HEARTHSTONE NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and neglect.<BR/>On 7/5/2023 at 9:00pm, CNA A attempted to transfer Resident # 1 from her wheelchair to her bed using a mechanical lift. CNA A attempted the transfer with one person, although Resident # 1 required two-person assistance. As a result, the mechanical lift fell on top of Resident # 1 and the cross bar struck Resident # 1 in head causing a bump, soreness, headache causing injury to her head in which she had to take medication. <BR/>An (IJ) Immediate Jeopardy was identified on 7/28/2023 at 6:45pm. While the (IJ) Immediate Jeopardy was removed on 7/30/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed all residents who require the use of a mechanical lift at risk to be neglected. <BR/>Findings included: <BR/>Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain), WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and body mass index of 50.0-59.9.<BR/>Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. <BR/>Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. <BR/>In an interview on 7/28/2023 at 3:00pm with Resident # 1 stated on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated she asked CNA A where the other staff was to assist him, she stated CNA A responded, don't worry he was going to do it himself and that he didn't have anyone to help him at the time. Resident # 1 stated she didn't think that CNA A knew what he was doing. Resident # 1 stated when she was up in the sling, that CNA A went to the opposite side of the bed leaning across the bed to pull her from the sling onto the bed. She stated once he pulled her, she went down on the bed and the mechanical lift came down on top of her on the bed. Resident # 1 stated when the mechanical lift fell over the grab bar struck her in her head causing her head to hurt. <BR/>In an interview on 7/28/2023 at 1:34pm with NP, revealed Resident # 1 had a faint bruise to the right side of her forehead. NP stated the incident occurred on 7/5/2023, she stated Resident # 1 reported that CNA A was trying to transfer her using the mechanical lift and the lift fell on top of her. The NP stated Resident # 1 stated she was hit in the head with the bar from the mechanical lift causing her head to hurt. She stated she assessed Resident #1 on 7/6/2023. The NP stated Resident #1 complained of a headache and soreness to the touch she stated she prescribed Tylenol. NP stated Resident # 1 was agreeable to take the tylenol and rest, as Resident # 1 stated she did not want to participate in therapy due to her head hurting. <BR/>In an interview on 7/28/2023 at 3:49pm with the DON, revealed Resident # 1required a mechanical lift and that Resident # 1 was a two-person assist. The DON stated staff have access to PCC (Point Click Care) system in which staff could review to know what the care needs were for the residents. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. <BR/>In an interview with the ADM on 7/28/2023 at 4:43pm, revealed Resident # 1 was hit on the is of her face by one of the arms from the mechanical lift. The ADM stated the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care system for the resident's care needs. The ADM reported that the staff was agency staff and that he advised that the staff could not return to the facility. <BR/>Review of progress notes reflected no incident report completed of the incident. <BR/>Policies reviewed:<BR/>Review of facility policy Resident rights dated Dec. 2016 reflect the following: <BR/>Residents have to right to be free from neglect<BR/>This was determined to be an (IJ) Immediate Jeopardy (IJ) on 7/28/2023 at 6:45pm. The ADM was notified. The ADM was provided with the IJ template on 7/28/2023 at 6:45PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 7/29/2023 at 6:22PM <BR/>Plan of Removal: Immediate Jeopardy <BR/>The notification of Immediate Threat states as follows:<BR/>F600 The facility failed to ensure that the resident was free from neglect. <BR/>Statement of Deficient Practice:<BR/>All residents who require a Mechanical lift could be at risk of harm and injury from neglect. <BR/>Action Item 1<BR/>Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff<BR/>Target date: 7/31/2023<BR/>Action Item 2<BR/>Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee<BR/>Target date: 7/28/23<BR/>Action Item 3<BR/>Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee<BR/>Target date: 7/28/2023<BR/>Action Item 4<BR/>All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23.