Every finding on record at Village at Cook Springs Skilled Nursing Facility

Based on observations, interviews, resident record review, and review of the training book How to Be a Nurse Assistant a Quality Approach to Long Term Care the facility failed to ensure Certified Nursing Assistant (CNA) #3, did not create the potential for cross-contamination during incontinent care for Resident Identifier (RI) #8 on 12/19/2023 when she was observed not washing or sanitizing her hands after doffing dirty gloves before touching the clean gloves and not washing hands after perineal care was completed. This had the potential to affect one of three residents who were observed for incontinent care. Findings include: The training book American Health Care Association's HOW TO BE A NURSE ASSISTANT A QUALITY APPROACH TO LONG TERM CARE, eighth edition by [NAME], RN, used by the facility for training purposes, documented on page 68: . Hand Hygiene . Before and after contact with a resident or their environment . Before putting on gloves . After removing gloves . RI #8 was admitted to the facility on [DATE]. An observation of CNA #3 performing perineal care on RI #8 was made on 12/19/2023 at 11:58 PM. CNA #3 was observed entering RI #8's room and she washed her hands, then donned gloves. CNA #3 pulled back the sheet and blanket off RI #8, opened the plastic bag and set the bag on the end of the bed, removed the brief and put the brief in the plastic bag at the end of the bed. CNA #3 with the same gloves on and without washing her hands cleaned the perineal area with several wipes, threw them in the plastic bag and removed her gloves. CNA #3 then got a new pair of gloves out of another staff members pocket and without washing or sanitizing her hands she donned the gloves. CNA #3 then put the clean brief on the resident. CNA #3 doffed the gloves and then again without washing or sanitizing her hands donned another pair of gloves. On 12/19/2023 at 12:24 PM during an interview with CNA #3, she stated, according to facility policy, she should have washed her hands before putting on gloves and after taking them off. CNA #3 stated that she did not wash or sanitize her hands after removing gloves because she was nervous. CNA #3 stated, that not washing or sanitizing hands during perineal care could be a risk of infection. CNA #3 stated, there was a risk of germs if handwashing was not performed after perineal care was completed. On 12/20/2023 at 1:46 PM the Infection Preventionist (IP)/Assistant Director of Nursing (ADON), said, staff should wash their hands during perineal care before, after putting on gloves, in between clean and dirty, and before they start perineal care. The IP stated that the risk of not washing or sanitizing hands before putting on gloves or after taking off gloves was spreading germs. The IP stated, staff members should wash or sanitize hands when switching dirty to clean, due to the risk for infection. IP stated, when perineal care was done, then staff were to remove gloves and wash hands. The IP stated, there was a risk of spreading germs if removing gloves and washing hands were not completed after perineal care.

Based on observation, interviews, resident record review, and a facility policy titled Perineal Care (Incontinent Care), the facility failed to ensure a Certified Nursing Assistant (CNA) #4 provided perineal care for Resident Identifier (RI) #6 to correctly and thoroughly clean RI #6 during incontinent care on 12/19/2023. This had the potential to affect one of three sampled residents with urinary incontinence. Findings include: A facility policy titled Perineal Care (Incontinent Care) with an effective date of 6/20214 documented: PURPOSE: Good perineal care helps prevent infections, irritation, and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed. Residents should receive perineal care during routine baths or showers. PROCESS: 1. General . b) Remove any fecal matter or urine wiping with tissue from front to back. c) Pre-moistened disposable wipes or washcloth should be used. 2. a) Wash pubic area first, washing from front to back; use a different corner or a new wipe with each wipe. b) Turn the resident on to . (their) side and wipe from front to back wiping . to rectum extending over the buttocks, changing wipes or corners as needed. RI #6 was admitted to the facility on [DATE] with diagnoses to include Overactive Bladder and a Personal History of Urinary Tract Infection (UTI). RI #6's quarterly Minimum Data Set (MDS) assessment dated [DATE], documented RI #6 had a Brief Interview for Mental Status (BIMS) score of 15 and was always incontinent of urine and bowel and was dependent for toileting hygiene. On 12/19/2023 at 4:49 PM, RI #6 was observed during incontinent care. The Assistant Director of Nursing (ADON), CNA #4, CNA #5, and CNA #6 were all present. CNA #4, was observed cleaning RI #6's perineal area with wipes and CNA #4 wiped up toward the front of the perineum. The Surveyor asked that RI #6's brief be reopened and RI #6 be re-wiped. RI #6 was rolled to the right side, RI #6's perineum was wiped multiple times and there was bowel movement/stool observed on the wipes. 12/19/2023 at 5:01 PM, during an interview with the ADON, regarding the incontinent care provided to RI #6, she stated, it was not as good as it should have been. 12/19/2023 at 5:40 PM, during an interview with CNA #5 regarding the incontinent care provided to RI #6, he stated, the perineal care was not complete. CNA #5 said, RI #6 was cleaned upward instead of downward and RI #6 should have been wiped until clean. 12/19/2023 at 6:03 PM, during an interview with CNA #4 regarding the incontinent care provided to RI #6, he stated, he should have cleaned better and wiped downwards toward the back and not upwards toward the front; it was an error.

Based on interviews, record review and review of the facility's policy titled Medication, Oral/Sublingual Administration, the facility failed to ensure that nurses documented administration of [MEDICATION(S)] 50mg (milligrams), an as needed (PRN) medication on Resident Identifier (RI) #1's Electronic Administration Record (EMAR). This deficient practice affected one of two residents sampled for administration of PRN medications. Findings include: Review of the facility's policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 revealed, PURPOSE: To administer oral medications in an organized and safe manner. PROCESS: . 4. Administer medication . 7. Document on MAR. RI #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] HCL 50mg tablet-give 1 tablet every 6 hours as needed for pain . A review of RI #1's Controlled Drug Record date received 03/10/2021, revealed, Employee Identifier (EI) #2, Licensed Practical Nurse (LPN) signed out a [MEDICATION(S)] 50mg tablet on 3/18/21 at 9 PM, on 3/22/21 EI #3, Registered Nurse (RN) signed out a [MEDICATION(S)] 50mg tablet at 9 AM and on 3/29/21 EI #4, LPN signed out a [MEDICATION(S)] 50mg tablet at 4 PM. A review of RI #1's EMAR (Administration Record) for the month of: March 2021 revealed, no dose of [MEDICATION(S)] 50mg was documented for 3/18/21, 3/22/21 and 3/29/21. On 3/31/2021 at 3:05 PM, an interview was conducted with EI #4, Licensed Practical Nurse (LPN). EI #4 was shown a copy of the Controlled Drug Record for [MEDICATION(S)] 50mg. EI #4 was asked if that was her signature on 3/29/21 at 4 PM. EI #4 replied, yes. EI #4 was asked if RI #1 received a dose of [MEDICATION(S)] 50mg on 3/29/2021 at 4 PM. EI #4 replied, yes. EI #4 was shown a copy of RI #1's March 2021 EMAR. EI #4 was asked where was the administraton of the [MEDICATION(S)] 50mg that was given on 3/29/21 at 4 PM documented. EI #4 replied, she had gotten busy and forgot. EI #4 was asked what was the risk to the resident when pain medication was given but not documented. EI #4 replied, the resident has to be watched for adverse reactions and effectiveness and that RI #1 was a fall risk and the medication could make him/her dizzy. EI #4 was asked if administration of [MEDICATION(S)] was not documented on the EMAR how did the oncoming nurses know to watch for adverse reactions and dizziness and follow up on effectiveness of the medication. EI #4 replied, the nurses pass it on in the 24 hour report and verbally. EI #4 was asked what was the policy regarding documentation of medication administration. EI #4 replied, documentation should be done. EI #4 was asked was documention of administration of [MEDICATION(S)] done. EI #4 replied, no. EI #4 was asked what would happen if [MEDICATION(S)] was given and not documented and another nurse gave another dose to soon. EI #4 replied, that would not happen because they check and double check. EI #4 was asked what was checked. EI #4 replied, we check to see what was ordered, check the EMAR and check the controlled drug sheet to see if anything was given. On 3/31/2021 at 5:30 PM, a telephone interview was conducted with EI #2, LPN. EI #2 was asked on 3/18/2021 at 9 PM did RI #1 receive a dose of [MEDICATION(S)] 50mg. EI #2 replied, yes. EI #2 was asked why the [MEDICATION(S)] dose was not documented on the EMAR. EI #2 replied she just got busy. EI #2 was asked how did other nurses know that [MEDICATION(S)] was administered if not documented on the EMAR. EI #2 replied, the dose is documented on the Controlled Drug Record and that was what she goes by. EI #2 was asked what was the policy for medication administration. EI #2 replied, to document in the computer (EMAR). EI #2 was asked what was the risk to the resident when PRN [MEDICATION(S)] was not documented on the EMAR. EI #2 replied, it was documented, it was just not documented twice and that she always went by the Controlled Drug Record. EI #2 was asked what should she have done. EI #2 replied, taken the time to document the dose on the EMAR when it was given. On 4/1/2021 at 8:00 AM, an interview was conducted with EI #3, Registered Nurse (RN). EI #3 was shown a copy of RI #1's Controlled Drug Record for [MEDICATION(S)] 50mg. EI #3 was asked when did she administer RI #1 a dose of [MEDICATION(S)] 50 mg. EI #3 replied, on 3/22/21 at 9 AM. EI #3 was shown a copy of RI #1's March 2021 EMAR and asked where was the dose of [MEDICATION(S)] 50mg given on 3/22/2021 at 9 AM documented. EI #3 replied, that was the day the medication was locked and she was unable to chart the administration of that dose. EI #3 explained, if the person before her clicked prepare medication and did not go back and sign it as given the medication is locked and can only be unlocked by the person who locked it. EI #3 was asked what should a nurse do when administering a PRN medication. EI #3 replied, check the controlled book and computer to see when the last dose was given. If time for another dose, administer medication and document dose on the EMAR. On 4/1/2021 at 8:13 AM, an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked what was the process when giving a PRN medication. EI #1 replied, check the Physician Orders, remove the medication from controlled drug box, sign it out and document on the EMAR the PRN medication was given. EI #1 was asked what was the risk to the resident if PRN [MEDICATION(S)] was given and not documented on the EMAR. EI #1 replied, the medication could potentially be given again to soon which could cause an increase in sedation. EI #1 was asked when looking at the EMAR and Controlled Drug Record for RI #, what should the nurses have done. EI #1 replied, when the medication was given the nurses should have documented the dose on the EMAR.

Based on interviews, review of Resident Identifier (RI) #1's facility and hospital medical records, the Emergency Medical Services (EMS) run report, a complaint received by the State Survey Agency and various facility documents, the facility failed to ensure the licensed nursing staff promptly identified and acted upon a change in RI #1's condition. During the 7:00 PM to 7:00 AM shift on [DATE], RI #1 was found to have a temperature of 99.1 that increased to 100.0, a heart rate of 135 and oxygen saturation of 81%. The licensed nurse did not assess the resident or notify the physician to address RI #1's declining status. The Charge Nurse assigned to care for RI #1 during the 7:00 AM to 7:00 PM shift on [DATE], noticed the resident looked sick. On [DATE] between the hours of 11:30 AM and 12:00 PM, the facility's Director of Nursing (DON) reviewed RI #1's vital signs from the previous shift and noticed the resident did not look right, was pale in color and lethargic. The Charge Nurse and DON failed to notify the physician to obtain treatment orders to address RI #1's change in condition. At approximately 4:30 PM on [DATE], RI #1's responsible party was called and told the resident had a bad cough and a low-grade fever. At 5:21 PM, EMS was called to transport RI #1, to the local hospital with a chief complaint of respiratory distress. When EMS arrived, they found the resident unresponsive, cyanotic, diaphoretic, hot, pupils non-reactive and decreased lung sounds. Upon arriving at the local hospital's emergency room , RI #1 was noted to be in severe respiratory distress, with auditory rales and wheezing noted from the doorway of his/her room. RI #1 expired at 9:20 PM, approximately three hours after arriving in the ER. This deficient practice placed RI #1, one of three sampled residents reviewed for change in condition in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On [DATE] at 5:20 PM, the facility's Executive Director was given the immediate jeopardy template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F684. Findings include: On [DATE], the State Survey Agency received a complaint which alleged the facility failed to recognize and treat a change in RI #1's condition that ultimately led to the resident dying on [DATE]. RI #1 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. In a telephone interview on [DATE] at 7:20 PM, RI #1's Responsible Party (RP) stated she received a call on [DATE] at 4:30 PM that the resident had a bad cough and a low-grade fever. The RP asked if RI #1 could be treated in the nursing facility because sometimes the resident is bothered when he/she had to go to the hospital. The staff stated they would check with the doctor and call her back. According to the RP, she was told if RI #1 did not go out to the hospital, he/she would die. When the resident arrived in the emergency room , the physician stated the resident was too far gone, that he/she had about an hour to live. The RP stated the resident lived a little over an hour; that no one called to inform her that RI #1 was sick. The RP stated the resident had to be sick for a few days, the resident had dementia and could not tell anyone how sick he/she was, someone should have been watching him/her; someone dropped the ball. The facility's CNA (Certified Nursing Assistant) ASSIGNMENT sheet for the 7:00 PM to 7:00 AM shift on [DATE] indicated Employee Identifier (EI) #1, a CNA was assigned to care for RI #1. The vital sign log sheet for 7:00 PM to 7:00 AM shift on [DATE], indicated at 9:00 PM, RI #1 had a temperature of 99.1, a heart rate of 135 and oxygen saturation of 81%. A second recording taken at an unknown time, indicated the resident had a temperature of 100.0. On [DATE] at 5:35 PM, a telephone interview was conducted with EI #1, the CNA assigned to care for RI #1 during the 7:00 PM to 7:00 AM shift on [DATE]. EI #1 stated she recalled the resident but doesn't remember recording RI #1's vital signs on [DATE]. EI #1 stated the resident's vital signs were taken at night. The vital signs are then recorded on a sheet and placed on the nurses' station for the nurse. When asked what she would do if the vital signs were abnormal, EI #1 stated notify the nurse. In a follow-up telephone interview on [DATE] at 2:41 PM, EI #1, a CNA was asked if a heart rate of 135 and an oxygen saturation of 81% were normal. EI #1 replied, no. The DAILY STAFFING BY STATION/WING indicated EI #2, a Licensed Practical Nurse (LPN) was assigned to care for RI #1 during the 7:00 PM to 7:00 AM shift on [DATE]. On [DATE] at 5:13 PM, a telephone interview was conducted with EI #2, the LPN assigned to care for RI #1 during the 7:00 PM to 7:00 AM shift on [DATE]. EI #2 stated she was no longer employed by the facility and did not recall RI #1. When asked what she did when RI #1 presented with a temperature of 99.1, a heart rate of 135 and oxygen saturation of 81% on [DATE], EI #2 stated she couldn't recall back that far, that she didn't remember RI #1's name or that situation. EI #2 stated if there were issues, management should have brought it to her attention. EI #2 stated, If there is no documentation, it never happened, right? There is no documentation in RI #1's medical record of an assessment done by the licensed nurse when RI #1 was noted to have a temperature of 99.1, a heart rate of 135 and oxygen saturation of 81%. In a follow-up telephone interview on [DATE] at 2:06 PM, EI #2, an LPN was asked what should have been done when RI #1 was noted with a temperature of 99.1. EI #2 replied, Tylenol should have been administered, it should be documented within RI #1's medical record and the resident's temperature should be rechecked in an hour. According to EI #2, if the resident had an oxygen saturation of 81%, the physician should be notified to see if he wanted the resident to receive oxygen. When asked what she did when RI #1's temperature increased to 100.0, EI #2 stated this was not reported to her. When asked where it be would charted (documented) as to what she provided to RI #1 when the resident had a temperature of 99.1 and 100.0, a heart rate of 135 and oxygen saturation of 81%, EI #2 stated in the nurses' notes and the 24-hour report for the oncoming nurse. The TWENTY FOUR HOUR REPORT FORM used to List the Name of Residents with New Incidence, New Orders, or Change in Condition did not indicate RI #1 had a new incidence, a new order or change in condition on [DATE]. On [DATE] at 11:51 AM, an interview was conducted with EI #4, the Registered Nurse (RN) assigned to care for RI #1 during the 7:00 AM to 7:00 PM shift on [DATE]. EI #4 acknowledged that he did remember RI #1. EI #4 stated the resident was sent out to the hospital at 5:57 PM on [DATE] because the resident had an elevated temperature and heart rate. EI #4 stated the resident appeared pale and looked as if he/she needed to go to the hospital. When asked how the resident was during his shift on [DATE], EI #4 stated he wasn't told anything in report, that he doesn't remember if he just noticed the resident or if a CNA came and told him something about the resident. EI #4 stated the resident just looked sick, so he/she was sent out. In an interview on [DATE] at 5:56 PM, EI #3, the DON, also known as the Clinical Services Administrator (CSA) acknowledged that when she reviewed RI #1's vital signs from the 7:00 PM to 7:00 AM shift on [DATE] she went and looked at the resident. According to EI #3, RI #1 did not look right, the resident's color was pale, RI #1 wasn't his/her feisty self, that he/she was lethargic. EI #3 stated she told the nurse, EI #4, to assess the resident and call the doctor. When asked if she followed up with EI #4 to see if he assessed the resident and called the doctor, EI #3 stated she did that evening. During a follow-up interview on [DATE] at 4:11 PM, EI #3, the DON was asked what should be done when a resident has abnormal vital signs. EI #3 replied, since COVID-19, if the resident has a temperature over 99 or a change in condition, the physician should be called. The resident should then be made comfortable until orders are received from the physician. Oxygen should be applied for the decreased oxygen saturation; the head of the resident's bed should be raised; and the ambulance should be called to come and transport the resident to the hospital. According to EI #3, usually the resident's vital signs are checked three times per night around 9:00 PM. EI #3 stated it appeared as though RI #1's temperature was rechecked and found to be 100.0. EI #3 stated for the resident's elevated temperature, Tylenol suppository should have been administered. RI #1's oxygen saturation and heart rate should have been rechecked (there is no documentation RI #1's oxygen saturation and heart rate were rechecked after RI #1 was found to have a heart rate of 135 and oxygen saturation of 81%). EI #3 stated if the CNA had brought RI #1's vital signs to her, she would have retaken the vital signs, which is what the nurse should have done. When asked what else should have occurred, EI #3 stated the nurse should have documented in the nurses (departmental) notes a timeline of what had occurred and reported to the oncoming shift. According to RI #1's [DATE] EMAR (Electronic Medication Administration Record, [REDACTED]. In an interview on [DATE] at 8:50 AM, EI #3, the DON was asked what time she assessed RI #1 on [DATE]. EI #3 replied, between 11:30 AM and 12:00 PM. When asked what should she have done when she read that RI #1 had vital signs on [DATE] of an elevated temperature, elevated heart rate and decreased oxygen saturation, EI #3 stated she told the Charge Nurse, EI #4. According to EI #3, the Charge Nurse should have then rechecked RI# 1's vital signs. When asked should this have been documented, EI #3 replied, of course. When asked where the assessment she completed of RI #1 on [DATE] between 11:30 AM and 12:00 PM be documented, EI #3 replied, the nurse, EI #4, was supposed to come behind her and document his assessment in the nurses (departmental) notes. EI #3 was asked why RI #1 was not sent out to the local hospital after she completed her assessment of the resident around 11:30 AM to 12:00 PM. EI #3 answered because she told the Charge Nurse. When asked if EI #4 had been counseled regarding this incident, EI #3 replied no. When asked if she identified a concern in the delay in treating RI #1's change in condition, EI #3 stated there wasn't a delay. In a follow-up telephone interview on [DATE] at 12:03 PM, EI #4, a RN was asked what he did when the Director of Nursing (DON), EI #3, informed him to assess RI #1 on [DATE]. EI #4 stated he doesn't recall the DON telling him to do that. EI #4 stated had the DON told him, he would have done a total assessment of the resident that included taking a new set of vital signs, assessing to determine if the resident was diaphoretic (sweating heavily), and working to breathe. When asked if he was told the resident's vital signs from the previous shift, EI #4 replied no, he didn't remember. EI #4 stated had he known RI #1 had a temperature of 99.1, 100.0, a heart rate of 135 and oxygen saturation of 81%, he would have notified the physician, so the resident could be sent to the local hospital. EI #4 acknowledged the vital sign sheet was at the nurses' station for him to review. On [DATE] at 1:00 PM, EI #3, the DON was asked why it was important for staff to identify, promptly assess and act upon RI #1's change in condition. EI #3 replied, it would be very important. When asked why it would be very important, EI #3 replied it could be critical, resulting in death. When asked where the breakdown occurred in RI #1's delay in treatment, EI #3 replied, communication between night shift and day shift. EI #3 was asked about RI #1's vital signs being abnormal around 9:00 PM on [DATE], and she replied, Night shift nurse should have taken care of that, at that point. RI #1's Departmental Notes written by EI #4, a RN and dated [DATE] 5:57 PM, documented resident sent to (local hospital) per MD (Medical Doctor) orders w/ (with) 79% sat (saturation) on room air, heart rate 144, T (temperature) 100.9. Family aware. According to the Emergency Medical Services (EMS) run report, on [DATE] at 5:21 PM, EMS was called to the facility for RI #1 with a chief complaint of respiratory distress. When EMS, they found the resident unresponsive, cyanotic, diaphoretic, hot, pupils non-reactive and decreased lung sounds. RI #1's blood pressure was ,[DATE], pulse 140, respirations 57 and oxygen saturation of 82%. The report indicated the RN stated RI #1 was not ordered oxygen, but today started having a low oxygen saturation of 79% on room air. The resident was placed on six liters of oxygen by way of nasal cannula and RI #1's oxygen saturation increased to only 82%. RI #1 left the nursing facility at 5:43 PM and arrived at the local hospital at 6:06 PM. RI #1's hospital medical record documented . History of Present Illness Patient . present by EMS from the Village at Cook Springs nursing home. (He/She) has severe dementia, unable to care for (himself/herself) . has been febrile and coughing. (He/She) developed severe respiratory distress this evening, satting in the upper 70s on room air when EMS arrived, breathing 60 times a minute I spoke with (his/her) daughter . extensively outside the room, and she states that the patient would not want any type of life prolonging care . Physical Examination . ED (Emergency Department) Temperature 103.1 DegF (degrees Fahrenheit) . Respiratory Rate 50 br/min (breaths per minute) . ED Pulse Rate 144 bpm (beats per minute) . Systolic Blood Pressure 110 mmHg (millimeter of mercury) Diastolic Blood Pressure 59 mmHg . Oxygen Therapy Nonrebreather mask SpO2 (oxygen saturation) 88 % LOW Oxygen Flow Rate 15L/min (liters per minute) General: Severe distress, ill-appearing. Patient is in severe distress, no opening eyes to voice or withdrawing from painful stimuli . auditory wet breath sounds without stethoscope auscultation, Not alert . Respiratory: Patient has auditory rales and wheezing from the doorway, breathing 60 times a minute, very poor air movement . Neurological: Patient is obtunded (depressed level of consciousness) and stuporous (not able to be aroused) . Medical Decision Making . I gave (him/her) multiple doses of benzos (benzodiazepines) and narcotics to keep (him/her) comfortable and pain-free. (His/Her) labs show severe dehydration . and after about 3 hours (he/she) passed away. Time of death was 21:20 (9:20 PM) . According to RI #1's death certificate, the immediate cause of RI #1's death was listed as Pneumonia. ************************* On [DATE] at 11:26 AM, the facility submitted an acceptable removal plan which documented: On February 2, 2021 at 5:30pm the Quality Assurance Coordinator educated the Clinical Services Administrator regarding obtaining vital signs, vital sign parameters, documentation of vital signs and assessment of resident, recognizing changes in resident condition and assessing resident vital signs are abnormal, and protocol of reporting abnormalities to nurse or physician as indicated. On February 2, 2021 beginning at 5:36pm thru 9:13pm, the Clinical Services Administrator (CSA), and direct care staff initiated obtaining all residents' vital signs to identify any potential abnormalities. 1 resident was noted to have abnormal vital signs, nursing assessment completed, vital signs entered into medical record, assessment documentation completed, physician and Resident Representative notified as in-serviced. Clinical Services Administrator (CSA) educated the ADON, Unit Managers, and MDS RN's (designees) regarding obtaining vital signs, vital sign parameters, documentation of vital signs and assessment of resident for change of condition, recognizing changes in resident condition and assessing resident vital signs when abnormal, and protocol of reporting abnormalities to nurse or physician as indicated. February 2, 2021 at 5:45pm, nursing staff (RN, LPN, and CNA) were in-serviced by Clinical Services Administrator (CSA) and or designees (ADON, Unit Managers, and MDS RN's) regarding obtaining vital signs, vital sign parameters, documentation of vital signs and assessment of resident for change of condition, recognizing changes in resident condition and assessing resident vital signs when abnormal, and protocol of reporting abnormalities to nurse or physician as indicated. Licensed staff will document vital signs on the 24 hour report and shift report to the oncoming nurse. All in-services will be completed by Wednesday February 3, 2021 at 9pm. Any staff member not receiving education by February 3, 2021 will not be allowed to work until education is completed. Updated facility COVID-19 plan will be updated February 3, 2021 with obtaining vital signs, vital sign parameters, documentation of vital signs and assessment of resident, and protocol of reporting abnormalities to nurse or physician as indicated. Beginning on February 2, 2021 at 5:46pm, the CSA and or designees (ADON/Unit Managers/MDS/RN's) by the end of shift, will review vital sign log sheets for abnormalities. LPN/Charge Nurse will review vital sign sheets immediately upon completion to identify and abnormal vital signs and changes in condition. Upon review, the LPN/Charge Nurse will sign, time, and date the vital sign logs. The CSA and or designees (ADON/Unit Managers/MDS/RN's) will validate that vital signs were documented in the medical record and communicated to the physician and resident representative if applicable, and that any corresponding physician orders [REDACTED]. The Quality Assurance Coordinator, Home Office will be responsible for monitoring compliance with this Removal Plan. The facility's QAPI Committee including Medical Director met on February 2, 2021 at 9:30pm via phone and approved this plan. Discussed with physician education on obtaining vital signs, assessment of residents identified with abnormal vital signs, notification of abnormalities to MD and resident representative and documentation of above in residents medical record. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F684 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 990

