Every finding on record at YORK Post Acute

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe environment resulting in harm for one resident (Resident # 1) in a survey sample of 4 residents. This was cited at past non-compliance. Findings included: For Resident # 1, the facility staff failed to ensure the bed frame was free of jagged edges resulting in a large laceration on the right lower leg requiring stitches and hospitalization that was sustained during a transfer from Geri-chair to bed on 10/28/2023, resulting in harm for Resident #1. The facility staff failed to use a gait belt during transfer per the plan of care. Resident # 1 was admitted to the facility on [DATE] for skilled nursing care services with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease with Chronic Hypoxic Respiratory Failure, Atrial Fibrillation on Eliquis, and history of Stroke. Review of the clinical record was conducted 11/20/2023-11/21/2023. Review of Nurses Notes revealed documentation of an incident on 10/28/2023 when Resident # 1 received a deep laceration on the right lower leg contact with the lower bed frame. Resident # 1 was transferred to the hospital. Further review revealed the laceration required stitches and Resident # 1 was admitted to the hospital for 4 days. (Resident # 1 returned to the facility on [DATE]) It was determined that the bed frame had a jagged edge that caused the injury. The Nurses note written on 10/28/2023 at 7:38 p.m. by LPN (Licensed Practical Nurse)-B stated around 6:50 p.m., while pt was being transferred from geri chair to bed the residents right leg came into contact with the lower bed frame. writer then observed a deep laceration into the right lower anterior/lateral of leg shin area. site wrapped Review of the handwritten witness statement by LPN (Licensed Practical Nurse) -B revealed the following documentation: On 3-11 around the 6:50 time, Resident was being transferred to room in geri chair with legs up. when go to room__ ( room number redacted) rolled in resident feet first, past 1st (first) bed and partially past 2nd bed, then backed pt as closest to wall next to bed. 3-11 CNA stood to side behind geri chair when stopped and in position. lowered legs of chair. (geri chair was closest to bed as could get) and IV pole was moved to the right side of pt. had resident scoot forward in chair and with writers arm under pts armpit and right leg between pts R & L (right and Left) feet/legs lifted Pt to standing position and pivoted to bed. Writer noticed wound to the right leg/shin area of pt. Sat pt to bed, assessed deep laceration to R (right) leg/shin area. The handwritten witness statement by the Certified Nursing Assistant (CNA)-C who assisted with the transfer stated While transferring patient to bed, patient received injury in the process. 3-11 nurse was made away [sic] of the incident. The note was signed and dated by CNA-C. Review of Resident # 1's care plan revealed documentation on page 10 of 55 that stated: Goal: Maintain safety through appropriate assistance and safety measures. Interventions: Provide transfer assistance when transferring to and from different surfaces. Gait belt attended by at least 1 staff member. The Plan of Correction (POC) Required Elements document was reviewed and revealed: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Employee had received verbal education on 11/3/23, signed on 11/5/23 regarding monitoring resident arms and legs placement before transfers to ensure that limbs are not too close to hard surfaces that may cause injury. Administrator met with direct care staff during huddles to discuss resident safe transfers and repositioning. Once the bed frame was identified as the source of injury, the resident bed was immediately assessed and repaired 10/31/2022. Before the resident's return to the facility, a different bed was provided to the resident. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 11/2/2023, all bed frames for resident use had been inspected to ensure there are no potential hazards to residents. Any potential hazards identified were addressed with either a permanent or temporary solution. Facility has purchased 15 new beds on 10/11/2023 with delivery expected on 11/30/2023. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Operations Assistant Administrator or designee will include bed frames, headboard and foot board inspection as part of quarterly bed management inspection. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained, and Operations Assistant Administrator or designee will perform bedframe checks weekly for 8 weeks and per bed management inspection schedule thereafter to ensure there are no potential hazards to residents. Incident reports are being reviewed to ensure no additional resident injuries occurred from bed frames. Administrator designee will review the audit results for any patterns or trends and report any findings to our Quality Assurance Performance Improvement Committee. 5. Include dates when the corrective action will be completed. (The outside date by which all corrections must be made is the 45th calendar day after the survey ended. Date of compliance will be November 5, 2023. The form was signed by the Administrator. In addition, the Licensed Practical Nurse-B was counseled/educated on monitoring resident arms and legs placement before transfers to ensure that limbs are not too close to hard surfaces that may cause injury. On 11/21/2023 at 11:38 a.m., an interview was conducted with Licensed Practical Nurse-B who stated they transferred Resident # 1 from the Geri-chair to the bed on 10/28/2023. LPN-B stated CNA (Certified Nursing Assistant)-C was present during the transfer. On 11/21/2023 at 1:20 p.m., an interview was conducted with the Director of Nursing who stated all of the beds were examined for any sharp edges. She stated the facility nursing staff have been educated to protect the limbs of the residents from contact with the bed frames. On 11/21/2023 at 2:15 p.m., the Corporate Consultant stated Resident # 1 sustained a laceration on the right lower leg when he was transferred from the Geri-chair to the bed. The laceration was caused by a sharp edge on the bed frame when Resident # 1's leg came in contact with the jagged edge during the transfer technique to the bed. The Corporate Consultant stated she participated (along with the administrative team) in reenactments to determine exactly how the injury could have happened, She stated she felt pressure on her own skin from the sharp edge that was consistent with where the injury was sustained by Resident #1. The Corporate Consultant stated the facility's administrative team immediately checked all of the beds in search of any other hazards. She stated 15 beds had already been ordered for the facility and were scheduled for delivery on 11/30/2023. On 11/21/2023 during the end of day debriefing, the Administrator, Director of Nursing and Corporate Consultants were informed of the findings. The jagged edge of the bed frame caused the injury. The plan of correction for past non-compliance was accepted after review of the facility's documentation and staff interviews were conducted. Protective Caps were placed on the edge of the bed frame and the bed was taken out of circulation. All beds were examined for any hazards or safety concerns. Audits of the beds were conducted weekly. The Administrator stated audits would continue. Interviews were conducted with staff members who all stated they had been educated on checking beds for safety hazards and protecting limbs from contact with bed frames. There was documentation of temporary and permanent fixes being applied to any beds that were found to have safety hazards. Evidence showed that the nurse, LPN-B, was counseled and educated about ensuring limbs were protected during transfers. During the 2 days of survey, residents were observed in beds. Interviews were conducted with alert residents and staff. There was no deficient practice identified regarding accidents/hazards at the time of survey or since the allegation of compliance. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to implement the person-centered care plan for one resident (Resident # 1) in a survey sample of 4 residents. Findings included: For Resident # 1, the facility staff failed to implement the care plan intervention of use of a gait belt during a transfer from the Geri-chair to bed on 10/28/2023. Resident # 1 was admitted to the facility on [DATE] for skilled nursing care services with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease with Chronic Hypoxic Respiratory Failure, Chronic Heart Failure, Atrial Fibrillation on Eliquis, history of Stroke. Review of the clinical record was conducted on 11/20/2023 and 11/21/2023. Review of Nurses Notes revealed documentation of an incident on 10/28/2023 when Resident # 1 received a deep laceration on the right lower leg from a jagged edge on the bed frame. The Nurses note written on 10/28/2023 at 7:38 p.m. by LPN (Licensed Practical Nurse)-B stated around 6:50 p.m., while pt was being transferred from geri chair to bed the residents right leg came into contact with the lower bed frame. writer then observed a deep laceration into the right lower anterior/lateral of leg shin area. site wrapped Review of the handwritten witness statement by LPN (Licensed Practical Nurse) -B revealed the following documentation: On 3-11 around the 6:50 time, Resident was being transferred to room in geri chair with legs up. when go to room__ ( room number redacted) rolled in resident feet first, past 1st (first) bed and partially past 2nd bed, then backed pt as closest to wall next to bed. 3-11 CNA stood to side behind geri chair when stopped and in position. lowered legs of chair. (geri chair was closest to bed as could get) and IV pole was moved to the right side of pt. had resident scoot forward in chair and with writers arm under pts armpit and right leg between pts R & L (right and Left) feet/legs lifted Pt to standing position and pivoted to bed. Writer noticed wound to the right leg/shin area of pt. Sat pt to bed, assessed deep laceration to R (right) leg/shin area. The handwritten witness statement by the Certified Nursing Assistant (CNA)-C who assisted with the transfer stated While transferring patient to bed, patient received injury in the process. 