<BR/>Target date: 7/28/2023<BR/>Action Item 5<BR/>All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance<BR/> Target date: 7/28/2023<BR/>Action Item 6<BR/>Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant <BR/>Target date: 7/28/2023<BR/>Action Item 7<BR/>Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations<BR/>Target date: 7/28/2023<BR/>Action Item 8 <BR/>Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care [NAME] to identify resident needs. DON or designee<BR/>Target date: 7/29/2023<BR/>Action Item 9<BR/>Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee<BR/>Target date 7/31/2023<BR/>Action Item 10<BR/>Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee.<BR/>Target date: 7/31/2023<BR/>Action Item 11<BR/>The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator<BR/>Target date: 7/31/2023<BR/>Monitoring: 7/30/2023<BR/>Observation on 7/30/2023 at 11:00am, observed CNA D and CNA F complete a resident transfer using the mechanical lift. Staff were observed using appropriate hand hygiene, staff observed talking with Resident # 2 and explaining the process as they started. CNA D and CNA F were able to complete a successful transfer from the bed to the wheelchair. <BR/>Observation on 7/30/2023 at 11:30am, observed CNA C and CNA G completed a transfer for a Resident # 3 from her wheelchair into her bed. Staff were able to complete the transfer successfully, Resident # 3 stated she felt safe. <BR/>Interview on 7/30/2023 at 11:50am with CNA D, revealed she worked the 6am to 6pm shift, she stated she was facility staff not agency. She had been trained on how to use the mechanical lift and abuse/neglect she stated she used the [NAME] in PCC to see what the care needs are for residents. CNA D was able to explain the process of how to use the mechanical lift. <BR/>Interview on 7/30/2023 at 11:55am with CNA G, revealed she was agency staff, she stated she had been trained on how to use the mechanical lift safely and abuse/neglect She reported she had also been trained on how to access the PCC system to review the care needs for each resident. <BR/>Interview on 7/30/2023 at 12:00pm with CNA F, revealed she worked through a (staffing agency) she stated it was her second day at the facility. CNA F stated she had been in-serviced on how to use the mechanical lift safely, abuse/neglect, and how to access PCC for resident's care needs. <BR/>Interview on 7/30/2023 at 2:30pm with Resident # 2 revealed, she was doing fine and stated she felt safe at the facility. <BR/>Interview on 7/30/2023 at 3:00pm with Resident # 3 revealed, he felt safe at facility. <BR/>Record review on 7/30/2023 of in-services on abuse/neglect, Mechanical lift competency checklist dated 7/29/2023 reflected 20 staff had completed the training. <BR/>The ADM was informed the Immediate Jeopardy was removed on 7/30/2023 at 5:00PM. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1(Resident # 1) of 7 residents reviewed for accidents and supervision.<BR/>Staff attempted to use the mechanical lift to transfer Resident # 1 from her wheelchair to her bed with one person. As a result, the mechanical lift fell on top of Resident # 1, causing injury and pain to her head in which she was prescribed medication for the pain.<BR/>This failure placed all residents who require the use of a mechanical lift at risk for accidents, harm, and injuries.<BR/>An (IJ) Immediate Jeopardy was identified on 7/31/2023 at 1:35pm. While the (IJ) Immediate Jeopardy was removed on 7/31/2023 at 5:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, mechanical lifts and the effectiveness of their systems.<BR/>Findings included: <BR/>Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain)., WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and BODY MASS INDEX [BMI] 50.0-59.9,<BR/>In an interview on 7/28/2023 at 3:00pm with Resident # 1 revealed on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated the CNA A did not know how to appropriately use the mechanical lift or he would have known that he needed another person to safely operate the machine. Resident # 1 stated CNA A went to the other side of the bed and attempted to pull her from the mechanical lift onto the bed. She stated she fell on the bed and the mechanical lift fell on top of her, and the grab bar from the lift hit her in the head. Resident # 1 stated she had a headache, and her head was sore in the spot where the bar struck her in her head. She stated she was prescribed Tylenol for her pain. <BR/>Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. <BR/>Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. <BR/>In an interview on 7/28/2023 at 5:42pm with CNA C, revealed she recently started working at the facility. She stated she had not been trained