATION NAME]-[MEDICATION NAME] 5-325 was administered to Resident #3 on 1/28/18 and 1/29/18. The Medication, Treatment and Task Administration Record Report did not document a time for administration. The Controlled Narcotic Log page for Resident #3's [MEDICATION NAME]/[MEDICATION NAME] 5/325 documented, Directions give 1 tablet PO (by mouth) . The log documented the following entries: 1/28/18 at 7:20 p.m.: .amount used 1 . (signature of LPN #3) . 1/28/18 at 1:28 a.m.: .amount used 1 . 1/29/18 at 1:27 a.m.: .was administered . Reason: .hip pain . The Medication Administration Record [REDACTED]. j. Nurses Notes dated 1/29/18 at 4:56 a.m. and signed by LPN #4 documented, Resident in bed and very agitated, BP (blood pressure) 185/82 P (pulse) 105. Pain meds (medications) not helping with pain. Still complaining of left hip pain. Temp 99. Will continue to monitor. There was no documentation the x-ray had been completed at this time or that the physician or APN were notified of a delay in obtaining the x-ray. k. Nurses Notes dated 1/29/18 at 9:00 a.m. and signed by the Director of Nursing (DON) documented, Nursing Note: upon assessment, resident is up in w/c, no complaints voiced at this time; order for L (left) hip x-ray, facility van took resident over to (local hospital) at approx. (approximately) 10 a.m. for radiograph, (hospital staff member) x-ray-tech called this nurse and notified of Left [MEDICAL CONDITION], it was discussed that resident had a previous [MEDICAL CONDITION] hip that was non healing, but due to increased pain an order was obtained to send resident to ER (emergency room ) from the radiology dept. (department). This nurse notified (hospital staff member) in ER and gave report of fall and previous hip fx (fracture) . resident being sent for eval (evaluation) in ER . There was no documentation as to why the x-ray had not already been completed; why the resident was transferred out of bed to a wheelchair when no x-ray had been done to rule out a possible fracture; and why the resident was transported in a wheelchair via facility van as opposed to an ambulance, when he had continued to complain of unrelieved hip pain since the fall occurred the previous day. l. Nurses Notes dated 1/29/18 at 4:50 p.m. documented, .Res (resident) sent to hosp. (hospital) for X-Ray for lt (left) hip. X-ray result alert to fractured lt (left) hip. Resident admitted to hosp. m. A hospital Radiology Report dated 1/29/18 documented, admitted /Time 1/29/18 (9:42 a.m.) . Study Result Left Hip Radiographs . Procedure Date/Time: 1/29/18 (9:45 a.m.) . History: .Pain in left hip. Comparison: 10/11/17, CT scan dated 09/14/17 . Findings: Since the evaluations in October and September, there has then (been) interval femoral neck fracture. The femoral shaft shows superior and posterior displacement with impaction. The comminuted cortical [MEDICAL CONDITION] trochanter is again identified. The femoral head remains within the acetabulum. Impression: Interval femoral neck fracture with impaction and superior posterior displacement. The trochanteric cortical fractures are again noted. n. A hospital Emergency Department Record dated 1/29/18 at 10:19 a.m. documented, Patient went to outpatient x-ray for left hip pain after a fall. A fracture to the left hip was noted and patient was checked into the ER for an evaluation . Service: Orthopedics . Chief Complaint: pain left hip . Active Problems: Closed left [MEDICAL CONDITION] . Plan: .endoprosthesis (artificial device placed internally to replace a missing body part) left hip . o. The Hospitalist Consult Note dated 1/30/18 documented, .presented to the ER after a fall at the NH (nursing home). Workup revealed a L (left) [MEDICAL CONDITION] so he was admitted for surgical management. The patient is unable to provide any history. His (family members) are at the bedside. They say that he has been in the NH (Nursing Home) since Sept (September) after multiple falls at home resulted in non-surgical L [MEDICAL CONDITION] . Diagnostic studies L Hip XR (x-ray) . Impression: Interval femoral neck fracture with impaction and superior posterior displacement. The trochanteric cortical fractures are again noted . p. A hospital Operative Note dated 1/30/18 documented, .Service: Orthopedics . Date of Service: 1/30/18 . Date of Operation: 1/30/18 Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure Performed: Removal of broken femoral head and replacement with endoprosthesis . q. The hospital Discharge Summary dated 2/2/18 documented, .Active Hospital Problems [DIAGNOSES REDACTED]. admitting [DIAGNOSES REDACTED]. Discharge Diagnosis: [REDACTED]. Operations and/or Procedures: 1/30/18 Endoprosthesis of L Hip . Hospital course . presented with a closed left [MEDICAL CONDITION]. He was taken to the OR (operating room) for fixation on 1/30. His H/H (hemoglobin and hematocrit) has dropped from presentation but is stable at discharge . r. On 2/7/18 at 9:30 a.m., Licensed Practical Nurse (LPN) #2 was asked if a specific intervention was put in place after the resident fell on [DATE]. The LPN stated, The one before, they put a crash mat and they told the CNAs to walk by every 15 minutes and look in. The LPN was asked who they consisted of and stated, (Assistant Director of Nursing (ADON)). The LPN was asked if that was when the resident was up in the wheelchair and stated, Not necessarily when he was in the wheelchair. s. On 2/7/18 at 12:40 p.m., Certified Nursing Assistant (CNA) #4 was asked to describe what happened when the resident fell on [DATE]. The CNA stated, When I went back in there to change him, I had taken him to the bathroom and changed his clothes, he wasted some water (urinated). The CNA was asked where the resident was located after toileting and stated, By the recliner. The CNA was asked if the resident had been left alone and stated, Yes, I was going to change somebody, and he was trying to get up. Where the other lady's room was, I could see him. He was still in the chair, and I went in and checked him. The CNA was asked if she was the one who found the resident on the floor after he fell and stated, Yes. The CNA was asked if any specific interventions put in place after the resident fell on [DATE] and stated, Still make sure crash mat was down. I don't remember other things. CNA #4 was asked if there had been any in-service on what was to be done to prevent the resident from falling and stated, They told us if nobody was in the room with him, then he needs to come out of the room. The CNA was asked where would you go for information about a resident and stated, My supervisor, the nurse, the care plan. The CNA was asked if the resident could sit up in a wheelchair in the room alone and stated, Recliner or wheelchair, either one basically, he couldn't be alone; he had to come out of the room . t. On 2/7/18 at 12:55 p.m., CNA #6 was asked if she had worked on 1/22/18 and found the resident on the floor. The CNA stated, Yes, I went to empty the trash and he was on the floor. His room is here, and the trash is by his room. He was in front of the wheelchair. The CNA was asked if there were any interventions that were in place to help prevent the resident from falling and stated, We changed the crash mat, and I believe that's when they told us to take the wheelchair out when he's not in the wheelchair, and 15-minute checks on him. The CNA was asked what the 15 minute checks were and stated, Just walk by his room every 15 minutes and make sure he's not trying to get up by his (sic) self. The CNA was asked where she documented the 15-minute checks and stated, Oh, I did not. The CNA was asked if there was a special form or documentation in the kiosk (computer program) and stated, No. The CNA was asked if she could recall any other interventions that were put in place after the 1/22/18 fall. The CNA stated, They did put that he's not to be in his wheelchair in his room by himself. CNA #4 was asked how she knew about new interventions and stated, They tell us individually and put it in the care plan. The CNA was asked if the resident had fallen since that date and stated, Yes, a different shift; I can't remember which. u. On 2/7/18 at 5:10 p.m., the Assistant Director of Nursing (ADON) was shown the 1/22/18 Unusual Occurrence Report, and was asked if she had done the investigation. The ADON stated, I did. The ADON was asked if she had assessed the resident and stated, Yes. The ADON was asked if other staff members were in the resident's room after the resident fell and stated, I was the only one to enter the room at that time, and soon after, (LPN #2), another nurse. The ADON was asked where the resident was when she entered the room and stated, He was sitting right in front of the closet, facing the bed, with his back to the closet. The ADON was asked where the wheelchair was and stated, Between him and the closet. The ADON was asked if the resident had any injury and stated, Yes, skin tears on top of the left hand . was one on the wrist area and to the back of the hand. The ADON was