Based on interviews, review of Resident Identifier (RI) #1's medical and financial records, the facility's policy titled Credit Balances and a complaint received by the State Survey Agency, the facility failed to refund any and all refunds due to the resident and/or the resident's representative within 30 days from the date of discharge or expiration in the facility. This deficient practice affect RI #1, one of three sampled residents reviewed for personal funds. Findings include: On [DATE], the State Survey Agency received a complaint which alleged RI #1's representative had not received a refund of the money paid to the facility for the resident's room and board. According to the complaint, RI #1 was private pay and the representative paid for the entire month of [DATE]; however, a refund should have been issued for the remainder of the month the resident was not in the facility for the month of August. RI #1 was transferred to a local hospital and subsequently expired on [DATE]. The facility's policy titled Credit Balances dated [DATE], documented Purpose It is the policy of Noland Health Services (Noland) that credit balances be reported to Medicare and other payors in accordance with applicable rules, regulations and/or third party payor guidelines . Responsibilities It is the responsibility of the employees with Business Office responsibilities for identifying, working and monitoring credit balances . Procedure . Noland will resolve any credit balances owed to patients as appropriate . RI #1 was admitted to the facility on [DATE] and discharged on [DATE]. The facility's Billing Activity indicated RI #1 has a credit balance of $4389.00 as of [DATE]. In an interview on [DATE] at 4:00 PM, Employee Identifier (EI) #8, the facility's Business Office Manager was asked when RI #1 was discharged from the facility. EI #8 replied, [DATE]. When asked what credit balance was on RI #1's account after discharge, EI #8 replied, $4389.00 at the end of [DATE]. EI #8 was asked what amount had been refunded to the resident's representative. EI #8 replied, nothing had been refunded. EI #8 was asked why the refund process was taking so long. EI #8 replied, that when RI #1 was discharged there was an insurance balance due. EI #8 was asked when the insurance balance was paid. EI #8 replied, [DATE]. During a telephone interview on [DATE] at 1:46 PM, EI #9, the facility's home office Business Office Director was asked when RI #1 was discharged from the facility. EI #9 replied, [DATE]. When asked what credit balance was on RI #1's account, EI #9 stated $4389.00. EI #9 was asked what amount had been refunded and she stated, as of today no money had been refunded. When asked why the refund request was sent late, EI #9 replied she was unsure. During a telephone interview on [DATE] at 3:41 PM, RI #1's responsible party stated she received a call on [DATE] from a lady at the nursing facility, who stated she had realized RI #1's responsible party was owed a refund. This deficiency was cited as a result of the investigation of complaint/report number AL 990.

Based on interviews, review of the facility's policy titled Notification of a Change in Medical Condition of Residents and Resident Identifier (RI) #1's medical record, the facility failed to notify RI #1's responsible party was notified of the results of x-ray done on 8/1/2020 which indicated the resident had sustained a mildly displaced oblique [MEDICAL CONDITION] metacarpal. This deficient practice affected RI #1, one of three sampled residents reviewed for notification of change in status. Findings include: The facility's policy titled Notification of a Change in Medical Condition of Residents with an effective date of March 2018, documented PURPOSE To keep the physician, and family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. STANDARD Notification of the physician, resident's representative, should occur promptly, according to federal regulations, when there is a change in the resident's condition. This would include but is not limited to: . An accident involving the resident which results in injury and had the potential for requiring physician intervention . A change in the resident's physical, mental or psychosocial status . RI #1 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #1's Resident Incident Report indicated on 8/1/2020 at 7:30 PM, Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN) entered RI #1's room to do a weekly assessment and noticed discoloration (bruise) to the top of RI #1's left hand. The report documented EI #10 called the physician and received an order for [REDACTED]. During a telephone interview on 1/28/2021 at 1:38 AM, EI #10, a LPN was asked about RI #1's bruise to the left hand. EI #10 stated on her night to do the resident's weekly body assessment, she noticed discoloration to the top of RI #1's left hand that was not there during the previous week's assessment. EI #10 stated she completed an incident report, called the doctor and notified the resident's family. EI #10 stated she received an order from the Doctor for an x-ray. There was no swelling and the resident's hand was not warm to touch. EI #10 stated she thinks the x-ray was completed the next day since it was not ordered to be done immediately. EI #10 stated she reported to the on-coming nurse, EI #6. When asked if RI #1's responsible party was notified of the x-ray results, EI #10 replied she could not say. EI #10 stated she only notified the resident's family of the discoloration. When asked who is responsible for notifying the resident's family of the x-ray results, EI #10 stated the nurse who is on duty when the results are received in the facility. RI #1's Radiology Report of the left hand dated 8/2/2020, documented . Results: There is an oblique [MEDICAL CONDITION] metacarpal with mild medial displacement and shortening . Mild soft tissue swelling of the hand. Conclusion: Mildly displaced oblique [MEDICAL CONDITION] metacarpal. In a telephone interview on 1/25/2021 at 9:50 AM, the representative with the x-ray company stated RI #1's x-ray results were reported to the facility on [DATE] at 11:40 AM. On 1/29/2021 at 8:32 AM, an interview was conducted with EI #6, the LPN assigned to care for RI #1 during the day shift of 8/2/2020. EI #6 was asked what should occur if she received an abnormal x-ray report. EI #6 replied, call the physician, notify the resident's family and document in the nurses' notes that the physician and family were notified. When asked if she notified RI #1's family of the resident's fracture, EI #6 stated she could not recall. There is no documentation in RI #1's medical record of RI #1's responsible party being notified of the resident's x-ray results. During a telephone interview on 1/29/2021 at 3:41 PM, RI #1's responsible party was asked what she was told of the bruise found on RI #1's hand. RI #1's responsible party stated she was told the nurse went into the television room and saw a big bruise on the resident's hand. The nurse asked RI #1 what happened, but the resident didn't know. RI #1's responsible party stated she was notified that an x-ray was ordered but she was not notified of the results of the x-ray. She stated she called the facility for several days but never got an answer. This deficiency was cited as a result of the investigation of complaint/report number AL 990.

Based on interview, review of the facility's policy titled Guidelines-Vaccines-Pneumonia and Influenza, Resident Identifier (RI) #6's medical record and a complaint received by the State Survey Agency, the facility failed to honor the resident's representative request to not receive the flu vaccine (shot) was honored. The facility further failed to ensure consent was obtained from RI #6's representative and education was provided prior to the administration of Influenza (flu) vaccine. This deficient practice affected RI #6, one of three sampled residents reviewed for Influenza vaccine administration. Findings include: The State Survey Agency received a complaint which alleged it was documented in RI #6's medical record not to administer the flu shot because the resident would receive it from the Pulmonologist; however, the staff failed to honor this request, when they administered the flu shot to RI #6, without first notifying the resident's representative. The facility's policy titled Guidelines-Vaccines-Pneumonia and Influenza with an effective date of January 2018, documented Policy Noland Health Services is committed to providing protection from the seasonal influenza (flu) virus and pneumonia to our residents. Influenza: Flu season is determined to last as long as the [MEDICAL CONDITION] is in the community which the facility is located. Procedure: . 4. The resident or the resident's representative has the opportunity to refuse immunization and is provided education regarding the benefits and potential side effects of the influenza immunization . RI #6 was readmitted to the facility on [DATE]. RI #6's physician's orders [REDACTED]. RI #6's EMAR (Electronic Medication Administration Record) for the month of October 2019 indicated RI #6 was administered the flu vaccine on 10/16/2019. In a telephone interview on 1/28/2021 at 8:36 AM, RI #6's representative was asked how she knew RI #6 received the flu vaccine at the facility. RI #6's representative stated when she visited the resident, she noticed the resident had a Band-Aid on his/her arm, so she asked the staff what happened and was told the resident had been given the flu shot. When asked when she was notified the facility was administering the flu shot to RI #6 and given the opportunity to accept or decline the flu shot, RI #6's representative stated she was not. When asked if she was provided education/information regarding the risks and benefits of the flu shot (vaccine), RI #6's representative stated she was not provided any information regarding risks and benefits of the flu vaccine. According to RI #6's representative, it was documented in the resident's chart (medical record) that the resident was not to receive the flu vaccine at the facility. When asked who she told in the facility that RI #6 was not to be administered the flu vaccine, RI #6's representative stated she told a nurse, but she couldn't recall the nurse's name. An undated handwritten note written by Employee Identifier (EI) #7, a Licensed Practical Nurse (LPN) read (RI #6's representative) request Resident not to receive flu vac (vaccine). (He/She) will get it at Dr (Doctor) Visit. In an interview on 1/28/2021 at 10:30 AM, EI #7, an LPN acknowledged she wrote the handwritten note that indicated RI #6 was not to receive the flu vaccine. When asked when the note was written, EI #7 stated she didn't know. EI #7 further stated she didn't know if she communicated this information to other nursing staff. In a follow up interview on 1/28/2021 at 9:48 AM, RI #6's representative was asked how she felt when she found out RI #6 had received the flu shot at the facility. RI #6's representative stated she was angry and upset because she had told them not to give the flu shot to RI #6, but they did anyway. During an interview on 1/28/2021 at 10:28 AM, EI #3, the Director of Nursing/Infection Preventionist was asked where it was documented that residents or their representatives accepted the flu vaccine. EI #3 stated there is no consent. This deficiency was cited as a result of the investigation of complaint/report number AL 808.

Based on interviews, review of Resident Identifier (RI) #204's and RI #205's medical records, the Resident Incident Report, a typed statement and the hospital medical records, the facility failed to develop a care plan to address RI #204's use of a scoot chair and Dycem. On 3/21/2019, while sitting in the scoot chair at the nurses' station, RI #204 fell face forward onto the floor, hitting his/head. Employee Identifier (EI) #7, the Registered Nurse Supervisor who witnessed the fall, stated RI #204 slid from chair with cushion and Dycem still attached to resident's pants. The therapy staff indicated there should be two pieces of Dycem in RI #204's scoot chair. One piece of dycem was to be placed in the chair between the cushion and the chair. Then another piece of Dycem was to be placed on top of the cushion under the resident so the resident's bottom did not slide off the cushion and the cushion did not slide from the chair. EI #7 stated there was only one piece of Dycem and it was placed between the pad and RI #204's bottom. RI #204 was transferred and admitted to a local hospital's Intensive Care Unit for an Acute Subdural Hematoma. The facility further failed to ensure RI #205's care plan specified how RI #205 should be transferred and the level of assistance the resident required. RI #205 was assessed as requiring extensive assistance of two staff members for transfers. On 3/25/2019, EI #5 transferred RI #205 from the chair to the bed by herself using the Standup Lift. During the transfer, the resident became combative and fell to the floor hitting his/her head on the floor. The Licensed Practical Nurse/Restorative Nurse, EI #23, stated she assessed RI #205 prior to the fall and determined the resident was totally dependent on two staff for transfers with a Hoyer lift. RI #205 was transferred to the local hospital for further evaluation; the resident sustained [REDACTED]. These deficient practices placed RI #204 and RI #205, two of eight sampled residents reviewed for accidents and placed them in immediate jeopardy of serious injury, harm, impairment or death. On 7/26/2019 at 6:50 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Services and Vice President of Senior Living were given the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plans, F656. Findings include: 1) RI #204 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #204's Resident Incident Report prepared by Employee Identifier (EI) #7, a Registered Nurse (RN) indicated on 3/21/2019 at 9:14 PM while at the nurses' station Resident leaned forward out of scoot chair, slid from chair with cushion and dycem still attached to resident pants. Landed face first on floor. Assessed for injury . Large hematoma approx (approximately) size of baseball above left eye. Two skin tears above left eye with large amount of bleeding noted . RI #204's care plan titled Potential for falls related to dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair with Dycem. RI #204's care plan titled Resident needs assist with ADL's (activities of daily living) related to history [MEDICAL CONDITION] and dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair with Dycem. In an interview on 7/22/2019 at 9:57 AM, Employee Identifier (EI) #16, the Minimum Data Set (MDS) Coordinator was asked was RI #204 care planned for a scoot chair and Dycem. EI #16 replied, it was not on RI #204's fall or ADL care plan. When asked why she was not, EI #16 she was not sure. When asked should the resident have been care planned for the scoot chair and Dycem, EI #16 stated if it was listed as an intervention it should have been care planned. EI #16 was asked what was the negative outcome of not care planning RI #204's use of a scoot chair and Dycem. EI #16 replied, the Dycem or scoot chair would not be in place, which could cause the resident to possible slide and fall. During an interview with EI #33, the Occupational Therapy Assistant (OTA) on 7/22/2019 at 10:17 AM, she was asked when was the scoot chair and Dycem ordered for RI #204. EI #33 replied, she didn't know but when RI #204 was seen for a quarterly screen on 11/8/2018, the resident was already in the scoot chair. A typed statement signed by EI #33, an Occupational Therapy Assistant (OTA), dated 7/22/2018 (2019) documented Nursing issued scoot chair for (RI #204), date (he/she) was issued scoot chair is unknown by therapy staff, it is also unknown at this time that dycem and cushion was in place. Patient was seen for a quarterly screen on 11/8/18 and was evaluated with no concerns documented regarding patient's positioning in scoot chair. Patient was discharged from therapy services 12/4/18 with FMP (Functional Maintenance Plan) noting scoot chair as appropriate positioning. Patient evaluated by OT 3/19/19 with dysem (dycem), cushion, and leg rests with standard foot plates on scoot chair documented in evaluation with no concerns. On 7/23/2019 at 8:40 AM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked,were the interventions of the scoot chair and Dycem care planned for RI #204. EI #2 replied, no. RI #204's local hospital's History and Physical dated 3/22/2019, documented . Chief Complaint Pt (patient) resided at The Village at Cook Springs. Pt was sitting in a chair and fell forward and hit face. Lac (laceration) noted to left forehead. Takes aspirin. Hx (history) dementia History of Present Illness . The patient presented with fall. The onset was yesterday evening. The character of symptoms is pain with [MEDICAL CONDITION]. The degree at onset was moderate . Pt . with hx (history) of dementia and TIA ([MEDICAL CONDITION]) who presented to the ED (Emergency Department) from nursing home c/o (complaint of) fall onset the evening of 3/21/2019. Per EMS (Emergency Medical Service) report, pt fell from a rolling chair and hit (his/her) face. (He/She) now presents with a L (left) side head injury with laceration. Unknown L[NAME] (level of conscious). Pt.'s wound was bandaged en route to ED and sutured in the ED due to continuous bleeding. EMS notes BP (blood pressure) 200/100 en route. (He/She) takes 81 mg (milligram) ASA (aspirin) daily . In ED, . CT (Computed [NAME]ography) Head: Impression: There is a small left subdural hematoma. There is no mass effect or midline shift. There are small hemorrhagic contusions in the left frontal lobe. This is a critical result . Neurosurgery was consulted by ED physician. No intervention recommended at this time - neurosurgery will consult in the AM (morning) . Assessment/Plan 1. Acute subdural hematoma s/p (status [REDACTED]. [MEDICAL CONDITION] - appx (approximately) 4 sutures to left forehead . RI #204 was admitted to the Intensive Care Unit. RI #204's Neurosurgery Consult Note dated 3/22/2019, documented . CT shows small acute left frontoparietal SDH (subdural hematoma) without mass effect. stable this am (morning . The SDH is small and stable. No surgical intervention needed. No follow-up needed . The Discharge Summary revealed RI #204 was discharged home on[DATE] with hospice care arranged. 2) RI #205 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #205's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/7/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of two. RI #205 was assessed as being totally dependent on staff for transfers, requiring two plus persons physical assist. RI #205's Resident Incident Report prepared by Employee Identifier (EI) #19, a Licensed Practical Nurse (LPN) indicated on 3/25/2019 at 8:30 PM, . Resident was sitting on the edge of the bed, CNA (Certified Nursing Assistant) was undressing (him/her) to get (him/her) ready for bed. Resident was combative was grabbing onto her. CNA bent down and resident fell forward onto the floor. ROOT CAUSE: Resident requires 2 person assist with ADL (Activities of Daily Living) care . The report indicated the physician and resident representative were notified, neurological checks were initiated, an ice pack was applied to RI #205's head and the resident was transferred to a local hospital for evaluation. The report further indicated the facility staff involved was EI #5, a CNA. In a telephone interview on 7/15/2019 at 11:35 AM, EI #5, a CNA who no longer works at the facility, was asked why on 3/25/2019, did she not have assistance when she transferred RI #205 back to bed, EI #5 stated she wasn't taught to have two people and that she had watched other staff do it by themselves as well. According to EI #5, the white book at the nurses' station that contained residents' care plans did not indicate that RI #205 required two persons assist with a lift. RI #205's care plan titled (RI #205) has potential for falls related to muscle weakness and dementia with a problem onset date of 7/25/2016 did not include an approach of how the resident should be transferred or the level of assistance required, prior to 3/25/2019. On 3/25/2019, the care plan was updated to include . Resident is to be a 2 person assist when placing in bed . On 3/26/2019, the care plan was updated to include . Resident is to be a mechanical lift with all transfers . In a follow-up telephone interview on 7/22/2019 at 12:01 PM, EI #5 stated when RI #205 fell on [DATE], that she had only transferred the resident to the bed to a sitting position on the side of the bed. When asked if she was dressing the resident, EI #5 said no. When asked if she was changing the resident's pants, EI #5 said no, that she could not change the resident's pants until the resident was lying down on the bed. EI #5 was asked how could having a second person to assist with the transfer prevent the fall. EI #5 replied, one person could have been on each side of the resident, that as she went to pick the resident's legs up, the other person could have been behind or beside her. In an interview on 7/23/2019 at 5:12 PM, EI #16, the Minimum Data Set (MDS) Coordinator was asked what details should be included in a resident's care plan for the staff assisting with transfers. EI #16 replied, how the resident should be transferred and the number of staff it takes to transfer the resident. When asked why this information is important to include on the care plan, EI #16 replied, it lets the staff know how the resident should be transferred. When asked what could happen if the care plan did not give specific instructions on how the resident should be transferred, EI #16 answered, it would be confusing to the staff on how the resident should be transferred. EI #16 was asked prior to 3/25/2019, what instructions were provided on the resident's care plan. EI #16 stated, assist with transfer and ambulation as needed. When asked where on the care plan did it instruct the staff to use the Standup lift, EI #16 replied, it did not. When asked why it didn't, EI #16 replied she didn't know. In a follow-up interview on 7/24/2019 at 10:21 AM, EI #16, the MDS Coordinator stated RI #205 was assessed as being dependent on two persons for transfers; however, the care plan only indicated the resident was to be assisted with transfers as needed. On 7/24/2019 at 10:45 AM, an interview was conducted with EI #23, the LPN Restorative who assessed RI #205's functional status during the 3/7/2019 Quarterly MDS. EI #24 acknowledged that RI #205 was assessed as being totally dependent on two staff for transfers with a Hoyer lift. EI #24 stated she did not know why the staff would use a Standup lift with RI #205. When asked why RI #205's care plan was not updated to reflect the resident's assessed needs to be a two person assist with a Hoyer lift, EI #23 replied, she did not update the care plan. When asked why RI #205's care plan was not updated after the assessment was done on 3/7/2019 that indicated the resident was assessed to be a Hoyer lift transfer with two staff assistance, EI #23 replied, she didn't know and there was no excuse for it not being updated. In an interview on 7/25/2019 at 10:54 AM, EI #2, the Director of Nursing (DON) was asked why RI #205's care plan was not updated to reflect the resident required two person assistance for transfers. EI #2 replied, she didn't know but it should have been. RI #205's Emergency Documentation from the local hospital documented on 3/25/2019 . Per EMS (Emergency Medical Service) report pt (patient) was sitting on the edge of the bed and fell forward at The Village at Cook Springs, hitting the floor. Hematoma to R (right) forehead noted . Pt disorientedx4 (person, place, time, location). Daughter reports this is pt's baseline . The patient presents with head injury. The onset was just prior to arrival . The patient . with a hx (history) of Alzheimer's Dementia, TIA [MEDICAL CONDITION](Hypertension) who presents to the ED (Emergency Department) via EMS with a head injury . (He/She) is not on blood thinners. Patient cannot give adequate hx due to Dementia . The Computed [NAME]ography (CT) done on 3/25/2019 revealed Severe intracranial atrophy and severe supratentorial small vessel white matter disease without evidence of acute cortical infarct, [MEDICAL CONDITION], or mass lesion. RI #205 was discharged from the local hospital on [DATE] and transferred back to the facility with a discharge [DIAGNOSES REDACTED]. ************************* On 7/28/2019, the facility submitted an acceptable removal plan which documented . Beginning 7/27/19 all residents with falls in the last 30 days had fall care plans updated to include all risk factors and individualized interventions put in place and sent to Daily Care Guide. Beginning 7/28/19 all residents with fall care plans had fall care plan reviewed and updated to include all risk factors and individualized interventions put in place and sent to Daily Care Guide. Beginning 7/28/19 licensed staff and CNA's were in-serviced on fall care plans, Daily Care Guides, and identifying risk factors and following interventions listed on Daily Care Guides. Daily Care Guides will be printed daily to include new interventions, and changes made to resident care-plans. MDS staff will list resolved interventions on Daily Care Guides to ensure proper and timely communication for direct care staff. Interdisciplinary Team (IDT) will print daily care guides at the time the care-plan is updated, and make Daily Care Guides available to all nursing staff (RN/LPN/C.N.A). ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 7/28/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 361.