on how to use the mechanical lift at this facility. Stated if they needed to transfer a resident using the mechanical lift stated they would get another person to assist with the transfer while using the lift. <BR/>In an interview on 7/28/203 at 6:09pm with CNA B revealed she was agency staff. She stated the facility had not trained her on how to properly use the mechanical lift. However, stated whenever they needed to do a list using the mechanical lift, they needed two people to use the lift. <BR/>In an interview on 7/28/2023 at 3:49pm with the DON, revealed she could not find any of her in-services for the month of July. The DON stated she thought she did a training on mechanical lifts. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. <BR/>In an interview on 7/28/2023 at 4:43pm with the ADM, he revealed the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care for the resident's care needs. The ADM stated it was the DON's responsibility for the care staff to be trained, however reported that agency staff have to be trained and worked as a CNA for a year before being able to work for the agency. He stated they had completed trainings through the agency but was not able to indicate if this training had been completed. <BR/>Record review of MDS reflected there are 14 other residents that require the of a mechanical lift. <BR/>Review of progress notes reflected no incident report completed of the incident. <BR/>Policies reviewed:<BR/>Review of facility policy Resident rights dated Dec. 2016 reflect the following: <BR/>Residents have to right to be free from neglect<BR/>The facility does not have a Mechanical Lift policy<BR/>This was determined to be an Immediate Jeopardy on 7/31/2023 at 1:35-m. The ADM was notified. The ADM was provided with the IJ template on 7/31/2023 at 1:35pm. <BR/>The following Plan of Removal submitted by the facility was accepted on 7/31/2023 at 5:30pm.<BR/>Plan of Removal: Immediate Jeopardy<BR/>The notification of Immediate Threat states as follows:<BR/>F689 The facility failed to ensure that the resident that the resident received adequate supervision and assistive devices to prevent accidents.<BR/>Statement of Deficient Practice:<BR/>All residents who require a Mechanical lift could be at risk of harm and injury from incidents and accidents<BR/>Action Item 1<BR/>Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff<BR/> Target date: 7/28/2023<BR/>Action Item 2<BR/>Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee<BR/>Target date: 7/28/23<BR/>Action Item 3<BR/>Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee<BR/> Target date: 7/28/2023<BR/>Action Item 4<BR/>All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23.<BR/>Target date: 7/28/2023<BR/>Action Item 5<BR/>All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance<BR/> Target date: 7/28/2023<BR/>Action Item 6<BR/>Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant <BR/> Target date: 7/28/2023<BR/>Action Item 7<BR/>Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations<BR/> Target date: 7/28/2023<BR/>Action Item 8 <BR/>Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care [NAME] to identify resident needs. DON or designee<BR/> Target date: 7/29/2023<BR/>Action Item 9<BR/>Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee<BR/>Target date 7/31/2023<BR/>Action Item 10<BR/>Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee.<BR/>Target date: 7/31/2023<BR/>Action Item 11<BR/>The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator<BR/>Target date: 7/31/2023<BR/>Plan of removal monitoring 7/31/2023<BR/>An interview on 7/31/2023 at 5:09pm with the ADON, revealed she has been trained on abuse/ neglect, resident rights, safe transfer of residents using the mechanical lift. The ADON stated the abuse/neglect coordinator is the ADM. She was able to discuss the procedures if she see or suspect abuse/neglect. The ADON stated she had never seen or suspected abuse/neglect at this facility. She stated she had completed the competency check on how to use the mechanical lift. She was able to discuss the process of using the mechanical lift. Stated she has been able to discuss the process for reporting accidents/ incidents and assessment of the resident. <BR/>An interview on 7/31/2023 at 5:20pm with RN, revealed she had been trained on how to use the [NAME] lift, abuse/neglect, resident rights, incident and accident reports and reporting. She was able to discuss the process for reporting abuse/neglect stated the abuse/neglect coordinator is the administrator. RN was able to discuss the process and steps of using the mechanical lift. The RN was able to discuss the process for reporting incidents and accidents. Stated all incidents and accidents should be reported and documented immediately. She stated she had never seen or suspected abuse /neglect at this facility.