Every finding on record at Valley Senior Living on Columbia

Based on record review, facility reported incident (FRI) review, and staff interview, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 sampled residents (Resident #15) who had a fall with major injury. Failure to provide adequate supervision during personal cares resulted in a fall with a head injury and hospitalization. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.Findings include:The surveyor determined a deficient practice existed on 10/25/25. The facility immediately implemented corrective action, continued with staff education and monitoring, and completed corrective action on 10/31/25.Review of Resident #15's medical record occurred on all days survey. The current care plan stated . I need two staff to turn/roll side to side in bed . assist of two with toileting . at risk for falls . unaware of safety needs . Review of progress notes showed on 10/25/25 at 1:00 a.m., . resident had a fall from his bed during cares/toileting, and he is care planned AO2 [assist of two] staff and at this time AO1 [assist of one] staff was assisting . resident is on blood thinners and sent to ER for further evaluation . Resident #15's hospital history and physical dated 10/25/25 at 4:01 a.m., stated, . acute right frontal subdural hematoma [bleeding near the brain] . and identified an admission to the hospital's critical care unit.Review of the FRI investigation, dated 10/30/25, showed an undated written statement from a certified nurse aide (CNA) (#3) which stated . I stopped to change soiled brief of the resident . he began to kick his legs off the bed, I . put his legs back on the bed . resident once again kicked legs off the bed. I went to the other side, but resident slid off and hit the end table . I did not follow the care plan for brief change which resulted in this incident . Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the deficient practice by:- The facility educated CNA (#3) immediately following the incident and educated all other staff by 10/31/25 on resident safety and always follow the care plan. - The facility conducted facility wide audits after the incident to verify compliance and continued with results reported to the Quality Assurance Performance Improvement (QAPI) committee. On 08/06/26, interviews with five CNA's (# 4, #5, #6, #7, #8) verified education received on following care plans to ensure resident safety.

Based on observation, review of facility policy, and staff interview, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 1 of 1 sampled residents (Resident #17) and 3 supplemental residents (Resident #13, #50 and #91) observed with unclean fans. Failure to clean resident personal fans does not promote a homelike living environment or enhance the residents' quality of life. Findings include:Review of the facility policy titled Fans occurred on 08/05/26. This policy, dated 07/16/26, stated, . Approved resident room fans shall be cleaned and maintained to minimize dust accumulation .Observations on 08/03/26 at 2:35 p.m. showed the following;* A white table fan coated with a layer of dust on the grates blowing toward Resident #50's bed. * A small white fan with a thick coating of dust on the grates blowing toward Resident #13's bed.Observations on 08/04/26 showed the following;* At 1:55 p.m., a small white fan with a thick coating of dust on the grates blowing toward Resident #17's bed. * At 4:40 p.m., a black tower fan with a thick coating of dust on the grates blowing toward Resident #91's bed. During an interview on 08/05/26 8:59 a.m., an administrative staff (#1) stated environmental services staff were responsible for keeping the fans clean.

Based on -review of a facility reported incident (FRI), record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident (Resident #1). Failure to protect residents from sexual abuse places all residents at risk for psychosocial harm and mental and emotional distress. Findings include:The surveyors determined a deficient practice existed on 08/19/25. the facility implemented and completed corrective action on 09/02/25.Review of the facility policy titled Valley Senior Living Personnel Policy and Procedure 207.7 occurred on 11/26/25. This policy, dated October 2024, stated, . Every resident has the right to be free from abuse .Review of the FRI identified on 08/19/25 at 8;30 a.m., . Residents [#1 and #2] were self mobilizing their wheelchairs after breakfast down the hallway. [Resident #1] wheeled next to [Resident #2], reached out and cupped her breast, then blew kisses at her. - Review of Resident #1's medical record occurred on 11/26/25 and identified a diagnosis of dementia with other behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment and physical behaviors towards others. The care plan stated, . I have sexually inappropriate behaviors such as sexually explicit comments and inappropriate touching due to dementia . Be observant of my interactions with other residents, such as in communal room. Explain/reinforce why my behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Review of Resident #2's medical record occurred on 11/26/25. The quarterly MDS, dated [DATE], identified intact cognition.A progress note dated 08/19/25 at 11:14 a.m. stated, . SW (social worker) interviewed [Resident #2], charge nurse . present. She has some expressive aphasia so was prompted on what occurred. [Resident #2] stated that [Resident #1] touched her and when asked where, stated 'breast.' When asked if he said anything, she nodded yes but could not verbalize what was said. When asked if she was afraid, she said 'no'. When asked if she felt safe, she said 'yes.' .During an interview on 11/26/25 at 2:40 p.m., Resident #2 stated she could not recall the incident very clearly. When asked if she was afraid of [Resident #2] she nodded no. When asked if she was afraid of anyone else, she said, No. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented the corrective action for the deficient practice by: *Completing an investigation with interviews of residents and staff. *Placed Resident #1 on 72-hour monitoring *Completed an interdisciplinary team meeting immediately after the incident. *Referred Resident #1 to their primary care provider regarding his behavior and reviewing/adjusting medications. *Updated Resident #1's plan of care to include 1:1 supervision when out of his room. *Provided education to all nursing staff on supervision requirements, behavior interventions, and reporting on 08/19/25 through 09/02/25.

Based on record review, review of the facility reported incident (FRI) investigation, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #150) who fell during a staff assisted transfer. Failure to utilize the gait belt resulted in Resident #150's fall/fracture and placed all residents transferred with a gait belt at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 02/26/25. The facility implemented corrective action immediately, completed corrective action on 03/03/25, and continues with staff education and monitoring. Review of the facility policy titled Gait Belt Use occurred on 06/19/25. This policy, revised August 2023, stated, . Use an underhand grasp to hold on to the gait belt . Review of Resident #150's medical record occurred on all days of survey. Diagnoses included right femur fracture. The care plan stated, . TRANSFER: assist by 1 staff with gait belt . I am at risk for falls r/t [relate to] cognitive impairments, gait/balance problems, deconditioning . I have parkinsonism affecting my balance and mobility. A FRI investigation, dated 03/03/25, stated, . [Resident #150] was being assisted by [CNA [#3] in her room. [The] Resident is care planned as assist of one with [a] gait belt for transfers and ambulation. [CNA #3] had the gait belt in place and had assisted [the] resident from the bathroom to the sink in her room. LBSW [Licensed Baccalaureate Social Worker #4] came into the room and was talking to resident [#150]. At that time, [CNA #3] let go of the gait belt to throw trash in the bathroom. LBSW [#4] noted [the] resident starting to tip backward and yelled to notify [CNA [#3]. [The] Resident then fell backwards, hitting her head on the sink and fell to the ground. Resident [#150] complained of pain, was transferred to the ER [emergency room], and subsequently diagnosed with a displaced, right femur fracture. She required surgical repair. The facility failed to ensure staff utilized the gait belt while assisting Resident #150. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the following corrective actions to ensure all residents affected by the deficient practice were transferred in an appropriate manner: * Completed an investigation into Resident #150's fall/right femur fracture. * Suspended CNA (#3) following the incident and terminated him/her after completing the investigation. * Provided staff education regarding staff-assisted transfers/gait belt use via electronic messages and/or posted memos. * Completed competency testing to ensure staff met the requirements for staff-assisted transfers/gait belt use. * Updated resident care plans as necessary. * Updated policies and procedures addressing staff-assisted transfer/gait belt use. * Initiated a four-stage (plan-do-study-act) quality improvement plan.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 12 sampled residents (Resident #30, #153, and #275) observed during cares/wound care. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, catheter cares, dressing changes, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Dressings: Dry and Moist-to-Dry occurred on 06/18/25. This policy, dated April 2022, stated, . Apply antiseptic ointment (if ordered) with sterile cotton-tipped swab or gauze . Dispose of gloves and perform hand hygiene. Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/19/25. This policy, dated April 2025, stated, . EBPs apply when: A resident . has a wound. Indwelling medical devices include . urinary catheters . EBPs employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities . Examples of high-contact resident care activities . providing hygiene or grooming; changing briefs or assisting with toileting; transferring; bed mobility; wound care . Review of the facility policy titled Handwashing/Hand Hygiene occurred on 06/19/25. This policy, dated October 2024, stated, . Hand hygiene is indicated: after contact with . body fluids or contaminated surfaces; after touching a resident; after touching the resident's environment . - Review of Resident #30 medical record occurred on all days of survey. Diagnoses included us of a urinary device. The quarterly Minumum Data Set (MDS), dated [DATE], identified an indwelling catheter. The care plan stated, . I require the use of Enhanced Barrier Precautions d/t [due to] indwelling medical device. Observation on 06/16/25 at 2:28 p.m. showed two certified nurse aides (CNAs) (#6 and #7) applied a gown and gloves before entering Resident #30's room. One of the CNAs (#6) repositioned the resident's wheelchair, touched the resident's personal items, and without removing her gown and gloves exited the room to obtain an incontinence pad. The CNA (#6) returned to the room, transferred Resident #30 into bed, obtained a graduate, placed the resident's urinary catheter leg bag into the graduate, allowing the bag and the tip to touch the sides of the graduate, and drained the urine. Without removing the soiled gloves the CNA (#6) removed the resident's pants, ace wraps, and compression stockings. The CNA (#6) then removed the soiled gloves, applied new gloves, transferred the resident to a shower chair, exited the room, and transported Resident #30 to the shower room. The CNA failed to follow proper infection control standards for draining a urinary catheter bag, failed to remove her gown/gloves, and failed to complete hand hygiene. - Review of Resident #275's medical record occurred on all days of survey. Diagnoses included a left heel ulcer with a physician's order for Silvadene cream (topical ointment), xeroform (mesh gauze), absorbent dressing, and gauze. Observation on 06/17/25 at 8:13 a.m. showed the nurse (#2) applied gloves and applied Silvadene ointment to the Resident's 275's wound with a gloved finger, covered the wound with xeroform, and an absorbent dressing, and wrapped the area with gauze. The nurse (#2) failed to change gloves after applying ointment with gloved finger. - Review of Resident #153 medical record occurred on all days of survey. Diagnosis included a pressure injury to the left heel with a physician's order for xeroform, absorbent dressing, and wrap every day and evening shift. Observation on 06/17/25 at 10:25 a.m. showed two nurses (#2 and #5) performed Resident #153's dressing change. During the dressing change the nurses placed the bottle of wound cleanser and hand sanitizer directly on the floor and returned the items to the basin of supplies a few minutes later. The nurses failed to set the items on a clean barrier. During an interview on the afternoon of 06/18/25 an administrative nurse (#1) confirmed she expected staff to utilize a barrier for clean supplies and follow infection control policies.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 35 sampled residents (Resident #36). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2024, page A-32, stated, . Coding Instructions. Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #36's medical record occurred on all days of survey. The record included diagnoses of bipolar disorder, Tourette's disorder, and autistic disorder. A comprehensive MDS, dated [DATE], showed the facility failed to code Section A1500 for a serious mental illness. During an interview on 06/19/25 at 10:12 a.m., an administrative nurse (#1) confirmed staff failed to accurately code section A on Resident #36's MDS.