3-11 nurse was made away [sic] of the incident. The note was signed and dated by CNA-C. Review of Resident # 1's care plan revealed documentation on page 10 of 55 that stated: Goal: Maintain safety through appropriate assistance and safety measures. Interventions: Provide transfer assistance when transferring to and from different surfaces. Gait belt attended by at least 1 staff member. For transfers, a gait belt should be used. Review of the Facility's Transfer Assistance Program Policy, reviewed and approved on 07/24/2023 revealed the following excerpts: Policy: All staff will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer and/or pivot non-ambulatory residents as indicated. Employees should avoid manually lifting any resident, except in life threatening situations. Any employee in violation of this policy will be subject to disciplinary action, up to and including termination Under Procedure: All direct care staff members are responsible for knowing and following the transfer method determined by the residents' plan of care. Direct care staff should notify the nurse immediately if there is a change in the residents' ability to transfer with the evaluated transfer method an/or if the resident requests to use an alternative transfer method. Under Mechanical Lifting Device Selection: 3/ Gait Belt will be used when: a. The resident can bear weight on at least one foot, AND b. The resident is able to follow simple instructions, AND c. The resident can maintain trunk control in the sitting position, and requires minimal assistance with this task; On 11/21/2023 at 11:38 a.m., an interview was conducted with Licensed Practical Nurse-B who stated they transferred Resident # 1 from the Geri-chair to the bed on 10/28/2023. LPN-B stated CNA (Certified Nursing Assistant)-C was present during the transfer. LPN-B stated they did not use a gait belt. LPN-B stated Resident # 1 could stand and had no resistance during the transfer. On 11/21/2023 at 1:20 p.m., an interview was conducted with the Director of Nursing who stated care plans should be tailored for each resident and staff should follow the plan of care. The Director of Nursing stated that for transfers, a gait belt should have been used for Resident #1. The Director of Nursing stated that she assessed Resident # 1 after he returned to the facility using the transfer assistance evaluation and determined that a total lift (Hoyer lift) would be utilized in all future transfers. On 11/21/2023 at 2:15 p.m., the Corporate Consultant stated a gait belt was not used by the staff on the day a laceration on the right lower leg was sustained by Resident # 1 when he was transferred from the Geri-chair to the bed. The laceration was caused by a sharp edge on the bed frame when Resident # 1's leg came in contact with the jagged edge during the transfer technique to the bed. On 11/21/2023 during the end of day debriefing, the Administrator, Director of Nursing and Corporate Consultants were informed of the findings that the staff did not utilize the proper method of transfer utilizing the gait belt. They all agreed that a gait belt should have been used as written in the care plan. The nurse, LPN-B, was counseled and educated about ensuring limbs were protected during transfers. The nurse was also educated about following the plan of care. No further information was provided.

Based on staff interview and record review, the facility failed to ensure a resident's end of life wishes were clarified and consistent in the medical record for one of 44 residents (Resident (R) 129). The facility staff did not initiate CPR or call Emergency Medical Services (EMS) when R129 was found without a pulse or respirations. This resulted in Immediate Jeopardy at level 4 isolated on [DATE]. A Plan of Correction was reviewed for Past non-compliance and the Immediate Jeopardy was removed on [DATE]. Findings include: Review of R129's printed Face Sheet from the electronic medical record (EMR) Reports tab showed a facility admitted [DATE] with medical diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes, hypertension, pneumonia, abnormal electrocardiogram (EKG), heart failure, long term steroid use, interstitial pulmonary disease, heart disease, atrioventricular block, deep vein embolism and thrombosis. A review of R129's hospital discharge information (paper file) printed on [DATE] on page 26 of 87 stated Code Status: Full Code. A review of R129's Resident Info tab showed a POST [Physician Orders for Scope of Treatment] form the resident signed for a full code status to sustain life signed by R129, a Nurse Practitioner, and a facility witness in March of 2021. Review of R129's Notes tab showed on [DATE] at 9:25 PM the admitting nurse charted, arrived to facility around 501pm. pt A&Ox3 [alert and oriented to person, place, and time]. Review of R129's EMR Orders tab showed Nurse Practitioner (NP), Employee G, gave an order for a DNR status on [DATE]. In response to a request for where the documentation was located that R129 changed his code status, on [DATE] at 10:05 AM, the Director of Nursing (DON) stated, I can't find anything else. When clarified if she meant regarding the NP (Employee G) writing the DNR order, the DON responded Yes. During a telephone interview on [DATE] at 11:11 AM, NP Employee G stated she was reviewing her note in GeriMed (the EMR used) and noted she did not have access to the hospital or facility EMR. Employee G continued that When the nurse calls after hours to verify orders, when they are reading a code status, if they give me a DNR status I expect that they have the documentation in front of them that states that. When asked what she reviewed, Employee G stated, The orders via telephone. The nurse would read me the medication orders, wound care orders, and diet. My triage note showed the nurse called at 1701 [she clarified 5:01 PM]. Employee G clarified she was not at the facility and did not see or talk to the resident or family. In a telephone interview on [DATE] at 12:03 PM, the admitting Licensed Practical Nurse (LPN) E was asked the process for admission orders and verifying code status, LPN E responded, We now go off the paperwork and ask the resident and put in our notes that the patient confirmed the code status. If [the resident is] not cognitive we talk to the resident representative and chart that. LPN E was queried if he remembered speaking with R129 about his code status, he stated, No, not really. It [discussion] should be in my note if I did. LPN E's documented notes for [DATE] and [DATE] were read from the EMR, and LPN E responded No, it's not in there. I probably asked and didn't put it in my notes. I probably asked him and confirmed it with family, that's the way I usually work it. On [DATE] at 1:09 AM, LPN G documented Went to check on [R129] at 12:00 AM, checked his vitals BP was ,d+[DATE] breathing was shallow [R129] was lethargic but talking. At 12:45AM, I checked on [R129] and he had no pulse no respirations. Wife was notified and on call and DON [Director of Nursing] called. The note did not say if CPR was initiated or EMS was called. Review of the facility's policy titled, Advance Directive revised [DATE], indicated, Advance Directive will be discussed with the resident and/or family member upon admission as soon as clinically appropriate so the resident wishes, with respect to life prolonging treatments can be documented in the medical record The facility staff should attempt to obtain Advance Directives information from the resident, family, and/or hospital staff during the admission process. If advance directive information is provided, then this information will be placed in the resident medical record . The facility was notified of Immediate Jeopardy on [DATE] @5:07pm. The facility presented the following plan. 1. Resident expired on [DATE] therefore no corrective action can be taken with resident at this time. The provider and resident representative were made aware of resident's condition at the time of discharge. 2. The Director of Nursing / designee will review the medical records of all current residents to ensure accuracy of transcription of advance directive orders. Any variances noted will be addressed and provider / resident representative will be notified. 3. The Director of Nursing / designee will educate RN's and LPN's on comparing the code status from the Discharge Summary that is sent prior to admission with the discharge paperwork that accompanies the resident upon admission. Education will include but is not limited to the importance of proper transcription of code status orders and the nursing admission process which includes accurate code status. 4. The Director of Nursing / designee will review 100 % of newly admitted residents' medical records weekly for the next three months to ensure code status orders have been accurately transcribed and verified with resident / resident representative. The Director of Nursing / designee will identify any patterns or trends and report to the Quality Assurance and Performance Improvement committee at least quarterly. 5. The date of our allegation of compliance for this plan of correction is [DATE]. The survey team reviewed all the medical records of the residents to ensure accuracy of transcription of Advanced Directives. The survey team reviewed the documentation that the facility provided on any discrepancies they found and corrected. The survey team reviewed the education provided and interviewed staff about the education provided. The survey team reviewed the weekly monitoring for accuracy and completion. Immediate Jeopardy was removed on [DATE], past non-compliance.