<BR/>An interview on 7/31/2023 at 5:29pm with CNA D, revealed she worked 6pm-6am and had been in-serviced on abuse/neglect, resident rights, incidents/accidents of residents and the mechanical lift. She was the process for reporting abuse /neglect is the ensure that the resident is safe and alert a nurse to assess the resident for further injuries. Stated the administrator is the abuse/neglect coordinator stated she has never seen or suspected abuse /neglect at this facility. Staff reported the nurse complete the incident reports and they write statement of what they saw. Staff was able to discuss process in using the [NAME] lift with a resident. CNA D stated she completed the competency skills test to use the mechanical lift.<BR/>An interview on 7/31/2023 at 5:51pm with CNA E, revealed she worked 6am to 6pm shift. Stated she had been in-serviced on abuse/neglect, resident rights, incident and accidents reports, and how to operate the mechanical lift. <BR/>Record review of in-services on the following dated: 7/31/2023<BR/>Abuse/Neglect - 75%of staff and ongoing <BR/>Resident Rights - 75% staff have been in-serviced and ongoing <BR/>Incidents/Accidents- 75% staff have been in-serviced and ongoing <BR/>An (IJ) Immediate Jeopardy was identified on 7/331/2023 at 1:35pm. While the (IJ) Immediate Jeopardy was removed on 7/31/2023 at 5:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, resident rights, mechanical lifts and the effectiveness of their systems.<BR/>The ADM was advised that the (IJ) Immediate Jeopardy was lifted on 7/31/2023 at 5:45pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to label drugs and biologicals used in the facility with an expiration date for 1 of 3 insulin pens or to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 (B pod) of 1 medication refrigerators reviewed for medication storage.<BR/>1. Facility failed to write an open/expiration date on Resident #1's insulin vial.<BR/>2. The facility failed to ensure the medication room had a permanently affixed lock box inside the medication refrigerator. <BR/>3. <BR/>Facility failed to keep daily log of refrigerator temperature in the medication storage room B Pod.<BR/>4. <BR/>Facility failed to remove expired medical supplies (20 single use samplers expired [DATE], 2 Universal Viral Transport for viruses, chlamydia, mycoplasmas, and ureaplasmas expired [DATE], and 6 Eswab Collection & Transport System for aerobic anaerobic & fastidious bacteria expired [DATE]) in 1 of 2 medication storage room.<BR/>These failures could place residents at risk of receiving expired medication, drug diversion, and using expired supplies which could alter test results. <BR/>Findings include: <BR/>During observation of nurse medication cart A pod 200 Hall (1 of 3 medication carts observed) and interview on [DATE] at 09:10 a.m., an insulin pen (Insulin Aspart Solution Pen-injector 100 UNIT/ML) for Resident #1, was without open/expired date on insulin box or insulin pen. LVN A (agency nurse) stated it was her first day working at the facility. LVN A did not say more. She went to talk with the DON.<BR/>Observation of the B pod 100 Hall medication storage room, 1 of 2 medication storage rooms, on [DATE] at 10:53 a.m., with LVN D (agency nurse) revealed the refrigerator was unlockable and the narcotic box was not attached to refrigerator and held the medication: Lorazepam 2mg/mL vial and the temperature log for the refrigerator was not filled out daily.<BR/>Observation and interview on [DATE] at 10:53 a.m., with LVN D (KARE) B pod 100 Hall for 1 of 2 medication storage rooms, surveyor observed in drawers in the medication storage room expired supplies (- 20 Single Use Samplers expiration date [DATE],<BR/>- 2 Universal Viral Transport for Viruses, chlamydiae, mycoplasmas, and ureaplasmas expiration date 2022-09-30, - Eswab Collection & Transport System for aerobic anaerobic & fastidious bacteria expiration date [DATE]). LVN D stated he was not aware the locked narcotic box in the refrigerator had to be attached. LVN D stated with the locked narcotic box not being attached to the refrigerator, the narcotics could be misplaced or stolen. LVN D stated with the temperature of the refrigerator not being monitored daily, the temperature could be off, and medications could go bad. LVN D stated having and using expired items in drawer can cause infection, fever, septic shock, allergic reaction, and false results.