1. Based on record review and review of facility reported incident documents, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 1 closed record (Resident #285) reviewed for a fall. Failure to use a gait belt and to provide adequate supervision resulted Resident #285 sustaining a fracture. Findings include: Review of Resident #285's medical record occured on 05/16/24. The care plan identified the following: . Focus: I have an ADL [activities of daily living] self-care performance deficit r/t [related to] Activity intolerance following a hospital stay for weekend, near syncope . and chronic back pain r/t degenerative disc disease (Initiated on 07/12/23). Interventions: AMBULATION: I am able to ambulate with assist of 1 staff with gait belt and FWW [front wheeled walker] . PERSONAL HYGIENE: I require assistance by 1 staff with person hygiene, perineal and oral care. TOILET USE: I need assist of 1 with toileting. TRANSFER: I am able to transfer with assist of 1 with gait belt and my FWW. Focus: I am at risk for falls r/t Deconditioning, incontinence, near syncope . Goal: I will not sustain serious injury . Interventions: Be sure my call light is in reach and encourage me to use it for assistance as needed. I need a safe environment with even floors free from the spills and /or clutter, adequate reduced glare lighting . Review of Resident #285's nurses notes identified the following: * 11/29/24 at 9:03 p.m.; Resident was transferring to bed and lost balance fell and hit top of head. No injuries noted. Denies pain. Neuro [neurological] checks initiated. * 11/29/23 at 11:32 p.m.; . Resident fell at 2016 [8:16 p.m.] . [Name of physician] notified of fall and aware resident hit head. Neuro checks initiated. No injuries noted. Resident Alert and Oriented. Primary decision maker . notified of fall. * 11/30/23 at 2:30 a.m.; . Resident got up to go to the bathroom around 1:30am. Reported pain 10 out of 10. When resident sat in wheelchair she started gagging and spitting up thick sputum. Reported of feeling funny but couldn't explain. Action: Gave Tylenol 500 mg [milligrams] PRN [as needed]. Called [Name of physician] and notified of change in status. Resident primary decision maker [name] was notified. Resident sent to ER [emergency room ] via wheelchair at 0208 [2:08 a.m.] . Response: [Name of physician] stated, Send her in. [name of primary decision maker] stated, 'I'll go to the ER.' '' * 11/30/23 at 7:23 a.m.; . Resident returned from ER at this time. Per report from ER resident has TLSO [thoracic-lumbo-sacral orthosis] brace. * 11/30/23 at 11:22 a.m.; Resident Concern Progress Note . Resident had fall in room last evening and did not have gait belt on as care planned. Resident and CNA [certified nurse aide] reported that resident hit her head. No visible injury noted. At 1:30AM, resident woke up and vomited, provider updated and resident was sent to ER. RN [registered nurse] notified daughter of fall and notified her of change in status when she went to the ER. Daughter met resident in ER. Initial findings regarding Resident concern: CNA did not follow care plan for transfer/ambulation. Resident was assessed in ER, CT scan showed compression fracture of T-9. Resident returned to [nursing home]. Review of the Facility Reported Incident investigation identified a staff member assisted resident to the bathroom and the resident put the call light on when done. The staff member returned and assisted to pull her brief and pants up, then walked behind the resident to the sink where she was removed her dentures and put them away. The staff member left resident at the sink and moved to open the covers on resident's bed and set up her pillows. As the staff member turned around, the resident started to lean back and fell before he/she could get to her. The staff member did not have a gait belt on resident and reports that he/she didn't think the resident needed it. The facility failed to ensure staff followed Resident #285's plan of care by utilizing a gait belt and this failure resulted in a fall and fracture. 46963 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 1 of 1 sampled resident (Resident #165) who required one to one supervision with meals. Failure to stay with the resident while eating as care planned places the resident at risk for choking. Findings include: Review of the facility policy titled Care Plan, Comprehensive Interdisciplinary occurred on 05/16/24. This policy, dated March 2017, stated, . The services provided or arranged by the facility will meet professional standards of quality, be provided by qualified persons, and be culturally-competent and trauma-informed. Review of Resident #165's medical record occurred on all days of survey. The current care plan stated, . EATING: I am to eat all my meals out of bed in the upright position. Encourage me to go to the family room. I require 1:1 assist for meals d/t [due to] hx [history of] coughing with meals. I am at increased nutrition risk r/t [related to] h/o [history of] CVA [cerebrovascular accident/stroke], aphasia, dysphasia [language disorder that affects speech production and comprehension], and FTT [failure to thrive]. Provide and serve Regular diet with regular texture/thin liquids, breads and straws are ok per SLP [speech language pathology] 12/8/23. Resident does require assistance/observance at meals h/o of choking. I have a history of swallowing problems. Report to the dietitian if I have any difficulty with chewing/swallowing my food. A task that is completed by care staff stated NUTRITION - Snacks PM [afternoon] -encourage high calorie item; HS [bedtime] -choc milk or ice cream *needs 1:1 supervision-high choking risk. During an observation on 05/14/24 at 10:55 a.m., the certified nurse aide (CNA) (#7) placed a supplement shake with a straw on the resident's bedside table and left the resident unattended. During an interview on 05/15/24 at 1:51 p.m., the nurse (#5) stated the resident could reach the protein shake independently but would expect the CNA who gave the shake to stay with the resident.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for (2 of 21) sampled residents (Resident #49, and #154) and one supplemental resident (Resident #56) observed during personal cares. Failure to follow infection control standards related to hand hygiene and emptying of a urinary bag has the potential to spread infection throughout the facility and could transmit those infections to residents, staff, and visitors. Findings Include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 05/15/24. This policy, revised in May 2023, stated, . all personnel shall follow the handwashing/hand hygiene procedures . 2. Before and after direct contact with residents. Review of the facility skills validation titled Emptying Urinary Drainage Bag occurred in 05/15/24. This skills validation, revised on February 2022, stated, . 8. Place graduate on paper towel. 9. Do not let spout or clamp touch the graduate. 11. Place graduate on a paper towel on a flat surface. - Observation on 05/13/24 at 2:09 p.m., showed a certified nurse aide (CNA) (#2) carried his/her soiled gown out of an unidentified resident's room and placed it on a table outside of Resident #56's room. The CNA (#2) entered Resident 56's room to answer the call light, removed the resident's shoes, and exited the room. The CNA (#2) re-entered the room with a mechanical lift and transferred the resident into bed. The CNA adjusted Resident #56's socks and blanket, placed the call light and a stuffed animal next the resident, offered the resident a drink then exited the room. The CNA (#2) failed to perform hand hygiene before entering and before exiting Resident #56's room. - Observation on 05/14/24 at 10:19 a.m., showed a CNA (#3) placed a graduated container on Resident #154's bedding and failed to place a paper towel barrier under the container. The CNA held the entire urine collection bag inside the container and the spout, clamp, and leg bag touched the urine contents and the sides of the container. The CNA (#3) emptied the urine, rinsed and dried the graduate container, and placed it on Resident #154's dresser without a barrier between the container and dresser. The CNA (#3) failed to disinfect the catheter spout after it had touched the inside of the container. During an interview on 05/16/24 at 12:32 p.m., an administrative nurse (#1) confirmed staff should have performed hand hygiene and followed proper procedures for emptying the catheter drainage bag. - During an observation on 05/14/24 at 9:08 a.m., a CNA (#6) transferred Resident #49 from the recliner to the bath chair. Without wearing gloves, the CNA (#6) removed a wet brief from the resident and discarded it in the garbage. The CNA stated, I should have had gloves on. Without performing hand hygiene, the CNA then wrapped a blanket around the resident, opened the resident's door, and wheeled the resident to the tub room. During an interview on 05/16/24 at 11:00 a.m. administrative nurse (#1) confirmed staff should perform hand hygiene after handling a wet brief. 19410

Based on observation, record review, review of the facility policy, and staff interview, the facility failed to develop a comprehensive care plan for 2 of 5 sampled residents on oxygen (Resident #32 and #47). Failure to develop a comprehensive care plan limited staffs' ability to communicate needs and ensure the continuity of care. Findings include: Review of the facility policy titled Care Plan, Comprehensive Interdisciplinary occurred on 05/16/24. This policy, dated 03/2017, stated, . The comprehensive care plan must describe the following: 1. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. - Review of Resident #32's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease, heart disease, and palliative care. Physician's orders stated the following: . O2 [oxygen] PRN [as needed] 1.5 Liters per nasal cannula for comfort as needed and every day shift daily. O2 sat [saturation] when PRN O2 orders are in place . O2 tubing to be changed every night shift . Change nasal cannula every night shift every 14 day(s) . and as needed . Observations on all days of survey showed Resident #32 with oxygen on per nasal cannula at all times. Resident #32's current plan of care failed to identify oxygen use related to respiratory/cardiac diagnoses and palliative care. - Review of Resident #47's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease. Physician's orders stated the following: . Check O2 sats every shift for prn oxygen use . 1 L/min [liter per minute] oxygen via nasal cannula continuously as needed for For [sic] O2 less than 90 or SOB [shortness of breath] . Observations on 05/13/24 at 1:33 p.m. and 05/14/24 at 10:16 a.m. showed Resident #47 with oxygen. Review of Resident #47's annual Minimum Data Set (MDS), dated [DATE], identified oxygen use. The resident's current plan of care failed to identify O2 use. During an interview on 05/16/24 at 11:00 a.m., an administrative nurse (#1) confirmed staff are expected to include residents' use of oxygen on the plan of care. 19410