Based on staff interview, record review, and policy review, the facility failed to ensure the physician was notified for a change of condition for one of 44 residents (Resident (R) 129). This failure to notify the physician when R129 was found to have low blood pressure, shallow breathing, and lethargy, resulted in Immediate Jeopardy at level 4 isolated on [DATE]. A Plan of Correction was reviewed for Past non-compliance and the Immediate Jeopardy was removed on [DATE]. Findings include: Review of R129's printed Face Sheet from the electronic medical record (EMR) Reports tab showed a facility admitted [DATE] with medical diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes, hypertension, pneumonia, abnormal electrocardiogram (EKG), heart failure, long term steroid use, interstitial pulmonary disease, heart disease, atrioventricular block, deep vein embolism and thrombosis, major depressive disorder, and urine retention. Review of R129's EMR Notes tab showed that Licensed Practical Nurse (LPN) E documented at 9:33 PM on [DATE] the resident arrived at the facility for admission at 5:01 PM with a blood pressure (BP) of ,d+[DATE]. Review of R129's EMR Vital Signs tab showed the following BP were documented on [DATE]. At 11:48 AM the BP was recorded at ,d+[DATE] and ,d+[DATE] at 4:24 PM. On [DATE] at 1:09 AM, LPN G documented Went to check on [R129] at 12:00 AM, checked his vitals BP was ,d+[DATE] breathing was shallow [R129] was lethargic but talking. At 12:45 AM, I checked on [R129] and he had no pulse no respirations. Wife was notified and on call and DON [Director of Nursing] called. During an interview on [DATE] at 2:43 PM regarding the BP of ,d+[DATE], the DON expressed an expectation would be that the nurse would have notified the practitioner. It was her first time working with us so I don't know what her thoughts about the BP was, she might have thought it was fine. In a telephone interview on [DATE] at 3:07 PM, LPN G identified a normal adult blood pressure from ,d+[DATE] to about ,d+[DATE] and stated ,d+[DATE] would not be considered a normal adult blood pressure. When asked what she would do if she had a patient with a BP like that, LPN G responded If the patient is conscious, have them sit up and elevate their legs, give water, anything like that to elevate the blood pressure, and I'd contact the doctor. If the patient is unconscious, if I was in the nursing home, I would call 911 then call the doctor. After reviewing LPN G's charting, she confirmed she did not contact the doctor. Review of the facility's policy titled, Notification of Changes, revised [DATE], showed, Policy: The facility must immediately inform the resident; consult with the resident's physician or other professional (ex. Physician assistant, nurse practitioner, clinical nurse specialist, etc); and if known, notify the residents representative when there is: .A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). The facility was notified of Immediate Jeopardy on [DATE] @5:07pm. The facility presented the following plan. 1. The nurse involved in Resident #129 care, on [DATE], is no longer employed. Resident #129 expired in the facility on [DATE]. 2. The clinical notes for all residents were reviewed for the past 24 hours to ensure the nursing staff had notified the provider of a change in condition. Any variances were immediately corrected. 3. Registered and Licensed Nurses will be re-educated on Notification of Change, including but not limited to, the importance of notifying the physician of any change in condition to include abnormal blood pressures, breathing or lethargy. 4. The DON/designee review the morning meeting report including clinical notes at least weekly for 8 weeks to ensure any change in condition had appropriate notification of changes. Any variances will be corrected immediately, and audit findings will be reported to the Quality Assurance Performance Improvement Committee. 5. Our allegation of compliance is [DATE] The survey team reviewed the documentation provided and verified the agency nurse involved with care was no longer working at the facility. The survey team interviewed staff from all three shifts regarding physician notification of change in condition. The survey team reviewed the education provided to the staff, to ensure in included reasons for notification of change in condition such as Respiratory status change in vital signs, blood glucose (hyper or hypoglycemic) altered mental status, and pain. The survey team verified that the monitoring of clinical notes was completed. Immediate Jeopardy was removed on [DATE], past non-compliance.

Based on interview, record review, and review of facility policy, the facility failed to protect the resident's right to be free from physical abuse by staff CNA C and CNA D for one (Resident (R) 42) of two residents reviewed for abuse. CNA C and CNA D caused bruising on R42's lower arms. This is harm. Findings include: Review of R42's Face Sheet printed from the electronic medical record (EMR) Resident Info tab showed medical diagnoses that included generalized muscle weakness, abnormalities of gait and mobility, and dementia. Review of a facility investigation showed that on 12/04/22 CNA C and CNA D were going to change R42 using a blue brief (incontinent product). R42 requested a pull up style product and relayed she was told No and that she would be changed whether she liked it or not. R42 stated that she tried to fight them by hitting and clawing but the aides held her arms. The bruising to the lower arms was photographed and included in the facility investigation. The facility investigation showed the two certified nurse aides had been suspended during the investigation; terminated at the end of the investigation and reported to the regulatory board. In a interview on 06/14/23 at 2:00 PM, R42's Resident Representative (RR42) stated she had met with the Administrator and the CNAs involved were terminated and no longer work here. Everything is good. During an interview on 06/14/23 at 9:09 PM regarding the incident described by R42, the Administrator stated, Yes, it's substantiated the aides held the resident down causing bruises [to the lower arms]. Review of the facility's policy titled, Resident Abuse Policy and Procedure, revised 10/31/22, showed, Policy: It is the policy of this facility to ensure the resident will be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. The facility will: -Not tolerate the use of verbal, sexual, physical or mental abuse, corporal punishment or involuntary seclusion, neglect, misappropriation of resident property, and exploitation towards the facilities residents by any individual Although the facility presented a plan with evidence for Past non-compliance, Past non-compliance could not be considered because the facility failed to fully implement their plan. Cross reference to F943.

Based on observation, staff interview and facility documentation review, the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food service safety in the main kitchen, which had the potential to affect Residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to wear proper hair restraints when in food preparation areas. On 6/13/23 at 11:30 AM, during an inspection of the kitchen, Surveyor C observed the Assistant Administrator/Employee F enter the kitchen and walk halfway into the kitchen which was around the steam table area. The Dietary Manager/Employee D noticed that the Assistant Administrator did not have any type of hair restraint (hair net or hat) on and immediately asked him to exit the kitchen. Employee F did leave the kitchen and did not re-enter. On 6/13/23 at approximately 11:45 AM, while conducting an inspection of the kitchen Employee E, who was a dietary aide, was observed working the tray line, assisting with meal trays for the lunch meal. Employee E did not have a beard guard on and did have facial hair. The Dietary Manager, who was accompanying Surveyor C was asked what is required for hair restraints and she said, He had one on earlier and proceeded to obtain a beard guard and assisted Employee E with putting it on. 2. Facility staff failed to air dry dishes in a manner to prevent wet nesting and the growth of bacteria. On 6/14/23 at 10:00 AM, Employee E, a dietary aide was observed in the dish room/dishwasher area. Employee E removed plates from the dishwasher, stacked them and took them to a cart where they were stacked while wet. On 6/14/23 at approximately 10:10 AM, Surveyor C interviewed the dietary manager. She was asked how dishes are dried? The dietary manager said, everything is to be air dried, we don't want wet nesting, it can harbor bacteria. The dietary manager and Surveyor C then went to stack of plates and plate covers and confirmed they had water on the surface and were stacked wet, which is wet nesting and not permissible. Review of the facility policy titled, Dining Service, Food Service and Meal Distribution was reviewed. The policy didn't address how dishes are to be dried to prevent wet nesting. The U.S. Public Health Service, 2017 Food Code, published by the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration was reviewed. An excerpt from this document on page 151 read, . After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 . On 6/15/23, around 11:30 AM, the facility Administrator was made aware of the above findings. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure that four of four residents (Resident (R) 19, R35, R54, and R65) reviewed for bed rail use, had documented alternatives to the use of bed rails before the rails were used. Findings include: 1. Review of R19's quarterly Minimum Data Set (MDS) assessment reference date (ARD) of 05/18/23 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, or indicative of being cognitively intact. During an interview on 06/13/23 at 1:51 PM, it was noted that R19 had bilateral upper side rails on her bed. Review of Bed Rail Entrapment Risk Evaluation forms, dated 02/15/23 and 05/23/23, found no documentation regarding what alternatives were attempted prior to the use of bed rails. A review of the facility admission packet showed the Bed Rail Consent was included as a blank form to be completed with the other admission forms. In an interview on 06/15/23 at 12:50 PM the Admission/Resident Navigator, Employee J, stated, The form is in the admission packet and is signed and then nursing staff is to go in to evaluate for function and mobility. When asked to clarify if everybody signs the Bed Rail Consent form, Employee J stated, Yes. 2. Review of R35's quarterly MDS with an ARD of 06/02/23 showed a BIMS score of 06 out of a possible 15, indicative of severe cognitive impairment. During an interview on 06/14/23 at 12:59 PM bilateral upper rails were noted on R35's bed. Review of Bed Rail Entrapment Risk Evaluation forms, dated 06/06/23, found no documentation regarding what alternatives were attempted prior to the use of bed rails. 