asked if the resident could move his extremities after the 1/22/18 fall and stated, Yes, he could. The ADON was asked where the assessment for range of motion was documented and stated, It's not. The ADON was asked if the fall was investigated and the ADON stated, I had asked them how they found him; (CNA #4) said she had just come out of the room a few minutes prior and was coming back in the room to back get him back to bed. The ADON was asked if the resident was up in the wheelchair at the time of the fall and stated, Yes. At that point, I stated he should not be up in the wheelchair unattended in the room, also for his wheelchair, whether in recliner or bed, the wheelchair should be out of sight, either next to the closet or behind the recliner. We also discussed the 'cookie cutter' care plan, the bed low, call light, and previous interventions of a crash mat was down next to the bed. I felt with the crash mat, he had a very wide crash mat, and that prevented him from rolling his wheelchair to the bed. I did change the crash mat out to the skinny one, just because I felt he could not get to the bed. The ADON was asked to review the Unusual Occurrence Investigation Report dated 1/22/18 and asked what question 8 said after What immediate interventions have you initiated to prevent this event from occurring again? The ADON reviewed the report and stated, Resident is not to be left unattended in room while sitting up in wheelchair. Wheelchair to be moved out of sight while laying (sic) in bed or sitting up in recliner. Resident had a large crash mat this mat was changed to smaller mat. The ADON was asked how this information was communicated to staff and stated, Those 2 CNAs were told, and later after (LPN #2) got out of assessment, the nurse was told. The ADON was asked if any other staff was provided with the intervention instructions and stated, The next nurse oncoming, 4 to 12 (4:00 p.m. to 12:00 a.m. shift), and I had a discussion with, I believe it was (LPN #5). I just told her about the fall, which she was already aware, and the intervention that was in place. The ADON was asked how are new interventions communicated to the staff and stated, In report, I would assume with the other CNAs, and I would hope, the oncoming nurse would have a conversation. The ADON was asked if there had been a formal in-service on the new interventions and stated, I didn't write it out, no, it was all verbal communication. Typically, if I am the one who puts the intervention in place, I have a direct conversation with the direct care staff at the time the intervention is put in place. I also ensure that it's put on the closet care plan and, in the case of (Resident #3), I immediately took the closet care plan and placed it on there. At 5:45 p.m., the ADON left the room to check with the lead CNA to see if there was a closet care plan for 1/22/18. At 5:50 p.m., the ADON returned and stated, There's not one. The ADON was asked if the care plan that was updated on 1/22/18 was available and stated, No. The ADON was asked if she had updated the closet care plan with interventions on 1/22/18 and stated, I pulled the MDS working care plan when he returned. On 1/22, what I had written on there was do not leave resident sitting up in wheelchair unattended. The ADON was asked if the resident was a high risk for falls and stated, Yes. The ADON was asked how staff knew who was at high risk and stated, When we put them on 'Eyes on the Resident' program, the way the aides, all staff, can identify them is by a green band placed on the resident's mode of transportation. A green band on a wheelchair. The ADON was asked what the Eyes on the Resident program was and stated, It's a program we've implemented for falls, and it means that resident should be rounded on every 15 minutes by all nursing staff. The ADON was asked if the staff documented these rounds anywhere and stated, No. The ADON was asked how the facility ensured that the staff did the rounds every 15 minutes and stated, I guess there's no real proof without documentation. The ADON was asked how staff were notified when a resident was initially placed on the Eyes on the Resident program and stated, Staff is in-serviced on each resident when they are placed on the program. The in-service regarding Resident #3's interventions was requested at this time, and the ADON stated, I didn't do a written (in-service). Verbally. The ADON was asked who was in-serviced regarding the Eyes on the Resident program for this resident and stated, At this point, I can't remember which fall it was on, or who was involved in it. I do recall December 10th, there was an in-service for everyone. The ADON was asked if newly hired nursing staff had been in-serviced on the fall interventions since 12/10/17 and stated, Yes, I would hope, during orientation. The ADON was asked if she knew for sure whether new staff had been in-serviced and stated, No. The ADON was referred to the Unusual Occurrence Report dated 1/28/18 and asked who the nurse was at the time of the incident and who had completed the form. The ADON stated, (Licensed Practical Nurse (LPN) #3). The ADON was asked who had completed the investigation for that date, as there was no nurse's signature on the form. The ADON stated, (LPN #3). The ADON was asked how she could tell and stated, I don't know; it's not signed. On 2/7/18 at 10:20 a.m., LPN #3 was asked for an interview and stated she had to leave for a doctors appointment. On 2/8/18 at 9:00 a.m., the DON was asked about LPN #3 and stated that the LPN called in sick for the day. v. On 2/7/18 at 6:40 p.m., LPN #5 was asked if there was an intervention added for the resident not to be left unattended when up in the wheelchair, after the fall on 1/22/18. The LPN stated, Yes, and wheelchair out of sight. LPN #5 was asked how she knew about this intervention and stated, From a previous fall. w. On 2/7/18 at 6:52 p.m., the Director of Nursing (DON) was asked how falls were investigated and stated, Reviewing the I & A (Incident and Accident) and the intervention, the care plan, and ensuring the intervention was in place. The DON was referred to the 1/22/18 report and asked what occurred and stated, On 1/22, the intervention was that the resident was not to be left unattended, the wheelchair was out of sight while lying in bed and his large crash mat was changed out to a smaller one. The DON was asked if the care plan had been updated at that time and stated, We updated the closet care plan, so when new caregiver came in they would know, and in Caretracker (electronic documentation system). The DON was asked if the resident was alone in the room on 1/28/18 when he fell and fractured his hip. The DON stated, He was. The DON was asked if the resident was up in the wheelchair prior to the fall and stated, It states he was. He was trying to transfer from his wheelchair to his recliner. The DON was asked if the facility's investigation of the incident had identified that the resident was left alone / unattended in the wheelchair. The DON gave no response. The DON was asked if this was reviewed and stated, I did not, no. The DON was asked if there had been an investigation after a fall to determine the cause of the fall. The DON gave no response. The DON was asked why the resident was alone at the time of the fall and stated, The CNA was in another resident's room at the time. The DON was asked if she had asked the CNA about the fall and stated, I did not. The DON was asked if staff should have been with the resident while he was up in the wheelchair. The DON gave no response initially, then stated, I would imagine he propelled himself back to his room. The Director of Nursing (DON) was asked if the hip x-ray that was ordered on [DATE] was obtained that day, as documented on the Unusual Occurrence Report. The DON stated, No, it was obtained the next morning. The DON was asked why the x-ray was not obtained the day it was ordered and stated, Because the (mobile x-ray provider) was not able to come out that night. We called them, and they couldn't come. The DON left the room and returned at 7:42 p.m. and stated, (Mobile x-ray provider) is sending their confirmation receipt of when we requested the x-ray on the 28th. When I came in that following morning (1/29/18), I was informed by one of my staff members (mobile x-ray provider) was going to be late. I just remembered, as soon as we realized they were running late, I called the hospital to see when we could get him in. The DON was asked if the APN or physician had been notified that the x-ray ordered on [DATE] had not yet been done as of the morning of 1/29/18 and stated, I did call her (APN). The DON was asked where that was documented and stated, It's not documented. The DON was asked how the resident was transported to the hospital and stated, By facility van. The DON was asked if the resident had been transported in the van, seated in the wheelchair and stated, Yes. The DON was asked why the resident was sent by the van and not secured in