Based on observation, record review, and review of facility policy, the facility failed to provide care and services to prevent the development of pressure ulcers for 1 of 8 sampled residents (Resident #165) with prevalon boots (used for pressure relief) as ordered by the provider. Failure to apply the pressure relief boots as ordered may result in the development/worsening of pressure ulcers. Findings include: Review of the facility policy titled Standards of Care occurred on 05/16/24. This policy, dated 05/01/24, stated, . Additional pressure relief measures will be maintained for residents who are considered at risk for pressure injury. Review of Resident #165's medical record occurred on all days of survey. Diagnoses included a stage three pressure ulcer on the right ankle. The current care plan stated, I have a potential impairment to skin integrity r/t [related to] Impaired [sic] mobility . I need assistance to apply bilateral prevalon boots, on while in bed. A provider's order, dated 11/13/23, stated, Prevalon boot to BLE [bilateral lower extremities] for potential for high risk skin breakdown r/t immobility to be worn when in bed. Observations on 05/14/24 at 10:55 a.m. and 05/15/24 at 12:00 p.m. showed Resident #165 in bed without prevalon boots in place. The facility failed to implement pressure relief interventions for Resident #165 as ordered.

Based on observation, record review, and staff interview, the facility failed to provide appropriate toileting for 1 of 29 sampled residents (Resident #98) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Review of Resident #98's medical record occurred on all days of survey. Diagnoses included skin breakdown. The quarterly Minimum Data Set (MDS), dated [DATE], identified frequently incontinent of urine, extensive assist of two for toileting, and at risk for pressure ulcers. The current care plan stated, . at risk for alterations to skin integrity . TOILET USE: I need assist of 2 with total lift . I am incontinent of bowel and bladder . * Observation on 05/13/24 at 4:09 p.m. showed Resident #98 sitting in the wheelchair in her room with urine on the floor under the wheelchair. * Observation on 05/13/24 at 5:24 p.m. showed two certified nurse aides (CNAs) (#10 and #11) entered Resident #98's room and observed the resident's clothing, wheelchair, and floor wet with urine. The CNAs assisted Resident #98 with incontinence cares. Resident #98 stated she felt wet and uncomfortable. Review of the CNA toileting task report stated, staff need to assist Resident #98 with toileting every 3 hours from 4:00 a.m. to 10:00 p.m. Review of Resident #98's toileting task report, dated March 1st through May 15th, 2024, identified 76 occasions where staff failed to assist the resident with toileting every three hours from 4:00 a.m. to 10:00 p.m. The log showed gaps of approximately 3.5 to 7 hours between staff assistance with toileting. During an interview on 05/14/24 at 2:49 p.m., an administrative nurse (#1) confirmed staff are expected to provide toileting assistance to all residents. 40489

Based on record review and staff interview, the facility failed to ensure residents' records contained the hospice election form for 1 of 5 sampled residents (Resident #79) receiving hospice services. Failure to obtain this document limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: Review of Resident #79's medical record occurred on all days of survey and identified Resident #79 elected Hospice services on 04/29/24. The medical record lacked the hospice election form. During an interview on 05/15/24 at 5:07 p.m., an administrative nurse (#1) confirmed the medical record for Resident #79 lacked the hospice election form.

Based on observation, record review, and resident and staff interview, the facility failed to follow a physician's order for removal of a foley catheter for 1 of 7 sampled residents with a catheter (Resident #147). Failure to follow physician orders for the removal of the foley catheter and to attempt voiding trials may result in an increased risk of catheter associated urinary tract infections (CAUTI) and decreased quality of life. Findings Include: The facility failed to provide a copy of their policy addressing physician orders. During an interview on 06/06/23 at 03:50 p.m., Resident (#147) complained of having a catheter and stated, I want it out. Physician orders on 04/27/2023 at 7:23 a.m., stated, Attempt voiding trial with next scheduled catheter change (5-16-2023). Remove catheter in the morning. Leave out for 4 hours and push fluids. Resident to void immediately before bladder scan. Replace 16 Fr [French] foley catheter with 10 mL [milliliter] balloon if bladder scan amount 250 mL or greater. Update urology if he passed or failed voiding trial. Review of the resident's medical record occurred on all days of survey and lacked information/documentation the facility followed physician orders and completed a voiding trial. During an interview on 06/08/23 at 09:47 a.m., an administrative staff member (#3) confirmed the physician orders were not followed.

Based on observation, review of facility policy, record review, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 3 residents (Resident #56) observed during insulin administration. Failure to obtain an accurate label for an insulin pen following an order change may result in residents receiving too much/little insulin and/or having a negative reaction. Findings include: Review of the facility policy Medication Labeling occurred on 06/08/23. This policy, revised May 2016, stated, . All legend resident medications regardless of source shall be properly labeled as follows . If necessary, a signal type label shall be placed on the medication indicating that there has been a change order affecting the administration of the medication and that the nurse should turn to the resident's health record for correct information . Review of Resident #56's medical record occurred on 06/07/23. A physician's order, dated 04/28/23, included Lantus 10 units subcutaneous every morning. Observation on 06/07/23 at 8:16 a.m. showed Resident #56's Lantus Solostar Pen (type of inulin) with a label that read Administer 40 units subcutaneous every am. The nurse (#1) stated I will give what the MAR [medication administration record] says. When questioned on the process for order changes and relabeling the nurse identified that staff notifies pharmacy and pharmacy brings up a new label. The nurse (#1) stated We notified the pharmacy, I don't know why there isn't a new label. During an interview on 06/07/23 at 10:00 a.m., an administrative nurse (#2) stated she expected staff to notify the pharmacy and apply a see order change sticker to the insulin pen label until pharmacy can replace with a new label.

Based on observation, review of facility policy, and staff interview the facility failed to store dietary supplements under safe and sanitary conditions in 2 of 5 medication carts (Riverside Long Hall and [NAME] Short Hall) observed. Failure to remove scoops in dietary supplements may result in contamination of supplements or spread of infection to residents. Findings include: Review of the facility policy, Dining Services Policy, occurred 06/08/23. This policy, revised 2017, stated, . Sufficient storage facilities are provided to keep food safe . and by methods designed to prevent contamination. Scoops are not to be stored in food or ice containers. - Observation on 06/06/23 at 3:10 p.m. of the Riverside Long Hall medication cart showed a container of PUSH Collagen Dipeptide Concentrate powder (a wound healing dietary supplement) for Resident #70 with a scoop in the container. - Observation on 06/06/23 at 4:30 p.m. of the [NAME] Short Hall medication cart showed a container of PUSH Collagen Dipeptide Concentrate powder labeled STOCK with a scoop in the container. During an interview on the morning of 06/08/23, an administrative nurse (#2) confirmed nursing staff failed to remove the scoops from the supplement containers.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide/offer fluids to 4 of 12 sampled residents (Resident #58, #73, #151 and #161) observed during cares and/or required staff assistance for fluid intake. Failure to provide fluids and/or assistance with fluid intake may result in dehydration, constipation, and urinary tract infections. Findings include: Review of the facility policy titled Hydration/Dehydration occurred on 03/03/22. This policy, revised October 2021, stated, . The facility will offer each resident sufficient fluid intake to maintain adequate hydration. - Review of Resident #161's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS), dated [DATE], identified Resident #161 required extensive assist of one staff member for eating. The current care plan stated, . I have an ADL [activity of daily living] self-care performance deficit r/t [related to] Activity Intolerance, Acute Respiratory Failure. I need 1:1 [one to one] assistance with my meals. Observations showed the following: * 03/01/22 at 10:11 a.m. a CNA (certified nursing assistant) (#2) and a staff nurse (#3) provided toileting for Resident #161 and failed to offer fluids before or after cares. * 03/02/22 7:55 a.m. an unidentified staff member checked Resident #161's vital signs and no fluids available in the resident's room. * 03/02/22 2:50 p.m. a CNA (#4) and a staff nurse (#5) provided toileting for Resident #161 and failed to offer fluids before or after cares. * 03/02/22 3:05 p.m. a CNA (#6) entered Resident #161's room, answered the call light, and failed to offer fluids to the resident. - Review of Resident #58's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], identified Resident #58 required total assist of one staff member for eating. The current care plan stated, . I have Dementia . Anxiety . I require total assist with meals . I am at nutritional risk with potential for weight loss . dehydration . impairment to skin integrity r/t dementia . provide and serve honey thick liquids, supplements as ordered . Observations of Resident #58 showed the following: * 03/01/22 at 10:40 a.m. Two CNA's (# 14 and #15) provided transfer and cares for Resident #58 and failed to offer fluids before or after cares. * 03/02/22 at 10:07 a.m. a CNA (#15) provided transfer and cares for Resident #58 and failed to offer fluids before or after cares. - Review of Resident #151's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS, dated [DATE], identified Resident #151 required total assist of one staff member for eating. The current care plan stated,. I need assistance with my ADL's r/t impaired mobility from [CONDITION(S)] d/t [due to] spastic [CONDITION(S)] and contractures . EATING: I need staff assistance to eat my meals . provide and serve mechanical soft diet . Observation on 02/28/22 at 03:05 p.m. showed two CNA's (#16 and #17) provide catheter cares and transfer Resident #151 from bed to the wheelchair. Observations showed fluids available however staff failed to offer fluids before or after cares. - Review of Resident #73's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS, dated [DATE], identified Resident #73 required extensive assist of one staff member for eating. The current care plan stated, . I have an ADL self-care performance deficit r/t weakness and debility related to my [CONDITION(S)] [[CONDITION(S)]] . EATING: I need staff assistance/supervision at meals. Please assist/cue me . Observation on 03/01/22 at 9:05 a.m. showed two CNA's (#7 and #8) transferred Resident #73 to the bed and failed to offer fluids before or after cares. During an interview on 03/03/22 at 9:30 a.m., an administrative nurse (#10) stated it is the facility's expectation to offer resident's fluids with cares.