Based on interviews, review of Resident Identifier (RI) #50's medical record and RI #52's medical record, the facility's policy titled Abuse, Neglect, and Exploitation, the Alabama Department of Public Health Online Incident Reporting System and the facility's investigation files, the facility failed to ensure RI #50 and RI #52 were free from abuse perpetrated by a visitor of the facility, who is also the spouse of a resident residing in the facility. On 2/11/2019, without the consent of RI #50, the visitor came up behind RI #50 and placed his hands down the shirt of the resident, while the resident sat in the Dining room. RI #50 stated he/she was scared and shocked by the incident. Due to the facility not implementing interventions to protect and/or prevent further abuse from occurring, on 4/29/2019, without the consent of RI #52, the visitor kissed RI #52 on the forehead and ran his hand down the resident's clothing from the left breast to the resident's pubic area. RI #52 was hitting and screaming at the visitor to stop. A staff member intervened and instructed the visitor he had to leave the facility immediately. RI #52 stated he/she cried as he/she felt violated. These deficient practices placed RI #50 and RI #52, two of 11 sampled residents reviewed for abuse and placed them in immediate jeopardy of serious injury, harm, impairment or death. On 7/26/2019 at 6:50 PM, the facility's Administrator, Director of Nursing (DON), Director of Clinical Services and Vice President of Senior Living were given the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's policy titled Abuse, Neglect, and Exploitation with an effective date of 11/2016 documented Introduction The resident has the right to be free from verbal, sexual, physical and mental abuse . Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals . Definitions Abuse Coordinator -Facility representative responsible for coordinating the policies and procedures for abuse, neglect and exploitation and evaluating how policies are operationalized. The facility's Abuse Coordinator is the Director of Nursing. Abuse means the willfull infliction of injury, unreasonable confinements, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking . 1) RI #50 was admitted to the facility on [DATE]. RI #50's Annual Minimum Data Set (MDS) with an assessment reference date of 2/7/2019 indicated RI #50 was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 14. According to the Alabama Department of Public Health Online Incident Reporting System on 2/14/2019 at 4:58 PM, the facility reported an allegation of sexual abuse that involved RI #50 and a visitor (another resident's spouse). The report documented the incident occurred on 2/11/2019 at 11:30 AM in which Unit Manager received a call at 3:44pm from resident's representative (RI #50's spouse), stating (RI #50) had contacted him one day this week, he was unsure of the day, and stated to him someone had put their hands down (his/her) shirt. (RI #50's spouse) stated he thought the incident happened on over the weekend but he wasn't sure and he was unsure of the time but it did happen during meal time . The actions taken by the facility were listed as . (RI #50's) sponsor could not return to the facility until we finish the investigation . Investigation begun results to follow. In an interview on 7/23/2019 at 5:11 PM, RI #50 was asked if she remembered the incident that happened in (MONTH) (2019) when a someone touched him/her. RI #50 replied, yes he/she was in the dining room and a male came up behind him/her and put his hand under his/her shift. RI #50 stated he/she was shocked and when the male spoke, he/she knew it was not his/her spouse. RI #50 stated no one witnessed the incident and he/she returned to his/her room and called his/her spouse. When asked how that incident made RI #50 feel, the resident replied he/she was scared and shocked. 2) RI #52 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #52's Quarterly MDS with an assessment reference date of 5/2/2019 indicated RI #52 is moderately impaired in cognitive skills for daily decision making, with a BIMS of 11. According to the Alabama Department of Public Health Online Incident Reporting System on 4/29/2019 at 2:54 PM, the facility submitted an allegation of sexual abuse that involved RI #52 and a visitor (another resident's spouse). The report documented the incident occurred on 4/29/2019 at 12:55 PM, in which . (name) is the husband of a resident in the facility. (Name) was visiting his wife in the resident dining room. Staff member heard (RI #52) yell stop. Staff turned around and (visitor) had his hand on (RI #52) near (his/her) private area. the staff member instructed (visitor) he had to leave immediately. (RI #52) stated as (visitor) was leaving the dining room he came to (him/her) and kissed (him/her) head and ran his hand down (his/her) from (his/her) breast to (his/her) vagina . Contained within the facility's investigation file was a handwritten statement from Employee Identifier (EI) #32, a Licensed Practical Nurse (LPN) which documented 4/29/19 While serving plates in the dining room, I heard (RI #52) yelling Stop! When I turned around I saw (RI #-- spouse/visitor) with his (L) (left) arm across (RI #52's) chest, (RI #52) was trying to push him away and continued saying stop, don't do that. I asked (RI #52) what happened and (he/she) stated that (another resident's spouse/visitor) had run his hand from (his/her) (L) breast down to (his/her) private area. The CNA who was at the table stated that what (RI #52) said was true . In an interview on 7/13/2019 at 10:45 AM, RI #52 stated a man groped him/her in the dining room on 4/29/2019. RI #52 explained the male, who was the spouse of another resident, ran his hand down RI #52's breast and in between the resident's legs. When asked how did this make him/her feel, RI #52 replied, just awful that he/she told the male to stop and tried to push the man's arm away. RI #52 stated he/she almost cried when it happened because it made him/her feel violated. RI #52 further explained that it made him/her upset and angry. In an interview on 7/22/2019 at 4:20 PM, EI #2, the DON/Abuse Coordinator acknowledged after the (MONTH) 2019 incident involving the visitor and RI #50, the visitor was allowed to continue to visit the facility. When asked if anything was done different, EI #2 replied, no the visitor continued to visit his spouse, a resident of the facility, in an open area, usually in the Dining room or lounge. ************************* On 7/28/2019, the facility submitted an acceptable removal plan which documented: On 7/27/19, all residents with behavior careplans were reviewed and updated. On 7/27/19, the company Vice President of Senior Living (VP) provided both the facility Executive Director (Administrator) and the facility Clinical Services Administrator (Director of Nursing) with in-service education regarding the facility's policy entitled Abuse, Neglect and Exploitation. On 7/27/19, the RN, NHA, Legal Nurse Consultant provided in-service education on abuse reporting and investigating to facility Executive Director, Director of Nursing and divisional staff. Divisional Staff will then provide in-service education to staff regarding the proper identification, reporting and investigation of abuse. This staff training began on 7/27/19. To ensure the protection of all residents, staff will immediately identify Abuse as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, and mental abuse, including abuse facilitated or enabled, through the use of technology. Willful, as used by this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. In-service education will be completed by 7/28/19. Any staff members who do not receive in-service education by 7/28/19, will not be allowed to work until they have received in-service education. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 7/28/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 361.

Based on interviews and review of Resident Identifier (RI) #204's medical record, RI #205's medical record, the Resident Incident Report, a typed statement, the hospital medical records and the facility's policy titled Mechanical Lift, the facility failed to ensure the Dycem was correctly placed in RI #204's scoot chair. On 3/21/2019, while sitting in the scoot chair at the nurses' station, RI #204 fell face forward onto the floor, hitting his/head. Employee Identifier (EI) #7, the Registered Nurse Supervisor who witnessed the fall, stated RI #204 slid from chair with cushion and Dycem still attached to resident's pants. The therapy staff indicated there should be two pieces of Dycem in RI #204's scoot chair. One piece of dycem was to be placed in the chair between the cushion and the chair. Then another piece of Dycem was to be placed on top of the cushion under the resident so the resident's bottom did not slide off the cushion and the cushion did not slide from the chair. EI #7 stated there was only one piece of Dycem and it was placed between the pad and RI #204's bottom. RI #204 was transferred and admitted to a local hospital's Intensive Care Unit for an Acute Subdural Hematoma. The facility further failed to ensure EI #5, a Certified Nursing Assistant (CNA) transferred RI #205, as determined by the resident's comprehensive assessment. RI #205 was assessed as requiring extensive assistance of two staff members for transfers. On 3/25/2019, EI #5 transferred RI #205 from the chair to the bed by herself using the Standup Lift. During the transfer, the resident became combative and fell to the floor hitting his/her head on the floor. The Licensed Practical Nurse/Restorative Nurse, EI #23, stated she assessed RI #205 prior to the fall and determined the resident was totally dependent on two staff for transfers with a Hoyer lift. RI #205 was transferred to the local hospital for further evaluation; the resident sustained [REDACTED]. These deficient practices placed RI #204 and RI #205, two of eight sampled residents reviewed for falls and placed them in immediate jeopardy of serious injury, harm, impairment or death. On 7/26/2019 at 6:50 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Services and Vice President of Senior Living were given the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy in the area of Quality of Care, F 689. Findings include: 1) RI #204 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #204's Quarterly MDS with an assessment reference date of 2/4/2019, indicated the resident was moderately impaired in cognitive skills for daily decision making, with long and short term memory problems. RI #204's Resident Incident Report prepared by EI #7, a Registered Nurse (RN) indicated on 3/21/2019 at 9:14 PM while at the nurses' station Resident leaned forward out of scoot chair, slid from chair with cushion and dycem still attached to resident pants. Landed face first on floor. Assessed for injury. Neuro checks initiated. MD (Medical Doctor) notified with new orders to send to ER (emergency room ). Non-verbal. Alert. ROOT CAUSE - leaned forward in chair. Intervention - PT/OT (Physical Therapy/Occupational Therapy) consulted for new chair. Large hematoma approx (approximately) size of baseball above left eye. Two skin tears above left eye with large amount of bleeding noted . RI #205's Departmental Notes written by EI #7, a RN, and dated 3/21/2019 10:26 PM, documented At approx. 9:14pm looked up from nurse's station and saw resident leaning forward out of scoot chair. Resident slid from chair with cushion and dycem still attached to resident pants. Resident landed face first on floor. Log rolled resident onto (his/her) back to assess fro injury. Large hematoma noted above left eye with large amount of bleeding noted coming from two skin tears also above left eye . PT/OT consulted for possible change of chair from scoot chair to geri-chair if appropriate. A typed statement signed by EI #33, an Occupational Therapy Assistant (OTA), dated 7/22/2018 (2019) documented Nursing issued scoot chair for (RI #204), date (he/she) was issued scoot chair is unknown by therapy staff, it is also unknown at this time that dycem and cushion was in place. Patient was seen for a quarterly screen on 11/8/18 and was evaluated with no concerns documented regarding patient's positioning in scoot chair. Patient was discharged from therapy services 12/4/18 with FMP (Functional Maintenance Plan) noting scoot chair as appropriate positioning. Patient evaluated by OT 3/19/19 with dysem (dycem), cushion, and leg rests with standard foot plates on scoot chair documented in evaluation with no concerns. RI #204's care plan titled Potential for falls related to dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair. RI #204's care plan titled Resident needs assist with ADL's (activities of daily living) related to history [MEDICAL CONDITION] and dementia with a problem onset date of 5/25/2018, did not include an approach for the use of a scoot chair. In an interview on 7/16/2019 at 9:30 AM, EI #14, a Physical Therapy Assistant was asked, what was the appropriate way to use dycem. EI #14 replied, to place the dycem between the resident and the sitting surface and if the sitting surface was a cushion, then place the dycem between the cushion and the sitting surface as well as between the resident and the cushion. When asked why would a resident fall out of a scoot chair that had dycem in place, EI #14 replied, the dycem may need to be replaced. During a telephone interview on 7/16/2019 at 9:53 AM, EI #15, an Occupational Therapist was asked, what was the appropriate way to use dycem. EI #15 replied, place dycem under any movable surface and under the patient. When asked why would a resident fall out of a scoot chair that had dycem in place, EI #15 replied, the dycem may not have been positioned appropriately or it needed to be replaced. In a follow-up telephone interview on 7/17/2019 at 11:36 AM, EI #15, the OT stated during the re-evaluation of RI #204 on 3/19/2019, there was two pieces of dycem in the resident's scoot chair. One piece of dycem was under the cushion and another piece of dycem was under the patient. In an interview on 7/20/2019 at 1:43 PM, EI #7, a Registered Nurse (RN) Supervisor acknowledged that she was at the nurses' station charting when RI #204 fell on [DATE]. When asked if RI #204 was exhibiting any behaviors prior to the fall, EI #7 said no. When asked what happened, EI #7 replied that she saw RI #204 fall forward from the scoot chair, all in one continuous motion. In a follow-up interview on 7/24/2019 at 11:13 AM, EI #7, a RN Supervisor was asked how was the dycem placed in RI #204's scoot chair prior to the resident falling on 3/21/2019. EI #7 replied, she didn't remember. After the resident fell , EI #7 stated, the dycem was attached to the resident and the cushion. During an interview on 7/24/2019 at 11:19 AM, EI #6, the RN Unit Manager was asked, who was responsible for placing dycem in a resident's chair. EI #6 replied, it can be the nurses or the Certified Nursing Assistants; whoever places the resident in the chair is responsible for making sure the dycem in the chair. When asked who trained the staff on the proper way to place dycem in RI #204's scoot chair, EI #6 stated, the CNAs should learn this in CNA class, that anyone could show the CNAs how to put dycem in the chair. On 7/25/2019 at 10:35 AM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked, during the investigation of RI #204's fall on 3/21/2019, did she determine if the dycem in RI #204's scoot chair was properly placed. EI #2 replied, there was nothing in the investigation to reflect that. EI #2 further stated, the dycem was attached to the resident, so it had to have been in the chair because there was no other ay to place it in the scoot chair. When asked if there was supposed to be two pieces of dycem in RI #204's scoot chair, EI #2 replied, it doesn't necessarily have to be. During an interview on 7/15/2019 at 11:17 AM, EI #7, a RN Supervisor was asked how was RI #204 and the dycem placed in the resident's scoot chair. EI #7 replied, it was the scoot chair, the pad, the dycem and then RI #204's bottom. In an interview on 7/17/2019 at 11:45 AM, EI #33, the OTA was asked how should dycem be properly placed in RI #204's scoot chair. EI #33 replied, a piece of dycem is placed in the chair between the cushion and the chair. Then another piece of dycem is placed on top of the cushion under the resident so the resident's bottom does not slide off the cushion and the cushion does not slide from the chair. RI #204's local hospital's History and Physical dated 3/22/2019, documented . Chief Complaint Pt (patient) resided at The Village at Cook Springs. Pt was sitting in a chair and fell forward and hit face. Lac (laceration) noted to left forehead. Takes aspirin. Hx (history) dementia History of Present Illness . The patient presented with fall. The onset was yesterday evening. The character of symptoms is pain with [MEDICAL CONDITION]. The degree at onset was moderate . Pt . with hx (history) of dementia and TIA ([MEDICAL CONDITION]) who presented to the ED (Emergency Department) from nursing home c/o (complaint of) fall onset the evening of 3/21/2019. Per EMS (Emergency Medical Service) report, pt fell from a rolling chair and hit (his/her) face. (He/She) now presents with a L (left) side head injury with laceration. Unknown L[NAME] (level of conscious). Pt.'s wound was bandaged en route to ED and sutured in the ED due to continuous bleeding. EMS notes BP (blood pressure) 200/100 en route. (He/She) takes 81 mg (milligram) ASA (aspirin) daily . In ED, . CT (Computed [NAME]ography) Head: Impression: There is a small left subdural hematoma. There is no mass effect or midline shift. There are small hemorrhagic contusions in the left frontal lobe. This is a critical result . Neurosurgery was consulted by ED physician. No intervention recommended at this time - neurosurgery will consult in the AM (morning) . Assessment/Plan 1. Acute subdural hematoma s/p (status [REDACTED]. [MEDICAL CONDITION] - appx (approximately) 4 sutures to left forehead . RI #204 was admitted to the Intensive Care Unit. RI #204's Neurosurgery Consult Note dated 3/22/2019, documented . CT shows small acute left frontoparietal SDH (subdural hematoma) without mass effect. stable this am (morning . The SDH is small and stable. No surgical intervention needed. No follow-up needed . The Discharge Summary revealed RI #204 was discharged home on[DATE] with hospice care arranged. 2) RI #205 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #205's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/7/2019 indicated the resident was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of two. RI #205 was assessed as being totally dependent on staff for transfers, requiring two plus persons physical assist. RI #205's Resident Incident Report prepared by Employee Identifier (EI) #19, a Licensed Practical Nurse (LPN) indicated on 3/25/2019 at 8:30 PM, . Resident was sitting on the edge of the bed, CNA (Certified Nursing Assistant) was undressing (him/her) to get (him/her) ready for bed. Resident was combative was grabbing onto her. CNA bent down and resident fell forward onto the floor. ROOT CAUSE: Resident requires 2 person assist with ADL (Activities of Daily Living) care . The report indicated the physician and resident representative were notified, neurological checks were initiated, an ice pack was applied to RI #205's head and the resident was transferred to a local hospital for evaluation. The report further indicated the facility staff involved was EI #5, a CNA. In a telephone interview on 7/15/2019 at 11:35 AM, EI #5, a CNA who no longer works at the facility, stated on 3/25/2019, she had just used the stand up lift to place RI #205 back in the bed. As EI #5 lowered RI #205 to a sitting position, EI #5 moved the lift back and RI #205 became combative by pushing against EI #5 and holding onto the CNA's shirt. EI #5 stated the resident then fell forward onto the floor and hit his/her head. EI #5 stated that it happened so quick that she had no time to catch the resident. When asked why did she not have assistance when she transferred RI #205 back to bed, EI #5 stated she wasn't taught to have two people and that she had watched other staff do it by themselves as well. According to EI #5, the white book at the nurses' station that contained residents' care plans did not indicate that RI #205 required two persons assist with a lift. RI #205's care plan titled (RI #205) has potential for falls related to muscle weakness and dementia with a problem onset date of 7/25/2016 did not include an approach of how the resident should be transferred or the level of assistance required, prior to 3/25/2019. On 3/25/2019, the care plan was updated to include . Resident is to be a 2 person assist when placing in bed . On 3/26/2019, the care plan was updated to include . Resident is to be a mechanical lift with all transfers . In a follow-up telephone interview on 7/22/2019 at 12:01 PM, EI #5 stated when RI #205 fell on [DATE], that she had only transferred the resident to the bed to a sitting position on the side of the bed. When asked if she was dressing the resident, EI #5 said no. When asked if she was changing the resident's pants, EI #5 said no, that she could not change the resident's pants until the resident was lying down on the bed. EI #5 was asked how could having a second person to assist with the transfer prevent the fall. EI #5 replied, one person could have been on each side of the resident, that as she went to pick the resident's legs up, the other person could have been behind or beside her. In a telephone interview on 7/23/2019 at 8:33 AM, EI #19, a LPN was asked how many staff are required to transfer a resident with a Standup lift. EI #19 replied, that she believed it was two but couldn't be completely sure. The facility's policy titled Mechanical Lift with an effective date of (MONTH) (YEAR), documented PURPOSE: A mechanical lift should be used to help lift residents who may be too heavy to lift, or who cannot assist with a transfer. STANDARD: Two nursing staff should be used for the mechanic (mechanical) lift . On 7/24/2019 at 10:45 AM, an interview was conducted with EI #23, the LPN Restorative who assessed RI #205's functional status during the 3/7/2019 Quarterly MDS. EI #24 acknowledged that RI #205 was assessed as being totally dependent on two staff for transfers with a Hoyer lift. EI #24 stated she did not know why the staff would use a Standup lift with RI #205. EI #23 explained that to be able to use the Standup lift, the resident must be able to follow directions and since RI #205 was demented and sometimes could not comprehend directions, the Standup lift was not the best option. Review of RI #205's hospital records with an admission date of [DATE] revealed Emergency Documentation with Radiology Orders for CT Head or Brain with a reason documented as Head Injury and a Discharge [DIAGNOSES REDACTED]. According to a document titled Mechanical Lifts, Bed Bolsters, T&P (Turn and Position), and Heel Floating Objectives Skills Fair (MONTH) (YEAR), there are two types of mechanical lifts, the Hoyer lift and the Standup Lift. The documented further listed . Standup Lift Resident has to be able to follow directions . RI #205's Emergency Documentation from the local hospital documented on 3/25/2019 . Per EMS (Emergency Medical Service) report pt (patient) was sitting on the edge of the bed and fell forward at The Village at Cook Springs, hitting the floor. Hematoma to R (right) forehead noted . Pt disorientedx4 (person, place, time, location). Daughter reports this is pt's baseline . The patient presents with head injury. The onset was just prior to arrival . The patient . with a hx (history) of Alzheimer's Dementia, TIA [MEDICAL CONDITION](Hypertension) who presents to the ED (Emergency Department) via EMS with a head injury . (He/She) is not on blood thinners. Patient cannot give adequate hx due to Dementia . The Computed [NAME]ography (CT) done on 3/25/2019 revealed Severe intracranial atrophy and severe supratentorial small vessel white matter disease without evidence of acute cortical infarct, [MEDICAL CONDITION], or mass lesion. RI #205 was discharged from the local hospital on [DATE] and transferred back to the facility with a discharge [DIAGNOSES REDACTED]. ************************* On 7/28/2019, the facility submitted an acceptable removal plan which documented . All other residents with fall risks factors have the potential to be affected. On 07/27/19 facility staff reviewed residents who had a fall in the last thirty (30) days to identify fall risk factors. Facility staff reviewed the resident's Fall Risk Care Plans, updated as indicated, listed fall risk indicators and updated Daily Care Guides. Beginning 07/27/19, nursing staff (RN/LPN/C.N.A) was in-serviced on mechanical lift use with 2-person assist. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19 will not be allowed to work until they have received in-service education. On 07/27/19 nursing staff began to provide in-service education on identifying fall risk factors, and following both resident care-plans and Daily Care Guides. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19, will not be allowed to work until they have received in-service education. On 07/27/19 nursing staff began to provide in-service education on mechanical lift use with 2-person assist, to include the Sara-3000 stand-up lift. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19, will not be allowed to work until they have received in-service education. On 07/27/19 licensed staff began to receive in-service education concerning fall-risk care-plans, fall-risk indicators, and updating Daily Care Guides for both residents being admitted and readmitted to the facility. In-service education will be completed by 07/28/19. Any staff members who do not receive in-service education by 07/28/19, will not be allowed to work until they have received in-service education. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 7/28/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 361.