<BR/>In an interview on [DATE] at 11:15 a.m., DON stated they are attempting to get (facility) processes together at the facility, but it is taking time (over half the staff are agency). She stated they have been working on it. DON has been at the facility for two months. DON stated the nurses will be going through the medication carts and medication storage rooms twice a week checking for open dates and expired items. DON stated the malfunction of expired items or false results could be the negative outcome for having medication/items that have expired on-hand.<BR/>In an interview on [DATE] at 03:06 p.m., the RN Regional Consultant stated insulin was to be dated (with open date and expiration date 28 days after opening) as soon as it was opened. The narcotics locked box in the refrigerator should be attached so narcotics do not get stolen. <BR/>Review of facility's Storage and Expiration Dating of Medications, Biological dated [DATE] revealed:<BR/>Procedure<BR/>1. <BR/>Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.<BR/>1.3. <BR/>If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.<BR/>Review of facility's Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles dated [DATE] revealed:<BR/>Procedure<BR/>4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier.<BR/>14. Controlled Substances Storage:<BR/>14.4 Controlled Substances stored in the refrigerator must be in a separate container and double locked.<BR/>Review of the facility's Storage and Expiration Dating of Medications, Biological dated [DATE] revealed:<BR/>Procedure<BR/> 10. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. 14.4 Controlled Substances stored in the refrigerator must be in a separate container and double locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control.<BR/>The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. <BR/>This failure could place residents at risk for development of communicable diseases and infections. <BR/>Findings included: <BR/>Record review of Resident #17's undated face sheet, reflected she was an [AGE] year-old female admitted [DATE] with diagnoses of Encephalopathy (brain disfunction), Acute Respiratory Failure, Diabetes, Pneumonia, Anxiety, and Major Depressive Disorder. <BR/>Record review of Resident #17's Quarterly MDS assessment dated Dec. 25, 2024, reflected a BIMS score of 06, which indicated the resident's cognitive ability was severely impaired. <BR/>Record review of Resident #17's Care Plan, reflected a Focus area was initiated for Acute Infection on 11/21/24 with a goal for the infection to resolve without complications.<BR/>Record review of Resident #44's undated face sheet, reflected she was a [AGE] year-old female admitted [DATE] with diagnoses of Dementia, Depression, High Blood Pressure, and a Personal History of Urinary Tract Infections. <BR/>Record review of Resident #44's Quarterly MDS assessment dated Dec. 24, 2024, reflected a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. <BR/>Record review of Resident #44's Care Plan, reflected a Focus area was initiated for Resident is at risk for infection-Covid 19 with a goal to not exhibit signs and symptoms of Covid-19. <BR/>Observation on 1/29/25 at 9:03 a.m., revealed MA removed a blood pressure cuff from the top of the medication cart and entered the resident's room to take the blood pressure of Resident #17. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #17 in the resident's room. She returned to the medication cart and moved to the next resident without performing hand hygiene or cleaning the blood pressure cuff. <BR/>Observation on 1/29/25 at 9:15 a.m., revealed MA removed the un-sanitized blood pressure cuff from the top of the medication cart and proceeded to take the blood pressure of Resident #44. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #44 in the resident's room. She returned to the medication cart and moved the cart back to the nurse's station where she left it. The blood pressure cuff was left on top of the first medication cart and was never sanitized. Hand hygiene was not done until MA moved to a different cart, where she performed hand hygiene before starting on the new cart. <BR/>In an interview on 01/29/25 09:44 a.m., MA stated she forget the hand hygiene between Resident #17 and Resident #44 but does not know why. She stated that she did not clean the blood pressure cuff between residents. She stated she usually keeps the hand sanitizer near her on the cart and does do it. She stated it was important to do hand hygiene and clean the cuff to avoid spreading infections from resident to resident. She stated that the negative outcome to residents if it was not done, was they could develop infections and get sick. <BR/>In an interview on 1/30/25 at 9:54 a.m., the DON stated, the policy for hand hygiene during medication administration was to clean hands before and after each resident and as needed.