Based on observation, review of professional reference, review of facility policy and staff interview, the facility failed to follow infection control practices for 5 of 35 sampled residents (Resident #46, #70, #124, #140, #151) and 2 supplemental residents (#32 and #121) observed during cares. Failure to follow standard infection control practices has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: TRANSMISSION BASED PRECAUTIONS Review of CDC (Centers for Disease Control and Prevention) guidance found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html, updated August 13, 2021, stated, Reusable eye protection should [sic] cleaned and disinfected after each patient encounter. Ensure appropriate cleaning and disinfection after each use if reusable face shields or goggles are used. Review of CDC guidance found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated February 2, 2022, stated, . a NIOSH [National Institute for Occupational Safety and Health]-approved respirator or facemask is indicated for PPE [personal protective equipment] . during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. - Review of Resident #124's medical record occurred on all days of the survey. The physician's order dated 02/25/22, stated, Full Standard,Contact, Droplet Precautions . Observation on 02/28/22 at 2:41 p.m. showed Resident #124's door open with an isolation cart outside the room. Signage on the resident's door indicated contact precautions and PPE to be worn by staff but failed to include droplet precautions. Observation on 02/28/22 at 4:31 p.m. showed a CNA (certified nursing assistant) (#6) removed her gloves and gown prior to exiting Resident #124's room and removed the N95 masks outside the room. The CNA failed to remove and disinfect her goggles. The CNA wearing the contaminated goggles entered another resident's room. Observation on 02/28/22 at 4:33 p.m. showed a CNA (#7) removed his gloves and gown prior to exiting Resident #124's room and removed the N95 masks outside the room. The CNA failed to remove and disinfect his goggles. The CNA walked down the hallway and interacted with staff while wearing the contaminated goggles. - Review of Resident #46's medical record occurred on all days of the survey. The physician's order dated 02/22/22, stated, Full Standard,Contact, Droplet Precautions . Observation on 02/28/22 at 3:40 p.m. showed Resident #46's door open with an isolation cart outside the room with signage indicating contact and droplet precautions and PPE to be worn by staff. Observation on 02/28/22 at 4:28 p.m. showed a certified nursing assistant (CNA) (#5) donned PPE and entered Resident #46's room to provide cares. The CNA removed his gloves and gown prior to exiting the room. The CNA failed to disinfect his goggles, dispose of the N95 mask or store it in an acceptable way, and apply a new surgical mask. The CNA walked down the hall and interacted with staff while wearing the contaminated goggles and N95 mask. Observation on 03/01/22 at 1:09 p.m. showed two CNAs (#8 and #9) donned PPE and entered Resident #46's room to provide cares. The CNAs removed their gloves and gowns prior to exiting the room and removed the N95 mask outside the room. When asked where to get disinfectant wipes to clean goggles, the CNA (#8) stated, Well, we usually use the wipes from the lift, or we can use these wipes, indicating the bleach wipes in Resident #124's isolation cart. The CNA (#8) continued down the hall to store the lift while wearing the contaminated goggles and the CNA (#9) continued down the hall and interacted with a resident while wearing the contaminated goggles. Both CNAs failed to perform hand hygiene, failed to disinfect their goggles, and continued to wear the contaminated goggles. During an interview on 03/02/22 at 9:32 a.m., an administrative nurse (#1) stated she expects staff to disinfect eye protection, change face masks and perform hand hygiene for the appropriate infection upon leaving a transmission based precaution room and before performing another task. DRESSING CHANGE/HAND HYGIENE/PERINEAL CARES - Observation on 03/01/22 at 9:22 a.m. showed a nurse (#12) changed Resident #140's dressing to her sacrum. With donned gloves, the nurse removed the soiled dressing, used a wipe to clean bowel movement (BM) around the wound and without changing gloves, applied the new clean dressing. - Observation on 03/02/22 at 8:40 a.m. showed a CNA (#9) assisted Resident #70 with morning cares. During cares, the CNA dropped the washcloth on the bathroom floor, picked it up, and proceeded to wash the resident's perineal area with the same wash cloth. During an interview on 03/03/22 at 10:00 a.m., an administrative nurse (#13), stated she expected staff to follow standard infection control practices. DISINFECTION OF EQUIPMENT Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment occurred on 03/03/22. This policy, revised August 2020, stated, . Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC [Center for Disease Control] recommendations for disinfections . Reusable resident care equipment will be decontaminated and/or sterilized between residents . -Observation on 02/28/22 at 3:05 p.m. showed two CNAs (#16 and #17) utilized a total lift and transferred Resident #151 to bed to provide perineal cares. Following cares, the CNA (#17) removed the lift from the resident's room, and placed it in the hallway. The CNA failed to disinfect the lift. An unidentified CNA transported the contaminated lift into another resident's room. - Observation on 02/28/22 at 3:15 p.m. showed two CNAs (#16 and #17) used a total lift and transferred Resident #32 to bed to provide BM cares. One CNA (#16) remained gloved throughout cares, touching/moving the lift to the hallway and failed to clean the lift after use. An unidentified CNA transported the lift down the hall to another resident's room. - Observation on 02/28/22 at 4:14 p.m. showed two CNAs (#16 and #17) used a total lift and transferred Resident #121 to and from the bed to provide perineal cares. Following cares, the CNA (#17) removed the lift from the resident's room and placed it in the hallway. The CNA failed to disinfect the lift. During an interview on 03/03/22 at 8:15 a.m., an administrative nurse (#1) stated she expects staff to disinfect all lifts between each resident use.

Based on record review, review of the facility policy, review of the facility's investigation, resident and staff interview, the facility failed to implement policies related to the investigation and reporting of abuse/neglect for 1 of 1 sampled resident (Resident #35) with an injury of unknown origin. Failure to recognize an injury of unknown origin as potential abuse/neglect and implement their investigation/reporting policy placed all residents at risk for abuse/neglect and possible injury. Findings include: Review of the facility policy titled Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property occurred on 03/02/22. This policy, revised 08/12/19, stated, . Valley Senior Living will ensure that all alleged violations involving . mistreatment . are reported to the Administrator of the facility and to other officials (including to the State Survey Agency .) in accordance with State law through established procedures. All alleged violations that . result in serious bodily injury will be reported immediately, but not later than 2 hours after the allegation is made. During an interview on 02/28/22 at 2:06 p.m. Resident #35 stated, My pain is in my left hip, broke it 3 months ago. Girls that haven't worked with me before pulled on my sling. I said don't jerk me, but they were being 'butt heads' and would not listen. Doctor said it will heal by itself, but I'll always have pain. Resident #35 said he reported the incident to the charge nurse, she said they put me in my chair the right way, and they said they did. She wouldn't listen so I dropped it. Review of Resident #35's medical record occurred on all days of survey. The current care plan stated, I am totally dependent on 2 staff for transferring. Total mechanical body lift . Review of Resident #35's progress notes identified the following: * 09/16/21 at 3:26 p.m., Resident is reporting an increase in pain to Left stump. States he felt during reposition earlier today it may have got pulled on. Has been utilizing PRN [as needed] [MEDICATION(S)] which he reported has been somewhat effective. * 09/16/21 at 7:00 p.m., Writer called to notified [sic] on-call Physician about resident's pain to both knees and that resident suggesting going to the hospital. But NP [nurse practitioner] did not see the need for resident going to the hospital since there was no redness, swelling or bruise to affected areas. One time dose of [MEDICATION(S)] 50mg [milligrams] order. * 09/17/21 at 9:35 a.m., Received a call from [Facility Name] [CONDITION(S)] nurse at approximately 0850 [8:50 a.m.] stating upon assisting resident from the wheelchair with the lift resident reported an increase amount of pain to the left stump. [Facility Name] [CONDITION(S)] Nurse stated resident was assisted back down into wheelchair and was going to be transferred to [Facility Name] ER for further evaluation. Informed [Facility Name] [CONDITION(S)] Nurse that resident had reported earlier the pain seemed to be better under control and no discomfort was noted with transfer from bed to wheelchair this morning. [Facility Name] [CONDITION(S)] Nurse stated the total lift that they utilize are different than the total lift utilized here. [Facility Name] [CONDITION(S)] nurse stated the total lifts here have 4 hooks and the total lifts utilized at [CONDITION(S)] only have 2 hooks for the sling. * 09/17/21 at 1:52 p.m., Received a call from [Facility Name] [CONDITION(S)] Nurse at approximately 1352 [1:52 p.m.] and [Facility Name] [CONDITION(S)] Nurse stated [Facility Name] ER was in touch with them and that resident was going to be admitted to the hospital for fracture of left femur. * 09/17/21 at 3:58 p.m., Received a call from [Facility Name] ER Nurse at approximately 1530 [3:30 p.m.] that resident would be discharging from the ER and going straight to [CONDITION(S)]. Per [Facility Name] ER Nurse resident [sic] due to the type of fracture resident has it is a non operative type of fracture and will heal on it's own. [Physician] updated regarding resident returning from ER after completing [CONDITION(S)]. Review of the [CONDITION(S)] note dated 09/17/21 at 2:57 p.m. stated, patient arrived from [Facility Name] for his [CONDITION(S)] treatment. When checking [Resident #35] into [CONDITION(S)], he informed staff that he was pulled on hard by two CNA's [sic] Thursday morning at the nursing home during a transfer. We attempted to Hoyer [total body mechanical lift] lift him into the [CONDITION(S)] chair today and just a small movement of his left stump to string the Hoyer pad up to our lift caused him severe pain in his left hip. Visiting with the patient, he agreed to have his left sided pain evaluated in ER [emergency room ] prior to his [CONDITION(S)] treatment. Informed ER staff and [Facility Name] staff of the plan. Review of the Injury Observation form dated 09/17/21 at 08:31 a.m., stated, Fracture to left hip. Resident stated it could have occurred during repositioning or from how he was positioned in the wheelchair on 9/16. Classification of Injury - Injury of known or suspected source. Review of an email regarding the investigation of Resident #35's fracture occurred on 03/03/22. This email, dated 09/17/21 at 5:39 p.m., stated, [Nurse #4] and [Administrator #2] talked about [Resident #35] and his concern this afternoon that two aides at Valley Senior Living were the cause of his fracture from a transfer yesterday. He described the transfer, which was appropriate to his care plan, but he had pain from the transfer. He said the staff laughed about his pain which I don't have the context of the conversation they were in, but we need to ask the staff about. While this could be construed as an allegation of abuse, I don't see this as reportable because 1. The specific transfer was described by the resident as a transfer appropriate to the care plan. It had an outcome of pain. The reported laughing of CNAs needs to be asked about but is not an allegation of abuse, neglect, or mistreatment. 2. We do not know when the fracture occurred . A provider note dated 09/20/21, stated, the exact mechanism and time of the injury is unclear. He is attributing it to a particular staff during a particular transfer . he did not have any fall or specific trauma, and is not able to get himself out of bed without assistance . Review of an Orthopedic Clinic Progress Note dated 09/22/21, stated, [Resident #35] . who presents to the clinic today for left subtrochanteric femur fracture in setting of AKA [above the knee amputation]. DOI [date of injury] 9/16/21 after he was boosted in his wheelchair. During an interview on 03/03/22 at 9:45 a.m., two administrative staff (#2 and #3) confirmed the facility did not report the alleged violation of serious injury to the State Survey Agency. During an interview on 03/03/22 at 10:06 a.m., a nurse (#4) stated, Resident #35 told me, They pulled on the sling and when they did that, something hurt. The nurse (#4) demonstrated pulling up on the sling from behind the resident.