3. Review of R54's five-day readmission MDS with an ARD of 06/05/23 showed a BIMS score of 14 out of 15, or indicative of being cognitively intact. During an interview on 06/13/23 at 1:58 PM it was noted that R54 had bilateral upper bed rails. A review of the Bed Rail / Entrapment Risk Evaluation, dated 02/08/23, showed no bed rails were recommended and no alternatives attempted. 4. Review of R65's Face Sheet from the EMR Resident Info tab showed medical diagnoses that included hemiplegia affecting the dominant side and altered mental status. Review of R65's quarterly MDS with an ARD of 04/06/23 showed a BIMS score of 04 out of 15, or indicative of severe cognitive impairment. A review of the Bed Rail / Entrapment Risk Evaluation, dated 04/04/23, showed no documented attempted alternatives. During an interview on 06/05/23 at 1:05 PM regarding bed rail assessments, Registered Nurse (RN) B stated, We usually see how they move in the bed and use the rails for mobility. When asked if mobility is attempted without the rails, RN B responded For some, but residents prefer the rails. Responding to the query if alternates to bed rails were attempted were documented, RN B stated, No, not that I am aware of. Review of the facility's policy titled, Bed Rail Policy, revised 02/18/18, indicated, Policy: Residents are assessed for appropriate alternatives prior to installing a bed rail. If a bedrail is indicated, the facility will take measures to develop and implement a strategy to minimize the possibility of resident entrapment while using side rails-.This will include assessment of residents who have a need for or desire to use side rails and that may have characteristics that place them at special risk for entrapment. The assessment will also include inspection of the bed, mattress and side rail for risk of entrapment.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an influenza vaccine for 1 resident, Resident #69, out of 5 residents reviewed for influenza immunization. The findings included: The facility staff failed to provide influenza immunization for Resident #69. On 6/14/23 at approximately 10:30 AM, a clinical record review was performed and revealed Resident #69, who was admitted to the facility on [DATE], had no documentation with regard to influenza immunization, to include the resident's current influenza vaccination status, offer to provide immunization against influenza infection, or documentation of resident refusal or medical contraindication. On 6/14/23 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON) who accessed the clinical record for Resident #69 and verified the findings. The DON confirmed there was no additional information. A facility policy was requested and received. On 6/15/23 at approximately 3:00 PM, a review of the facility policy entitled, Infection Control, Influenza Vaccine was conducted. It stated under the subtitle, Policy, .All residents should receive the influenza immunization unless medically contraindicated or refused. On 6/15/23 at approximately 4:00 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure employees received training on abuse, neglect and exploitation for 1 employee, (Employee #28), in a sample of 5 employees reviewed for training. The findings included: For Employee #28 who had been an employee for greater than 2 years, the facility staff failed to provide any evidence of training on abuse, neglect and exploitation. On 6/14/23, the facility Administrator was asked to provide in-service training for 5 employees. On the afternoon of 6/14/23, the facility administrator submitted training records for 4 of the 5 employees being sampled. The Administrator stated they were still looking for Employee #28's records. On the morning of 6/15/23, the facility Administrator acknowledged they were still trying to pull together Employee #28's training records. On 6/15/23 at 12:15 PM, the facility administrator was asked to provide the facility policy with regards to annual training needs of staff. The Administrator let the survey team know they do not have a policy with regards to annual in-service/training of facility staff. The facility administration submitted no further documentation prior to the conclusion of the survey.

Based on staff interview and facility documentation review, the facility staff failed to ensure employees received Resident Rights training and education for 1 employee, (Employee #28), in a sample of 5 employees reviewed for training. The findings included: For Employee #28, the facility staff failed to provide any evidence of Resident Rights training. On 6/14/23, the facility Administrator was asked to provide in-service training for 5 employees. On the afternoon of 6/14/23, the facility administrator submitted training records for 4 of the 5 employees being sampled. The Administrator stated they were still looking for Employee #28's records. On the morning of 6/15/23, the facility Administrator acknowledged they were still trying to pull together Employee #28's training records. On 6/15/23 at 12:15 PM, the facility administrator was asked to provide the facility policy with regards to annual training needs of staff. The Administrator let the survey team know they do not have a policy with regards to annual in-service/training of facility staff. The facility administration submitted no further documentation prior to the conclusion of the survey.

Based on staff record review, staff interview and facility documentation review, the facility staff failed to offer and/or provide up to date COVID-19 immunization for 1 resident, Resident #69, in a survey sample of 5 residents reviewed for COVID-19 vaccination. The findings include: The facility staff failed to offer and/or provide a COVID-19 bivalent booster vaccine for Residents #69. On 6/14/23 at approximately 10:30 AM, a clinical record review was performed and revealed Resident #69 completed a primary COVID-19 vaccine series on 9/27/21, however there was no evidence that Resident #69 had been offered or received a COVID-19 bivalent booster dose. On 6/14/23 at approximately 4:15 PM, an interview was conducted with the Director of Nursing (DON) who confirmed the facility policies and procedures follow CDC (Centers for Disease Control and Prevention) guidance and recommendations for resident COVID-19 immunization. The DON stated there were no concerns with the facility's ability to provide COVID-19 immunizations to residents. The DON stated that it is expected for all residents to be provided the opportunity to be up to date with COVID-19 immunizations, including the bivalent COVID-19 booster. The DON accessed the clinical records for Resident #69 and verified the findings. The facility's COVID-19 vaccination policy for residents was requested and received. On 6/15/23 at approximately 11:00 AM, a review of the facility's policy titled, COVID-19 Vaccine was conducted. It stated under the subheading Purpose, Maximizing COVID-19 vaccination rates in the facility will help reduce the risk residents and staff have of contracting and spreading COVID-19 and subheading Offering the COVID-19 Vaccine read, COVID-19 vaccinations will be offered to all staff and residents .per CDC [Centers for Disease Control and Prevention] and/or FDA [Food and Drug Administration] guidelines . The CDC (Centers for Disease Control and Prevention) document titled, Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States, updated March 16, 2023, page 3, Recommendations for COVID-19 vaccine use, subtitle, Booster vaccination, read, People ages 6 months and older are recommended to receive 1 bivalent mRNA booster dose after completion of any FDA-approved or FDA-authorized primary series or previously received monovalent booster dose(s). The CDC (Centers for Disease Control and Prevention) document titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, updated March 2, 2023, page 2, COVID-19 Boosters, subtitle, Updated Boosters, read, The updated boosters are called 'updated' because they protect against both the original virus that causes COVID-19 and the Omicron variant BA.4 and BA.5 .Updated COVID-19 boosters became available on: September 2, 2022, for people aged [AGE] years and older .You are up to date with your COVID-19 vaccines when you have completed a COVID-19 vaccine primary series and got the most recent booster dose. The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022, page 2, item 1, read, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses .HCP [Healthcare Personnel], patients, and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. On 6/15/23 at approximately 3:00 PM, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store controlled medications appropriately in 1 of 3 medication carts within the facility. The findings included: The facility staff failed to secure controlled medications in a separately locked, permanently affixed compartment. On 6/13/23 at 2PM, the pharmacy delivery arrived. LPN C was observed to receive and sign for controlled medications from the delivery person. While Surveyor C was conducting medication administration observations with LPN B, LPN C approached with several packets of controlled medications and said she would secure them in her (LPN C's medication cart) until LPN B was able to receive them and log them. On 6/13/23 at 2:40 PM, LPN C was asked about the controlled medications. LPN C said she still had them secured in her medication cart. Surveyor C asked to see them. LPN C opened one of her drawers on the medication cart and received 4 cards of controlled medications. When asked why they were not secured under double lock, she said she was just holding them until LPN B could obtain them. The medications included: a. Oxycodone 5 mg, 30 tablets for Resident #181. b. Hydrocodone/apap tab 5/325 mg, 30 tablets for Resident #10. c. Clonazepam tablet 0.5 mg, 30 tablets for Resident #10. d. Tramadol HCL 50 mg tablets, 30 tablets for Resident #23. On 06/15/23 at 08:44 AM, an interview was conducted with LPN B. LPN B was asked about the storage of controlled medications, and she stated that they should be stored separate from other medications. LPN B went on to say that controlled medications are kept under two locks because people could misuse them. On 06/15/23 at 08:48 AM, an interview was conducted with RN B. RN B was asked about the storage of controlled medications. She said, They are double locked for extra protection because they are scheduled medications. The facility policy titled; Medication Administration Guidelines was reviewed. This policy read, . Controlled Substances: Controlled substances are secured under double locks and counted at the end of each shift with the incoming and outgoing nurse . The facility staff provided the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles. This policy was reviewed and an excerpt from it read, .General Storage Procedures: Facility should store Schedule II-V Controlled Substances and other medications deemed by facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device . During the end of day meeting held on 6/13/23, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was received.