<BR/>She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this is important for infection control and to not spread germs between residents which could give a resident an infection and make them sick. She said it was the responsibility of the DON, the Scheduler, and the ADON to train staff on this when staff is hired and at yearly competencies. <BR/>In an interview on 1/30/25 at 10:28 a.m., RN, she stated the policy for hand hygiene on medication administration was to sanitize hands before and after each resident and as needed.<BR/>She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this was important for minimize risk of spreading bacteria to other residents and causing cross contamination. She stated if this was not done, residents could get infections and become sick. She stated it was the responsibility of the DON, ADON and nurse management to train staff on this. <BR/>In an interview on 1/30/25 at 10:38 a.m., the ADM stated the policy for hand hygiene on medication administration was to clean hands before and after each resident. He stated the policy on cleaning equipment like blood pressure cuffs was to clean between residents. He stated this is important for infection control and to prevent giving a resident an infection which could make them sick. He stated it is the responsibility of the DON and ADM to train staff on this.<BR/>A record review of the facility policy titled, Handwashing/Hand Hygiene 2001 Med-Pass, Inc with a last revision date of 2019 reflected the following: <BR/>The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. <BR/>Hand Hygiene is indicated before and after direct contact with residents and before handling medications. <BR/>Hand Hygiene is indicated after handling contaminated equipment.<BR/>A record review of the facility's undated policy titled, 9. Medication and Preparation Administration-9.2 Preparation of Medication reflected the person administering medications adheres to good hand hygiene, which includes washing or sanitizing hands:<BR/>Before beginning a medication pass.<BR/>Prior to handling any medication.<BR/>After coming into direct contact with a resident.<BR/>When returning to the medication cart or preparation area.<BR/>After each room. <BR/>A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2022 reflected the following:<BR/>Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).<BR/>Durable medical equipment is cleaned and disinfected before reuse by another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #10) reviewed for care plans.<BR/>The facility failed to include Resident #10 was receiving hospice services in the comprehensive care plan.<BR/>This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met.<BR/>Findings included:<BR/>Record review of Resident #10's face sheet dated 01/30/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: diabetes (a group of diseases that result in too much sugar in the blood), hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated).<BR/>Record review of Resident #10's admission MDS assessment dated [DATE], reflected that Resident #10 had a BIMS score of 07 which reflected the resident was severely cognitively impaired. Resident #10's admission MDS assessment reflected that the resident was receiving hospice care.<BR/>Record review of Resident #10's Physician's Orders, dated 12/05/24, reflected the resident had an order for: Admit to Hospice.<BR/>Record review of care plan dated 11/13/2024 reflected Resident #10 was not care planned for receiving hospice services. <BR/>In an observation and interview on 01/28/25 at 12:21 PM, Resident #10 stated she was doing ok. She stated staff treated her well and she had everything she needed. Resident appeared pleasantly confused and was clean and dressed appropriately with no sign of pain or distress noticed.