Based on interviews, review of the facility's policy titled Abuse, Neglect, and Exploitation and Resident Identifier (RI) #61's and RI #141's medical record, the facility failed to timely report allegations of physical abuse to the State Agency involving RI #61 and RI #205 and RI #52 and RI #141. On 1/30/2019, RI #205 hit RI #61 in the face. The residents were immediately separated and no injuries were noted. The facility reported this allegation to the State Agency on 7/19/2019. On 5/3/2019, RI #141 hit RI #52 on the arm, twice before the Certified Nursing Assistant (CNA) could intervene.The facility reported this allegation to the State Agency on 7/10/2019. This affected two of five allegations of abuse reviewed the survey. Findings include: The facility's policy titled Abuse, Neglect, and Exploitation with an effective date of 11/2016 documented . Process . V. Response and Reporting of Abuse, Neglect, and Exploitation (including injuries of unknown souce, and misappropriation of resident property) The following outlines steps to be taken during an investigation. These steps may occur simultaneously, may be perfomed by more than one person and not in any definitive order when there is an allegation or suspicision of abuse, neglect, or exploitation: A. Respond to the needs of the resident and protect them from further incident. B. Notify the Director of Nursing and Executive Director or their designee. C. Initiate an investigation immediately. D. Report to State agency immediately but no later than 2 hours . 1) RI #61's Resident Incident Report reviewed by EI #22, the Registered Nurse (RN) Unit Manager; EI #2, the DON; and EI #1, the Administrator dated 1/30/2019 11:00 AM documented Notified by CNA (Certified Nursing Assistant) that while resident was outside the shower room waiting on (his/her) shower, another resident (RI #205) hit (him/her) in the face, moving (his/her) glasses down. Residents were separated immediately and writer assessed resident for injuries. No apparent injuries noted . In an interview on 7/22/2019 at 5:00 PM, EI #2, the DON/Abuse Coordinator acknowledged the incident involving RI #61 and RI #205 was not reported to the State Agency as an allegation of abuse and it should have been. When asked why the allegation of abuse was not reported to the State Agency, EI #2 stated it was overlooked, that she did not do a good job readying the Incident Report. During an interview with EI #1, the Administrator on 7/22/2019 at 6:22 PM, he stated the incident involving RI #61 and RI #205 should have been reported to the State Agency. According to EI #1, section five of the facility's policy related to response and the reporting of abuse was not followed. According to the Online Incident Reporting System Report on 7/19/2019 at 4:36 PM, the facility reported to the State Agency an allegation of physical abuse involving RI #61 and RI #205 that occurred on 1/30/2019 at 11:00 AM. 2) RI #141's Departmental Notes dated 5/3/2019 8:24 AM, documented CNA reported that resident approached another resident (RI #52) in in the dining room and attempted to take (his/her) drinks, when that resident asked (him/her) not to drink (his/her) drinks resident began yelling and threatening to hit the other resident. This resident then proceeded to hit the other resident in the arm, when that resident tried pushing (him/her) away, (he/she) hit (him/her) again before the CNA could reach them . In an interview on 7/24/2019 at 6:18 PM, EI #2, the DON/Abuse Coordinator acknowledged the incident between RI #52 and RI #141 was not timely reported to the State Agency. According to the Online Incident Reporting System Report on 7/10/2019 at 5:34 PM, the facility reported to the State Agency an allegation of physical abuse involving RI #52 and RI #141 that occurred on 5/3/2019 at 8:04 AM. This deficiency was cited as a result of the investigation of complaint/report number AL 361.

Based on observation, interview and review of Resident Identifier (RI) #117's medical record, the facility failed to ensure Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA) washed her hands after handling RI #117's wet incontinence brief and before touching the resident's clean incontinence brief. This affected RI #117, one of three sampled residents observed for incontinence care. Findings include: RI #117 was readmitted to the facility on [DATE]. RI #117's Significant Change in Status Assessment with an assessment reference date of 7/4/2019 indicated the resident was assessed as requiring extensive assistance with toileting and being frequently incontinence of bowel and bladder. During the provision of incontinence care on 7/11/2019 at 9:15 AM, EI #11, a CNA removed RI #117's wet incontinence brief. After EI #11 cleansed the resident, she went to the resident's closet and removed a clean incontinence brief. EI #11 did not wash her hands or remove her gloves before she touched RI #117's clean incontinence brief. In an interview on 7/11/2019 at 9:57 AM, EI #11, a CNA was asked, what should have been done after she removed the soiled brief and before touching the clean brief. EI #11 replied, she should have washed her hands. When asked if she did that, EI #11 stated that missed that step. When asked what was the potential for harm, EI #11 replied, contamination of the clean brief.