Based on observation, interview, and record review, the facility failed to provide the care and assistance for personal grooming for one of 44 residents (Resident (R) 35). Findings include: Observation of R35 on 06/14/23 at 9:06 AM showed the female resident had minimum half inch long facial hair on the lower right cheek and chin. In an interview on 06/14/23 at 12:54 PM, R35's family member stated, As of March 1 she was put on hospice and a CNA [certified nurse aide] was assigned she did things like that [shaving]. The CNA had shoulder surgery and the facility has not done it [shaved R35]. In an interview and observation on 06/14/23 at 4:45 PM, CNA B confirmed R35 had facial hair and stated She can switch on you and may or may not let you shave her. She's hospice also and they also help out. At 4:50 PM on 06/14/23, the Director of Nursing [DON] entered R35's room, observed R35 and asked her if she wanted the facial hair shaved off. R35 responded Yes. The DON exited the room and confirmed that R35 needed to be shaved. Review of the facility policies titled, Bath (Bed), Bath (Partial), and Activities of Daily Living (ADL) (Daily Life Functions) did not address the dignity of shaving unwanted facial hair for residents.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide care and services in accordance with professional standards for 2 residents, Residents #229 and #6, in a survey sample of 44 residents. The findings included: 1. For Resident #229, facility staff failed to administer medications as ordered by the physician on 4/1/22 and 4/5/22. On 6/14/23, Resident #229's clinical record was reviewed and revealed physician orders, schedule times, and actual administration times as follows: *Carbidopa 25mg-levodopa 100mg tablet (1/2 tab) TABLET Oral, Two times daily for Five Days--scheduled for 4/1/22 at 6:00 PM--documented as given at 8:07 PM *Carbidopa 25mg-levodopa 100mg tablet (1/2 tab) TABLET Oral, Three times daily for Five Days--scheduled for 4/5/22 at 6:00 PM--documented as given at 8:47 PM On 6/15/23, an interview was conducted with the Director of Nursing (DON) who confirmed the findings and stated that medications are expected to be given as ordered by the physician. She stated that medications can be given within an hour before or an hour after of the scheduled time and verified the previously referenced administration times did not meet her expectation. The DON stated that the facility's professional nursing standards reference was [NAME]. A facility policy on medication administration was requested and received. Review of the facility policy entitled, Medication Administration Guidelines, revised 9/8/2017, heading Medication Administration read, Medications are administered in accordance with written orders of attending physicians, manufacturer's specifications, and professional standards of practice and Medications are administered within one hour before or within one hour after the schedules time . According to [NAME] Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors. On 6/15/23, the Facility Administrator was updated on the findings. No further information was provided. 2. For Resident #6, the facility staff failed to perform a dressing change to a peripherally inserted central catheter (PICC) intravenous access site as ordered by the physician. On 6/13/23 at approximately 1:30 PM, Resident #6 was interviewed and a double lumen PICC line (peripherally inserted central catheter/line with two access ports) covered with a semipermeable dressing at the insertion site dated 6/5 was observed to her right upper arm. Resident #6 stated I'm not sure what this thing is for in reference to the PICC line. On 6/14/23 at approximately 3:30 PM, a second observation, with the Director of Nursing (DON) present, revealed that the PICC dressing had not been changed and was still dated 6/5. The DON stated, These dressings are expected to be changed at least once every seven days or as needed if the dressing becomes soiled, this dressing should have been changed on the 12th at minimum. On 6/14/23, review of Resident #6's clinical record revealed a physician's order dated 5/31/23 which read, Change Catheter Site Dressing on admission, then q [every] week and PRN [as needed]. The physician's order also read, PICC Catheters: Measure arm circumference on admission, with each dressing change, & PRN and PICC Catheters: Measure external catheter length on admission, with each dressing change & PRN. There was no evidence in the clinical record for any PICC dressing changes and no measurements for arm circumference and external catheter length. These findings were confirmed by the DON. A facility policy was requested and received. On 6/14/23, review of the facility policy entitled, 6.4 Peripherally Inserted Central Catheter (PICC) Dressing Change, last revised on 8/15/08, subtitle, Considerations, item 1, read, The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Subtitle Guidance, item 1, read, Dressing changes using transparent dressings are performed: 24 hours post-insertion or upon admission, at least weekly, and if the integrity of the dressing has been compromised. Item 7 read, Length of external catheter and upper arm circumference (3 inches or 10 centimeters above insertion site) is obtained: Upon admission, during dressing changes, and if signs or symptoms of complications are present. On 6/14/23, the DON stated that [NAME]'s was the basis for nursing standards utilized within the facility. According to The [NAME] Manual of Nursing Practice, 11th edition, Nursing Role in Intravenous Therapy, Catheter-Associated Bloodstream Infections, Preventative Measures, item 9b read, Transparent semipermeable dressing should be changed every 7 days. According to the Centers for Disease Control and Prevention (CDC) publication entitled Checklist for Prevention of Central Line Associated Blood Stream Infections, based on 2011 CDC guidelines for prevention of intravascular catheter-associated bloodstream infections: https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html, For Clinicians: Handle and maintain central lines appropriately Immediately replace dressings that are wet, soiled, or dislodged, perform routine dressing changes using aseptic technique with clean or sterile gloves, change gauze dressings at least every two days or semipermeable dressings at least every seven days. On 6/14/23, the Facility Administrator was updated on the findings. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure employees received training on infection prevention and control for 1 employee, (Employee #28), in a sample of 5 employees reviewed for training. The findings included: For Employee #28, the facility staff failed to provide any evidence of infection prevention and control training. On 6/14/23, the facility Administrator was asked to provide in-service training for 5 employees. On the afternoon of 6/14/23, the facility administrator submitted training records for 4 of the 5 employees being sampled. The Administrator stated they were still looking for Employee #28's records. On the morning of 6/15/23, the facility Administrator acknowledged they were still trying to pull together Employee #28's training records. On 6/15/23 at 12:15 PM, the facility administrator was asked to provide the facility policy with regards to annual training needs of staff. The Administrator let the survey team know they do not have a policy with regards to annual in-service/training of facility staff. The facility administration submitted no further documentation prior to the conclusion of the survey.