<BR/>In an interview on 01/30/25 at 09:52 AM, the MDS nurse stated he was responsible for completing care plans. He stated there was a group of staff that were included in completing care plans as well, but he was responsible for completing the hospice care plans. He stated he had been trained to complete care plans accurately. He stated if a resident received hospice services, it should have been included in their care plan. He stated he was aware Resident #10 received hospice services, but he was not aware that Resident #10's care plan had not included hospice services. He stated he thought there could be a negative impact on resident's if they received hospice services and it was not care planned. <BR/>In an interview on 01/30/25 at 10:00 AM, the DON stated the MDS nurse was ultimately responsible for completing the care plans and he was responsible for care planning hospice services. She stated her and other staff reviewed the care plans as a group and made the MDS nurse aware if there were changes that needed to be made. She stated the MDS nurse and other staff had been trained on completing care plans accurately. She stated it was her expectation that hospice services be care planned. She stated she was aware that Resident #10 received hospice services. She stated she was not aware that Resident #10 was not care planned for hospice services, but she knew that Resident #10 should have been care planned for hospice services. She stated if hospice was not included in a resident's care plan or a care plan was completed inaccurately, it could have caused a delay in care or interventions, or certain things may or may not have happened if they were not care planned. <BR/>Review of facility policy dated 2001 (complete revision December 2016) titled Care Plans, Comprehensive Person-Centered revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; d. At least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control.<BR/>The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. <BR/>This failure could place residents at risk for development of communicable diseases and infections. <BR/>Findings included: <BR/>Record review of Resident #17's undated face sheet, reflected she was an [AGE] year-old female admitted [DATE] with diagnoses of Encephalopathy (brain disfunction), Acute Respiratory Failure, Diabetes, Pneumonia, Anxiety, and Major Depressive Disorder. <BR/>Record review of Resident #17's Quarterly MDS assessment dated Dec. 25, 2024, reflected a BIMS score of 06, which indicated the resident's cognitive ability was severely impaired. <BR/>Record review of Resident #17's Care Plan, reflected a Focus area was initiated for Acute Infection on 11/21/24 with a goal for the infection to resolve without complications.<BR/>Record review of Resident #44's undated face sheet, reflected she was a [AGE] year-old female admitted [DATE] with diagnoses of Dementia, Depression, High Blood Pressure, and a Personal History of Urinary Tract Infections. <BR/>Record review of Resident #44's Quarterly MDS assessment dated Dec. 24, 2024, reflected a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. <BR/>Record review of Resident #44's Care Plan, reflected a Focus area was initiated for Resident is at risk for infection-Covid 19 with a goal to not exhibit signs and symptoms of Covid-19. <BR/>Observation on 1/29/25 at 9:03 a.m., revealed MA removed a blood pressure cuff from the top of the medication cart and entered the resident's room to take the blood pressure of Resident #17. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #17 in the resident's room. She returned to the medication cart and moved to the next resident without performing hand hygiene or cleaning the blood pressure cuff. <BR/>Observation on 1/29/25 at 9:15 a.m., revealed MA removed the un-sanitized blood pressure cuff from the top of the medication cart and proceeded to take the blood pressure of Resident #44. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #44 in the resident's room. She returned to the medication cart and moved the cart back to the nurse's station where she left it. The blood pressure cuff was left on top of the first medication cart and was never sanitized. Hand hygiene was not done until MA moved to a different cart, where she performed hand hygiene before starting on the new cart. <BR/>In an interview on 01/29/25 09:44 a.m., MA stated she forget the hand hygiene between Resident #17 and Resident #44 but does not know why. She stated that she did not clean the blood pressure cuff between residents. She stated she usually keeps the hand sanitizer near her on the cart and does do it. She stated it was important to do hand hygiene and clean the cuff to avoid spreading infections from resident to resident. She stated that the negative outcome to residents if it was not done, was they could develop infections and get sick. <BR/>In an interview on 1/30/25 at 9:54 a.m., the DON stated, the policy for hand hygiene during medication administration was to clean hands before and after each resident and as needed.