an ambulance, since the x-ray had not yet been done to rule out fracture, and stated, He was already up in his wheelchair, and I assessed him to make sure he was comfortable. The DON was asked who had gotten the resident up into the wheelchair on the morning of the 29th and stated, I do not know. The DON was asked, after having found that the resident had fallen and was up in the wheelchair on the morning of the 29th, should that have been investigated? The DON stated, When I came in, he was up, and I assessed and he was okay. The DON was asked if she had asked who had gotten the resident up to the wheelchair after the resident had fallen and complained of hip pain during the night and stated, I did not. He was up. He seemed okay. The DON was asked if the resident should have been moved or transferred out of bed into a wheelchair after having a fall, followed by complaint of hip pain, when no x-ray had been completed to rule out fracture. The DON stated, They are not to be moved until the nurse assesses them. x. On 2/7/18 at 7:12 p.m., the CNA Supervisor provided the Profile History Report dated from 11/17/2017 through 2/2/18 for this resident. The CNA Supervisor identified this report as, Care-tracker. The report documented, .11/17/2017 - 2/2/2018 .Do Not Leave Unattended in Room While in Wheelchair . y. On 2/7/18 at 7:24 p.m., CNA #7 was asked if she had worked on 1/28/18 when the resident fell and stated, Yes, it was me and another lady (CNA #5). The CNA was asked if there were any special instructions and stated, I don't think there were any special instructions, but he had rounds every 15 minutes, and he had a crash mat. On the care plan of the care tracker, the only thing I know of, he has the eyes on resident and make rounds. The CNA was asked what the fall prevention interventions were for the resident and stated, Crash mat and have his bed in low position. The CNA was asked if the resident was up in his wheelchair or recliner at the time of the fall. CNA #7 stated, I know for sure he was in his recliner. The CNA was asked how do you know when there are fall interventions added for a resident and stated, We come 15 minutes early and they give us a report. 2. Resident #4 had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) Summary Report dated 2/16/17 documented, Falls; Risk for falls R/T (related to) balance impairment / use of [MEDICAL CONDITION] medications / impaired safety awareness. Staff to assist resident as needed with transfers and AD (TRUNCATED)

Complaint # (AR 976) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure necessary care and services, including assessments, monitoring and pain management measures, were provided after falls for Resident #3, as evidenced by: failure to ensure thorough post-fall assessments, including presence or absence of pain with range of motion, were conducted and documented; failure to ensure hip pain that was of increased severity after a fall was promptly evaluated to determine if a serious fall-related injury had occurred; failure to ensure the increased severity of the resident's pain was immediately communicated to the physician and/or Advance Practice Nurse (APN) after a fall that resulted in increased pain; failure to ensure oncoming shifts took necessary precautions to prevent potential exacerbation of any existing injury and provided ongoing monitoring, assessments and efforts to address the resident's condition; failure to ensure the physician or APN was immediately informed when there was a delay in obtaining x-rays as ordered, which resulted in a delay in [DIAGNOSES REDACTED].#3) of 4 (Residents #2, #3, #4 and #7) case mix residents who had a history of [REDACTED]. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #3, who experienced a fall that resulted in a fracture, which was not diagnosed and treated for [REDACTED]. The Administrator was informed of the Immediate Jeopardy condition on 2/7/18 at 10:00 p.m. The findings are: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/26/17 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance with transfers, did not walk in room, was not steady when moving from seated to a standing position, had functional limitation in range of motion to the lower extremity on one side, and had 2 or more falls prior to admission. a. A hospital Emergency Department (ED) Note dated 9/14/17 at 1:29 a.m., prior to the resident's admission to the facility, documented, .History Chief Complaint . Patient presents with Fall .This [AGE] year old male has fallen twice earlier today and presents with complaint of left thigh pain . CT (computed tomography) hip left WO (without) contrast . Final Result 1. There's a mildly displaced [MEDICAL CONDITION] greater trochanteric region with approximately 2 to 3 mm (millimeter) of distraction similar to the plain radiographic findings. 2. There's no [MEDICAL CONDITION] femoral neck. Femoral head remains approximated in the acetabulum as above. 3. Mild [MEDICAL CONDITION] across the load bearing joint . Assessment/Plan After confirmation via CT scan, we consult (Orthopedist) who comes and evaluates (Resident #3) in the ED. After working with case management and (long term care facility) we arrange for (Resident #3) to be sent to (long term care facility) for rehab (rehabilitation) . Final Diagnoses: [REDACTED]. b. A facility Nursing Note dated 9/14/17 at 5:56 p.m. documented, .had fall several days ago, x-ray completed . CT scan completed next day showed Lt (left) superior greater trochanter mild displacement . c. An Unusual Occurrence Report dated 1/22/18 at 3:35 p.m. and signed written by the Assistant Director of Nursing (ADON) documented, .Type of Unusual Occurrence: .Found on Floor . Describe exactly what was observed: (Resident) was found on floor in front of closet. Laying (sic) on back (with) arms at bilateral sides, legs straight out in front of body. Skin tear noted to (left) hand (times) 2, one on wrist (and) one on top of hand between pinky (and) 3rd finger. (Resident) stated was trying to get out of wc (wheelchair) (and) into his bed. R's (Resident's) crash mat is down beside bed preventing him to be able to pull wc up to bed . The Unusual Occurrence Investigation Report dated 1/22/18 also documented, .1. Date of Investigation: 1/22/18. Time of Unusual Occurrence (3:35) p.m. 3. Is caregiver(s) staff known? Yes If yes, Name(s) (Certified Nursing Assistant (CNA) #4). 4. Is this a repeat occurrence? Yes . If yes, in the last 30 days? Yes . 8. What immediate interventions have you initiated to prevent this event from occurring again? R is not to be left unattended in room while sitting up in wc. WC to be moved out of sight while laying (sic) in bed or sitting up in recliner . There was no documentation of an assessment of the resident's range of motion after this fall and no reference as to whether the resident had any complaint of pain after this fall. A form titled, 10 Questions at the time a Resident Falls attached to the Unusual Occurrence form dated 1/22/18 documented, .10. Who was in the area when the resident fell ? No one . A Nursing Note dated 1/22/18 at 4:54 p.m. documented, Nursing Note: res (resident) found on floor on his back, arm bilateral with legs stretched out. Skin tear to lt (left) hand, with treatment in place. Fall attributed to crash mat. Crash mat changed, aids (CNAs) changed, aids educated on the need to assist res (resident) into wheelchair and brought to common area while in wheelchair. Res plan of care updated to Res needs . There was no documentation the resident's range of motion was checked, as part of his post-fall assessment. d. The Resident Plan of Care updated 1/22/18 documented, Risk for falls R/T (related to) unsteady gait, weakness, and Hx (history) of falls . Wheelchair out of site (sight) while in bed (and) recliner. Do not leave in room unattended while (up) in wc (wheelchair) . e. An Unusual Occurrence Report dated 1/28/18 at 6:20 p.m. documented, .Type of Unusual Occurrence: Fall/Slip . Location of Unusual Occurrence: Resident Room . Physician Notified? Yes . Date 1/28/18. Time: (6:21 p.m.). Response: x-ray (left) hip . Describe exactly what was observed: Pt (Patient) found sitting on floor by bed. States he was trying to get from his w/c to his recliner. No redness or swelling c/o (complains of) pain to (left) hip 3/10 (severity of 3 on a scale of 1 to 10, with 1 indicating mild pain and 10 indicating severe pain) . X-ray to be done . The Unusual Occurrence Investigation Report also documented, .1. Date of Investigation: 1/28/18. Investigator: (blank). Date of Unusual Occurrence 1/28/18. Time of Unusual Occurrence (6:20 p.m.). 3. Is caregiver(s) staff known? Yes . 4. Is this a repeat occurrence? Yes If yes in the last 30 days? Yes Who was involved in the event? (blank) d. Include any other information that is pertinent to this incident such as patterns or trends. (blank). 