Based on observation, Resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide safe assistance for transfers for 2 Residents (Resident #1, Resident #2) in a sample size of 3 Residents. Resulting in harm for Resident #1. The findings included: 1) For Resident #1, the facility staff failed to safe transfer from the bed to the wheelchair on 11/10/2022 resulting in right distal femoral fracture which required surgical intervention. This is harm. On 12/28/2022 and 12/29/2022, Resident #1's clinical record was reviewed. According to Resident #1's annual Minimum Data Set with an Assessment Reference Date of 09/01/2022, Resident #1's Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Functional status for transfers was coded as requiring extensive assistance from staff with 2+ persons for physical assistance and support. Diagnoses included but were not limited to hemiplegia following cerebral infarction affecting the right dominant side and a left below-the-knee amputation. A care plan problem dated 08/03/2021 entitled, [Resident #1] is at risk for impaired Quality of Life included but was not limited to the following intervention: Encourage resident to allow use of lift x 2 staff for transfers out of bed. On 12/28/2022 at approximately 10:55 A.M., Resident #1 was interviewed. When asked about the fall that occurred in November 2022, Resident #1 stated that the CNA (certified nursing assistant) entered the room and told Resident #1 that they needed to be weighed in a weight chair. Resident #1 stated that she informed the CNA (CNA B) she wanted to use the slide board to transfer from the bed to her wheelchair and then transfer to the weight chair. Resident #1 then stated that the CNA didn't listen to her and tried to transfer Resident #1 from the bed to the weight chair without using a slide board or first donning Resident #1's prosthetic leg. Resident #1 then stated she fell to the floor. Resident #1 stated she was in a lot of pain (right leg) after the fall and eventually went to the hospital and had to have surgery. On 12/28/2022 at approximately 11:00 A.M., Resident #1 called a family member to discuss the incident with the surveyor. When asked about the fall that occurred in November 2022, the family member stated that (Resident #1) told the CNA there should be 2 people to conduct the transfer but the CNA attempted the transfer alone. On 12/28/2022 at 11:30 A.M., CNA B was interviewed. CNA B verified they have worked at the facility approximately 6 months. When asked about the fall that occurred in November 2022 involving Resident #1, CNA B stated that the nurse told her to weigh (Resident #1). CNA B then stated that (Resident #1) refused to don the leg prosthesis and that Resident #1 told the CNA she could stand and get in the chair without it. CNA B stated she then assisted Resident #1 to stand and pivot but that Resident #1 missed the chair and went to the floor. CNA B stated that Resident #1's right leg bent under her and the CNA was unable to hold (Resident #1) up. CNA B stated that after the incident, staff told her she should've used a hoyer (which is a mechanical lift). When asked about the process for knowing how to transfer each Resident, CNA B stated that, after the incident, she was told about a worksheet that listed how each Resident is to be safely transferred but she was unaware of the worksheet at the time. When asked if she currently had a worksheet, CNA B indicated she did not have a worksheet but they're kept in a book at the nurse's station. When asked to see the book, CNA B was unable to locate it. On 12/28/2022 at approximately 12:00 P.M., Registered Nurse B (RN B) was interviewed. When asked about the worksheets, RN B verified that nurses are supposed to print out the CNA Worksheet and give it to the CNA's. When asked if this was done today, RN B stated she printed some out yesterday and put them in the book at the (Liberty) nurse's station. When asked to see the book, it did not contain any CNA worksheets. A staff member nearby then printed out a CNA worksheet. For Resident #1 under Transfer Notes, it was documented, Hoyer lift only when resident declining to use prosthetic. Under the column entitled, Minimum Transfer Assist it was documented, Total lift, Assist x 2 [meaning 2 people]. On 12/28/2022 at approximately 12:25 P.M., Employee G, occupational therapy assistant, was interviewed. When asked about transfer options for Resident #1 prior to the fall in November 2022, Employee G stated that therapy was working with Resident #1 to use a sliding board with moderate assistance (meaning Resident #1 needed cues for leaning forward) or a step and shift over (when prosthetic was on) and only with therapy staff. Employee G stated that nursing staff was told to use a mechanical lift for safety. When asked about the weight chair, Employee G stated that weights can be obtained on the mechanical lift and the weight chair should not be used for anyone who cannot safely transfer. An excerpt of a physician's progress note dated 11/10/2022 under the header History of Present Illness documented, .being seen today for fall which resulted in RT [right] knee pain and lower leg pain. She fell while transferring. A radiology report dated 11/10/2022 documented the following excerpts: History: Fall. Findings: a distal femoral fracture is seen with lateral positioning and shortening. The fracture looks acute. An excerpt of a physician's progress note dated 11/10/2022 under the header History of Present Illness documented, .presents following hospitalization at [hospital name redacted] on 11/10/2022 after mechanical fall that resulted in a right distal femoral fracture. She underwent a nailing procedure for this. She does have some pain associated with the injury aggravated with activity and relieved adequately with her current pain management regimen. On 12/29/2022 at approximately 12:15 P.M., the Assistant Administrator and Director of Clinical Support were notified of findings. When asked if staff were supposed to use a mechanical lift to transfer Resident #1 prior to the fall on 11/10/2022, the Director of Clinical Support referred to a CNA Worksheet dated 11/09/2022 and stated a hoyer should've been used if the Resident (#1) refused to wear the leg prosthetic. The Director of Clinical Support also referred to a quarterly Transfer Assistance Evaluation dated 09/02/2022 which documented the following excerpt: Based on the above evaluation, the resident will be transferred with the minimum assistance of: Total lift with at least two staff members. On 12/29/2022 at approximately 1:45 P.M., the Assistant Administrator and the Director of Clinical Support stated there was no further documentation or information to submit. 2) For Resident #2, the facility staff failed to operate the mechanical lift according to manufacturers instructions while transferring Resident #2 from the shower chair to the bed on 12/28/2022. On 12/28/2022 at approximately 11:15 A.M., Resident #2 was observed seated in a shower chair in her room. Certified Nursing Assistant C (CNA C) and another CNA were positioning the mechanical lift in preparation to transfer Resident #2 to her bed. CNA C moved the mechanical lift legs under the shower chair from the left side of the chair. CNA C and the other CNA activated the lift, rolled the lift away from the shower chair, transferred Resident #2 to the bed, and lowered the lift. At no time in the process (lifting/lowering) did the facility staff open the lift legs to widen the base. After the procedure and exiting the room, CNA C was interviewed. When asked about the process for opening the lift legs, CNA C explained that if the shower chair was approached from the front of the chair, the lift legs would need to be opened but since the chair was approached from the side, it wasn't necessary to open the lift legs. On 12/28/2022, the facility staff provided a copy of the manufacturers instructions for the lift. On pg 4 of the instructions under the header, Warnings an excerpt documented, Patient lift may tip over if used incorrectly. Read and adhere to the operating instructions prior to lifting anyone. On page 5, an excerpt documented, Warning: During lifting or lowering, whenever possible, always keep the patient lift legs in maximum open position. On 12/28/2022 at approximately 5:00 P.M., the Director of Clinical Support was notified of findings. The Director of Clinical Support stated the expectation is to spread the base of the mechanical lift for stability.

Based on interview, clinical record review, and facility documentation the facility staff failed to show competency of the comprehensive care plan for 1 Resident (#12) in a survey sample of 3 Residents. The findings include: Resident # 12's CNA incorrectly stated that Resident #12 transfers by stand and pivot. However, the CNA worksheet and the care plan read that the resident was to use a sit to stand lift for transfers. On 2-10-23 at approximately 11:20 PM Resident #12 was observed in her wheelchair in the area near the nurses station. Attempts at interview were unsuccessful as Resident was unable to follow the conversation and or questions that were asked. A review of the most recent BIMS (Brief Interview of Mental Status) dated 12-12-22 revealed the Resident scored a 10/15 indicating moderate cognitive impairment. On 2-10-23 at approximately 11:40 AM, an interview was conducted with CNA D who was asked if Resident #12 was on her assignment and she stated that she was. She was then asked how Resident #12 transfers from bed to chair or wheel chair. CNA D stated, [Resident #12 name redacted] transfers by stand and pivot. When asked if she was sure of this information she stated that she was. When asked where she would locate information on how a resident is to transfer, she stated that The CNA Worksheet has all of that information. When asked if she has a CNA worksheet she stated that she did and indicated some folded papers sticking out of her pocket. When asked where she gets the CNA Worksheet she stated that they are given a copy at the beginning of each shift. When asked if she has anyone on her assignment that uses the sit to stand lift she stated that she did not. On 2-10-23 a review of the clinical record revealed that Resident #12's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12-12-22, coded the Resident as follows in section G 0110: Transfers - #3-Extensive assistance with #2 One-person physical assistance. The Resident was also coded as using a wheelchair with assistance of 1 person for mobility. Section G 0300 coded as follows: A - Moving seated to standing - #2 Not steady only able to stabilize with human