Based on interviews, review of Resident Identifier (RI) #1's medical record, RI #1's, the local hospital record for RI #1, the facility's investigation file, and Employee Identifier (EI) #2's, EI #3's and EI #4's orientation agenda, EI #2, EI #3 and EI #4, all Certified Nursing Assistants (CNAs) failed to follow RI #1's care plan and daily care guide when they transferred RI #1 without the use of a mechanical lift on 9/27/2018. RI #1 is care planned for two person assist with transfers with the mechanical lift. EI #2, EI #3 and EI #4, all said they transferred RI #1 from the bed to the Geri-chair and back to bed on 9/27/2018, by picking RI #1 up under his/her arms and pivoting the resident to and from the bed. After the transfer, RI #1 complained of pain to the left leg on 9/27/2018, 9/28/2018, 9/29/2018 and 9/30/2018. On 9/30/2018, RI #1 called his/her family member and reported that his/her leg was broken. RI #1's family member then telephone the facility and asked a licensed nurse to assess the resident. RI #1's left leg was found to be inverted at the knee and the resident grimaced and hollered out when the left leg was manipulated. RI #1 was transferred to the local hospital for further evaluation and treatment. The X-ray at the local hospital showed RI #1 had sustained a [MEDICAL CONDITION] tibia and fibula. This deficient practice affected and placed RI #1, one of three sampled residents reviewed for accidents in immediate jeopardy as this failure was likely to cause serious injury, harm or death. On 12/21/2018 at 8:30 PM, the Administrator, Director of Nursing (DON) and Director of Clinical Quality Services were notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plans, F656. Findings include: RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's care plan titled (RI #1) requires staff assistance with ADLs with a problem onset date of 5/14/2016, had an approach of . Transfers x2 with mechanical lift . RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/5/2018 indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14. RI #1 was assessed as being totally dependent on staff for transfers, requiring two plus person physical assist. RI #1 was further assessed as having an impairment on one side of his/her body in the upper and lower extremities. On 10/1/2018 at 8:27 AM, the facility self-reported to the Alabama State Survey Agency an injury of unknown source sustained by RI #1. According to the initial report, RI #1 complained of pain in the left lower leg on Sunday, 9/30/2018. Upon examination, there appeared to be an alteration in the resident's leg. Orders were received to send RI #1 to the local emergency room . X-rays that were done revealed RI #1 had sustained a left tibia/fibula fracture. RI #1 returned to the facility with an immobilizer to the left lower leg, with instructions to follow up with an orthopedist. The facility's undated Final Report (RI #1) documented . (EI #1) asked how fracture occurred and (EI #5) stated, Well, were not sure. Apparently, (RI #1) called (his/her) sister, (name), and told her (RI #1) was hurting and (his/her) leg was broken. (RI #1) also told (his/her) sister that CNA dropped (him/her) on Tuesday when they were getting (RI #1) up to get (his/her) hair done and broke (RI #1's) leg. (EI #5), RN (Registered Nurse) Manager, and (EI #14), RN Manager, went to (RI #1's) room to ask about the incident. (RI #1) was asked what happened to which (he/she) stated, Two of the girls were helping me out of bed to get in the chair and when I put my leg on the floor it twisted and it started hurting. (RI #1) was asked if the staff assisted (him/her) out of the bed with a lift to which she stated, No, they just picked me up under my arms and helped me. (RI #1) was asked if (he/she) was dropped by the staff to which she stated, No, they didn't drop me. They just helped me out of the bed and I twisted my leg and that's when it broke. (RI #1) said the event took place Tuesday, (MONTH) 25, (YEAR) when (he/she) was going to get (his/her) hair fixed. (EI #1) asked (EI #12), LPN (Licensed Practical Nurse), about the events of Sunday, (MONTH) 30, (YEAR). (EI #12) stated, On Sun (Sunday) [DATE], I spoke with (RI #1's) Sister/sponsor (name), on the phone. She asked me if (RI #1) was okay because (RI #1) called her and said that 2 CNA's dropped (him/her) on Tuesday and hurt (his/her) leg and we were waiting to get an x-ray to see if it was broken. I told (RI #1's sister/sponsor) that nothing was reported to me about in (an) incident with (RI #1) . I told (RI #1's sister/sponsor) that I would go check on (RI #1). I went to (RI #1's) room. Resident was sitting up in bed with call light in reach with no visible distress noted at this time. I asked (RI #1) if anything was wrong. (RI #1) said, nothing. I told (RI #1) (his/her) sister called and said (he/she) had told her that (his/her) leg was hurting. I asked if I could look at (his/her) leg and (RI #1) nodded. I then raised the blanket and assessed (RI #1's) leg. Resident's left leg noted to have swelling and bruising or discoloration around (his/her) knee. I attempted to touch (RI #1's) leg and (he/she) told me not to touch it. I had another nurse, (EI #13, a LPN) to come and assess resident's leg with me and we both noted resident's leg was swollen and rotated inward . (EI #1) met with (EI #2, a CNA) and asked her if she would relay when and how (RI #1) was transferred to the gerichair to go get (his/her) hair cut. (EI #2) stated, I was the CNA for (RI #1) Thursday, September, 27, (YEAR) and (EI #3, a CNA) and I transferred (RI #1) to the gerichair. (EI #1) asked if they used a lift or if they just transferred (RI #1) by themselves. (EI #2) stated, Just us by ourselves. We picked her up under (RI #1's) arms and put (him/her) in the chair. (EI #1) asked (EI #2) if at any time during the transfer did (RI #1) complain of pain, hurting or twisting (his/her) knee or was (RI #1) ever dropped in the floor during the transfer. (EI #2) stated, No, (RI #1) didn't (he/she) just transferred with us. (RI #1) never said anything hurt and no (RI #1) was not dropped on the floor. When (RI #1) got into the gerichair (he/she) did say (his/her) knee hurt. (EI #1) asked (EI #4, a CNA) what knowledge she had of anything associated with (RI #1) . (EI #4) stated, I helped (EI #2) put (RI #1) in the bed on Thursday, (MONTH) 27, (YEAR). We picked (RI #1) up under (his/her) arms and assisted (him/her) back to bed. (EI #1) met with (EI #3, a CNA) and spoke with her concerning the events surrounding (RI #1's) care (EI #3 stated, . I helped (EI #2) get (RI #1) up on Thursday to go get (his/her) hair cut. We picked (RI #1) up under (his/her) arms and pivoted (RI #1) to the chair. (RI #1) said (his/her) leg was hurt and broken. But she says (his/her) leg and (his/her) arm are broken all the time . Upon conclusion of investigation, it has been determined . (RI #1) did not go to the beauty shop until Thursday, (MONTH) 27, (YEAR). It was determined (RI #1) did sustain a fracture at some point, during a transfer but there was no evidence of (RI #1) being dropped and there were no findings of abuse . RI #1's physician's orders [REDACTED]. RI #1's local hospital report dated 9/30/2018, documented . History of Present Illness (RI #1) . with multiple medical problems comes in after an accident in a nursing home . nursing assistance (assistants) removing patient from (his/her) bed to a wheelchair to take (him/her) to an activity in the nursing home. (RI #1's) leg got tangled up . (RI #1) has an injury to (his/her) . left knee . (RI #1) has swelling and discoloration of the left knee . Physical Examination . Skin: . Ecchymosis (bruising) left knee . Neurological: Alert and oriented to person, place, time, and situation . Medical Decision Making Differential Diagnosis: [REDACTED]. Impression and Plan Left tibial fracture Plan . Follow up with . (name of orthopedist) Within 1 to 2 weeks . Notes: This is a Certified Medical Emergency . RI #1's left knee x-ray report dated 9/30/2018, documented . Diffuse osteopenia is evident . There is a deformity of the proximal tibia with suggestion of minimally displaced, impacted proximal tibial fracture. Associated proximal fibular fracture is also seen . Overlying soft tissue swelling is evident . On 12/18/2018 at 3:53 PM, an interview was conducted with EI #2, the CNA assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 9/27/2018. When asked if she was familiar with RI #1, EI #2 said yes. EI #2 was asked what type of care did RI #1 require and she replied, RI #1 was total care. When asked if she and EI #3, a CNA, transferred RI #1 from the bed to the gerichair on 9/27/2018, EI #2 replied Yes ma'am. EI #2 was asked, how RI #1 was transferred. EI #2 answered that she was on one side and EI #3 got on the other side, they each went under RI #1's arms and turned the resident and placed him/her into the gerichair. EI #2 was asked if RI #1's feet ever came in contact with the floor. EI #2 replied, Yes barely, just for a quick second. EI #2 was asked if RI #1 complained of pain when transferred. EI #2 stated when she got RI #1 into the chair, the resident said his/her leg hurt. EI #2 explained that she reported to EI #7, a LPN that RI #1 complained of pain. According to EI #2, EI #7 looked and assessed RI #1's leg and afterwards, she took RI #1 to the beauty shop. When asked who transferred RI #1 back to bed after the beauty shop, EI #2 said she and another CNA, EI #4. EI #2 stated she couldn't recall how she and EI #4 transferred RI #1 back to bed. When asked how RI #1 was care planned to be transferred, EI #2 said With two people and a mechanical lift. EI #2 was asked if she had ever cared for RI #1. EI #2 answered This was my first time having to transfer (RI #1) or care for (him/her). EI #2 was asked how she knew the type of care RI #1 required. EI #2 replied that she could look at the care plan book, where the care guides are located or ask a nurse. When asked if she asked anyone how RI #1 should be transferred, EI #2 said no and explained that she was asked to get the resident up for the beauty shop. She asked EI #3 to assist her and assumed it was okay to get the resident up the way they did. When asked if she followed the resident's care plan during the transfer, EI #2 replied No not fully, two persons did assist in getting (RI #1) up. Just the lift was not used. During an interview with EI #7, a LPN on 12/19/2018 at 10:29 AM, she was asked if EI #2 (CNA) had reported to her on 9/27/2018 that RI #1 was complaining that his/her leg hurt. EI #7 answered I remember when the Beauty shop lady (name) told me. She (beauty shop lady) brought RI #1 to the desk and said (RI #1) was complaining that (his/her) knee was hurting. When asked which knee, EI #7 stated it was the left knee. In an interview on 12/19/2018 at 1:20 PM, EI #3, a CNA acknowledged that she assisted EI #2 (CNA) in transferring RI #1 from the bed to the gerichair on 9/27/2018. When asked how they transferred RI #1, EI #3 stated they got RI #1 to sit up on the side of the bed. EI #2 went under one arm and EI #3 went under RI #1's other arm and they transferred the resident. EI #3 was asked if RI #1 complained of pain during the transfer. EI #3 replied, (RI #1) said (his/her) leg was broke but she always says that. I could see at least up to (RI #1's) knee. I don't remember what (RI #1) was wearing but I didn't see any dislocation or swelling or anything out of the ordinary. After that I went back to my section and (EI #4) and (EI #2) put (RI #1) back to bed. EI #3 was asked, why RI #1 was getting out of bed and EI #3 said to go to the beauty shop. EI #3 was asked, how RI #1 should have been transferred. EI #3 replied, with a lift. When asked if RI #1's care plan was followed, EI #3 answered No. EI #3 was asked how she would know the type of care a resident required. EI #3 replied that she would look at the daily care guide. When asked if she had ever cared for RI #1, EI #3 stated Only a few times, maybe about four times. When asked if she had ever transferred RI #1 from the bed and/or to the bed, EI #3 said no. In an interview on 12/18/2018 at 2:05 PM, EI #4, a CNA was asked if she provided care to RI #1 on 9/27/2018. EI #4 replied that she was on the bath team that day and RI #1 did not get a bath on that day. When asked she helped EI #2, a CNA, transfer RI #1 back to bed on 9/27/2018, EI #4 said yes. When asked how was the resident transferred, EI #4 stated Under the arms. EI #4 was asked, how RI #1 was care planned to be transferred. EI #4 answered, with a mechanical lift. When asked how would staff know the type or way a resident should be transferred, EI #4 stated by the care guide. When asked if RI #1's care plan was followed when they did not utilize a lift with RI #1's transfer on 9/27/2018, EI #4 replied No ma'am. RI #1's Daily Care Guide indicated RI #1 was totally dependent on staff for transfers, with an intervention listed as . Transfers x2 with mechanical lift (Role: CNA) . According to the facility's orientation agenda for EI #2, on 1/31/2018 EI #2 was provided education on Resident Care Services to include: Safety - Resident and Employees and Care Plans. EI #3's orientation agenda indicated on 3/6/2018, EI #3 was provided education on Resident Care Services to include Use of Equipment and Oxygen, Safe Lifting, and Safety - Residents and Employees. EI #4's orientation agenda indicated on 4/4/2017, EI #4 was provided education on Resident Care Services to include: Safety - Residents and Employees, Fall Prevention, and Care Plans. During an interview on 12/19/2018 at 4:54 PM, EI #5, the RN Unit Manager acknowledged that he informed the DON, EI #1, about RI #1's injury on 10/1/2018. EI #5 stated it was reported from the ER that RI #1 had a tibia/fibula [MEDICAL CONDITION] leg. When asked if the facility determined how RI #1 sustained the fracture, EI #5 explained that the DON (EI #1) had talked with everyone to try to piece together a time line. According to EI #5, the nursing assistants had gotten RI #1 up and did a stand pivot transfer. When asked how was RI #1 care planned to be transferred, EI #5 replied, I believe with a hoyer lift. EI #5 explained that generally it was two staff with a lift. EI #5 stated the facility determined there were two staff member that did the stand pivot transfer. When asked how the CNA staff was aware of the type of care a resident required, EI #5 stated the daily care guide. When asked if it was the CNA's responsibility to look at the daily care guide before providing care to a resident, EI #5 replied yes. EI #5 was asked if the staff followed RI #1's care plan when they transferred the resident without utilizing the lift. EI #5 responded, No. During an interview on 12/20/2018 at 10:35 AM, EI #1, the DON was asked what the results of the investigation were, EI #1 stated she could not find any evidence that RI #1 was dropped and there was no evidence of abuse. When asked what was her conclusion as to how RI #1 sustained the fracture, EI #1 replied, (RI #1) was transferred by two people but I don't' know if (he/she) sustained the fracture that day or not. EI #1 was asked how RI #1 was care planned to be transferred. EI #1 replied, by way of a lift with two staff assisting. EI #1 was asked, how the staff transferred RI #1. EI #1 stated (RI #1) was going to the beauty shop and they transferred (RI #1) with two people without the lift. They stood (RI #1) up, pivoted (him/her) into the Gerichair. When asked if RI #1's care plan was followed, EI #1 answered no. EI #1 was asked where the CNA went to find out what type care a resident required. EI #1 stated, the daily care guide that are kept at the nurses' station. EI #1 explained after follow-up with the orthopaedic surgeon, RI #1 was transferred to a local hospital on [DATE] for surgery to repair the fracture. When asked if RI #1 was provided the proper transfer on 9/27/2018, EI #1 replied No, I think it was an unfortunate accident. But I don't know if it (the fracture) happened that day. EI #1 was asked what the facility had done to ensure an incident like RI #1's didn't recur. EI #1 replied, the staff was in-serviced, a skilled fair was held 10/15/2018 through 10/17/2018 and all the nursing staff had to participate. During the skills fair, the mechanical lift and residents' daily care guides were discussed. Contained within the facility's investigation file was a typed statement signed by EI #11, the facility's Medical Director and RI #1's primary physician, which read (RI #1) [NAME]TOBER 3, (YEAR) HPI (History of Present Illness): On 9/27/18 the patient was being taken to the beauty shop and on standing and pivoting (he/she) felt (his/her) leg pop and told the beautician (he/she) thought it was broken. There was no report of any trauma such as falling. Xray in ED (emergency department) did show left tib/fib fracture and osteopenia was also noted. This most likely represents a pathological fracture due to the osteopenia and standing and not due to a traumatic injury. (RI #1) has seen orthopedics who plan to operated (operate) next week. In a telephone interview with EI #11, the facility's Medical Director and RI #1's primary physician on 12/20/2018 at 9:30 AM, he was asked if he reviewed RI #1's x-ray report. EI #11 replied no. When asked what evidence he had to support that RI #1 sustained a pathological fracture, EI #11 stated it was the resident's [DIAGNOSES REDACTED].#1's fracture, EI #11 replied, RI #1 pivoting and the weight of the resident's body on his/her leg. ************************** On 12/22/2018 at 8:56 PM, the facility submitted an acceptable Allegation of Compliance, which documented Allegation of Compliance - Quality of Care / Implement Care Plan . *RI #1 is no longer a resident at the facility. *On 09-30-18, RI #1 was assessed by nursing staff. RN reported that RI #1 exhibited pain upon manipulation of left leg. RN reported assessment findings to attending physician. RN obtained MD order to send RI #1 out for evaluation and treatment. X-Ray report revealed fracture of RI #1's left Tibia/Fibula. *On 10-1-18, DON presented to the facility's established Interdisciplinary Team (QAPI AD H[NAME] committee) RI #1's Injury of Unknown Origin. Upon investigation, it was discovered that RI #1's daily care guide and care plan was not properly followed by C.N.A. staff. DON reviewed all daily care guides for accuracy to include use of mechanical lifts. All residents and care-plans matched transfer mode upon review. *On 10-2-18 C.N.A's involved in RI #1's transfer were provided with in-service education on the importance of following daily care guides and the use of mechanical lifts. *Facility conducted a Skills Fair on 10/15/18, 10/16/18, & 10/17/18 to include education related to: 1) following the daily care guide, 2) use of mechanical lifts. *On or before 10-21-18 all C.N.A.s that did not attend Skills Fair were provided with in-service education related to: 1) following the daily care guide, 2) use of mechanical lifts. *On 11-14-18, the facility held Quality Assurance Committee (QAPI) Meeting. DON updated QAPI Committee regarding the incident related to RI #1, and the completion of in-service education related to this incident. *on 11-30-18 facility completed eight (8) weeks of QAPI monitoring. No observations of non-compliance were identified during monitoring. ************************** After review of the facility's Allegation of Compliance, investigation file, in-service/education records, Quality Assurance plan, staff interviews and observations of care provided, the facility implemented corrective actions from 9/30/2018 to 11/30/2018, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 988.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's investigation file, the facility's policy titled Pain Management, the local hospital record for RI #1, and Fundamentals of Nursing, the facility failed to ensure the licensed nursing staff assessed RI #1's surgical wounds as ordered and directed by the Orthopaedic Surgeon. The facility further failed to ensure the licensed nursing staff documented the administration, location and effectiveness of as needed pain medication. Beginning on 9/27/2018, RI #1 complained on pain in the leg and stated his/her leg was broken. Further staff interviews revealed RI #1 complained of pain daily and there was increased swelling and bruising; however, nothing was done by the staff to determine the root cause of RI #1's pain, swelling and bruising to the left leg. On 9/30/2018, RI #1 called his/her family member and reported that his/her leg was broken. RI #1's family member then telephoned the facility and asked a licensed nurse to assess the resident. RI #1's left leg was found to be swollen, bruised, discolored, inverted at the knee and the resident grimaced and hollered out when the left leg was manipulated. RI #1 was transferred to the local hospital for further evaluation and treatment. The X-ray at the local hospital showed RI #1 had sustained a [MEDICAL CONDITION] tibia and fibula. RI #1's physician stated if the staff would have informed him of RI #1's complaints of pain and swelling to the left leg, he would have ordered an X-ray. On 10/8/2018, RI #1 was transferred to a local hospital for surgery to repair the left tibia and fibula fracture. RI #1 returned to the facility on [DATE], with orders to assess and change the surgical site daily. There was no documentation to indicate RI #1's surgical site was assessed and changed daily as ordered. The licensed staff members assigned to care for RI #1 was unsure as to who was responsible for the care and treatment of [REDACTED]. From 10/15/2018 to 11/4/2018, the licensed staff failed to assess the condition of RI #1's surgical wound/incision. On 11/4/2018, a Licensed Practical Nurse (LPN) removed the Ace bandage from RI #1's surgical site and noted a small, orange size blister to the left knee and blistering to the surgical site with seropurluent exudate (a mixture of serum and pus). The Orthopedic Surgeon, who performed RI #1's surgery was not notified of this change in RI #1's surgical wound. From 11/4/2018 to 11/8/2018, the licensed staff failed to assess the condition of RI #1's surgical wound/incision. Then on 11/8/2018, RI #1 was transported from the facility to the Orthopedic Surgeon's office for a follow-up. The Orthopedic Surgeon assessed RI #1's surgical wound and noted he was very disappointed in the care RI #1 had received at the nursing facility. RI #1's skin was macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) as a result of the dressing not being changed and there was wound dehiscence (a surgical complication in which a wound ruptures along a surgical incision). The Orthopedic Surgeon's report documented . Patient at this time will be admitted through the ER into the hospital for local irrigation and debridement as well as application of wound vac. We will at this time watch this closely as this potentially could require skin graft in the future. Patient will be in house during this procedure and process . After medical clearance, RI #1 underwent a left above the knee amputation on 11/16/2018. Two days later, RI #1 was pronounced dead at 5:03 PM on 11/18/2018, with the cause of death listed [MEDICAL CONDITION]. These deficient practices affected and placed RI #1, one of three sampled residents reviewed for pain and wound care in immediate jeopardy as this failure was likely to cause serious injury, harm or death. On 12/21/2018 at 8:30 PM, the facility's Administrator, Director of Nursing Service (DON), and Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Resident Assessment, F658. Findings include: RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/5/2018 indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 14. 1) Contained within the facility's investigation file, which is not a part of RI #1's medical record, was a typed statement from EI #7, a LPN, dated 10/1/2018, which read I, (EI #7), was at the nurse's station on Thursday, (MONTH) 27, (YEAR), and (EI #10) from the beauty shop came to me with (RI #1) and told me (RI #1) was complaining about (his/her) knee hurting and (RI #1) said the girls twisted (his/her) when they were getting (him/her) out of the bed to get (his/her) hair fixed. I asked where they twisted (him/her) and (RI #1) said below (his/her) left knee. I assessed (his/her) left knee and there was no alteration or discoloration noted and when I touched (his/her) leg from the thigh to the ankle (he/she) stated none of that hurt . I was the nurse on Friday (9/28/2018) as well and when I assessed (RI #1's) knee there was no discoloration or alteration in the knee this day either. (RI #1) denied pain that day as well . During an interview with EI #7, a LPN on 12/19/2018 at 10:29 AM, she stated I remember when the Beauty shop lady (name) told me. She (beauty shop lady) brought RI #1 to the desk and said (RI #1) was complaining that (his/her) knee was hurting. When asked which knee, EI #7 stated it was the left knee. When asked what she did as the result of RI #1's complaint of pain, EI #7 stated she assessed RI #1's left knee and there was no alteration or discoloration. EI #7 was asked if she did an assessment and she said yes. When asked, how a nurse proves an assessment was done, EI #7 replied chart it. EI #7 was asked if she was able to show where she charted RI #1's assessment of the left knee. EI #7 answered I don't see where I documented it. Contained within the facility's investigation file, which is not a part of RI #1's medical record, was a typed statement from EI #6, the RN Wound Treatment Nurse, dated 10/2/2018, which read On (MONTH) 28, (YEAR) at approximately 1400 (2:00 PM) I was notified by (EI #7) LPN of (RI #1) having pain to (his/her) left leg. (EI #15) CNA accompanied me to (RI #1's) room. Upon entering (RI #1) was lying supine in the bed with (his/her) legs extended. I did an assessment of (his/her) leg, looking at the top and lateral sides. I noted extensive swelling to (his/her) knee but no redness or bruising was noted. I told (RI #1) that it might be arthritis due to location and the rain during this period. I saw nothing to compliment trauma or damage. I reported my impression to (EI #7) then returned to my duties . During an interview on 12/19/2018 at 3:08 PM, EI #6, the RN Wound Treatment Nurse acknowledged that EI #7 notified him that RI #1 was complaining that his/her knee was hurting. When asked what he did after being notified by EI #7, EI #6 stated he went and looked at RI #1's knee. EI #6 stated he didn't do a full body assessment, he just gazed at RI #1's knee. There was no redness or bruising or any kind of trauma. EI #6 stated he told RI #1 that it could possibly be arthritis. EI #6 stated there was swelling and the swelling looked arthritic to him. When asked if RI #1 complained of pain at this time, EI #6 stated he couldn't remember. EI #6 stated he shared his assessment and thoughts of RI #1 with EI #7. When asked if he documented his assessment, EI #6 replied no. In a follow-up interview on 12/20/2018 at 4:30 PM, EI #7, a LPN was asked if she notified EI #6, the RN Wound Treatment Nurse on 9/28/2018, that RI #1 had complaints of left leg pain. EI #7 stated she may have but she couldn't remember. EI #7 was asked how many times between 9/27/2018 and 9/30/2018, did she conduct an assessment of RI #1's complaint of pain. EI #7 replied, she observed RI #1's knee once on 9/27/2018 and it was not swollen. When asked if she recalled EI #6 reporting to her that RI #1 had extensive swelling of the knee, EI #7 stated she didn't want to say he (EI #6) didn't but she didn't remember. A review of RI #1's Departmental (nurses') Notes from 9/27/2018 to 9/29/2018, revealed there was no documentation or evidence that assessments had been performed when RI #1 complained of pain to his/her left leg and had extensive swelling. In an interview on 12/20/2018 at 10:35 AM, EI #1, the Director of Nursing acknowledged she conducted the investigation of RI #1's injury. When asked if during staff interviews, any staff admitted that RI #1 complained of leg pain, EI #1 replied yes. EI #1 was asked what staff did when RI #1 complained of pain. EI #1 stated, if the complaint was made to a CNA, the CNA told the nurse and the nurse assessed RI #1's leg. When asked if there was any documentation of RI #1's complaints of pain, EI #1 said no. EI #1 was asked how the facility's policy instructed the nurse to address complaints of pain. EI #1 replied that she didn't know if the facility had a policy that addressed that. EI #1 stated she would have to check. The facility's policy titled Pain Management with an effective date of (MONTH) (YEAR), documented PURPOSE: To ensure adequate treatment of [REDACTED]. STANDARD: The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice . PR[NAME]ESS: . 3. Documentation a) The presence and level of the residents pain should be documented. b) The resident's response to pain medication should be documented in the medical record. In another interview on 12/21/2018 at 9:58 AM, EI #7, a LPN acknowledged that she administered pain medication to RI #1 on 9/29/2018 at 6:00 PM. When asked where RI #1's complaint of pain was and was the pain medication effective, EI #7 stated she didn't remember. RI #1's physician's orders [REDACTED]. According to RI #1's MEDICATION RECORD for the month of (MONTH) (YEAR), RI #1 was not administered [MEDICATION NAME] HCL 50 MG from 9/1/2018 to 9/30/2018; however, RI #1's CONTROLLED DRUG RECORD indicated [MEDICATION NAME] HCL 50 MG was removed from the controlled drug storage every day from 9/1/2018 to 9/30/2018, with the exception of 9/26/2018. RI #1's CONTROLLED DRUG RECORD and Departmental Notes did not indicate the location of RI #1's pain or whether or not the pain medication was effective. Page 621 of Chapter 32 titled Medication Administration of FUNDAMENTALS OF NURSING with a copyright date of (YEAR), documented . prn (as needed) Orders. Sometimes the health care provider orders a medication to be given only when a patient requires it. This is a prn order . When administering prn medications, document assessment findings to show why the patient needs the medication and the time of administration. Frequently evaluate the effectiveness of the medication and record evaluation date appropriately . In a follow up interview with EI #1, the DON on 12/21/2018 beginning at 12:30 PM, she was asked where she would expect the nurses to document their assessments of RI #1. EI #1 replied, if it was something out of the ordinary, it would be documented in the nurses' notes but if it was not out of the ordinary, it would not be documented because the staff documented by exception. EI #1 was asked if she expected EI #6, the RN Wound Treatment Nurse, to document his assessment of RI #1 when on 9/28/2018 he observed RI #1 to have extensive swelling to the left knee. EI #1 stated she thought it was common for RI #1 to have swelling. When asked to provide documentation that RI #1's swelling to the left knee was common, EI #1 stated she would have to look through RI #1's nurses' notes. EI #1 later responded that she could not find any nurses' notes that indicated RI #1 had [MEDICAL CONDITION] (swelling) to the left knee. EI #1 was asked where the resident's response to prn medication would be documented. EI #1 replied, in the resident's chart. 2) Contained within the facility's investigation file was a typed statement signed by EI #11, the facility's Medical Director and RI #1's primary physician, which read (RI #1) [NAME]TOBER 3, (YEAR) HPI (History of Present Illness): On 9/27/18 the patient was being taken to the beauty shop and on standing and pivoting (he/she) felt (his/her) leg pop and told the beautician (he/she) thought it was broken. There was no report of any trauma such as falling. Xray in ED (emergency department) did show left tib/fib fracture and osteopenia was also noted. This most likely represents a pathological fracture due to the osteopenia and standing and not due to a traumatic injury. (RI #1) has seen orthopedics who plan to operated (operate) next week. RI #1's Orthopaedic Surgeon's report dated 10/4/2018, documented . Chief Complaint: complaint left tibial plateau fracture . At this time patient (RI #1) comes to our clinic for evaluation and two-view x-ray of the left tibia and fibula demonstrates a proximal tibial fracture noted with impaction . (RI #1) will be scheduled for a CT (Computed Tomography) scan of the left knee and at this time patient will likely need open reduction internal fixation of the left proximal tibia . Physical Exam . Patient is neurovascularly intact to the left lower extremity . RI #1's Computed Tomography of the left lower extremity dated 10/4/2018, revealed . Findings: There are impacted fractures of both the tibia and fibula . Impaction is mild . Osteopenia is present. There is [MEDICAL CONDITION]. OPINION: Impacted fractures of the fibula and tibia . According to RI #1's local hospital record, RI #1 was admitted to the local hospital on [DATE] for an open reduction internal fixation of the left proximal tibial plateau fracture. The Discharge Summary dated 10/12/2018, documented . ADMISSION Diagnosis: [REDACTED]. DISCHARGE Diagnoses: [REDACTED]. 2. status [REDACTED]. HOSPITAL COURSE: The patient was admitted for the above-mentioned procedure, was taken from the postanesthesia recovery unit to the floor for observation purposes. The patient had 24 hours of requisite antibiotics and the patient to remain in (his/her) knee immobilizer throughout (his/her) stay. At this time, the patient was mobilized very slowly with physical therapy. The patient was respected (his/her) weightbearing limitations and at this time, the patient was deemed ready for discharge on 10/12/2018 . DISCHARGE INSTRUCTIONS: The patient is to be nonweightbearing strictly on the left lower extremity. Remain in (his/her) Velcro knee immobilizer throughout stay, may remove for hygiene purposes only and check dressing. Dressing is to be assessed daily and change for any saturation with 4 x 4s, [MEDICATION NAME] tape and Ace wrap. FOLLOWUP: The patient is instructed to follow up with Dr. (Orthopaedic Surgeon) at (location) in approximately 2 weeks. RI #1's physician's orders [REDACTED]. Dressing is daily change 4x4 [MEDICATION NAME] tape acewrap nonweight bearing strictly on LLE (left lower extremity) no ROM (range of motion) left knee remain in knee immoblizer (immobilizer) . RI #1's Departmental Notes dated 10/12/2018 8:46 PM, documented readmitted to unit at 5:30pm via (by way of) EMS (emergency medical service) stretcher. Resident is alert to person and oriented x3. Assessment completed; . Resident has a immobilizer to (his/her) left leg. Upon further inspection the left leg it has blue and black bruising. It is swollen upper thigh to (his/her) toes. The leg has an ace wrap in place . RI #1's undated TREATMENT RECORD indicated RI #1 had a treatment order for Change 4x4 on (L) (left) leg daily secured [MEDICATION NAME] tape & acewrap. According to this record, this treatment was only documented as being provided on the 13th (of (MONTH) (YEAR)). In an interview on 12/20/2018 at 5:21 PM, EI #18, the RN Unit Manager was asked if she transcribed RI #1's orders when the resident was readmitted to the facility on [DATE]. EI #18 said yes. When asked what the wound care orders were, EI #18 said RI #1 was to be non-weight bearing on the left lower extremity, the knee immobilizer was to remain in place but could be removed for hygiene purposes, check the dressing daily and change it with any saturation with 4x4s, [MEDICATION NAME] and Ace wrap. EI #18 was asked if RI #1 had orders for daily dressing changes. EI #18 replied that she read it as daily but she could see how it was as needed too. When asked who was responsible for checking RI #1's surgical wound dressing daily, EI #18 replied the nurses on the unit and the Treatment Nurse. EI #18 was asked how someone would know the treatment orders were being implemented as ordered. EI #18 answered, review the Treatment Record to see if it had been signed off. RI #1's Wound Assessment Report dated 10/15/2018 electronically signed by EI #6, the RN Wound Treatment Nurse, indicated RI #1 had a surgical incision to the left inner knee that measured 11.50 cm in length and 0.10 cm in width. The wound was closed, healing and had 12 staples present and intact. RI #1's Wound Assessment Report dated 10/15/2018 electronically signed by EI #6, the RN Wound Treatment Nurse, indicated RI #1 had a surgical incision to the left lateral knee that measured 12.50 cm in length and 0.10 cm in width. The wound was closed, healing and had 25 staples present and intact. In an interview on 12/19/2018 at 3:08 PM, EI #6, the RN Wound Treatment Nurse was asked if RI #1 had orders for wound care when he/she was readmitted to the facility after having surgery. EI #6 stated he didn't remember. EI #6 explained that he didn't know he was supposed to care for surgical wounds. EI #6 stated he only documented once regarding RI #1's surgical wound and that was before he found out the Charge Nurses were responsible for caring for RI #1's surgical wound. A review of RI #1's Departmental (nurses') Notes from 10/13/2018 to 11/4/2018 revealed the following: . 10/13/2018 11:17 AM . Immiobilzer (immobilizer) intact to left leg, swelling noted to toes and thighs, leg elevated via (by way of) x1 pillow . 10/13/2018 3:20 PM . left leg immobilizer intact, . dressing changed to left knee, no drainage noted, incision with stables (staples) no s/s (sign/symptom) of infection at this time . left leg elevated on pillow for comfort and reduce swelling . 10/14/2018 10:46 AM . Incision to left leg left side of knee 25 staples notes, incision to right of knee 12 staples noted. Drainage present incision site cleaned with WC (wound cleanser), patted dry, covered with 4x4, wrapped with ace bandage and brace applied . 10/15/2018 6:53 AM . (L) (left) knee Immobilizer in place and fitted properly . 10/16/2018 4:59 PM Surgical Incision/Left Knee// . Cleaned incision with Vasche, covered with post-op surgical dressing . The Orthopaedic Surgeon's progress note dated 10/25/2018, documented . Patient (RI #1) . presents to my clinic today in follow up open reduction internal fixation of the left tibial plateau . Physical Exam at this time reveals medial and lateral incision appear to be healing nicely there is no evidence of wound dehiscence. Patient is neurovascularly intact in the left lower extremity . Care Plan Patient at this time had (his/her) staples removed and steri strips places (placed) uneventfully. patient was placed in hinged knee brace set 0-45 degrees . At this time I would recommend daily dressing changes on this patient recommendation will continue to be non weight bearing on the left lower extremity and active range of motion of the knee 0-45 degrees only. There was documentation of this sent to the nursing facility today. I will see (RI #1) back in 2 weeks for clinical recheck. In an interview on 12/20/2018 at 5:21 PM, EI #18, the RN Unit Manager acknowledged that when RI #1 returned from the follow-up with the Orthopaedic Surgeon on 10/25/2018, the resident had orders to change the left knee dressing as needed. When asked if she saw this treatment on RI #1's Treatment Record, EI #18 stated the strict dressing change order was listed on the (MONTH) (YEAR) Treatment Record but there were no orders listed on RI #1's (MONTH) (YEAR) Treatment Record. EI #18 explained, RI #1's treatment orders should have been clarified to see what dressing needed to be put in place. When asked who would have been responsible to clarify the treatment order, EI #18 said the Charge Nurse or the Treatment Nurse. EI #18 was asked where else would it be documented that RI #1's left knee dressing was checked and changed as needed. EI #18 replied that she only knew of the Treatment Record or the nurses' notes. EI #18 was asked to review RI #1's nurses' notes and asked how many times after 10/25/2018 was there any documentation of RI #1's left knee surgical site. EI #18 answered, once on 11/4/2018. RI #1's Departmental (nurses') Notes dated 11/4/2018 7:24 PM, written by EI #19, a LPN, documented . Ace bandage removed to evaluate surgival (surgical) site with blister noted to left knee approx (approximately) sixe (size) of a small orange, blistering to surgical site, seropurluent (a mixture of serum and pus) exudate noted slightly below surgical site, Tx (treatment) order written to clean left knee and surgical site with W/C (wound cleanser), applu (apply) derma-gran &4x4 wrap with kerlix Q2days (every two days) and PRN as resident allows . New order left under TX nurse door to see if any modifications are needed . In an interview on 12/19/2018 at 6:02 PM, EI #19, a LPN was asked what orders RI #1 had when the resident returned to the facility on [DATE]. EI #19 stated, RI #1 had orders to be non-weight bearing to the left lower extremity, keep the left lower extremity in the knee immobilizer, it could be removed for hygiene purposes and check the dressing. EI #19 was asked, who was responsible for checking the dressing. EI #19 replied, the Treatment Nurse if he was in the building and if he wasn't here, the nurses. When asked where would it be documented that the dressing was checked, EI #19 stated on the Treatment Record. EI #19 acknowledged that she changed RI #1's surgical site dressing on 11/4/2018 and notified the the physician, and not the Orthopaedic Surgeon, of her assessment of RI #1's surgical wound. In a follow-up interview on 12/20/2018 at 6:32 PM, EI #6, the RN Wound Treatment Nurse acknowledged that he was not sure why EI #19 would place RI #1's new treatment order under his door (on 11/4/2018) because he didn't provide care and treatment of [REDACTED]. The Orthopaedic Surgeon's progress note dated 11/8/2018, documented . Patient (RI #1) . presents to my clinic today in follow up open reduction internal fixation left tibial plateau fracture . At this time patient returns and dressing is assessed and reveals patients skin is macerated as a result from the dressing not being changed at the frequency per my request. I am very disappointed in the care that (he/she) has received at this facility. Patient at this time will be admitted through the ER into the hospital for local irrigation and debridement as well as application of wound vac. We will at this time watch this closely as this potentially could require skin graft in the future. Patient will be in house during this procedure and process . Physical exam at this time reveals wound dehiscence noted with superficial only. There is evidence of maceration noted around its periphery however no exposed implants . In an interview on 12/19/2018 at 10:29 AM, EI #7, a LPN was asked if she ever performed wound care on RI #1's surgical wound. EI #7 said she did once, when she assisted EI #6, the RN Wound Treatment Nurse. According to EI #7, she was EI #6's assistant. When asked what type care/treatment was provided, EI #7 stated she didn't know but RI #1 had a surgical incision on the knee. During an interview with EI #7, a LPN, on 12/20/2018 at 4:30 PM, she was asked after RI #1 returned to the facility on [DATE], how many times was she assigned to care for RI #1. EI #7 replied, every Monday through Friday. When asked if she ever observed or assessed RI #1's surgical wound dressing, EI #7 said she did. When asked to explain how she observed and/or assessed the surgical wound, EI #7 stated she would carefully look at the bandage. EI #7 was asked if she ever noticed any drainage and she stated one time when she was with EI #6, the Treatment Nurse, there was some drainage but she couldn't recall when it was or how much drainage was noted. EI #7 was asked if she documented her observation and/or assessment of RI #1's surgical wound. EI #7 answered that she did not. In a follow up interview on 12/21/2018 at 9:58 AM, EI #7, a LPN was asked who was responsible for the treatment of [REDACTED].#7 replied, it had always been the Treatment Nurse. EI #7 acknowledged on 11/4/2018, RI #1 was observed to have a blister on the left knee surgical site the size of a small orange. EI #7 stated the physician was called and there were orders given to apply derma-gran and 4x4, wrap with Kerlix every two days. EI #7 stated based on the order, the dressing should have been done on 11/6/2018 and 11/8/2018. When asked if it was done as ordered, EI #7 replied not according to the tx (treatment) record. When asked who should have provided the treatment, EI #7 said the Treatment Nurse. In an interview with EI #1, the DON on 12/21/2018 at 12:30 PM, she was asked after the completion of the facility's investigation did she identify which nurse did not perform surgical wound care on RI #1. EI #1 replied, yes. When asked which nurse was it, EI #1 said it was EI #7, the LPN. EI #1 was asked, who was responsible for the care and treatment of [REDACTED].#1 replied, the charge nurses. When asked if the charge nurses were aware of this, EI #1 stated, Yes ma'am. I did an inservice. When asked when the in-service was conducted, EI #1 stated (MONTH) (YEAR). EI #1 was asked if she specify when the in-service was conducted in (MONTH) (YEAR). EI #1 explained that she would have to say it was after she found out RI #1 was being readmitted back into the hospital; RI #1 was readmitted to the hospital on [DATE]. The local hospital's History and Physical for RI #1 dated 11/8/2018, documented . Pt (patient) seen and examined. With help of nurse (his/her) left lower extremity was unbandaged. (He/She) has extensive necrotic skin breakdown on about 40% of the LLE (left lower extremity) from the prepatellar surface down to the dorsum of the left foot in multiple areas . (He/She) has necrotic areas from pressure from the knee immobilizer that appears to have been left on for an extended period of time . I was told that the surgical plan is for I&D of the left knee today, however to my exam it appears (his/her) whole left lower extremity from the knee down may be infected and/or vascularly compromised. I do not feel (he/she) is stable for surgery yet and recommend delaying surgery for [REDACTED]. However if Dr. (Orthopaedic Surgeon) feels it is imperative to remove infected/necrotic tissue right away than an argument could be made for that as well . Contained within the local hospital record for RI #1 was a progress note dated 11/8/2018, which read . Called The Village at Cook Springs and spoke with nursing staff concerning patient. They reported . that the surgical site (dressing) on the top of the left knee was changed on 11/4/18 . The local hospital's Discharge Documentation for RI #1 dated 11/18/2018, documented . Pt (RI #1) was seen by Dr. (Orthopaedic Surgeon) of Orthopedic surgery for [REDACTED]. Pt declined clinically and was transferred to the ICU prior to surgery. (He/She) underwent L (left) AKA (above knee amputation) on 11/16 . (He/She) was treated for [REDACTED]. (He/She) was nonresponsive, pupils were dilated and nonreactive, with agonal breaths . Pt was pronounced dead at 5:03 pm. Family was at bedside. Cause of death:[MEDICAL CONDITION] . During an interview with the Orthopedic Surgeon on 1/3/2019 at 5:00 PM, he was asked what it meant when it was documented in his progress notes dated 10/4/2018 and 10/25/2018 that RI #1 was neurvascularly intact in the left lower extremity. The Orthopedic Surgeon stated that RI #1 had a pulse present. When asked what he expected the staff to do when RI #1 had an order to assess the dressing daily, the Orthopedic Surgeon stated lay eyes on the dressing, to check it for saturation, drainage. The Surgeon explained that he was aware RI #1 was in a nursing facility and not a hospital so he didn't expect much but he had hoped they would check for saturation, drainage, physical changes and report any concerns to him. The Surgeon reported communication was a big problem. He stated if the staff had concerns about the orders that were sent to the facility regarding RI #1's surgical wound care, the staff should have contacted him. When asked what treatment should the facility have implemented when RI #1 returned back to the facility from the follow-up on 10/25/2018, the Surgeon stated, to carry out the dry dressing changes, visually inspect the wound to see if there were any changes. The Surgeon stated if anyone at that facility would have laid eyes on RI #1's surgical incision, they would have known the dressing needed to be changed and concerns reported to the Surgeon. When asked to describe the appearance of RI #1's surgical incision when the resident returned to his office on 11/8/2018, the Surgeon stated the dressing was saturated and macerated as if it had not been changed in a while and there was significant wound breakdown. The Surgeon stated he had someone call the facility to ask when the dressing was changed last and was told 11/4/2018. When asked if he was aware the staff had noted an orange size blister to RI #1's surgical site on 11/4/2018, the Surgeon stated he did not. The Surgeon explained he would have expected the staff to call him if there were concerns with RI #1's surgical incision. He stated had he been called, he would have more than likely asked for the resident to bought into his office. He stated to have an orange size blister to a surgical incision was not good and he would have liked to know some measurements of the blister. The Surgeon stated because of the condition of RI #1's surgical incision, he had RI #1 admitted to the hospital for irrigation and debridement of the surgical site. He further stated that RI #1 could not go back to that nursing facility because he felt the care of the resident's surgical incision was substandard. The Surgeon stated he was aware when RI #1 returned to the hospital, she had a [DIAGNOSES REDACTED]. When asked how RI #1's [DIAGNOSES REDACTED]. The Surgeon stated the primary factor for RI #1's left above the knee amputation was the infection. When asked why the left above the amputation did not occur until 11/16/2018, the Surgeon stated RI #1 had to have medical clearance. He explained RI #1 was an elderly patient with multiple co-morbidities and required consultation from other Sp