8. What immediate interventions have you initiated to prevent this event from occurring again? Sending R (resident) out for x-ray from radiology, sent straight to ER (emergency room ) d/t (due to) new Fx (fracture). Staff to assist R to room (after) each meal r/t safety . An Office of Long Term Care (OLTC) Witness Statement form dated 1/28/18 at 6:20 p.m. and signed by Certified Nursing Assistant (CNA) #5 documented, State in your own words what you witnessed (be very descriptive) and sign below . Coming out of another resident's room going into another, heard (Resident #3) yell, went to room (Resident #3) was on floor laughing saying he slipped out his wheelchair trying to get in recliner. A Physician's Telephone Order dated 1/28/18 at 6:25 p.m. documented, X-ray (left) hip. A Nursing Note dated 1/28/18 at 7:26 p.m. and signed by Licensed Practical Nurse (LPN) #3 documented, Nursing Note: fall documentation (6:20 p.m.) CNA found patient sitting on floor beside bed states he was trying to get from his wheelchair to the recliner. Complains of pain 3/10 (severity 3 on a scale of 1 to 10) to left hip . (6:21 p.m.) new order received from (Advanced Practice Nurse) to get x-ray l (left) hip . There was no documentation that indicated any efforts to make arrangements for the x-ray to be completed and no documentation of an assessment to determine if the resident's hip pain was worse when range of motion was attempted. f. The January 2018 Medication, Treatment and Task Administration Record Report dated documented [MEDICATION NAME]-[MEDICATION NAME] 5-325 was administered to Resident #3 on 1/28/18 and 1/29/18. The Medication, Treatment and Task Administration Record Report did not document a time for administration. The Controlled Narcotic Log page for Resident #3's [MEDICATION NAME]/[MEDICATION NAME] 5/325 documented, Directions give 1 tablet PO (by mouth) . The log documented the following entries: 1/28/18 at 7:20 p.m.: .amount used 1 . (signature of LPN #3) . 1/28/18 at 1:28 a.m.: .amount used 1 . 1/29/18 at 1:27 a.m.: .was administered . Reason: .hip pain . The Medication Administration Record [REDACTED]. Nurses Notes dated 1/29/18 at 4:56 a.m. and signed by LPN #4 documented, Resident in bed and very agitated, BP (blood pressure) 185/82 P (pulse) 105. Pain meds (medications) not helping with pain. Still complaining of left hip pain. Temp 99. Will continue to monitor. There was no documentation the physician or APN were notified of the continued hip pain that was unrelieved by pain medication. g. Nurses Notes dated 1/29/18 at 9:00 a.m. and signed by the Director of Nursing (DON) documented, Nursing Note: upon assessment, resident is up in w/c, no complaints voiced at this time; order for L (left) hip x-ray, facility van took resident over to (local hospital) at approx. (approximately) 10 a.m. for radiograph, (hospital staff member) x-ray-tech called this nurse and notified of Left [MEDICAL CONDITION], it was discussed that resident had a previous [MEDICAL CONDITION] hip that was non healing, but due to increased pain an order was obtained to send resident to ER (emergency room ) from the radiology dept. (department). This nurse notified (hospital staff member) in ER and gave report of fall and previous hip fx (fracture) . resident being sent for eval (evaluation) in ER . There was no documentation as to why the x-ray had not already been completed; why the resident was transferred out of bed to a wheelchair when no x-ray had been done to rule out a possible fracture; and why the resident was transported in a wheelchair via facility van as opposed to an ambulance, when he had continued to complain of unrelieved hip pain since the fall occurred the previous day. h. Nurses Notes dated 1/29/18 at 4:50 p.m. documented, .Res (resident) sent to hosp. (hospital) for X-Ray for lt (left) hip. X-ray result alert to fractured lt (left) hip. Resident admitted to hosp. i. A hospital Radiology Report dated 1/29/18 documented, admitted /Time 1/29/18 (9:42 a.m.) . Study Result Left Hip Radiographs . Procedure Date/Time: 1/29/18 (9:45 a.m.) . History: .Pain in left hip. Comparison: 10/11/17, CT scan dated 09/14/17 . Findings: Since the evaluations in October and September, there has then (been) interval femoral neck fracture. The femoral shaft shows superior and posterior displacement with impaction. The comminuted cortical [MEDICAL CONDITION] trochanter is again identified. The femoral head remains within the acetabulum. Impression: Interval femoral neck fracture with impaction and superior posterior displacement. The trochanteric cortical fractures are again noted. j. A hospital Emergency Department Record dated 1/29/18 at 10:19 a.m. documented, Patient went to outpatient x-ray for left hip pain after a fall. A fracture to the left hip was noted and patient was checked into the ER for an evaluation . Service: Orthopedics . Chief Complaint: pain left hip . Active Problems: Closed left [MEDICAL CONDITION] . Plan: .endoprosthesis (artificial device placed internally to replace a missing body part) left hip . k. The Hospitalist Consult Note dated 1/30/18 documented, .presented to the ER after a fall at the NH (nursing home). Workup revealed a L (left) [MEDICAL CONDITION] so he was admitted for surgical management. The patient is unable to provide any history. His (family members) are at the bedside. They say that he has been in the NH (Nursing Home) since Sept (September) after multiple falls at home resulted in non-surgical L [MEDICAL CONDITION] . Diagnostic studies L Hip XR (x-ray) . Impression: Interval femoral neck fracture with impaction and superior posterior displacement. The trochanteric cortical fractures are again noted . l. A hospital Operative Note dated 1/30/18 documented, .Service: Orthopedics . Date of Service: 1/30/18 . Date of Operation: 1/30/18 Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure Performed: Removal of broken femoral head and replacement with endoprosthesis . m. The hospital Discharge Summary dated 2/2/18 documented, .Active Hospital Problems [DIAGNOSES REDACTED]. admitting [DIAGNOSES REDACTED]. Discharge Diagnosis: [REDACTED]. Operations and/or Procedures: 1/30/18 Endoprosthesis of L Hip . Hospital course . presented with a closed left [MEDICAL CONDITION]. He was taken to the OR (operating room) for fixation on 1/30. His H/H (hemoglobin and hematocrit) has dropped from presentation but is stable at discharge . n. On 2/7/18 at 5:10 p.m., the Assistant Director of Nursing (ADON) was shown the 1/22/18 incident report, and was asked if she had done the investigation. The ADON stated, I did. The ADON was asked if she had assessed the resident and stated, Yes. The ADON was asked if the resident could move his extremities after the 1/22/18 fall and stated, Yes, he could. The ADON was asked where the assessment for range of motion was documented and stated, It's not. The ADON was referred to the incident report dated 1/28/18 and asked who the nurse was at the time of the incident and who had completed the form and stated, (Licensed Practical Nurse (LPN) #3). On 2/7/18 at 10:20 a.m., LPN #3 was asked for an interview and stated she had to leave for a doctor's appointment. On 2/8/18 at 9:00 a.m., the DON was asked about LPN #3 and stated that the LPN called in sick for the day. o. On 2/7/18 at 6:52 p.m., the Director of Nursing (DON) was asked if the hip x-ray that was ordered on [DATE] was obtained that day, as documented on the Unusual Occurrence Report. The DON stated, No, it was obtained the next morning. The DON was asked why the x-ray was not obtained the day it was ordered and stated, Because the (mobile x-ray provider) was not able to come out that night. We called them, and they couldn't come. The DON left the room and returned at 7:42 p.m. and stated, (Mobile x-ray provider) is sending their confirmation receipt of when we requested the x-ray on the 28th. When I came in that following morning (1/29/18), I was informed by one of my staff members (mobile x-ray provider) was going to be late. I just remembered, as soon as we realized they were running late, I called the hospital to see when we could get him in. The DON was asked if the APN or physician had been notified that the x-ray ordered on [DATE] had not yet been done as of the morning of 1/29/18 and the DON stated, I did call her (APN). The DON was asked where that was documented and stated, It's not documented. The DON was asked how the resident was transported to the hospital and stated, By facility van. The DON was asked if the resident had been transported in the van, seated in the wheelchair and stated, Yes. The DON was asked why the resident was sent by the van and not secured in an ambulance, since the x-ray had not yet been done to rule out fracture, and stated, He was already up in his wheelchair, and I assessed him to make sure he was comfortable. The DON was asked who had gotten the resident up into the wheelchair on the morning of the 29th and stated, I do not know. The DON was asked, after having found that the resident had fallen and was up in the wheelchair on the morning of the 29th, should that have been investigated? The DON stated, When I came