assistance. D - Moving on and off toilet -#2 Not steady only able to stabilize with human assistance. E - Surface to Surface - #2 Not steady only able to stabilize with human assistance. Resident #12's care plan read as follows: FOCUS: Restorative Nursing - Transfer Potential for decline in ability to ambulate or transfer STATUS: Active (Current) GOAL: [Resident #12 name redacted] will maintain the ability to transfer self independently [Resident #12 name redacted] will maintain ability to assist with transfers with use of sit to stand lift STATUS: Active (Current) Interventions: PT, OT screen as indicated STATUS: Active (Current) Notify nurse of any change in participation or endurance STATUS: Active (Current) Provide cues and assist as needed STATUS: Active (Current) A review of the CNA Worksheet Revealed that Resident #12 is listed as requiring a sit to stand lift. On 2/10/23 at approximately 11:55 AM an interview was conducted with LPN C, who was asked if she had a copy of the CNA Worksheet. She indicated that she did when asked to look at Worksheet and see how Resident #12 transfers. She was asked how the Resident transfers and she stated that she uses a sit to stand lift. When asked if the CNA assigned to her should be aware of this information if they are in possession of the worksheet she stated that they should. When asked if the CNA should be following the guidelines of the worksheet she stated that they should. When asked what could happen if they do not follow the guidelines, she stated they could be injured or fall. On 2/10/23 at approximately 12:45 PM an interview was conducted with the DON who was asked about the CNA Worksheet and if it should align with the care plan for each resident. The DON stated that the Worksheet was developed to aid the CNA's in knowing how to care for each Resident. She stated that among other things it outlines the type of transfers and equipment used with each Resident. On 2/10/23 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review, and facility documentation the facility staff failed to show competency of the comprehensive care plan for 1 Resident (#12) in a survey sample of 3 Residents. The findings include: Resident # 12's CNA incorrectly stated that Resident #12 transfers by stand and pivot. However, the CNA worksheet and the care plan read that the resident was to use a sit to stand lift for transfers. On 2-10-23 at approximately 11:20 PM Resident #12 was observed in her wheelchair in the area near the nurses station. Attempts at interview were unsuccessful as Resident was unable to follow the conversation and or questions that were asked. A review of the most recent BIMS (Brief Interview of Mental Status) dated 12-12-22 revealed the Resident scored a 10/15 indicating moderate cognitive impairment. On 2-10-23 at approximately 11:40 AM, an interview was conducted with CNA D who was asked if Resident #12 was on her assignment and she stated that she was. She was then asked how Resident #12 transfers from bed to chair or wheel chair. CNA D stated, [Resident #12 name redacted] transfers by stand and pivot. When asked if she was sure of this information she stated that she was. When asked where she would locate information on how a resident is to transfer, she stated that The CNA Worksheet has all of that information. When asked if she has a CNA worksheet she stated that she did and indicated some folded papers sticking out of her pocket. When asked where she gets the CNA Worksheet she stated that they are given a copy at the beginning of each shift. When asked if she has anyone on her assignment that uses the sit to stand lift she stated that she did not. On 2-10-23 a review of the clinical record revealed that Resident #12's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12-12-22, coded the Resident as follows in section G 0110: Transfers - #3-Extensive assistance with #2 One-person physical assistance. The Resident was also coded as using a wheelchair with assistance of 1 person for mobility. Section G 0300 coded as follows: A - Moving seated to standing - #2 Not steady only able to stabilize with human assistance. D - Moving on and off toilet -#2 Not steady only able to stabilize with human assistance. E - Surface to Surface - #2 Not steady only able to stabilize with human assistance. Resident #12's care plan read as follows: FOCUS: Restorative Nursing - Transfer Potential for decline in ability to ambulate or transfer STATUS: Active (Current) GOAL: [Resident #12 name redacted] will maintain the ability to transfer self independently [Resident #12 name redacted] will maintain ability to assist with transfers with use of sit to stand lift STATUS: Active (Current) Interventions: PT, OT screen as indicated STATUS: Active (Current) Notify nurse of any change in participation or endurance STATUS: Active (Current) Provide cues and assist as needed STATUS: Active (Current) A review of the CNA Worksheet Revealed that Resident #12 is listed as requiring a sit to stand lift. On 2/10/23 at approximately 11:55 AM an interview was conducted with LPN C, who was asked if she had a copy of the CNA Worksheet. She indicated that she did when asked to look at Worksheet and see how Resident #12 transfers. She was asked how the Resident transfers and she stated that she uses a sit to stand lift. When asked if the CNA assigned to her should be aware of this information if they are in possession of the worksheet she stated that they should. When asked if the CNA should be following the guidelines of the worksheet she stated that they should. When asked what could happen if they do not follow the guidelines, she stated they could be injured or fall. On 2/10/23 at approximately 12:45 PM an interview was conducted with the DON who was asked about the CNA Worksheet and if it should align with the care plan for each resident. The DON stated that the Worksheet was developed to aid the CNA's in knowing how to care for each Resident. She stated that among other things it outlines the type of transfers and equipment used with each Resident. On 2/10/23 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated when opened, and sealed closed. These failures had the potential to increase the spread of infection to any resident who received meals from the kitchen. Findings include: On 04/12/21 at 9:39 AM, during the initial tour of the kitchen with the facility Kitchen Manager, the following were observed and verified: In the dry storage pantry, there was an open bag of cereal that was not sealed closed or dated when opened. There were three bags of cereal that did not have dates when opened. Additionally, there was one bag on long grain rice that did not have a date when opened. On 04/14/21 at 7:23 AM, the Dietary Manager (DM) stated that she had disposed of the opened bag of cereal that was in the dry storage pantry. She stated that all staff were supposed to date foods when they were opened, and seal opened food. The DM stated that she reminded all staff to date opened food.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure a resident's dignity for one of 37 sampled residents (Resident (R) 33. Observation revealed the resident had remnants of breakfast foods on the front of his shirt. Additionally, the resident had not been shaved and his face was peeling and scaly. This failure had the potential to affect the resident's self-esteem, self-worth, and enhance his quality of life. Findings include: Review of the facility's policy titled, Resident Rights Policy, revised 04/06/05, revealed, . Resident rights. The facility protects and promotes the rights of each resident admitted providing a dignified existence, self-determination . Review of R33's Admission Record, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated the resident had a moderately impaired cognition level. R 33's Care Plan dated 09/15/2020 states that the resident required extensive assist with activities of daily living (ADL). Observation on 04/13/21 at 9:15 AM, revealed R33's face to be scaly and unshaven. The resident was sleeping and his shirt was visibly soiled. Bath records were pulled for one month and they do not record if a resident was shaved. R33 does receive bed baths. Records indicate that from 03/13/21 to 04/13/21, R33 had 19 complete bed baths, four partial bed baths, and nine days of no bathing. Interview with R33 on 04/13/21 at 11:53 AM, revealed that he had not received a bath or was washed up that morning. When asked the last time he was shaved, he could not remember. R33 stated that he would like to be shaved. Observation on 04/14/21 at 11:32 AM, R33 revealed eyes closed and resting in his bed with remnants of breakfast food all over his shirt. He is shaved and his face is no longer scaly. Resident awakes and I ask when he was shaved, and he stated yesterday. I asked if the CNA offered to shave him and he said no that he asked to be shaved. R33 was pleased and asked how do I look. Interview on 04/14/21 at 11:45 AM, with the DON revealed that R33's CNA was pulled from the floor at 10:55 AM to help transport a resident to [NAME] Hospital. I asked her to accompany me to the resident's room. R33 was sleeping and the DON put on gloves and woke him up. Eggs and oatmeal were present on his shirt. She removed the food and told R33 that someone would be in to get him cleaned up. When asked who was responsible for R33's care in the absence of his CNA, the DON stated that everyone should help. Breakfast trays are delivered to the unit at 7:45 AM. R33's tray had been removed from his room.