Based on observation, review of facility policy, and staff interview, the facility failed to provide care in a manner that enhanced or maintained residents' dignity for 2 of 36 sampled residents (Resident #111 and #130). Failure to ensure residents' privacy while providing personal cares does not enhance their quality of life and is a violation of residents' rights. Findings include: Review of the facility's standards of care policy occurred on 01/30/20 and identified skills/tasks to be completed by the certified nursing assistants (CNAs). The document stated, Privacy/Dignity . Knock & count to 5 or await response before entering room . - Observation on 01/27/20 at 2:58 p.m. showed a staff member (#1) assisted Resident #111 to the bathroom. While the resident was in the bathroom and seated on the toilet, another unidentified staff member knocked on the door to the resident's room. The staff member (#1) stated, Just a minute; however, the unidentified staff member entered the room to bring fresh water. While Resident #111 was standing and the staff member (#1) provided perineal care, a different unidentified staff member knocked on the door. The staff member (#1) again stated, Just a minute; however, the unidentified staff member entered the room to bring fresh water. The staff member noticed Resident #111 already had water, looked into the bathroom, and stated, Oh, you already have some (water), and then left the room. - Observation on 01/28/20 at 4:49 p.m. showed a CNA (#3) assisted Resident #130 with catheter care in the resident's room. An unidentified staff member knocked on the door and immediately entered the room. The staff member stated, Oh, and then left the room. During an interview on the morning of 01/30/20, a supervisory staff member (#2) stated staff are expected to knock on doors and wait for a response.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASRR), the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #50) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASRR Provider Manual states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (Mental illness, intellectual disability, and conditions related to intellectual disability (referred to in a regulatory language as related conditions or RC)) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #50's medical record occurred on all days of survey. The record showed an initial PASRR completed on 08/08/18 and identified a [DIAGNOSES REDACTED]. A psychiatric progress note, dated 09/05/19, identified a [DIAGNOSES REDACTED]. The record lacked evidence of an updated Level I screening/change in status assessment since this diagnosis.

Based on observation, record review, review of professional literature, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being for 1 of 1 sampled resident (Resident #104) toileted with a full body mechanical lift who experienced unnecessary anxiety and pain during toileting. Failure to recognize and acknowledge Resident #104 was experiencing pain and address the underlying cause for her pain resulted in Resident #104's experiencing avoidable anxiety and pain while being toileted with a lift. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, page 1035, states, . Positioning a client in good body alignment and changing the position regularly and systematically are essential aspects of nursing practice . people who are weak, frail, in pain . rely on nurses to provide or assist with position changes . Any position, correct or incorrect, can be detrimental if maintained for a prolonged period. Frequent change of positions help to prevent muscle discomfort . When the client is not able to move independently or assist with moving, the preferred method is for two or more nurses to move or turn the client and use assistive equipment. Appropriate assistance reduces the risk of muscle strain and body injury to both the client and nurse, and is likely to protect the dignity and comfort of the client. Review of Resident #104's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. The residents annual Minimum Data Set (MDS), dated [DATE], identified Resident #104 as being totally dependent with transfers, requiring extensive assistance with toileting (two plus), and receiving of scheduled and as needed (PRN) pain medications. The MDS further indicated Resident #104 has clear speech and responds adequately to simple, direct, communication. Resident #104's most recent care plan, stated, . I require (total assistance) by (2) staff for toileting. I am checked and changed every 2 hours or PRN. I wear a medium brief for incontinence. I dribble urine and am incontinent of bowel. I am able to use the commode if I request . I require assistance by 1 staff to turn/roll side to side in bed . I have (Chronic) pain r/t left shoulder pain . Anticipate my need for pain relief and respond immediately to any complaints of pain . report any signs/symptoms (s/sx) of non-verbal pain: Changes in breathing (noisy,deep/shallow, labored, fast/slow; Vocalizations (grunting, moans, yelling out, silence); Mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide, open/narrow slits/shut, glazed, tearing, no focus); Face ( crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) . I do have a history of hollering out either my daughters name or making comments of just take me now when frustrated or in pain. I am usually . calm . I can answer you but am quite passive and content to let you take care of me. Observation on 02/06/18 showed the following: * 1:22 p.m.: A certified nursing assistant (CNA) (#12) transported Resident #104 to her room to perform toileting cares. Resident #104 stated, I think I went in my pants. After retrieval of a sit to stand lift, the CNA (#12) waited for another staff member before transferring Resident #104 from her wheel chair (WC) to the commode. An unidentified CNA entered the room and stated, This resident uses a Hoyer lift (a full body mechanical lift). * 1:30 p.m.: The unidentified CNA returned to the Resident #104's room with a full body mechanical lift. * 1:35 p.m.: Both CNAs (#12 and unidentified) applied the toileting sling to the resident and raised the lift. Resident #104 was left suspended in the toileting sling for approximately 4 minutes while one of the CNAs (#12) positioned the commode under her and attempted to remove her brief which was soiled with bowel movement (BM). The CNA (#12) was unable to remove the soiled brief. She tore away the tabs on each side of the brief causing the back of the brief to fall into the commode. * 1:39 p.m.: The unidentified CNA lowered Resident #104 onto the commode and exited the room. Resident #104 stated, Right now this hurts me, as she sat at an angle on the commode, leaning back while her feet dangled in the air. * 1:44 p.m.: Resident #104 asked the CNA (#12), Can you stand me up now? Please. I'm not ok. I'm uncomfortable. I am afraid I am going to fall out. Resident #104 had been improperly positioned on the commode for 6 minutes. * 1:45 p.m.: Resident #104 stated, It hurts an awful lot. Please lift me up. Oh, how my legs hurt. I don't know how I'm going to be able to stand. My back, my back, how it hurts. The CNA (#12) emptied Resident #104's nephrostomy bag. Resident #104 grimaced and asked, Can I get up now? You called a long time ago, and no one has come yet. Please call again. * 1:52 p.m.: In a weepy sounding voice Resident #104 asked the CNA (#12), Can I get up now? You called a long time ago, and no one has come yet. Please call again. * 1:54 p.m.: Resident #104 yelled, Why aren't they coming? I feel like I'm going to pass out. * 1:55 p.m.: A second CNA (#20) entered Resident #104's room. * 1:56 p.m.: Resident #104 cried, Help! Help! As one CNA (#20) raised the lift, the second CNA (#12) attempted to remove Resident #104's brief again by pulling it from the front, but she was unsuccessful. The CNA (#12) then stepped behind her and pulled the brief from the back, smearing BM across Resident #104's peri area. * 1:58 p.m.: As the CNA (#12) wiped the BM from her peri area, Resident #104 continued to cry and yell out in pain as she hung in the sling with her elbows elevated toward the ceiling. * 2:00 p.m.: The surveyor left the room in an effort to locate a staff nurse. Resident #104 had been hanging in the lift for 5 minutes. * 2:01 p.m.: A nurse (#11) entered Resident #104's room with the surveyor. Resident #104 continued to cry and yell out, Let me down! as the CNA (#12) continued to clean the BM from her peri area. * 2:02 p.m.: Both CNAs (#12 and #20) lowered Resident #104 onto the commode. She yelled, I can't feel my ass, or arms and hands! Help me! Help me! Give me something to put me down! Give me something to put me down! One of the CNAs (#20) commented, Let's lay her down on the bed and finish cleaning her up there. Resident #104 had been suspended in the lift for 7 minutes. The other CNA (#20) then looked for a clean sheet and chux (disposable pad), but was unable to find either. She (#20) left the room to retrieve the items. Resident #104 continued to cry and yell as she sat on the commode, soiled with BM. * 2:06 p.m.: After the CNAs (#12 and #20) had transferred Resident #104 from the commode to her bed, the nurse (#11) and one of the CNA (#20) exited the room. Resident #104 yelled, My ass end hurts. The remaining CNA (#12) removed the toileting sling, catching the velcro in Resident #104's hair. She shouted, Ouch. Ouch that hurt. Boy do I hurt? It hurts so much. My rear hurts so bad? It has never hurt like that before. Please be careful! It hurts so bad now. Resident #104 laid on her back in silence and appeared exhausted while the CNA (#12) retrieved cleansing wipes and a clean brief. Resident #104 stated, It's burning! Please get me out! Can you give me a pill I can go out with? The CNA (#12) did not respond to Resident #104's question. The CNA (#12) attempted to roll the resident onto her left side. Resident #104 grimaced and with tears on her face cried, Ow, it hurts so bad. I can't lay on this side. Tell them I want a pill to go out. It hurts terrible. Please give me something. It hurts so bad. Please get my daughter in here. * 2:10 p.m.: The CNA (#12) was unable to roll the resident onto her left side and called for assistance. * 2:15 p.m.: The CNA (#12) called the nurse requesting Resident #104 be given something for pain. Resident #104 stated, It hurts. I can't hear you. Please help me. It kills my ass and I can't hear what you are saying. Oh it hurts! * 2:18 p.m.: A CNA mentor (#21) entered Resident #104's room and assisted the CNA (#12) to roll the resident onto her left side in order to continue cleansing her peri area. Resident #104 stated, [MEDICAL CONDITION] you are touching me. * 2:22 p.m.: After running out of wipes, the CNA (#12) used a wet wash cloth to cleanse the BM from Resident #104's peri area. The resident continued saying, Ow, it hurts. * 2:30 p.m.: Staff rolled Resident #104 onto her right side and continued cleaning her. She stated, It still hurts in the crease so bad. Then a nurse (#19) entered Resident #104's room. * 2:33 p.m.: Both CNAs (#12 and #21) adjusted Resident's #104 clothing. She grimaced, clenched teeth, and stated, My ass hurts. No, I don't want to lay on my side. Why does it hurt so much? [MEDICAL CONDITION] someone did something. No, its my ass that hurts. The nurse (#19) administered Resident #104's pain medication and exited the room. The pain medication was administered 56 minutes after Resident #104 first complained of having pain. * 2:38 p.m.: Both CNAs (#12 and #21) transferred Resident #104 from her bed back into her WC. Looking at the commode, Resident #104 stated, I don't have to sit on that thing again do I? She (#104) continued to complain of buttock pain. * 2:41 p.m.: Resident #104 continued to grimace with any movement/positional change in her WC. * 2:45 p.m.: Staff transported Resident #104 to the afternoon activity. During an interview on 02/06/18 at 05:00 p.m., three administrative staff members (#3, #22 and #23) confirmed staff failed to: * recognize/acknowledge Resident #104 verbal and non-verbal signs/symptoms of pain as care-planned, * immediately address the cause(s) of Resident #104's pain as outlined on her care plan, * reposition Resident #104 on the commode, * reposition Resident #104 in the toileting sling, and * report Resident #104's continued complaints of pain throughout the 56 minute toileting care to her nurse for assessment as care-planned. These failures resulted in Resident #104 experiencing avoidable anxiety and pain while being toileted.