Based on interviews and review of the facility's policy titled Guidelines Wound Management, the facility failed to ensure a procedure was in place that directed staff as to how surgical wounds should be cared for and who was responsible for the care and treatment of [REDACTED].#1 was readmitted back to the facility with a surgical wound/incision to the left knee. The licensed staff members assigned to care for RI #1 was unsure as to who was responsible for the care and treatment of [REDACTED]. From 10/15/2018 to 11/4/2018, the licensed staff failed to assess the condition of RI #1's surgical wound/incision. On 11/4/2018, a Licensed Practical Nurse (LPN) removed the Ace bandage from RI #1's surgical site and noted a small, orange size blister to the left knee and blistering to the surgical site with seropurluent exudate (a mixture of serum and pus). The Orthopedic Surgeon, who performed RI #1's surgery was not notified of this change in RI #1's surgical wound. From 11/4/2018 to 11/8/2018, the licensed staff failed to assess the condition of RI #1's surgical wound/incision. Then on 11/8/2018, RI #1 was transported from the facility to the Orthopedic Surgeon's office for a follow-up. The Orthopedic Surgeon assessed RI #1's surgical wound and noted he was very disappointed in the care RI #1 had received at the nursing facility. RI #1's skin was macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture) as a result of the dressing not being changed and there was wound dehiscence (a surgical complication in which a wound ruptures along a surgical incision). The Orthopedic Surgeon's report documented . Patient at this time will be admitted through the ER into the hospital for local irrigation and debridement as well as application of wound vac. We will at this time watch this closely as this potentially could require skin graft in the future. Patient will be in house during this procedure and process . After medical clearance, RI #1 underwent a left above the knee amputation on 11/16/2018. Two days later, RI #1 was pronounced dead at 5:03 PM on 11/18/2018, with the cause of death listed [MEDICAL CONDITION]. This deficient practice affected and placed RI #1, one of five sampled residents in immediate jeopardy as this failure was likely to cause serious injury, harm or death. On 12/21/2018 at 8:30 PM, the Administrator, Director of Nursing (DON) and Director of Clinical Quality Services were notified of the findings of immediate jeopardy in the area of Administration, F835. Findings include: Refer to F658 The facility's policy titled Guidelines Wound Management with an effective date of (MONTH) (YEAR), did not address the care and treatment of [REDACTED]. In an interview on 12/19/2018 at 3:08 PM, EI #6, the Registered Nurse (RN) Treatment Nurse acknowledged that he had been employed with the facility since 9/11/2018. When asked what his responsibilities were, EI #6 stated he took care of all the pressure and arterial ulcers and did body audits on all residents that were admitted . EI #6 explained he was not supposed to take care of surgical wounds/incisions. EI #6 stated surgical wounds/incisions were the responsibility of the nurses. When asked who was responsible for the care and treatment of [REDACTED].#6 replied he was not and assumed it was the nurses. During an interview with EI #18, the RN Unit Manager on 12/20/2018 at 5:21 PM, she was asked who was responsible for the care and treatment of [REDACTED]. EI #18 replied, the nurses on the unit and the Treatment Nurse. When asked who ultimately was responsible, EI #18 stated Everybody. The nurses when the Treatment Nurse is not here. In an interview on 12/21/2018 at 9:58 AM, EI #7, a LPN was asked who was responsible for the treatment of [REDACTED].#7 replied, it had always been the Treatment Nurse. On 12/21/2018 at 4:33 PM, an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked, who was responsible for the care and treatment of [REDACTED].#1 replied, the charge nurses. When asked if the charge nurses were aware of this, EI #1 stated, Yes ma'am. I did an inservice. When asked when the in-service was conducted, EI #1 stated (MONTH) (YEAR). EI #1 was asked if she could specify when the in-service was conducted in (MONTH) (YEAR). EI #1 explained that she would have to say it was after she found out RI #1 was being readmitted back into the hospital; RI #1 was readmitted to the hospital on [DATE]. ************************** On 12/22/2018 at 8:56 PM, the facility submitted an acceptable Allegation of Compliance, which documented Allegation of Compliance - Administration . * On 11-08-18, DON & assigned designee(s) began providing in-service education to all nursing staff (RN/LPN) regarding charge nurse responsibility for assessing, evaluating, and treating wounds per MD orders. * On 11/08/18 Clinical Administration approved new procedure directing the treatment of [REDACTED]. * On or before 11-30-18 all nursing staff (RN/LPN) were provided with in-service education regarding wound care procedures. * On 12-15-18, facility completed QAPI monitoring. No observation of non-compliance were identified during monitoring. ************************** After review of the facility's Allegation of Compliance, investigation file, in-service/education records, Quality Assurance plan, staff interviews and observations of care provided, the facility implemented corrective actions from 11/8/2018 to 12/15/2018, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 988.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the local hospital record for RI #1, the facility's investigation file, and Employee Identifier (EI) #2's and EI #3's orientation agenda, EI #2 and EI #3, both Certified Nursing Assistants (CNAs) failed to use a mechanical lift, as determined necessary by RI #1's comprehensive assessment and care plan, when they transferred RI #1 from the bed to the Geri-chair on 9/27/2018. Instead of the mechanical lift, the staff picked RI #1 up under the resident's arm and pivoted him/her to the Geri-chair. When RI #1 was placed in the Geri-chair, he/she complained that his/her knee hurt and leg was broken. RI #1 complained of pain on 9/27/2018, 9/28/2018, 9/29/2018 and 9/30/2018. On 9/30/2018, RI #1 called his/her family member and reported that his/her leg was broken. RI #1's family member then telephoned the facility and asked a licensed nurse to assess the resident. RI #1's left leg was found to be swollen, bruised, discolored, inverted at the knee and the resident grimaced and hollered out when the left leg was manipulated. RI #1 was transferred to the local hospital for further evaluation and treatment. The X-ray at the local hospital showed RI #1 had sustained a [MEDICAL CONDITION] tibia and fibula. The facility's Medical Director and RI #1's primary physician stated RI #1's fracture was likely caused by pivoting and the weight of RI #1's body on his/her leg. This deficient practice affected and placed RI #1, one of three sampled residents reviewed for accidents in immediate jeopardy as this failure was likely to cause serious injury, harm or death. On 12/21/2018 at 8:30 PM, the facility's Administrator, Director of Nursing Service (DON), and Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Quality of Care, F689. Findings include: RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's care plan titled (RI #1) requires staff assistance with ADLs with a problem onset date of 5/14/2016, had an approach of . Transfers x2 with mechanical lift . RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/5/2018 indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14. RI #1 was assessed as being totally dependent on staff for transfers, requiring two plus person physical assist. RI #1 was further assessed as having an impairment on one side of his/her body in the upper and lower extremities. On 10/1/2018 at 8:27 AM, the facility self-reported to the Alabama State Survey Agency an injury of unknown source sustained by RI #1. According to the initial report, RI #1 complained of pain in the left lower leg on Sunday, 9/30/2018. Upon examination, there appeared to be an alteration in the resident's leg. Orders were received to send RI #1 to the local emergency room . X-rays that were done revealed RI #1 had sustained a left tibia/fibula fracture. RI #1 returned to the facility with an immobilizer to the left lower leg, with instructions to follow up with an orthopedist. The facility's undated Final Report (RI #1) documented On Monday, (MONTH) 01, (YEAR), at approximately 7:50am (EI #1), RN, DON was notified by (EI #5), RN Manager, resident (RI #1), had been sent to the ER complaining of left leg pain and rotation of left leg. Upon returning from ER it was reported (RI #1) had a tibia/fibula fracture of left leg and returned to facility with an immobilizer to be worn with orders to see Dr. (name), orthopedist in 10-14 days. (EI #1) asked how fracture occurred and (EI #5) stated, Well, were (we are) not sure. Apparently, (RI #1) called (his/her) sister, (name), and told her (RI #1) was hurting and (his/her) leg was broken. (RI #1) also told (his/her) sister that CNA dropped (him/her) on Tuesday when they were getting (RI #1) up to get (his/her) hair done and broke (RI #1's) leg. (EI #5), RN Manager, and (EI #14), RN Manager, went to (RI #1's) room to ask about the incident. (RI #1) was asked what happened to which (he/she) stated, Two of the girls were helping me out of bed to get in the chair and when I put my leg on the floor it twisted and it started hurting. (RI #1) was asked if the staff assisted (him/her) out of the bed with a lift to which she stated, No, they just picked me up under my arms and helped me. (RI #1) was asked if (he/she) was dropped by the staff to which she stated, No, they didn't drop me. They just helped me out of the bed and I twisted my leg and that's when it broke. (RI #1) said the event took place Tuesday, (MONTH) 25, (YEAR) when (he/she) was going to her (his/her hair fixed. (EI #1) asked (EI #12), LPN, about the events of Sunday, (MONTH) 30, (YEAR). (EI #12 stated, On Sun (Sunday) [DATE], I spoke with (RI #1's) Sister/sponsor (name), on the phone. She asked me if (RI #1) was okay because (RI #1) called her and said that 2 CNA's dropped (him/her) on Tuesday and hurt (his/her) leg and we were waiting to get an x-ray to see if it was broken. I told (RI #1's sister/sponsor) that nothing was reported to me about in (an) incident with (RI #1) . I told (RI #1's sister/sponsor) that I would go check on (RI #1). I went to (RI #1's) room. Resident was sitting up in bed with call light in reach with no visible distress noted at this time. I asked (RI #1) if anything was wrong. (RI #1) said, nothing. I told (RI #1) (his/her) sister called and said (he/she) had told her that (his/her) leg was hurting. I asked if I could look at (his/her) leg and (RI #1) nodded. I then raised the blanket and assessed (RI #1's) leg. Resident's left leg noted to have swelling and bruising or discoloration around (his/her) knee. I attempted to touch (RI #1's) leg and (he/she) told me not to touch it. I had another nurse, (EI #13, a LPN) to come and assess resident's leg with me and we both noted resident's leg was swollen and rotated inward . (EI #1) met with (EI #2, a CNA) and asked her if she would relay when and how (RI #1) was transferred to the gerichair to go get (his/her) hair cut. (EI #2) stated, I was the CNA for (RI #1) Thursday, September, 27, (YEAR) and (EI #3, a CNA) and I transferred (RI #1) to the gerichair. (EI #1) asked if they used a lift or if they just transferred (RI #1) by themselves. (EI #2) stated, Just us by ourselves. We picked her up under (RI #1's) arms and put (him/her) in the chair. (EI #1) asked (EI #2) if at any time during the transfer did (RI #1) complain of pain, hurting or twisting (his/her) knee or was (RI #1) ever dropped in the floor during the transfer. (EI #2) stated, No, (RI #1) didn't (he/she) just transferred with us. (RI #1) never said anything hurt and no (RI #1) was not dropped on the floor. When (RI #1) got into the gerichair (he/she) did say (his/her) knee hurt. (EI #1) met with (EI #3, a CNA) and spoke with her concerning the events surrounding (RI #1's) care (EI #3 stated, . I helped (EI #2) get (RI #1) up on Thursday to go get (his/her) hair cut. We picked (RI #1) up under (his/her) arms and pivoted (RI #1) to the chair. (RI #1) said (his/her) leg was hurt and broken. But she says (his/her) leg and (his/her) arm are broken all the time . Upon conclusion of investigation, it has been determined . (RI #1) did not go to the beauty shop until Thursday, (MONTH) 27, (YEAR). It was determined (RI #1) did sustain a fracture at some point, during a transfer but there was no evidence of (RI #1) being dropped and there were no findings of abuse . RI #1's Departmental Notes dated 9/30/2018 at 3:47 PM, written by EI #8, a RN Supervisor, documented Staff received a phone call from residents sponsor, who stated that (RI #1) had called her and told her that the CNAs had dropped (him/her) on Tuesday and hurt (his/her) leg. Upon inspection of the leg it was noted that (RI #1's) left leg was inverted at the knee, and resident grimaced and hollered out with any manipulation of (his/her) left leg. P.C. (phone call) to sponsor to inform her of my findings and recommendation to send out to the hospital for evaluation and treatment . RI #1's physician's orders [REDACTED]. RI #'s local hospital report dated 9/30/2018, documented . History of Present Illness (RI #1) . with multiple medical problems comes in after an accident in a nursing home . nursing assistance (assistants) removing patient from (his/her) bed to a wheelchair to take (him/her) to an activity in the nursing home. (RI #1's) leg got tangled up . (RI #1) has an injury to (his/her) . left knee . (RI #1) has swelling and discoloration of the left knee . Physical Examination . Skin: . Ecchymosis (bruising) left knee . Neurological: Alert and oriented to person, place, time, and situation . Medical Decision Making Differential Diagnosis: [REDACTED]. Impression and Plan Left tibial fracture Plan . Follow up with . (name of orthopedist) Within 1 to 2 weeks . Notes: This is a Certified Medical Emergency . RI #1's left knee x-ray report dated 9/30/2018, documented . Diffuse osteopenia is evident . There is a deformity of the proximal tibia with suggestion of minimally displaced, impacted proximal tibial fracture. Associated proximal fibular fracture is also seen . Overlying soft tissue swelling is evident . On 12/18/2018 at 3:53 PM, an interview was conducted with EI #2, the CNA assigned to care for RI #1 during the 7:00 AM to 3:00 PM shift on 9/27/2018. When asked if she was familiar with RI #1, EI #2 said yes. EI #2 was asked what type of care did RI #1 require and she replied, RI #1 was total care. When asked if she and EI #3, a CNA, transferred RI #1 from the bed to the gerichair on 9/27/2018, EI #2 replied Yes ma'am. EI #2 was asked, how RI #1 was transferred. EI #2 answered that she was on one side and EI #3 got on the other side, they each went under RI #1's arms and turned the resident and placed him/her into the gerichair. EI #2 was asked if RI #1's feet ever came in contact with the floor. EI #2 replied, Yes barely, just for a quick second. EI #2 was asked if RI #1 complained of pain when transferred. EI #2 stated when she got RI #1 into the chair, the resident said his/her leg hurt. EI #2 explained that she reported to EI #7, a LPN that RI #1 complained of pain. According to EI #2, EI #7 looked and assessed RI #1's leg and afterwards, she took RI #1 to the beauty shop. When asked who transferred RI #1 back to bed after the beauty shop, EI #2 said she and another CNA, EI #4. EI #2 stated she couldn't recall how she and EI #4 transferred RI #1 back to bed. When asked how RI #1 was care planned to be transferred, EI #2 said With two people and a mechanical lift. EI #2 was asked if she had ever cared for RI #1. EI #2 answered This was my first time having to transfer (RI #1) or care for (him/her). EI #2 was asked how she knew the type of care RI #1 required. EI #2 replied that she could look at the care plan book, where the care guides are located or ask a nurse. When asked if she asked anyone how RI #1 should be transferred, EI #2 said no and explained that she was asked to get the resident up for the beauty shop. She asked EI #3 to assist her and assumed it was okay to get the resident up the way they did. When asked if she followed the resident's care plan during the transfer, EI #2 replied No not fully, two persons did assist in getting (RI #1) up. Just the lift was not used. During an interview with EI #7, a LPN on 12/19/2018 at 10:29 AM, she was asked if EI #2 (CNA) had reported to her on 9/27/2018 that RI #1 was complaining that his/her leg hurt. EI #7 answered I remember when the Beauty shop lady (name) told me. She (beauty shop lady) brought RI #1 to the desk and said (RI #1) was complaining that (his/her) knee was hurting. When asked which knee, EI #7 stated it was the left knee. In an interview on 12/19/2018 at 1:20 PM, EI #3, a CNA acknowledged that she assisted EI #2 (CNA) in transferring RI #1 from the bed to the gerichair on 9/27/2018. When asked how they transferred RI #1, EI #3 stated they got RI #1 to sit up on the side of the bed. EI #2 went under one arm and EI #3 went under RI #1's other arm and they transferred the resident. EI #3 was asked if RI #1 complained of pain during the transfer. EI #3 replied, (RI #1) said (his/her) leg was broke but she always says that. I could see at least up to (RI #1's) knee. I don't remember what (RI #1) was wearing but I didn't see any dislocation or swelling or anything out of the ordinary. After that I went back to my section and (EI #4) and (EI #2) put (RI #1) back to bed. EI #3 was asked, why RI #1 was getting out of bed and EI #3 said to go to the beauty shop. EI #3 was asked, how RI #1 should have been transferred. EI #3 replied, with a lift. When asked if RI #1's care plan was followed, EI #3 answered No. EI #3 was asked how she would know the type of care a resident required. EI #3 replied that she would look at the daily care guide. When asked if she had ever cared for RI #1, EI #3 stated Only a few times, maybe about four times. When asked if she had ever transferred RI #1 from the bed and/or to the bed prior to 9/27/2018, EI #3 said no. In an interview on 12/18/2018 at 2:05 PM, EI #4, a CNA was asked if she provided care to RI #1 on 9/27/2018. EI #4 replied that she was on the bath team that day and RI #1 did not get a bath on that day. When asked she helped EI #2, a CNA, transfer RI #1 back to bed on 9/27/2018, EI #4 said yes. When asked how was the resident transferred, EI #4 stated Under the arms. EI #4 was asked, how RI #1 was care planned to be transferred. EI #4 answered, with a mechanical lift. When asked how would staff know the type or way a resident should be transferred, EI #4 stated by the care guide. When asked if RI #1's care plan was followed when they did not utilize a lift with RI #1's transfer on 9/27/2018, EI #4 replied No ma'am. RI #1's Daily Care Guide indicated RI #1 was totally dependent on staff for transfers, with an intervention listed as . Transfers x2 with mechanical lift (Role: CNA) . According to the facility's orientation agenda for EI #2, on 1/31/2018 EI #2 was provided education on Resident Care Services to include: Safety - Resident and Employees and Care Plans. EI #3's orientation agenda indicated on 3/6/2018, EI #3 was provided education on Resident Care Services to include Use of Equipment and Oxygen, Safe Lifting, and Safety - Residents and Employees. During an interview on 12/19/2018 at 4:54 PM, EI #5, the RN Unit Manager acknowledged that he informed the DON, EI #1, about RI #1's injury on 10/1/2018. EI #5 stated it was reported from the ER that RI #1 had a tibia/fibula [MEDICAL CONDITION] leg. When asked if the facility determined how RI #1 sustained the fracture, EI #5 explained that the DON (EI #1) had talked with everyone to try to piece together a time line. According to EI #5, the nursing assistants had gotten RI #1 up and did a stand pivot transfer. When asked how was RI #1 care planned to be transferred, EI #5 replied, I believe with a hoyer lift. EI #5 explained that generally it was two staff with a lift. EI #5 stated the facility determined there were two staff members that did the stand pivot transfer. When asked how the CNA staff was aware of the type of care a resident required, EI #5 stated the daily care guide. When asked if it was the CNA's responsibility to look at the daily care guide before providing care to a resident, EI #5 replied yes. EI #5 was asked if the staff followed RI #1's care plan when they transferred the resident without utilizing the lift. EI #5 responded, No. During an interview on 12/20/2018 at 10:35 AM, EI #1, the DON acknowledged that on 10/1/2018, EI #5 called her while she was enroute to work to report that RI #1 had sustained a [MEDICAL CONDITION] leg. EI #1 stated when she arrived at the facility, she began the investigation. When asked what the results of the investigation were, EI #1 stated she could not find any evidence that RI #1 was dropped and there was no evidence of abuse. When asked what was her conclusion as to how RI #1 sustained the fracture, EI #1 replied, (RI #1) was transferred by two people but I don't' know if (he/she) sustained the fracture that day or not. EI #1 was asked how RI #1 was care planned to be transferred. EI #1 replied, by way of a lift with two staff assisting. EI #1 was asked, how the staff transferred RI #1. EI #1 stated (RI #1) was going to the beauty shop and they transferred (RI #1) with two people without the lift. They stood (RI #1) up, pivoted (him/her) into the Gerichair. When asked if RI #1's care plan was followed, EI #1 answered no. EI #1 was asked where the CNA went to find out what type care a resident required. EI #1 stated, the daily care guides are kept at the nurses' station. EI #1 explained after follow-up with the Orthopedic Surgeon, RI #1 was transferred to a local hospital on [DATE] for surgery to repair the fracture. When asked if RI #1 was provided the proper transfer on 9/27/2018, EI #1 replied No, I think it was an unfortunate accident. But I don't know if it (the fracture) happened that day. EI #1 was asked what the facility had done to ensure an incident like RI #1's didn't recur. EI #1 replied, the staff was in-serviced, a skilled fair was held 10/15/2018 through 10/17/2018 and all the nursing staff had to participate. During the skills fair, the mechanical lift and residents' daily care guides were discussed. Contained within the facility's investigation file was a typed statement signed by EI #11, the facility's Medical Director and RI #1's primary physician, which read (RI #1) [NAME]TOBER 3, (YEAR) HPI (History of Present Illness): On 9/27/18 the patient was being taken to the beauty shop and on standing and pivoting (he/she) felt (his/her) leg pop and told the beautician (he/she) thought it was broken. There was no report of any trauma such as falling. Xray in ED (emergency department) did show left tib/fib fracture and osteopenia was also noted. This most likely represents a pathological fracture due to the osteopenia and standing and not due to a traumatic injury. (RI #1) has seen orthopedics who plan to operated (operate) next week. In a telephone interview on 12/20/2018 at 9:30 AM, with EI #11, the facility's Medical Director and RI #1's primary physician, he was asked if he reviewed RI #1's x-ray report. EI #11 replied no. When asked what evidence he had to support that RI #1 sustained a pathological fracture, EI #11 stated it was the resident's [DIAGNOSES REDACTED].#1's fracture, EI #11 replied, RI #1 pivoting and the weight of the resident's body on his/her leg. ************************** On 12/22/2018 at 8:56 PM, the facility submitted an acceptable Allegation of Compliance, which documented Allegation of Compliance - Accidents . *RI #1 is no longer a resident at the facility. *On 09-30-18, RI #1 was assessed by nursing staff. RN reported that RI #1 exhibited pain upon manipulation of left leg. RN reported assessment findings to attending physician. RN obtained MD order to send RI #1 out for evaluation and treatment. X-Ray report revealed fracture of RI #1's left Tibia/Fibula. * On 10-1-18, DON presented RI #1's Injury of Unknown Origin to the facility's established Interdisciplinary Team (QAPI AD H[NAME] committee). *Facility conducted a Skills Fair on 10/15/18, 10/16/18, & 10/17/18 to include education related to: 1) following the daily care guide, 2) use of mechanical lifts. *On or before 10-21-18 all C.N.A.s that did not attend Skills Fair were provided with in-service education related to: 1) following the daily care guide, 2) use of mechanical lifts. *On 11-30-18, facility completed QAPI monitoring. No observations of non-compliance or negative findings identified. *On 12-12-18, facility completed QAPI monitoring. No observations of non-compliance or negative finding were identified. *All Incidents & Accidents from 9/27/18 to present were reviewed by DON and no falls were noted, related to not following resident care-plan(s). ************************** After review of the facility's Allegation of Compliance, investigation file, in-service/education records, Quality Assurance plan, staff interviews and observations of care provided, the facility implemented corrective actions from 9/30/2018 to 12/12/2018, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 988.