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to implement an effective pressure ulcer program resulting in harm for 1 resident (Resident #2) of 20 residents in the survey sample. The facility investigated the incident, and developed a plan of correction prior to survey, resulting in a finding of Past Non-Compliance. For Resident #2 the facility staff failed to identify a pressure ulcer prior to the area becoming a Stage III pressure ulcer. The findings included: Resident #2, was admitted to the facility 12-6-13. [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 3-31-16 was coded as a quarterly assessment. Resident #2 was coded as having short and long term memory deficits and required extensive assistance with making daily life decisions. Resident #2 was also coded as needing extensive to total assistance of one staff member to perform activities of daily living. Section M, the area devoted to identification of skin issues, revealed Resident #2 had been coded as at risk for development of pressure ulcers, however, had no pressure ulcers. Resident #2's nursing progress notes were reviewed and revealed that on 4-29-16 the Resident was identified to have a pressure ulcer on her sacrum, and that treatment was initiated. No other notes describe the wound until a full assessment note was completed on 5-2-16 by Registered Nurse (RN) C. A skin assessment was conducted on 4-29-16 and documented on a second form as a stage 3 pressure ulcer upon identification. Those forms are described and included in detail below. Review of Resident #2's clinical record revealed 2 facility documents both named Initial Skin Documentation/Assessment Form. The forms documented that on 4-29-16, Resident #2 had developed, and been identified with a Stage III pressure ulcer, to the coccyx. This was the initial identification and evaluation. The document stated that the wound measured 1.2 centimeters (cm) long by 1.0 cm wide by 0.2 cm deep, had purulent (pus) drainage, had 55% granulation tissue (healing), and 45% intact purple skin, and the surrounding tissue was bright red. The most recent Guidance from NPUAP (National Pressure Ulcer Advisor Panel) April 2016, defined staging of pressure ulcers as follows: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discolorationIntact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The facility skin assessments (3 total) continued weekly from initial identification and continuing for 2 more weeks up until the time of survey, were reviewed and were as follows: 1. The initial assessment was documented on 4-29-16. For this assessment the wound was described as measurements of 1.2 centimeters (cm) long by 1.0 cm wide by 0.2 cm deep, had purulent (pus) drainage, had 55% granulation tissue (healing), and 45% intact purple skin, pain was not documented, and the surrounding tissue was bright red. 2. The second facility assessment was documented on 5-5-16. For this assessment the wound had progressed to reveal measurements of 0.9 cm long x 0.5 cm wide x 0.2 cm deep, had serosanguinous drainage (clear/bloody), had Granulation tissue 60% and yellow necrotic slough 40%, with episodic pain, and surrounding tissue was bright red. 3. The third facility assessment was documented on 5-12-16. For this assessment the wound had improved to reveal measurements of 0.6 cm long x 0.2 cm wide x 0. 1 cm deep, had serosanguinous drainage (clear/bloody), had Granulation tissue 100%, with episodic pain, and surrounding tissue was bright red. Resident #2 was observed by surveyors on 5-18-16, at 3:00 p.m. during wound care observations with the Wound nurse Licensed Practical Nurse (LPN) B, and the Assistant Director of Nursing (ADON) Registered Nurse (RN) C. This was the fourth facility assessment, and Resident #2 was lying in bed on her right side exposing the coccyx wound. The wound size had worsened, and measured 0.9 centimeters (cm) long by 0.4 cm wide by 0.1 cm deep. The wound appeared to be healing at the base of wound, and was clean without drainage, pink, moist and had no slough or eschar was present in the wound bed. physician's orders [REDACTED]. April 2016 - Prior to identifying the stage 3 pressure ulcer on 4-29-16, no preventative skin interventions were ordered. There was an order for [REDACTED]. May 2016 - After identifying the stage 3 pressure ulcer, and on 4-29-16, orders appeared on the May most recent recapitulated physician's orders [REDACTED]. The Hi Cal supplement 2 ounces twice daily was increased to three times daily, and the Promod supplement was increased from one time daily to two times daily. There appeared a wound treatment order also on 4-29-16 for Triad 12's paste, Cleanse coccyx area with normal saline, pat dry and apply Triad to area, cover with Allevyn dressing daily and as needed until healed, then discontinue. The order was changed on 5/3/16. On 5-3-16 (5 days after identification) new orders appeared on the POS for Wound Specialist doctors (VOHRA) to evaluate and treat the wound, and for an alternating air mattress. On 5-5-16 the Wound doctor (VOHRA) initial evaluation was completed. The document described the wound as stage 3, measuring 0.9 cm long x 0.5 cm wide x 0.2 cm deep, had serosanguinous drainage (clear/bloody), had Granulation tissue 60% and yellow necrotic slough 40%, with episodic pain. The doctor recommended to discontinue house barrier cream once daily, and to institute Santyl debridement enzymatic ointment and cover with [MEDICATION NAME] dressing, once daily, and as needed. This new order was instituted on 5-6-16, and then discontinued on 5-12-16. Santyl Ointment is described as; www.santyl.com indicated: [MEDICATION NAME] SANTYL® Ointment is a sterile enzymatic [MEDICATION NAME] ointment which contains 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] USP. The enzyme [MEDICATION NAME] is derived from the fermentation by ,[MEDICAL CONDITION]. histolyticum. It possesses the unique ability to digest collagen in necrotic tissue. On 5-12-16 the Wound doctor (VOHRA) conducted a second evaluation of the wound. The second document described the wound as stage 3, measuring 0.6 cm long x 0.2 cm wide x 0.1 cm deep, had serosanguinous drainage (clear/bloody), had Granulation tissue 100%. The doctor recommended to discontinue Santyl ointment daily, and to institute Calcium Alginate once daily. On 5-12-16 a new doctors order was received for Calcium Alginate and cover with [MEDICATION NAME] dressing once daily, and as needed. The order included cleaning the wound prior to applying the dressing with normal saline. Calcium alginate dressings are highly absorbent biodegradable dressings made from seaweed, and this dressing continued through the time of survey. Review of Resident #2's skin and pressure ulcer care plan revealed no initiation or revision dates, therefore it is impossible to determine by staff or surveyors if the care plan was instituted before or after the identified pressure ulcer. Under the heading Problems The document states (name of Resident) has a pressure area, and Resident has altered skin integrity. The interventions that follow the problem area appear to have been implemented after the identification of the stage 3 pressure ulcer, and not before as a prevention. Evidence concludes that this is the only pressure ulcer wound this Resident had experienced in at least 6 months. This conclusion is born out by 2 previous MDS assessments, which denote that the Resident had no wounds, and MDS assessments were completed every 3 months. The care plan is revised accordingly, quarterly, as the MDS assessment provides the basis for care planning per regulation. INTERVIEWS; On 5-18-16, and 5-19-16 interviews were conducted with staff members responsible for the daily care of Resident #2. On 5-19-16 CNA (certified nursing assistant) A, the staff member caring for Resident #2, stated that she had cared for Resident #2, and that she would report to the nurse if there was ever anything different or not normal. CNA A stated she would report anything different to the nurse as you never know if the previous person did not report it (a change in the skin). When interviewed, during wound care observations on 5-18-16, the Certified Wound Care Nurse LPN B, and the nurse providing wound care, the ADON (assistant director of nursing) RN C, indicated that at the time of Resident #2's development of a stage 3 pressure ulcer, the facility did not have a dedicated wound care nurse. The ADON stated that she was present upon identification, and was responsible for identifying, assessing, staging, and measuring Resident #2's stage 3 pressure ulcer. LPN B, and the ADON RN C also stated all of the staff were responsible for reporting any changes in skin integrity to the floor nurse. The floor nurse was to report to a supervisory nurse who would initiate documentation in the nurses notes, and do the initial skin assessment. Then appropriate treatment needs and interventions would be called in to the physician, to obtain an order for [REDACTED]. Review of the facility's policy entitled Pressure Ulcer Treatment Program included; Procedure: All staff were responsible for reporting any changes in skin integrity to the floor nurse. The floor nurse was to report to a supervisory nurse who would initiate documentation in the nurses notes, and do the initial skin assessment. Then appropriate treatment needs and interventions would be called in to the physician, to obtain an order. Potential contributing factors should be identified and appropriate preventative strategies should be initiated and documented in the plan of care. The document did not state who was responsible for this step. The Resident should be discussed at the next care plan meeting where multi-disciplinary approaches can be included in the plan of care. This step in the process could take up to 3 months as care plan meetings are held quarterly. The facility pressure ulcer policy followed the old NPUAP staging guidelines. The Administrator, DON, Corporate Vice President of Operations, and RN Corporate Director of Operations were informed of the failure of the staff, for Resident #2, to identify a pressure ulcer before it was identified as a Stage 3 pressure ulcer. The corporate Director of Operations RN consultant stated that staff had identified the deficient practice, and a plan of correction had been developed prior to survey. She was able to provide documentation to that effect, and the following describes the credible evidence for a decision of Past non-Compliance. On 5-19-16 at 11:00 a.m. the Director of nursing and Administrator presented the facility plan of correction for the incident, which had been previously developed, and after the incident occurred, to prevent further incidents of this nature to occur. The plan of correction included a head to toe assessment of Resident #2, and all residents in the facility. It also included a 100% clinical record audit for all Residents to look for documents that had not been coded correctly, care plans were updated, and risk protocols instituted. The staff was retrained on pressure area identification, and evaluation. Audits are being completed weekly for 6 weeks to include 20 % of the Residents each week, and reviewed by the DON. The quality Assurance Committee are reviewing these records quarterly, and no new incidents of this type have occurred since this late identification for Resident #2. The facility Allegation of Compliance (AOC) date was 5-13-16, and credible evidence was accepted for the AOC date. This incident is found to be Past Non-Compliance, as the facility identified the non-compliant practice and corrected it prior to survey. The DON and Administrator were notified of the findings at end of day debrief on 5-19-16 at 2:00 p.m. No further information was provided.