1. Based on record review, facility policy and procedure review, and staff interview, the facility failed to ensure 1 of 1 sample resident (Resident #1) who experienced an injury and decline following a fall, 1 of 1 sampled resident (Resident #3) who fell from a Hoyer lift (a type of mechanical lift that supports the entire weight of the resident), and 2 of 3 sampled residents (Resident #2 and #16) observed during transfers utilizing a stand lift (a type of mechanical lift designed to support only the upper body of the resident and requires the resident have some weight-bearing capability) received adequate supervision and assistance to prevent accidents and injury. Findings include: Review of the facility procedure titled "TRANSFERRING THE RESIDENT TO AND FROM BED TO CHAIR" occurred on 12/22/11. This procedure, revised April 2010, stated, "A. Transfer from Bed to Chair or to Ambulate: 1. Equipment: a. Gait belt is always used in transfers with 1-2 staff members. . . ." Review of the facility procedure titled "Fall Risk Assessment" occurred on 12/22/11. This procedure, revised May 2007, stated, "PURPOSE: To identify and set up a prevention plan for those residents at high risk for falls . . . PROCEDURE: A. Upon admission (within 24 hours), follow up after a fall with Fall Assessment . . . and quarterly thereafter, the resident will be assessed for risk of fall. At the discretion of the Charge Nurse or Care Coordinator, the assessment may be done more frequently if the resident has a change in condition . . . C. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention care plan should be initiated and documented on the care plan. D. Possible interventions for high risk residents might include: 1. Low beds with blue mat 2. Defined perimeter mattress 3. Bed and/or chair checks 4. Schedules for toileting and/or exercise 5. Environmental modifications (e.g., room arrangement) 6. Other anticipation of needs as defined in Care Plan. . . ." Review of the facility procedure titled "Fall Management" occurred on 12/22/11. This procedure, revised May 2007, stated, "POLICY All residents admitted to Skilled Nursing of Valley Memorial Homes will be assessed upon admission for being at risk for falls and reassessed according to change in medical condition and/or quarterly. PURPOSE: 1. To provide a safe environment for resident and enhance resident care by reducing number of falls. 2. Implement appropriate fall prevention strategies. PROCEDURE: 1. Fall Risk Assessment from will be completed upon admission with quarterly assessments, and with changes in condition (if indicated). 2. If resident indicates to be at risk for falls and/or if a resident falls, the following fall prevention strategies will be considered: A. Orient or re-orient resident to call light, bathroom location, and bedrail use. B. Remind resident about careful ambulation, body mechanics, and other precautionary practices. C. Inform resident to call (using call light) for assistance. D. Place bed in low position when unattended. E. Secure locks on beds and wheelchairs when appropriate for safety. F. Use side rails and/or restraint alternatives . . . G. Place call light, personal items, cane and/or walker within easy reach. H. Place needed items on functional side of resident. I. Review selection and use of proper non-slip footwear. J. Place on regular observation/schedule and toilet resident as he/she requests. K. Assure floor areas are dry and unobstructed. L. Clear room of unnecessary equipment. M. Cognitive status of resident is a consideration for all strategies. 3. Immediate post-fall actions: A. Assess and document status of Resident. B. Treat sustained injuries. C. Inspect environment to determine potential cause of falls. D. Interview resident and witnesses. E. Assess need for restraint alternatives and document findings . . . 4. Additional Treatment A. Attending physician or GNP (Geriatric Nurse Practitioner) notified and resident examined if injury noted. B. Family notified of resident's injury, unless permission is not granted by resident. C. Review Care Plan. D. Referral to PT (physical therapy) and/or OT (occupational therapy) as indicated. E. Follow-up Assessment of Resident by Licensed Nurse utilizing Physical Assessment Monitoring Form. 5. Documentation A. Complete Physical Assessment Monitoring Form every shift as indicated. (Licensed Nurse) B. Complete Resident/Incident/Accident Report, as indicated in procedure. C. RN Care Coordinator or designee will evaluate fall and document results. (Fall RAP sheet or chart note may be used for documentation of follow up). D. Resident compliance/non-compliance with fall prevention strategies. E. Inability of resident to understand fall precautions ([DIAGNOSES REDACTED]. F. Update Care Plan. . . ." Review of information provided by the facility titled "Report" occurred on 12/22/11. This undated information, stated, "Verbal or taped Include all pertinent info: Falls . . . Change in condition . . . ADL changes Family concerns or complaints. . . ." Review of the facility procedure titled "PAL PRO 1 Lift, Procedure for the use of" occurred on 12/22/11. This procedure, dated 10/01/98, stated, "PURPOSE: To provide instruction for safe use of the PAL PRO 1 Lift. The PAL PRO 1 Lift is a total body lift . . . CAUTIONS FOR USE OF PAL: 1. Always have 2 staff persons present when using the Pro 1 . . . 8. Make sure all 4 loops from the sling are on the hooks of the hanger before lifting a resident. 9. Do not use sling that shows excessive wear or is torn. 10. Use only PAL slings designed for use with the PAL PRO 1 model . . . PROCEDURE: . . . B. SELECTING THE STYLE OF SLING TO BE USED The first step is to select the style of the sling to be used . . . All the styles have a color coded border to easily indicate the size of the sling . . . The loops on the straps are color coded for positioning the sling to the desired location. Changing the orientation of these loops will change the angle of the person being transferred. This comes in handy for charting the colors that would work best for each individual. . . ." - Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified the resident with a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition; showed the resident required extensive assistance of one staff member for toilet use and transfers; no falls since admission or the prior assessment; continent of bowel and bladder; and not on a toileting program. The medical record showed the resident with a history of falls, occurring on 10/31/11, 11/13/11, 11/26/11, two occurrences on 12/08/11, and on 12/20/11. The care plan, dated September 2011, stated, ". . . 09/27/11 . . . After a long hospital stay for pneumonia, I'm quite weak and need help with my cares until I get stronger . . . Interventions, I may need help with bed mobility: assist of 1-2 with bed mobility, I need help with transfers: transfers with assist of 1-2, I need help with ambulation: ambulates with assist of 1 with use of FWW (front-wheeled walker) , distance as tolerated. (This intervention was crossed out and "I am not walking anymore" handwritten on December 2011) . . . I need help with toileting: requires assist of 1 with toileting. I am usually continent of bladder and of bowel. (A handwritten note, dated December 2011, identified the resident as occasionally incontinent of bowel and with an indwelling catheter) . . . I can feed myself after being set up (A hand written note, dated December 2011, identified the resident currently needs help with his meals) . . . I have been evaled (evaluated) by therapy (and) deemed safe to use my electric scooter (handwritten and dated October 2011). . . ." An additional section of the care plan, dated October 2011, stated, ". . . 10/10/2011 . . . I can be unsteady on my feet at time (sic), especially since I've been sick, so please help me when I request so I don't fall . . . Interventions, Keep my furniture in consistent place to promote familiarity. Keep walkways open and free of clutter, Staff will report changes in LOC (level of consciousness) i.e. increased confusion, sedation, lethargy. Report unsteady gait, transfers, physical strength, etc . . . I transfer with assist of 1. I am able to ambulate with assist of 1 with FWW (front-wheeled walker). Uses w/c (wheelchair) for primary mobility . . . Please make sure my call light (is) within reach. Encourage to use for assistance with transfers/ambulation. Safety devices: I will use my call light for help, though I do appreciate when staff come in and check on me . . . Staff will (sic) falls risk assessment quarterly. . . ." A handwritten intervention, dated 11/11 (November 2011), stated, "I like to be Independent in my rooms (sic), I don't always like to let staff help me, so I may make unsafe decisions that put me at higher risk of falling," and another intervention, dated 12/11 (December 2011), stated, "perimeter mattress, bed (checks), fall mat." The care plan identified inconsistencies regarding the level of assistance Resident #1 required. During an interview on 12/21/11 at 4:20 p.m., an administrative nurse (#12) stated staff implemented a perimeter mattress, bed alarm, low bed, and fall mat after his fall from his bed on 12/20/11. (The care plan listed above lacked the specific date the facility staff implemented these interventions.) During the initial tour, family members visiting Resident #1 stated he was alert, cognitively intact, ambulatory, and spoke clearly prior to his second fall on 12/08/11. Observations during the survey showed Resident #1 lethargic; his eyes closed the majority of the time; speech incomprehensible; decreased responsiveness; bedridden; bruising under both eyes, on the right side of his neck, and on the right side of his forehead. Review of Resident #1's Resident Care Notes identified the following: *12/08/11 at 10:50 a.m. - "Data: (name of CNA) in rm (room) (with) resid (Resident). Resid stepped back (with) walker (after) washing his hands @ (at) sink. Resid lost his balance, fell back, landing on buttocks . . . Resid did not hit head. No injuries observed. Resid able to move all 4 extremities (without) difficulty. Resid assisted to stand (with) (3) assists et walker. Resid amb (ambulated) to electric scooter (with) assist. (No) difficulty." *12/08/11 at 8:30 p.m. - "Data: (name of CNA) in room with resident assisting with HS (hour of sleep) cares as he allowed. He was at the sink brushing teeth, she was tidying room. She heard him hit the floor. Found face down, head turn (sic) so (right) cheek resting on floor. Arms at sides. Blood coming from both nares. Large bump to right side of head. (Right) eye swollen. Call placed to (name of physician) as (Resident #1) was unresponsive to verbal and pain stimuli. Assist of 4 to roll to back, maintaining good head alignment. Call placed to (name of son). Unresponsiveness lasted from 7:50 p.m.