in, he was up, and I assessed and he was okay. The DON was asked if she had asked who had gotten the resident up to the wheelchair after the resident had fallen and complained of hip pain during the night and stated, I did not. He was up. He seemed okay. The DON was asked if the resident should have been moved or transferred out of bed into a wheelchair after having a fall, followed by complaint of hip pain, when no x-ray had been completed to rule out fracture. The DON stated, They are not to be moved until the nurse assesses them. p. The immediate jeopardy was removed, and the scope/severity reduced to H on 2/8/17 at 12:05 p.m., when the facility implemented the following Plan of Removal: 1.) All staff was in-serviced beginning on 2/7/18 at 2230 (10:30 p.m.) on the following: No staff may work the floor until they have received the following in-service. Staff will be in-serviced prior to beginning their shift, prior to returning from a Leave of Absence. Assessment of the resident following a fall, notification to MD (Medical Doctor)/APN of change in condition or pain following a fall, assessment and reassessment of pain by nonverbal or verbal (see pain pocket card, a pain assessment tool that includes the Wong-Baker faces, and indicators of pain other than verbal), immediate notification to APN/MD if EMS (Emergency Medical Services) or x-ray is delayed, Interventions for falls must be monitored, communicated to staff, and re-evaluated for effectiveness; interventions to be placed in electronic medication administration software (IMAR) for monitoring by floor nurse. 2.) Audit on 100% of residents to identify residents at risk for falls or have had a fall with fracture in last 3 months was completed 2/8/2018 per DON / ADON / designee. One discrepancy was found and the APN was notified and gave orders for a STAT (immediate) radiograph. 3.) DON/Designee will ensure interventions for falls are communicated to staff and are in place and effective. The interventions will be re-evaluated by floor nurses every 2 hours and documented in IMAR. If any intervention is deemed ineffective, a new intervention will be implemented and evaluated by the DON/designee. 4.) DON/designee will be notified immediately following a fall to provide guidance and ensure proper interventions are in place and interventions are directly related to causative factors. 5.) MD/APN will be notified via phone by direct care nurse / DON / designee immediately of any fall or change of condition / pain related to post fall if delay in x-ray or EMS transport occurs. The notification will be documented in the nurse's note. 6.) Upon assessment following a fall, if resident has indication of pain, they will be transported via EMS. Incidents will be reviewed daily by the DON / designee in fall risk meeting to determine compliance. 7.) The fall risk meeting will be conducted daily to review documentation and causative factors to determine root cause of falls to further evaluate proper intervention is in place. 8.) Pain Pocket Card placed on each nurse's medicine cart, treatment cart, and Medicare computer on wheels to be used as reference for verbal and non-verbal pain assessment per direct care nurse / designee. DON / designee will monitor pain documentation daily per electronic healthcare record for compliance. 9.) Non-weight bearing status will be maintained with all residents with falls until assessment is completed and determination made that resident is without resident (sic) or pain per direct care nurse / designee. 10.) The DON / designee will monitor the floor nurse's documentation of all residents with falls with orders for radiology exam orders post fall to ensure no delay of obtaining radiology exams. The monitoring will occur daily for 2 weeks, then 3 X (times) weekly thereafter. Any discrepancies will be corrected immediately and will be reported by the designee to the DON and DON / designee will report to the Administrator. 11.) The DON / designee will monitor all residents post falls to ensure appropriate assessment monitoring and interventions are being implemented. The monitoring will occur daily for 2 weeks, then 3 X weekly thereafter. Any discrepancies will be corrected immediately and will be reported by the designee to the DON and DON / designee will report to the Administrator. 12.) The DON / designee will monitor all residents post fall requiring transport to hospital and the route in which they were transported. The monitoring will occur daily for 2 weeks, then 3 X weekly thereafter. Any discrepancies will be corrected immediately and will be reported by the designee to the DON and DON / designee will report to the Administrator. 13.) The DON / designee will monitor all residents post fall for change of condition, new complaints of pain, and ensure proper positioning / bedrest prior to treatment, if treatment is indicated. The monitoring will occur daily for 2 weeks, then 3 x weekly thereafter. Any discrepancies will be corrected immediately and will be reported by the designee to the DON and DON / designee will report to the Administrator.

Complaint # (AR 976) Substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility's Nursing Administration failed to ensure the lack of an effective, consistently implemented fall prevention program was identified and addressed, to ensure adequate supervision and assistance for residents who were at risk for falls, as evidenced by: failure to ensure planned interventions were consistently implemented to prevent falls to the extent possible and reduce the potential for injury from falls that did occur for 2 (Residents #2 and #4); of 8 (Residents #1 thru #8) case mix residents who were at risk for falls, failure to ensure falls were thoroughly investigated for causative factors and interventions were developed and implemented based on those causative factors to decrease the potential for further falls / injuries for 2 (Residents #2 and #3) of 8 (Residents #1 through #8) case mix residents who were at risk for falls; failure to ensure the necessary precautions were taken after falls until thorough assessments or diagnostic procedures were completed to determine if any serious injury was present and prevent potential exacerbation of any fall-related pain or injuries for 3 (Residents #2, #3, and #4) of 4 (Resident #2, #3, #4, and #7) case mix residents who had sustained fractures; failure to ensure a resident at risk for falls received adequate supervision during a shower to prevent a fall for 1 (Resident #1) of 8 (Residents #1 thru #8) case mix residents who were at risk for falls. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents #2, #3, and #4, who experienced falls that resulted in a fractures, and had the potential to cause more than minimal harm to 72 residents who were at risk for falls, as documented on a list provided by the Director of Nursing (DON) on 2/8/18. The Administrator was informed of the Immediate Jeopardy condition on 2/7/18 at 10:00 p.m. The findings are: 1. The facility's Job Description for the DON, provided by the Assistant Director of Nursing (ADON) on 2/8/18, documented, 1. Day to day supervision of Nursing Staff, full round of each hall, make prior to stand up QA (Quality Assurance) meeting. Report then made and or reviewed and calls to MD (Medical Doctor) and APN (Advanced Practice Nurse) if needed. 2. Discipline issues and education related to all Nursing Staff . 6. LPN (Licensed Practical Nurse) and RN (Registered Nurse) in-service and education the last Thursday of every month. 7. General in-services quarterly - usually discuss Quality Measures with staff and educate in an interactive format unless a specific topic(s) needs addressed . 11. Attend all Care Plan meetings (each Thursday) and implement changes needed to plan of care . 14. Policy and Procedure review and updates . 20. Oversee Admissions, review referrals and meet with team to discuss (educate staff if resident has special needs) . 22 Oversee and review I and As (Incidents and Accidents), MDSs (Minimum Data Sets) and Care Plans . QAPI (Quality Assurance and Performance Improvement) . 2. The facility's Floor Nurse Job Description (Charge Nurse), provided by the ADON on 2/7/18, documented, .2. Charge - The Floor Nurse is responsible for immediate supervision of the Nursing Assistant. The Floor Nurse should oversee the care of residents . ensure that proper care is being given by the Nursing Assistant. This includes staffing assignments as needed. 3. Assessment - The Floor Nurse is held accountable for overall care and well-being of the Resident during the Nurse's shift. They must document their assessment on each resident in the Nurses Notes. The Floor Nurse is responsible for notifying families and Physicians for any change of conditions . 9. Documentation: The Floor Nurse is responsible for required documentation for the residents in their assigned area . 3. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/26/17 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS), required limited assistance with transfers, did not walk in room, was not steady when moving from seated to standing position, had functional limitation in range of motion to the lower extremity on one side, and had 2 or more falls prior to admission. a. A hospital Emergency Department (ED) Note dated 9/14/17 at 1:29 a.m., prior to the resident's admission to the facility, documented, .History Chief Complaint . Patient presents with Fall .This [AGE] year old male has fallen twice earlier today and presents with complaint of left thigh pain . CT (computed tomography) hip left WO (without) contrast . Final Result 1. There's a mildly displaced [MEDICAL CONDITION] greater trochanteric region with approximately 2 to 3 mm (millimeter) of distraction similar to the plain radiographic findings. 2. There's no [MEDICAL CONDITION] femoral neck. Femoral head remains approximated in the acetabulum as above. 3. Mild [MEDICAL CONDITION] across the load bearing joint . Assessment/Plan After confirmation via CT scan, we consult (Orthopedist) who comes and evaluates (Resident #3) in the ED. After working with case management and (long term care facility) we arrange for (Resident #3) to be sent to (long term care facility) for rehab (rehabilitation) . Final Diagnoses: [REDACTED]. b. A facility Nursing Note dated 9/14/17 at 5:56 p.m. documented, .had fall several days ago, x-ray completed . CT scan completed next day showed Lt (left) superior greater trochanter mild displacement . c. A Fall Risk Evaluation (not dated or signed, but attached to an Unusual Occurrence Report dated 9/19/17) documented, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan . Total Score 11 . d. A Nurse Aide's Information Sheet dated 12/20/17 in the resident's clinical record documented, .Comments: .Eyes on Resident (facility monitoring program) . e. An Unusual Occurrence Report dated 1/22/18 at 3:35 p.m. and signed written by the Assistant Director of Nursing (ADON) documented, .Type of Unusual Occurrence: .Found on Floor . Describe exactly what was observed: (Resident) was found on floor in front of closet. Laying (sic) on back (with) arms at bilateral sides, legs straight out in front of body. Skin tear noted to (left) hand (times) 2, one on wrist (and) one on top of hand between pinky (and) 3rd finger. (Resident) stated was trying to get out of wc (wheelchair) (and) into his bed. R's (Resident's) crash mat is down beside bed preventing him to be able to pull wc up to bed . f. The Unusual Occurrence Investigation Report dated 1/22/18 also documented, .1. Date of Investigation: 1/22/18. Time of Unusual Occurrence (3:35) p.m. 3. Is caregiver(s) staff known? Yes. If yes, Name(s) (Certified Nursing Assistant (CNA) #4). 4. Is this a repeat occurrence? Yes . If yes, in the last 30 days? Yes . 7. Summarize factors that contributed to this unusual occurrence: a. Based on the gathered facts, what may have caused the event to occur? (i.e. (such as) if a resident fell , what caused the resident to fall?) R (Resident) tried to transfer self but could not get wc all the way to bedside due to crash mat on floor . c. Who was involved in the event? R only. d. Include any other information that is pertinent to this incident such as patterns or trends. Resident has had many falls, uses knees as mode of transportation. 8. What immediate interventions have you initiated to prevent this event from occurring again? R is not to be left unattended in room while sitting up in wc. WC to be moved out of sight while laying (sic) in bed or sitting up in recliner . A Fall Risk Evaluation form attached to the Unusual Occurrence Report dated 1/22/18 documented, .Total Score 20 . A score of 10 or greater indicates high risk for falls . A Nursing Note dated 1/22/18 at 4:54 p.m. documented, Nursing Note: res (resident) found on floor on his back, arm bilateral with legs stretched out. Skin tear to lt (left) hand, with treatment in place. Fall attributed to crash mat. Crash mat changed, aids (CNAs) changed, aids educated on the need to assist res (resident) into wheelchair and brought to common area while in wheelchair. Res plan of care updated to Res needs . g. The Resident Plan of Care updated 1/22/18 documented, Risk for falls R/T (related to) unsteady gait, weakness, and Hx (history) of falls . Wheelchair out of site (sight) while in bed (and) recliner. Do not leave in room unattended while (up) in wc (wheelchair) . h. An Unusual Occurrence Report dated 1/28/18 at 6:20 p.m. documented, .Type of Unusual Occurrence: Fall/Slip . Location of Unusual Occurrence: Resident Room . Physician Notified? Yes . Date 1/28/18. Time: (6:21 p.m.). Response: x-ray (left) hip . Describe exactly what was observed: Pt (Patient) found sitting on floor by bed. States he was trying to get from his w/c to his recliner. No redness or swelling c/o (complains of) pain to (left) hip 3/10 (severity of 3 on a scale of 1 to 10, with 1 indicating mild pain and 10 indicating severe pain) . X-ray to be done . The Unusual Occurrence Investigation Report also documented, .1. Date of Investigation: 1/28/18. Investigator: (blank). Date of Unusual Occurrence 1/28/18. Time of Unusual Occurrence (6:20 p.m.). 3. Is caregiver(s) staff known? Yes . 4. Is this a repeat occurrence? Yes If yes in the last 30 days? Yes . 5. Contributing Factors: Unsafe position / posture / transfer . 6. Environmental Contributing Factors: check all that apply and any additional factors: (no check marks were documented for any of the available factors on the form) . 7. Summarize factors that contributed to this unusual occurrence: .Based on the gathered facts, what may have caused the event to occur? (the response area for this question was blank) b. What other information is needed before a conclusion can be made? (the response area for this question was blank). c. Who was involved in the event? (blank) d. Include any other information that is pertinent to this incident such as patterns or trends. (blank). 8. What immediate interventions have you initiated to prevent this event from occurring again? Sending R (resident) out for x-ray from radiology, sent straight to ER (emergency room ) d/t (due to) new Fx (fracture). Staff to assist R to room (after) each meal r/t (related to) safety . 9. Conclusion: (check one). Cause unknown (or) Probable Cause known (no check mark was documented next to either option) . Charge Nurse to begin investigation by completing Sections 1-9 at time of Unusual Occurrence . There was no documentation of any further effort to determine the causative factors of this fall and there was no indication that the investigation identified the failure to implement the previously planned intervention to not leave the resident unattended in the wheelchair. A Fall Risk Evaluation form (not dated or signed, but attached to the 1/28/18 Unusual Occurrence Report) documented the resident's fall risk score was 20, which indicated a high risk for falls. A form titled, 10 Questions at the time a Resident Falls was attached to the Unusual Occurrence form dated 1/28/18. This form documented .2. Ask resident: What were you trying to do? Transfer from w/c to recliner . 4. Position of Resident? Sitting on floor with head resting on side of bed . 10. Who was in the area when the resident fell ? CNA . An Office of Long Term Care (OLTC) Witness Statement form dated 1/28/18 at 6:20 p.m. and signed by Certified Nursing Assistant (CNA) #5 documented, State in your own words what you witnessed (be very descriptive) and sign below . Coming out of another resident's room going into another, heard (Resident #3) yell, went to room (Resident #3) was on floor laughing saying he slipped out his wheelchair trying to get in recliner. A Physician's Telephone Order dated 1/28/18 at 6:25 p.m. documented, X-ray (left) hip. A Nursing Note dated 1/28/18 at 7:26 p.m. and signed by Licensed Practical Nurse (LPN) #3 documented, Nursing Note: fall documentation (6:20 p.m.) CAN (sic) found patient sitting on floor beside bed states he was trying to get from his wheelchair to the recliner. Complains of pain 3/10 (severity 3 on a scale of 1 to 10) to left hip . (6:21 p.m.) new order received from (Advanced Practice Nurse) to get x-ray l (left) hip . There was no documentation that indicated any efforts to make arrangements for the x-ray to be completed. i. The January 2018 Medication, Treatment and Task Administration Record Report dated documented [MEDICATION NAME]-[MEDICATION NAME] 5-325 was administered to Resident #3 on 1/28/18 and 1/29/18. The Medication, Treatment and Task Administration Record Report did not document a time for administration. The Controlled Narcotic Log page for Resident #3's [MEDICATION NAME]/[MEDICATION NAME] 5/325 documented, Directions give 1 tablet PO (by mouth) . The log documented the following entries: 1/28/18 at 7:20 p.m.: .amount used 1 . (signature of LPN #3) . 1/28/18 at 1:28 a.m.: .amount used 1 . 