Based on interviews, review of the facility's policy titled Notification of a Change in Medical Condition of Residents, Resident Identifier (RI) #1's medical record, the local hospital record for RI #1, and the facility's investigation file, the facility's licensed nursing staff delayed treatment of [REDACTED].#1's physician of the resident's daily complaints of pain from 9/27/2018 to 9/30/2018 and swelling of the left leg that was noted on 9/28/2018. On 9/27/2018, Employee Identifier (EI) #2 and EI #3, both Certified Nursing Assistants (CNAs) transferred from the bed to the Geri-chair on 9/27/2018 (Refer to F656). Instead of using the mechanical lift, EI #2 and EI #3 picked RI #1 up under the resident's arms and pivoted the resident to the Geri-chair. When RI #1 was placed in the Geri-chair, he/she complained that his/her knee hurt and leg was broken. EI #3 acknowledged RI #1 informed them that his/her leg hurt and was broken. Neither of these staff members reported RI #1's complaint of pain to the licensed nursing staff. While in the beauty shop on 9/27/2018, RI #1 reported to the beautician, EI #10, that his/her leg hurt. EI #10 reported to EI #7, a Licensed Practical Nurse (LPN) that RI #1 was complaining that his/her knee hurt and the girls (CNAs) twisted it when they got him/her up out of bed to go get his/her hair fixed. EI #7, a LPN stated she assessed RI #1's left knee and stated there was no pain, alteration or discoloration noted; however, EI #7 failed to document her assessment of RI #1 (Refer to F658). On 9/28/2018, after being told RI #1 was complaining of left leg pain, EI #6, the Registered Nurse (RN) Wound Treatment Nurse, noted RI #1 had extensive swelling to the left knee. EI #6 informed RI #1 he thought the swelling was arthritic in nature. Further staff interviews revealed RI #1 complained of pain daily and there was increased swelling and bruising; however, nothing was done by the staff to determine the root cause of RI #1's pain, swelling and bruising to the left leg. On 9/30/2018, RI #1 called his/her family member and reported that his/her leg was broken. RI #1's family member then telephoned the facility and asked a licensed nurse to assess the resident. RI #1's left leg was found to be swollen, bruised, discolored, inverted at the knee and the resident grimaced and hollered out when the left leg was manipulated. RI #1 was transferred to the local hospital for further evaluation and treatment. The X-ray at the local hospital showed RI #1 had sustained a [MEDICAL CONDITION] tibia and fibula. RI #1's physician stated if the staff would have informed him of RI #1's complaints of pain and swelling to the left leg, he would have ordered an X-ray. This deficient practice affected and placed RI #1, one of five sampled residents in immediate jeopardy as this failure was likely to cause serious injury, harm or death. On 12/21/2018 at 8:30 PM, the Administrator, Director of Nursing (DON) and Director of Clinical Quality Services were notified of the findings of immediate jeopardy in the area of Quality of Care, F684 Findings include: The facility's policy titled Notification of a Change in Medical Condition of Residents with an effective date of (MONTH) (YEAR), documented PURPOSE To keep the physician, and family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. STANDARD Notification of the physician, resident's representative, should occur promptly, according to federal regulations, when there is a change in the resident's condition . RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/5/2018 indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 14. On 10/1/2018 at 8:27 AM, the facility self-reported to the Alabama State Survey Agency an injury of unknown source sustained by RI #1. According to the initial report, RI #1 complained of pain in the left lower leg on Sunday, 9/30/2018. Upon examination, there appeared to be an alteration in the resident's leg. Orders were received to send RI #1 to the local emergency room . X-rays done revealed RI #1 had sustained a left tibia/fibula fracture. RI #1 returned to the facility with an immobilizer to the left lower leg, with instructions to follow up with an orthopedist. The facility's undated Final Report (RI #1) documented On Monday, (MONTH) 01, (YEAR), at approximately 7:50am (EI #1), RN, DON was notified by (EI #5), RN Manager, resident (RI #1), had been sent to the ER complaining of left leg pain and rotation of left leg. Upon returning from ER it was reported (RI #1) had a tibia/fibula fracture of left leg and returned to facility with an immobilizer to be worn with orders to see Dr. (name), orthopedist in 10-14 days. (EI #1) asked how fracture occurred and (EI #5) stated, Well, were (we are) not sure. Apparently, (RI #1) called (his/her) sister, (name), and told her (RI #1) was hurting and (his/her) leg was broken. (RI #1) also told (his/her) sister that CNA dropped (him/her) on Tuesday when they were getting (RI #1) up to get (his/her) hair done and broke (RI #1's) leg. (EI #5), RN Manager, and (EI #14), RN Manager, went to (RI #1's) room to ask about the incident. (RI #1) was asked what happened to which (he/she) stated, Two of the girls were helping me out of bed to get in the chair and when I put my leg on the floor it twisted and it started hurting. (RI #1) was asked if (he/she) was dropped by the staff to which she stated, No, they didn't drop me. They just helped me out of the bed and I twisted my leg and that's when it broke. (RI #1) said the event took place Tuesday, (MONTH) 25, (YEAR) when (he/she) was going to get (his/her) hair fixed . (EI #1) asked (EI #12), LPN, about the events of Sunday, (MONTH) 30, (YEAR). (EI #12 stated, On Sun (Sunday) [DATE], I spoke with (RI #1's) Sister/sponsor (name), on the phone. She asked me if (RI #1) was okay because (RI #1) called her and said that 2 CNA's dropped (him/her) on Tuesday and hurt (his/her) leg and we were waiting to get an x-ray to see if it was broken. I told (RI #1's sister/sponsor) that nothing was reported to me about in (an) incident with (RI #1) . I told (RI #1's sister/sponsor) that I would go check on (RI #1). I went to (RI #1's) room. Resident was sitting up in bed with call light in reach with no visible distress noted at this time. I asked (RI #1) if anything was wrong. (RI #1) said, nothing. I told (RI #1) (his/her) sister called and said (he/she) had told her that (his/her) leg was hurting. I asked if I could look at (his/her) leg and (RI #1) nodded. I then raised the blanket and assessed (RI #1's) leg. Resident's left leg noted to have swelling and bruising or discoloration around (his/her) knee. I attempted to touch (RI #1's) leg and (he/she) told me not to touch it. I had another nurse, (EI #13, a LPN) to come and assess resident's leg with me and we both noted resident's leg was swollen and rotated inward . (EI #1) interviewed (EI #7), LPN, Charge nurse asking about (RI #1). (EI #1) asked if she had any information concerning (RI #1's) leg. (EI #7) stated, I was at the nurse's station on Thursday, (MONTH) 27, (YEAR), and (EI #10) from the beauty shop came to me with (RI #1) and told me (RI #1) was complaining about (his/her) knee hurting and (RI #1) said the girls twisted (his/her) when they were getting (him/her) out of the bed to get (his/her) hair fixed. I asked (RI #1) where they twisted (him/her) and (he/she) said below (his/her) left knee . I was the nurse on Friday (9/28/2018) as well and when I assessed (RI #1's) knee there was no discoloration or alteration in the knee this day either. (RI #1) denied pain that day as well . (EI #6, the RN Treatment Nurse) stated, On (MONTH) 28, (YEAR) at approximately 1400 (2:00 PM) I was notified by (EI #7) LPN of (RI #1) having pain to (his/her) left leg. (EI #15) CNA accompanied me to (RI #1's) room. Upon entering (RI #1) was lying supine in the bed with (his/her) legs extended. I did an assessment of (his/her) leg, looking at the top and lateral sides. I noted extensive swelling to (his/her) knee but no redness or bruising was noted. I told (RI #1) that it might be arthritis due to location and the rain during this period . I reported my impression to (EI #7) then returned to my duties . (EI #1) spoke with (EI #16), CNA to ask (EI #16) when she was assigned to (RI #1). (EI #16 stated, Wednesday (9/26/2018), Thursday (9/27/2018), Saturday (9/29/2018) . (EI #1) then asked (EI #16) what care (EI #16) provided to (RI #1) on Thursday. (EI #16) stated, I changed (him/her) about 3 times that shift . (EI #1) asked (EI #16) if she noticed anything unusual concerning (RI #1's) leg this day (EI #16) stated, It was a little swollen but not bruised or anything else. I was only assigned to (him/her) for part of the shift then (EI #17, a CNA) was assigned to (RI #1) when she came in. I did help (EI #17) and at one point change (RI #1) and (RI #1) did say (his/her) leg hurt but it didn't look any different than it did earlier in the day (EI #1) then asked (EI #16) to tell about Saturday, (MONTH) 29, (YEAR). (EI #16) stated, I went into (RI #1's) room to check on (him/her) and change (him/her) and (his/her) leg around (his/her) knee was more swollen and it was bruised. (RI #1) said it hurt and (he/she) acted like the pain was worse than the other days. I told the nurse and he went and looked at it. (EI #1) asked the name of the nurses and (EI #16) stated it was (EI #9, a LPN) . (EI #1) spoke with (EI #17, a CNA) and asked her what was her recollection of taking care of (RI #1). (EI #17) stated, I took care of (RI #1) Thursday, (MONTH) 27, (YEAR). I changed her. (EI #16) helped me . When I saw (RI #1's) leg it was swollen at the knee. When we rolled (him/her) over to change (him/her) (RI #1) did complain of pain. I told the nurse, but I don't remember who it was . (EI #1) spoke with (EI #9, a LPN), via phone, and asked (EI #9 if he knew of (RI #1) complaining of pain in (his/her) left leg . (EI #9) stated, (EI #16) came and told me (RI #1) was complaining of (his/her) leg hurting. I went to (RI #1's) room and asked (him/her) what was wrong and (RI #1) stated (his/her) shin hurt. I looked at both (his/her) legs and did not see anything abnormal with either leg. During an interview with EI #7, a LPN on 12/19/2018 at 10:29 AM, she acknowledged that she did not inform RI #1's physician of the resident's complaint of pain or that the resident's left leg had been twisted. In an interview on 12/19/2018 at 3:08 PM, EI #6, the RN Treatment Nurse acknowledged that EI #7 (LPN) had reported to him that RI #1 was complaining of pain on 9/28/2018. According to EI #6, he went to RI #1's room and gazed at the resident's leg and noted it was swollen. EI #6 stated the swelling appeared arthritic to him. EI #6 explained that after he looked at RI #1's leg, he only reported his feeling and thoughts to EI #7. During a telephone interview with EI #9, a LPN on 12/20/2018 at 7:03 PM, he acknowledged that he did not inform RI #1's physician of the resident's complaint of pain. RI #1's Departmental Notes dated 9/30/2018 at 3:47 PM, written by EI #8, a RN Supervisor, documented Staff received a phone call from residents sponsor, who stated that (RI #1) had called her and told her that the CNAs had dropped (him/her) on Tuesday and hurt (his/her) leg. Upon inspection of the leg it was noted that (RI #1's) left leg was inverted at the knee, and resident grimaced and hollered out with any manipulation of (his/her) left leg. P.C. (phone call) to sponsor to inform her of my findings and recommendation to send out to the hospital for evaluation and treatment . RI #1's physician's orders [REDACTED]. RI #'s local hospital report dated 9/30/2018, documented . History of Present Illness (RI #1) . with multiple medical problems comes in after an accident in a nursing home . nursing assistance (assistants) removing patient from (his/her) bed to a wheelchair to take (him/her) to an activity in the nursing home. (RI #1's) leg got tangled up . (RI #1) has an injury to (his/her) . left knee . (RI #1) has swelling and discoloration of the left knee . Physical Examination . Skin: . Ecchymosis (bruising) left knee . Neurological: Alert and oriented to person, place, time, and situation . Medical Decision Making Differential Diagnosis: [REDACTED]. Impression and Plan Left tibial fracture Plan . Follow up with . (name of orthopedist) Within 1 to 2 weeks . Notes: This is a Certified Medical Emergency . RI #1's left knee x-ray report dated 9/30/2018, documented . There is a deformity of the proximal tibia with suggestion of minimally displaced, impacted proximal tibial fracture. Associated proximal fibular fracture is also seen . Overlying soft tissue swelling is evident . In a telephone interview with EI #11, the facility's Medical Director and RI #1's primary physician on 12/20/2018 at 9:30 AM, acknowledged he was not made aware of RI #1's injury or complaints of pain until it was identified RI #1 had sustained a tibia/fibula fracture. In a follow-up telephone interview with EI #11, the facility's Medical Director and RI #1's primary physician on 12/21/2018 at 2:48 PM, he was asked if the licensed nurses had reported to him, RI #1 had swelling to the left leg and was complaining of pain, what would he have instructed the staff to do. EI #11 stated he would have informed them to get an X-ray. ************************** On 12/22/2018 at 8:56 PM, the facility submitted an acceptable Allegation of Compliance, which documented Allegation of Compliance - Quality of Care . RI #1 complained of pain to the left lower leg on 9/27/18, 9/28/18, 9/29/18, & 9/30/18. *RI #1 is no longer a resident at the facility. * On 09-30-18, RI #1 was assessed by nursing staff. RN reported that RI #1 exhibited pain upon manipulation of left leg. RN reported assessment findings to attending physician. RN obtained MD order to send RI #1 out for evaluation and treatment. X-Ray report revealed fracture of RI #1's left Tibia/Fibula. *On 10/23/18, RN was provided with in-service education by DON, ADON & Staff Development Coordinator related to notifying MD of resident change in condition. *On or before 11/30/18, all licensed staff (RN/LPN) were provided with in-service education related to pain management. *Monitoring was completed by 11/30/18 and no negative finding found. *Since 9/30/18 RN Managers monitored pain management by: 1) reviewing 24 hour reports for pain, and verifying pain was addressed, 2) reviewing nurses notes for documentation for pain and verifying pain was addressed, 3) review controlled drug record for documentation of pain medication administered, 4) provide re-education with staff as needed, 5) document on monitoring record. As a result of review, no negative findings. ************************** After review of the facility's Allegation of Compliance, investigation file, in-service/education records, Quality Assurance plan, staff interviews and observations of care provided, the facility implemented corrective actions from 9/30/2018 to 11/30/2018, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 988.