- 8:08 p.m. Unable to assess (right) eye refraction. (Left) eye sluggish, 2 mm (millimeter) dilation. Son requested he be sent to the ER (emergency room ) and stated he would come. Call placed to (Name of facility) for ambulance. C-collar applied by ambulance staff. Assisted by staff to move to gurney." *12/08/11 at 10:30 p.m. - "Data: Call from hospital. (Resident #1) will be returning. X-rays, scan negative. Will be sending clamp if nose bleeds clamp until stops if unable to stop, send back to ER. . . ." *12/08/11 at 11:45 p.m. - "Data: Back on unit at 11:30 p.m. Transported on gurney from (Name of ER) per our facility gurney et staff. 4 assist to transfer to bed . . . Responds with eye flutter, mumbling to voice." *12/09/11 at 3:30 a.m. - "Data" Sleepy oriented X (times) 3. Does not remember fall. Denies pain. Dried blood to nares. Nurse explained we wanted to wait until moring (sic) to clean nose well outside of nare cleansed. No headache. Slightly reddened area to lateral (upper) (left) arm. Bilateral black eyes, hematoma-like area to (right) eye and right side of head." *12/09/11 at 6:15 a.m. - "Data: Noc (night) nurse states resident has bloody nose she is unable to stop - even (with) nose clamp et ice pack et pinching via fingers. Call placed to ER et informed resident would be sent over." *12/09/11 at 6:45 a.m. - "Data: Resident transported to ER @ this time. Went via gurney et accompanied by noc nurse et CNA. . . ." *12/09/11 at 10:00 a.m. - "Data: Resident admitted to (name of hospital) . . . Dx (diagnosis) of nose bleed." During an interview on 12/20/11 at 4:00 p.m., a CNA (#32) identified she was with the resident in his room during the second fall on the evening of 12/08/11. She stated when she assisted Resident #1 with HS cares, he wanted to wash his face at the sink independently. She stated while he washed his face, she walked over to adjust his bed, and then she looked and saw Resident #1 fall back and hit the right side of his head on the floor, resulting in blood loss and emergency treatment. She further stated she was unaware of Resident #1's fall that occurred that same morning on 12/08/11. Review of Resident #1's Resident Care Notes upon return from his hospital admission identified the following: *12/16/11 late entry for 11:40 a.m. - "Data: Resid returned from (name of hospital) via gurney, accompanied by . . . transport aid . . . hosp diagnosis (sic) - fall, coagulopathy, closed head injury, subdural (hematoma), subarachnoid bleed, epistaxis . . . anemia - acute blood loss, acute [DIAGNOSES REDACTED], hypernatremia, peripheral edema . . . [DIAGNOSES REDACTED], et coccyx skin breakdown. . . ." *12/16/11 at 4:00 p.m. - "Data: Skin assessment done. Lge (large) bruises under both eyes - purple red in color. Bruises to lateral jaw-line down to neck - faded purple. Knuckles to both hands are red. Purple bruise to (left) forearm et (left) elbow. Red bruise to crook of (right) arm. . . ." Review of the Physician Discharge Summary for Resident #1's hospital stay December 09-16, 2011, stated, ". . . Discharge (or Final) Diagnoses: [REDACTED]. . Closed head injuries: subdural hematoma; subarachnoid bleed (small); parenchymal bleed - secondary to above Epistaxis; severe Anemia of acuate (sic) blood loss - epistaxis; requiring transfusions X 3 units . . . Hospital Course: . . . 3. Acute [DIAGNOSES REDACTED]. . . ." Review of the Resident Care Notes showed the following entries after Resident #1's return from the hospital: *12/17/11 at 2:45 p.m. - "Data: . . . Lethargic but arousable - barely opens eyes. Speech mumbled at times . . . Ate fair for lunch (with) staff feeding him . . . Bedrest - turned et repos (repositioned) timed (every) 2 hr (hours) et prn (as needed). Total assist (with) ADLs (activities of daily living). . . ." *12/19/11 at 2:30 a.m. - "Data . . . Speech still cont (continues) to be non-coherent . . . Res (resident) bedrest. . . ." *12/19/11 at 10:00 a.m. - "Data . . . Resident awake this am (morning) speaking another language besides English. Remains . . . on bedrest . . . Received total assist (with) ADLs. . . ." *Resident Care Note not timed or dated. Per staff member, entry completed 12/20/11 at 12:30 a.m. - ". . . Res found sitting on floor by bed, back up against bed . . . Res on antibiotics for[DIAGNOSES REDACTED] (clostridium difficile) (no) injuries noted res is non verbal, talks garbled so you can't understand what he is saying. . . ." *12/20/11 at 9:45 a.m. - "Data: . . . Resid offers no verbalization this am . . . Has remained on bedrest. . . ." *12/20/11, untimed - "Data: Bed check et fall mat had been placed this am after fall et perimeter mattress placed on bed this am. Res remains confused et requires extensive to total assist (with) ADLs. Will cont to monitor." During an interview on 12/20/11 at 4:00 p.m., two CNAs (#32 and #33) stated they were unaware of Resident #1's fall from bed earlier that morning, at 12:30 a.m. Both CNAs stated the fall was not on their written report sheet and was not communicated to them. Review of the CNA report sheet on the afternoon of 12/20/11 showed the facility failed to identify/communicate Resident #1's fall, which occurred that same morning at 12:30 a.m., to the oncoming shift caring for the resident. During an interview on 12/21/11 at 11:15 a.m., when asked about the inconsistencies in the medical record regarding the level of assistance Resident #1 required, an administrative nurse (#12) stated Resident #1 required assistance of one staff member for transfers and toileting since his admission, and stated she expected staff to use a gait belt when assisting him. She stated she was unaware staff failed to use a gait belt when assisting Resident #1 during both incidents on 12/08/11. She stated the use of gait belts are not always identified on a resident's care plan, as it is the facility's expectation to use a gait belt when a resident requires assistance. This nurse (#12) stated she expected the CNA (#32) working the evening shift on 12/08/11 to have known about Resident #1's fall earlier that morning, and to have been extra cautious when caring for the resident. The nurse (#12) stated communication occurs between shifts by the following methods: the nurse working each shift fills out a shift report sheet which the CNAs read when they start their shift, or the nurses tape a verbal report for the nurse starting the next shift. At 11:55 a.m., this nurse (#12) stated the CNA report sheet correctly identified both falls occurring on 12/08/11, and confirmed staff failed to identify Resident #1's fall occurring at 12:30 a.m. on 12/20/11. Based on evidence reviewed, the facility staff failed to take a proactive approach and implement fall interventions upon Resident #1's return from the hospital on [DATE] to prevent further falls; failed to ensure effective communication of Resident #1's falls to oncoming shifts; and failed to provide the assistance necessary to ensure Resident #1's safety on the evening of 12/08/11. These failures resulted in an avoidable fall on the evening of 12/08/11, which required extensive acute medical interventions to treat life-threatening injuries. - Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated intact cognition; showed the resident required extensive assistance of two or more staff members for transfers; and had no falls since the prior assessment. The care plan, dated September 2011, stated, ". . . I fell and broke my right hip and lower leg, so I need lots of help with my ADLs . . . Bed Mobility: I need assist of 1 or 2 with bed mobility . . . Transfers: I need transfers with assist of 2 and total lift (care plan revised to assist of 1 for transfers without a total lift, dated November 2011) . . . I will have safe transfer to and from bed, w/c, and toilet . . ." Review of Resident #3's Resident Care Notes identified the following: *08/30/11 at 6:00 a.m. - "Data: Resident's BR (bathroom) call light on, resident found laying on the BR floor on Rt) (right) side, resident denied hitting head et (and) saying she was ok, able to move extremities (with) (no) c/o (complaints of) . . . resident hoyered off of the floor (with) assist of 4, bruise noted to Rt) knee - pink in color - measuring 3 cm X (by) 3.8 cm, sm (small) red, purple bruise to Rt) (upper) cheek, resident still denied hitting head but writer pointed out bruise to Rt) cheek et resident said "well I don't know I guess I must have hit my head," CNA (certified nurse aide) assisting resident to change gown et resident unable to bear wt (weight) on Rt) leg et c/o her pain being a 9, writer asked resident if she wanted to go to the ER (emergency room ) et get checked out resident said "yeah I suppose I should," resident given a prn (as needed) percocet before going over to the ER." *08/30/11 at 11:00 a.m. - "Data: (Resident) returned from . . . ER . . ." (Orders upon Resident #3's return from the ER, stated, "Res (resident) to be NWB (non-weight bearing) until is seen by (name of physician).") Review of the Emergency Department Note, dated 09/01/11, for the incident on 08/30/11, stated, ". . . PHYSICAL EXAMINATION: . . . EXTREMITIES: She is able to fully flex and extend the knee, but she has some pain with that . . . I did get x-ray of the tib-fib (tibia-fibula) (outer lower leg bone). I did review this and I do not see any obvious fractures. Radiology report pending. ASSESSMENT: 1. Right leg contusion (bruise). 