1/29/18 at 1:27 a.m.: .was administered . Reason: .hip pain . The Medication Administration Record [REDACTED]. j. Nurses Notes dated 1/29/18 at 4:56 a.m. and signed by LPN #4 documented, Resident in bed and very agitated, BP (blood pressure) 185/82 P (pulse) 105. Pain meds (medications) not helping with pain. Still complaining of left hip pain. Temp 99. Will continue to monitor. There was no documentation the x-ray had been completed at this time or that the physician or APN were notified of a delay in obtaining the x-ray. k. Nurses Notes dated 1/29/18 at 9:00 a.m. and signed by the Director of Nursing (DON) documented, Nursing Note: upon assessment, resident is up in w/c, no complaints voiced at this time; order for L (left) hip x-ray, facility van took resident over to (local hospital) at approx. (approximately) 10 a.m. for radiograph, (hospital staff member) x-ray-tech called this nurse and notified of Left [MEDICAL CONDITION], it was discussed that resident had a previous [MEDICAL CONDITION] hip that was non healing, but due to increased pain an order was obtained to send resident to ER (emergency room ) from the radiology dept. (department). This nurse notified (hospital staff member) in ER and gave report of fall and previous hip fx (fracture) . resident being sent for eval (evaluation) in ER . There was no documentation as to why the x-ray had not already been completed; why the resident was transferred out of bed to a wheelchair when no x-ray had been done to rule out a possible fracture; and why the resident was transported in a wheelchair via facility van as opposed to an ambulance, when he had continued to complain of unrelieved hip pain since the fall occurred the previous day. l. Nurses Notes dated 1/29/18 at 4:50 p.m. documented, .Res (resident) sent to hosp. (hospital) for X-Ray for lt (left) hip. X-ray result alert to fractured lt (left) hip. Resident admitted to hosp. m. A hospital Radiology Report dated 1/29/18 documented, admitted /Time 1/29/18 (9:42 a.m.) . Study Result Left Hip Radiographs . Procedure Date/Time: 1/29/18 (9:45 a.m.) . History: .Pain in left hip. Comparison: 10/11/17, CT scan dated 09/14/17 . Findings: Since the evaluations in October and September, there has then (been) interval femoral neck fracture. The femoral shaft shows superior and posterior displacement with impaction. The comminuted cortical [MEDICAL CONDITION] trochanter is again identified. The femoral head remains within the acetabulum. Impression: Interval femoral neck fracture with impaction and superior posterior displacement. The trochanteric cortical fractures are again noted. n. A hospital Emergency Department Record dated 1/29/18 at 10:19 a.m. documented, Patient went to outpatient x-ray for left hip pain after a fall. A fracture to the left hip was noted and patient was checked into the ER for an evaluation . Service: Orthopedics . Chief Complaint: pain left hip . Active Problems: Closed left [MEDICAL CONDITION] . Plan: .endoprosthesis (artificial device placed internally to replace a missing body part) left hip . o. The Hospitalist Consult Note dated 1/30/18 documented, .presented to the ER after a fall at the NH (nursing home). Workup revealed a L (left) [MEDICAL CONDITION] so he was admitted for surgical management. The patient is unable to provide any history. His (family members) are at the bedside. They say that he has been in the NH (Nursing Home) since Sept (September) after multiple falls at home resulted in non-surgical L [MEDICAL CONDITION] . Diagnostic studies L Hip XR (x-ray) . Impression: Interval femoral neck fracture with impaction and superior posterior displacement. The trochanteric cortical fractures are again noted . p. A hospital Operative Note dated 1/30/18 documented, .Service: Orthopedics . Date of Service: 1/30/18 . Date of Operation: 1/30/18 Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. Procedure Performed: Removal of broken femoral head and replacement with endoprosthesis . q. The hospital Discharge Summary dated 2/2/18 documented, .Active Hospital Problems [DIAGNOSES REDACTED]. admitting [DIAGNOSES REDACTED]. Discharge Diagnosis: [REDACTED]. Operations and/or Procedures: 1/30/18 Endoprosthesis of L Hip . Hospital course . presented with a closed left [MEDICAL CONDITION]. He was taken to the OR (operating room) for fixation on 1/30. His H/H (hemoglobin and hematocrit) has dropped from presentation but is stable at discharge . r. On 2/7/18 at 9:30 a.m., Licensed Practical Nurse (LPN) #2 was asked if a specific intervention was put in place after the resident fell on [DATE]. The LPN stated, The one before, they put a crash mat and they told the CNAs to walk by every 15 minutes and look in. The LPN was asked who they consisted of and stated, (Assistant Director of Nursing (ADON)). The LPN was asked if that was when the resident was up in the wheelchair and stated, Not necessarily when he was in the wheelchair. s. On 2/7/18 at 12:40 p.m., Certified Nursing Assistant (CNA) #4 was asked to describe what happened when the resident fell on [DATE]. The CNA stated, When I went back in there to change him, I had taken him to the bathroom and changed his clothes, he wasted some water (urinated). The CNA was asked where the resident was located after toileting and stated, By the recliner. The CNA was asked if the resident had been left alone and stated, Yes, I was going to change somebody, and he was trying to get up. Where the other lady's room was, I could see him. He was still in the chair, and I went in and checked him. The CNA was asked if she was the one who found the resident on the floor after he fell and stated, Yes. The CNA was asked if any specific interventions put in place after the resident fell on [DATE] and stated, Still make sure crash mat was down. I don't remember other things. CNA #4 was asked if there had been any in-service on what was to be done to prevent the resident from falling and stated, They told us if nobody was in the room with him, then he needs to come out of the room. The CNA was asked where would you go for information about a resident and stated, My supervisor, the nurse, the care plan. The CNA was asked if the resident could sit up in a wheelchair in the room alone and stated, Recliner or wheelchair, either one basically, he couldn't be alone; he had to come out of the room . t. On 2/7/18 at 12:55 p.m., CNA #6 was asked if she had worked on 1/22/18 and found the resident on the floor. The CNA stated, Yes, I went to empty the trash and he was on the floor. His room is here, and the trash is by his room. He was in front of the wheelchair. The CNA was asked if there were any interventions that were in place to help prevent the resident from falling and stated, We changed the crash mat, and I believe that's when they told us to take the wheelchair out when he's not in the wheelchair, and 15-minute checks on him. The CNA was asked what the 15 minute checks were and stated, Just walk by his room every 15 minutes and make sure he's not trying to get up by his (sic) self. The CNA was asked where she documented the 15-minute checks and stated, Oh, I did not. The CNA was asked if there was a special form or documentation in the kiosk (computer program) and stated, No. The CNA was asked if she could recall any other interventions that were put in place after the 1/22/18 fall. The CNA stated, They did put that he's not to be in his wheelchair in his room by himself. CNA #4 was asked how she knew about new interventions and stated, They tell us individually and put it in the care plan. The CNA was asked if the resident had fallen since that date and stated, Yes, a different shift; I can't remember which. u. On 2/7/18 at 5:10 p.m., the Assistant Director of Nursing (ADON) was shown the 1/22/18 Unusual Occurrence Report, and was asked if she had done the investigation. The ADON stated, I did. The ADON was asked if she had assessed the resident and stated, Yes. The ADON was asked if other staff members were in the resident's room after the resident fell and stated, I was the only one to enter the room at that time, and soon after, (LPN #2), another nurse. The ADON was asked where the resident was when she entered the room and stated, He was sitting right in front of the closet, facing the bed, with his back to the closet. The ADON was asked where the wheelchair was and stated, Between him and the closet. The ADON was asked if the resident had any injury and stated, Yes, skin tears on top of the left hand . was one on the wrist area and to the back of the hand. The ADON was asked if the resident could move his extremities after the 1/22/18 fall and stated, Yes, he could. The ADON was asked where the assessment for range of motion was documented and stated, It's not. The ADON was asked if the fall was investigated and the ADON stated, I had asked them how they found him; (CNA #4) said she had just come out of the room a few minutes prior and was coming back in the room to back get him back to bed. The ADON was asked if the resident was up in the wheelchair at the time of the fall and stated, Yes. At that point, I stated he should not be up in the wheelchair unattended in the