Based on observations, interviews and a review of a facility policy titled ,Food, Leftover-Storage and Use and a document titled, Food Code, the facility failed to ensure: 1. eleven honey thickener waters were not in the cooler passed the use by date of [DATE]; 2. a worker washed her hands after dropping a thermometer cover to the floor and before taking the temperature of a milk and; 3. plates were free of debris in the plate warmer. This was observed on one of three days of the survey and had the potential to affect 151 of 151 resident who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled Food, Leftover-Storage and Use, with an effective date of ,[DATE] revealed: PURPOSE: To assure that food borne illnesses are avoided .PR[NAME]ESS 9. Opened bulk items that require refrigeration once opened may be stored up to thirty (30) days but not beyond the best by or expiration date then discarded. On [DATE] at 8:40 a.m., the surveyor toured cooler #2 with EI #9, Dining Service Manager. The surveyor observed eleven Ready Care Lemon Flavored water Honey Consistency Thickener dated [DATE]. On [DATE] at 9:05 a.m. the surveyor conducted an interview with EI #9. EI #9 was asked what was expired in the cooler. EI #9 replied, Honey Thickened Water. EI #9 was asked why was it expired in the cooler. EI #9 replied, it was beyond the use by date on the container. EI #9 was asked who was responsible for removing expired items out of the cooler. EI #9 replied, anyone who sees it should be pulling it. EI #9 was asked why should expired items be removed from the cooler. EI #9 replied, because it was beyond the use by date, it affects the quality and safety of the product. EI #9 was asked what did the facility policy say regarding expired food items in the cooler. EI #9 replied, it should be deposed of immediately. EI #9 was asked when should expired items be removed from the cooler. EI #9 replied, preferably on the expiration date or as soon as it is found. EI #9 was asked why was it important not to serve residents expired food. EI #9 replied, because the manufacture knows what the best use by date is, after that it was not good for consumption. 2) a review of a document titled Food Code U. S. Public Health Service , U. S. Food & Drug Administration, (YEAR), ,[DATE].13 Special Handwash ProceduresXXX,[DATE].14 When to Wash. FOOD EMPLOYEES shall clean their hands .(E) After handling soiled EQUIPMENT or UTENSILS On [DATE] at 11:30 a.m.,the surveyor observed EI #10, Dietary/Utility staff, dropped a thermometer cover to the floor. EI #10 picked up the thermometer cover off the floor. She went to a counter to get alcohol prep (wipes). She touched a trash can lid when she was near the counter. EI #10 did not wash her hands. On [DATE] at 09:07 a.m., the surveyor conducted an interview with EI #10. EI #10 was asked what did she drop on the floor. EI #10 replied, thermometer top on the floor. EI #10 was asked what did she do after she dropped the thermometer top on the floor. EI #10 replied, she kept it in her hands. EI #10 was asked did she wash the thermometer with water. EI #10 replied, no. EI #10 was asked what was the facility policy on when you drop items on the floor in the kitchen. EI #10 replied, when she drops it wash it with soap and water. EI #10 was asked after looking at the floor, was it clean or dirty. EI #10 replied, dirty. EI #10 was asked why was it important that she wash items that are dropped to the floor in the kitchen. She replied, it is contaminated. EI #10 was asked did she open a milk carton to take the milk temperature. EI #10 replied, she did. EI #10 was asked did she wash her hands after picking up the thermometer cover off the floor. EI #10 replied no ma'am. On [DATE] at 11:35 an interview was conducted with EI #12, the Clinical Instructor. EI #12 was asked when picking up a thermometer cover off the floor should staff wash their hands. EI #12 replied, yes ma'am. EI #12 replied, it would be appropriate for staff to use hand sanitizer or washed their hands. 3) a review of a document titled, Food Code (YEAR) revealed ,[DATE].12 Soiled and Clean Tableware. Soiled TABLEWARE shall be removed from CONSUMER eating and drinking areas and handled so that clean TABLEWARE is not contaminated. On [DATE] at 12:21 p.m., the surveyor observed EI #11, the Cook. EI #11 picked up plates from the plate warmer. The surveyor observed spots on the plates before the worker picked up the plates from the warmer and the spots were brown. The surveyor observed several plates with spots on them. The surveyor observed a plate in the warmer that was dirty with a large amount of a red/yellow greasy looking areas on it. [DATE] at 10:08 a.m., the surveyor observed staff washing dishes in the dish room. During dishwashing, the surveyor observed a spot on a sectional plate ready to be put up. The worker wiped the spot in the plate and it came out. On [DATE] at 9:19 a.m., the surveyor conducted an interview with EI #11. EI #11 was asked what was on plates that she was plating. EI #11 replied, she thought it was a crumb from her gloves. EI #11 was asked who was responsible for making sure plates were clean. EI #11 replied, the staff person on the end of the dish line who put the dishes up in the dish room. EI #11 was asked what did the facility policy say regarding putting food on dirty plates on the tray line. EI #11 replied, she was not to put food on dirty plates. EI #11 said she would send dirty plates to the dish room. EI #11 was asked what did she observe on plates that she placed to the side. EI #11 replied, a crumb. EI #11 was asked why was it important that residents were not served food on dirty plates. EI #11 replied, she did not want to cross contaminate and she did not want the residents to get sick. EI #11 was asked was she observing plates carefully. EI #11 replied, she thought she was. On [DATE] at 9:48 a.m., the surveyor conducted an interview with EI #13, Dietary aide. EI #13 was asked did she pull dishes on [DATE] to be put up. EI #13 replied, yes ma'am. EI #13 was asked were plates on the table ready to be put away where they should go. EI #13 replied, yes ma'am. EI #13 was asked what did she see on one of the plates. EI #13 replied, one speck of something. EI #13 was asked did the speck come out. EI #13 replied, it did.

Based on observation, interview and review a facility policy Medication Administration Medication Administration Guidelines the facility failed to ensure licensed staff did not prepare Potassium liquid for Resident Identifier (RI) # 81 when the [MEDICATION NAME] was due to be given. The facility further failed to ensure medication was not left at RI #81's bedside while the staff returned to the medication cart for a stethoscope. This was observed on 8/14/18 and affected one of seven nurses observed for medication administration. Findings Include: A review of a facility policy Medication Administration Medication Administration - General Guidelines with a date of 3/11 revealed: .Procedures . 16. Read medication label and compare with Medication Administration Record [REDACTED] RI # 81 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #81's (MONTH) (YEAR) physician's orders [REDACTED].GIVE 7.5 ML (milliliters) . EVERY DAY .6 AM .LEVETIRACETAM ([MEDICATION NAME]) .GIVE 10 CC (cubic centimeters) . EVERY 12 HOURS 6 AM 6 PM . On 8/14/18 at 5:02 PM, the surveyor observed Employee Identifier (EI )#3, Licensed Practical Nurse, giving RI #81 the evening medication. EI #3 took the bottle of medication from the medication cart drawer and poured 10 milliliters into a medication cup. The surveyor read the label observing the bottle label to read Potassium. The surveyor asked EI #3 three separate times which medication she was giving and she replied [MEDICATION NAME] each time, while she poured the Potassium from the bottle to the medication cup. EI #3 placed the Potassium bottle back into the medication cart. The surveyor then stopped EI #3 at that point and asked her to remove the bottle and read the label. EI #3 removed the bottle and read the label Potassium. The surveyor informed EI #3 at that time that had she not stopped her (LPN), she would have administered the Potassium to the resident. EI #3 prepared the [MEDICATION NAME] 10 cc and entered RI #81's room. EI #3 left the room leaving the medication on the over the bed table. EI #3 opened the medication cart to get a stethoscope and returned to RI #81's room. EI #3 washed her hands, put on gloves, checked the tube placement and administered the medication. On 8/14/18 at 5:20 PM, an interview was conducted with EI #3. EI #3 was asked what was the policy on ensuring the correct medication was given to a resident. EI #3 replied she should have compared the medication bottle to the medication record. EI #3 was asked what medication had she poured to give RI #81. EI #3 replied, Potassium. EI #3 was asked what medication was due. EI #3 replied, the [MEDICATION NAME]. EI #3 was asked what time was the Potassium to be given. EI #3 replied, 6 AM. EI #3 was asked what would the harm be in giving a medication that was not ordered at that time. EI #3 replied, RI #81 could have gotten too much Potassium and side effects on the heart. EI #3 was asked what was the policy on leaving medication in the room unattended. EI #3 replied, you were not to leave sight of it. EI #3 was asked what was the harm in leaving a medication at the bedside unattended. EI #3 replied, someone could take the medication.

Based on observation, interview and record review, the facility failed to ensure the air conditioner temperature in Resident Identifier (RI) #37's room was not below 71 degrees. The temperature on the unit on 8/16/18 at 9:30 AM read at 69 degrees. Findings Include: RI #37 was admitted to the facility 10/14/16 with [DIAGNOSES REDACTED]. A review of RI #37's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 5/31/18 revealed a Brief Interview for Mental Status score of 11, indicating minimal difficulty with cognitive status. RI #37 was also coded for extensive assistance with transfers. A review of a Daily Care Guide for RI #37 revealed: : .Interventions .8/15/2018 Resident representative has asked the room air conditioner unit to be set for 74 degrees as the resident allows. On 8/16/18 at 9:30 AM, the surveyor observed RI #37's daughter enter RI #37's room. RI #37 told the daughter it was cold. The daughter went to the unit opened the cover and the reading was at 69 degrees. The surveyor observed the temperature on the air conditioner unit at 69 degrees. The surveyor briefly interviewed the daughter. The daughter reported she had came on several occasions and the temperature would be below 71 degrees. She said she attended a care plan meeting on 8/14/18 and asked for a note to be placed asking to not have the temperature below 74 degrees. On 8/16/18 at 9:30 AM, a brief interview with the RI #37 revealed the resident was unable to control the temperature on the unit. RI #37 revealed sometimes the staff that help with care turn it down because they say they are hot. On 8/16/18 at 9:40 AM, an observation and interview was conducted with Employee Identifier (EI) #1, Administrator. EI #1 was asked what was the reading on the unit. EI #1 replied, 69 degrees. EI #1 was asked what should the reading be. EI #1 replied, 71 degrees or greater. EI #1 was asked if the resident reported being cold. EI #1 replied, yes. EI #1 was asked what would the harm be in a resident's room temperature below 71 degrees. EI #1 replied, personal comfort for the resident may not be maintained. On 8/16/18 at 9:45 AM, an interview was conducted with EI #7. EI #7, a Certified Nursing Assistant assigned to care for RI #37, was asked what care RI #37 required. EI #7 replied everything. EI #7 was asked if RI #37 was able to change the temperature on the air conditioning unit. EI #7 replied, no. EI #7 was asked what should the temperature be. EI #7 replied, not below 74 degrees. On 8/16/18 at 9:55 AM an interview was conducted with EI #6, Licensed Practical Nurse. EI #6 was asked if the family for RI #37 asked her to place a note in the room concerning temperature . EI #6 replied yes and she told the unit manager and the manager said they could not put a note up but would add it to the care guide. EI #6 was asked how were the care guides reviewed. EI #6 replied, staff should check at the beginning of their shift.