2. status [REDACTED]. PLAN: I discussed the case with the patient and care coordinator. She was discharged back to the nursing home. She does have plenty of help there in moving about. I talked to her about following up with her primary or with orthopedics, particularly if she is not on a course of progressive improvement and I did talk to the patient and the caregiver about occult (hidden) fractures. ADDENDUM: The finalized report on this tib-fib did reveal a nondisplaced distal fibular fracture. The patient will be contacted and we will see if a postoperative boot or CAM (controlled ankle movement) walker will be tolerated by the patient for treatment of [REDACTED]. Review of Resident Care Notes following Resident #3's return from the ER identified the following: *08/31/11 at 6:50 a.m. - "Data: Bath aide and CNA in room Res refused shower. Bed bath given while in bed. Hoyer sling (blue) was used to get her out of bed. Blue sling was around her et she started sliding et she let go et slid through sling landing on her back/bottom lying on her w/c (wheelchair) footrests (with) head on her w/c seat. denies hitting head several abrasions to back from footrests. leg (sic) were stretched out in front of her next to her recliner. Staff tried to get w/c underneath her but unable . . . Res is alert. Has pain from previous incident on 8/30 (08/30/11). Res lifted from floor using mesh bath sling et hoyer (with) (three) assist. (Name of son) was called et informed . . . Did also inform him about crack to distal fibula et the orders we received . . ." *08/31/11 - "Data: appt (appointment) made (with) (name of physician) . . ." *08/31/11 at 11:00 p.m. - "Data . . . resident denied pain at time of assessment, says it hurts when she moves Rt) leg but if she is just laying still she feels ok, has been getting prn percocet for pain, will continue to monitor." *09/01/11 at 8:45 a.m. - "Data: To appt (with) (name of physician) . . ." *09/01/11 at 10:00 a.m. - "Data: Returned from appt. To wear boot @ (at) all times . . . NWB on (R) (right) L/E (lower extremity)." *09/07/11 at 12:40 p.m. - "Data: (Name of physician) here et Rsd (resident) c/o (increased) pain to R) hip . . . received x-ray orders to R) hip . . . ordered to (increase) percocet PRN order d/t (due to) (increased) pain . . . Action: Rsd to (name of facility) for R) hip x-ray." (Review of the x-ray results, dated 09/07/11, stated, ". . . Bony structures appear demineralized . . . There is a fracture involving the right femoral neck. That is mildly displaced and somewhat angulated . . . There is a degenerative change of both hips . . .") *09/07/11 at 3:00 p.m. - "D (data): Phone call from (Name of physician). A (action): Continue to use hoyer for transfers from bed-w/c-bed . . . He will talk over with collegues (sic) about plan for surgery . . ." *09/07/11 at 3:15 p.m. - "D: Notified son of (name of physician) plan. and of (right) hip fx (fracture)." Review of a physician progress notes [REDACTED]. . . being evaluated for hip surgery. Subjective: She fell a little over a week ago and sustained an injury to her right leg. Initially it appeared that she had fractured her fibula and nothing else. However, because of continued pain in her right hip area, another x-ray was taken, which showed a displaced fracture of the right femoral neck. She has been evaluated by orthopedic and it is felt that surgical intervention should be done . . ." Review of an additional Resident Care Note stated the following: *09/14/11 at 12:00 p.m. - "Data: Resid (resident) returned to VEC (Valley Eldercare) . . . Resid hosp (hospital) diagnosis - s/p (status [REDACTED]. . ." During an interview on 12/21/11 at 4:45 p.m., a CNA (#33) stated the facility has different types of Hoyer slings available to transfer residents, including full body slings and toileting slings. The CNA (#33) stated therapy determines the appropriate sling size to be used for each resident and stated each resident should have their own sling in their room. During an interview on 12/22/11 at 7:40 a.m., two CNAs (#22 and #23) stated the CNAs look at a weight chart in the clean utility room to determine the correct sling size for residents. On 12/22/11 at 7:45 a.m., a nurse (#43) stated therapy usually evaluates residents to determine the proper sling size when they are changed to a mechanical lift transfer. An interview with a physical therapy staff member (#24) and with an occupation therapy staff member (#25) occurred on 12/22/11 at 8:15 a.m. The staff members stated therapy does not always evaluate a resident for transfers when a clear reason exists for needing a different transfer method, such as changing to a non-weight bearing status. The therapy staff members (#24 and #25) stated the CNAs and nurses decide what size of mechanical lift sling to use based on the resident's weight. Discrepancies existed between different staff members when asked about the process to determine the appropriate size sling for residents who transfer with a mechanical lift. On the morning of 12/22/11, an administrative nurse (#12) stated she and another administrative staff nurse (#36) both investigated Resident #3's fall from the Hoyer lift, occurring on 08/31/11. She stated she was unaware what exact sling was used in the transfer, or what exactly happened to cause the fall, but more than likely staff used the wrong size sling. She stated the CNAs look at a weight guide to determine which sling to use when transferring residents. Each resident has their own sling located in their room. On 12/22/11 at 8:20 a.m., an administrative nurse (#36) involved in the fall investigation, stated she also didn't know what happened to cause Resident #3's fall from the Hoyer lift sling on 08/31/11. She stated she was unaware what exact sling they used, but stated the staff probably should have used a different sling, and "couldn't imagine her slipping out." The staff members failed to determine the specific type of sling used during the fall from the Hoyer lift on 08/31/11 (full body sling or toileting sling versus "blue" sling), why the resident slid out of the sling, and what interventions to implement to prevent a reoccurrence. Failure to determine the specific type of sling used during the fall from the Hoyer lift on 08/31/11 (full body sling or toileting sling, etc., versus "blue" sling) and why the resident slid out of the sling; and failure to have a consistent process in place across all facility disciplines to determine the safe and appropriate sling size may have resulted in an avoidable fall and harm to Resident #3. Failure to ensure safe transfers with a Hoyer lift may cause falls and injuries in the future to all residents who transfer with a Hoyer lift. - Review of Resident #2's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance of two or more staff members for transfers. The resident's current care plan identified the resident transferred with a mechanical stand lift and assistance of two staff members and showed the resident experienced occasional pain related to her arthritis. Observations of staff transferring Resident #2 showed the following: * 12/20/11 at 11:00 a.m. - Two certified nurse aides (CNAs) (#18 and #19) used a mechanical stand lift to transfer Resident #2 from her wheelchair to the commode and back to her wheelchair. During the transfer, the resident grimaced and said, "Oooh," indicating discomfort. Observation showed the resident slouched in the lift with her knees bent (i.e. unable to fully bear weight), shoulders shrugged upward, and her elbows bowed out. Resident #2 let go of the handle bar with her right hand and the CNA (#19) then placed her hand over the resident's hand to grasp on to the handle bar for the remainder of the transfer. * 12/20/11 at 5:45 p.m. - Two CNAs (#20 and #21) used a mechanical stand lift to transfer the resident from her wheelchair to the toilet and back to her wheelchair. During the transfer, observation showed Resident #2 slouched in the lift with her knees bent (i.e. unable to fully bear weight), the sling sliding up and resting under her axilla, her shoulders shrugged upward, and her elbows bowed out. * 12/22/11 at 7:45 a.m. - Two CNAs (#22 and #23) used a mechanical stand lift to transfer Resident #2 from the bath chair to her wheelchair. During the transfer, observation showed the resident with her eyes closed, slouched in the lift with her knees bent, the sling sliding up under her axilla, her shoulders shrugged upward, and her elbows bowed out. An interview with a physical and occupational therapist (#24 and #25) occurred on 12/22/11 at 8:15 a.m. After hearing about the observations of the mechanical stand lift transfers with Resident #2, the staff members stated staff should no longer transfer the resident with that type of lift. The staff members expect the CNAs to notify the nurse on duty if a resident experienced difficulty with transfers and the nurse then contacts therapy for an evaluation. They stated staff failed to notify/consult therapy regarding Resident #2's increased difficulty using the mechanical stand lift to transfer. - Review of Resident #16's medical record occurred on December 20-22, 2011. [DIAGNOSES REDACTED]. Resident #16's quarterly MDS, dated [DATE], showed the resident displayed moderate impairment in daily decision making, extensive two person physical assistance with transfers, extensive one person physical assistance with locomotion on the unit and with toileting, and bilateral functional limitation in range of motion to his lower extremities. Resident #16's current care plan, included the following intervention, dated 12/20/11, regarding transfers as "variable (with) transfers - (one) (with) PAL (type of standing mechanical lift) or (two) (person) stand/pivot." Observation on 12/21/11 at 7:50 a.m. showed a CNA (#10) transferred Resident #16 off of the toilet using a standing mechanical lift. Observation showed Resident #16's elbows suspended higher than his shoulders as the resident gripped the handle bars of the lift and his legs bent at the knees throughout the transfer. The CNA (#10) completed perineal cares for the resident and transferred the resident out of the bathroom and lowered him into his wheelchair. Throughout the entire transfer, the CNA (#10) failed to raise the mechanical lift to a higher position to allow the resident to bear full weight on his legs to alleviate the strain to his shoulders. Failure to use a mechanical stand lift appropriately has the potential to cause falls, injuries, or pain to Resident #2 and Resident #16, and all other residents who transfer with a mechanical stand lift. 2. Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #5) received the care and services necessary to attain the highest degree of safety possible while drinking coffee in his room/parlor. Failure to provide coffee at a safe temperature and/or in a safe container caused Resident #5 to experience unnecessary discomfort and treatment related to a burn to his groin. This also places other residents drinking coffee at risk for injury. Findings: Review of Resident #5's medical record occurred on December 19-22, 2011. The