room, also for his wheelchair, whether in recliner or bed, the wheelchair should be out of sight, either next to the closet or behind the recliner. We also discussed the 'cookie cutter' care plan, the bed low, call light, and previous interventions of a crash mat was down next to the bed. I felt with the crash mat, he had a very wide crash mat, and that prevented him from rolling his wheelchair to the bed. I did change the crash mat out to the skinny one, just because I felt he could not get to the bed. The ADON was asked to review the Unusual Occurrence Investigation Report dated 1/22/18 and asked what question 8 said after What immediate interventions have you initiated to prevent this event from occurring again? The ADON reviewed the report and stated, Resident is not to be left unattended in room while sitting up in wheelchair. Wheelchair to be moved out of sight while laying (sic) in bed or sitting up in recliner. Resident had a large crash mat this mat was changed to smaller mat. The ADON was asked how this information was communicated to staff and stated, Those 2 CNAs were told, and later after (LPN #2) got out of assessment, the nurse was told. The ADON was asked if any other staff was provided with the intervention instructions and stated, The next nurse oncoming, 4 to 12 (4:00 p.m. to 12:00 a.m. shift), and I had a discussion with, I believe it was (LPN #5). I just told her about the fall, which she was already aware, and the intervention that was in place. The ADON was asked how are new interventions communicated to the staff and stated, In report, I would assume with the other CNAs, and I would hope, the oncoming nurse would have a conversation. The ADON was asked if there had been a formal in-service on the new interventions and stated, I didn't write it out, no, it was all verbal communication. Typically, if I am the one who puts the intervention in place, I have a direct conversation with the direct care staff at the time the intervention is put in place. I also ensure that it's put on the closet care plan and, in the case of (Resident #3), I immediately took the closet care plan and placed it on there. At 5:45 p.m., the ADON left the room to check with the lead CNA to see if there was a closet care plan for 1/22/18. At 5:50 p.m., the ADON returned and stated, There's not one. The ADON was asked if the care plan that was updated on 1/22/18 was available and stated, No. The ADON was asked if she had updated the closet care plan with interventions on 1/22/18 and stated, I pulled the MDS working care plan when he returned. On 1/22, what I had written on there was do not leave resident sitting up in wheelchair unattended. The ADON was asked if the resident was a high risk for falls and stated, Yes. The ADON was asked how staff knew who was at high risk and stated, When we put them on 'Eyes on the Resident' program, the way the aides, all staff, can identify them is by a green band placed on the resident's mode of transportation. A green band on a wheelchair. The ADON was asked what the Eyes on the Resident program was and stated, It's a program we've implemented for falls, and it means that resident should be rounded on every 15 minutes by all nursing staff. The ADON was asked if the staff documented these rounds anywhere and stated, No. The ADON was asked how the facility ensured that the staff did the rounds every 15 minutes and stated, I guess there's no real proof without documentation. The ADON was asked how staff were notified when a resident was initially placed on the Eyes on the Resident program and stated, Staff is in-serviced on each resident when they are placed on the program. The in-service regarding Resident #3's interventions was requested at this time, and the ADON stated, I didn't do a written (in-service). Verbally. The ADON was asked who was in-serviced regarding the Eyes on the Resident program for this resident and stated, At this point, I can't remember which fall it was on, or who was involved in it. I do recall December 10th, there was an in-service for everyone. The ADON was asked if newly hired nursing staff had been in-serviced on the fall interventions since 12/10/17 and stated, Yes, I would hope, during orientation. The ADON was asked if she knew for sure whether new staff had been in-serviced and stated, No. The ADON was referred to the Unusual Occurrence Report dated 1/28/18 and asked who the nurse was at the time of the incident and who had completed the form. The ADON stated, (Licensed Practical Nurse (LPN) #3). The ADON was asked who had completed the investigation for that date, as there was no nurse's signature on the form. The ADON stated, (LPN #3). The ADON was asked how she could tell and stated, I don't know; it's not signed. On 2/7/18 at 10:20 a.m., LPN #3 was asked for an interview and stated she had to leave for a doctors appointment. On 2/8/18 at 9:00 a.m., the DON was asked about LPN #3 and stated that the LPN called in sick for the day. v. On 2/7/18 at 6:40 p.m., LPN #5 was asked if there was an intervention added for the resident not to be left unattended when up in the wheelchair, after the fall on 1/22/18. The LPN stated, Yes, and wheelchair out of sight. LPN #5 was asked how she knew about this intervention and stated, From a previous fall. w. On 2/7/18 at 6:52 p.m., the Director of Nursing (DON) was asked how falls were investigated and stated, Reviewing the I & A (Incident and Accident) and the intervention, the care plan, and ensuring the intervention was in place. The DON was referred to the 1/22/18 report and asked what occurred and stated, On 1/22, the intervention was that the resident was not to be left unattended, the wheelchair was out of sight while lying in bed and his large crash mat was changed out to a smaller one. The DON was asked if the care plan had been updated at that time and stated, We updated the closet care plan, so when new caregiver came in they would know, and in Caretracker (electronic documentation system). The DON was asked if the resident was alone in the room on 1/28/18 when he fell and fractured his hip. The DON stated, He was. The DON was asked if the resident was up in the wheelchair prior to the fall and stated, It states he was. He was trying to transfer from his wheelchair to his recliner. The DON was asked if the facility's investigation of the incident had identified that the resident was left alone / unattended in the wheelchair. The DON gave no response. The DON was asked if this was reviewed and stated, I did not, no. The DON was asked if there had been an investigation after a fall to determine the cause of the fall. The DON gave no response. The DON was asked why the resident was alone at the time of the fall and stated, The CNA was in another resident's room at the time. The DON was asked if she had asked the CNA about the fall and stated, I did not. The DON was asked if staff should have been with the resident while he was up in the wheelchair. The DON gave no response initially, then stated, I would imagine he propelled himself back to his room. The Director of Nursing (DON) was asked if the hip x-ray that was ordered on [DATE] was obtained that day, as documented on the Unusual Occurrence Report. The DON stated, No, it was obtained the next morning. The DON was asked why the x-ray was not obtained the day it was ordered and stated, Because the (mobile x-ray provider) was not able to come out that night. We called them, and they couldn't come. The DON left the room and returned at 7:42 p.m. and stated, (Mobile x-ray provider) is sending their confirmation receipt of when we requested the x-ray on the 28th. When I came in that following morning (1/29/18), I was informed by one of my staff members (mobile x-ray provider) was going to be late. I just remembered, as soon as we realized they were running late, I called the hospital to see when we could get him in. The DON was asked if the APN or physician had been notified that the x-ray ordered on [DATE] had not yet been done as of the morning of 1/29/18 and stated, I did call her (APN). The DON was asked where that was documented and stated, It's not documented. The DON was asked how the resident was transported to the hospital and stated, By facility van. The DON was asked if the resident had been transported in the van, seated in the wheelchair and stated, Yes. The DON was asked why the resident was sent by the van and not secured in an ambulance, since the x-ray had not yet been done to rule out fracture, and stated, He was already up in his wheelchair, and I assessed him to make sure he was comfortable. The DON was asked who had gotten the resident up into the wheelchair on the morning of the 29th and stated, I do not know. The DON was asked, after having found that the resident had fallen and was up in the wheelchair on the morning of the 29th, should that have been investigated? The DON stated, When I came in, he was up, and I assessed and he was okay. The DON was asked if she had asked who had gotten the resident up to (TRUNCATED)