<BR/>She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this is important for infection control and to not spread germs between residents which could give a resident an infection and make them sick. She said it was the responsibility of the DON, the Scheduler, and the ADON to train staff on this when staff is hired and at yearly competencies. <BR/>In an interview on 1/30/25 at 10:28 a.m., RN, she stated the policy for hand hygiene on medication administration was to sanitize hands before and after each resident and as needed.<BR/>She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this was important for minimize risk of spreading bacteria to other residents and causing cross contamination. She stated if this was not done, residents could get infections and become sick. She stated it was the responsibility of the DON, ADON and nurse management to train staff on this. <BR/>In an interview on 1/30/25 at 10:38 a.m., the ADM stated the policy for hand hygiene on medication administration was to clean hands before and after each resident. He stated the policy on cleaning equipment like blood pressure cuffs was to clean between residents. He stated this is important for infection control and to prevent giving a resident an infection which could make them sick. He stated it is the responsibility of the DON and ADM to train staff on this.<BR/>A record review of the facility policy titled, Handwashing/Hand Hygiene 2001 Med-Pass, Inc with a last revision date of 2019 reflected the following: <BR/>The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. <BR/>Hand Hygiene is indicated before and after direct contact with residents and before handling medications. <BR/>Hand Hygiene is indicated after handling contaminated equipment.<BR/>A record review of the facility's undated policy titled, 9. Medication and Preparation Administration-9.2 Preparation of Medication reflected the person administering medications adheres to good hand hygiene, which includes washing or sanitizing hands:<BR/>Before beginning a medication pass.<BR/>Prior to handling any medication.<BR/>After coming into direct contact with a resident.<BR/>When returning to the medication cart or preparation area.<BR/>After each room. <BR/>A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2022 reflected the following:<BR/>Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).<BR/>Durable medical equipment is cleaned and disinfected before reuse by another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and neglect.<BR/>On 7/5/2023 at 9:00pm, CNA A attempted to transfer Resident # 1 from her wheelchair to her bed using a mechanical lift. CNA A attempted the transfer with one person, although Resident # 1 required two-person assistance. As a result, the mechanical lift fell on top of Resident # 1 and the cross bar struck Resident # 1 in head causing a bump, soreness, headache causing injury to her head in which she had to take medication. <BR/>An (IJ) Immediate Jeopardy was identified on 7/28/2023 at 6:45pm. While the (IJ) Immediate Jeopardy was removed on 7/30/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed all residents who require the use of a mechanical lift at risk to be neglected. <BR/>Findings included: <BR/>Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain), WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and body mass index of 50.0-59.9.<BR/>Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. <BR/>Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. <BR/>In an interview on 7/28/2023 at 3:00pm with Resident # 1 stated on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated she asked CNA A where the other staff was to assist him, she stated CNA A responded, don't worry he was going to do it himself and that he didn't have anyone to help him at the time. Resident # 1 stated she didn't think that CNA A knew what he was doing. Resident # 1 stated when she was up in the sling, that CNA A went to the opposite side of the bed leaning across the bed to pull her from the sling onto the bed. She stated once he pulled her, she went down on the bed and the mechanical lift came down on top of her on the bed. Resident # 1 stated when the mechanical lift fell over the grab bar struck her in her head causing her head to hurt. <BR/>In an interview on 7/28/2023 at 1:34pm with NP, revealed Resident # 1 had a faint bruise to the right side of her forehead. NP stated the incident occurred on 7/5/2023, she stated Resident # 1 reported that CNA A was trying to transfer her using the mechanical lift and the lift fell on top of her. The NP stated Resident # 1 stated she was hit in the head with the bar from the mechanical lift causing her head to hurt. She stated she assessed Resident #1 on 7/6/2023. The NP stated Resident #1 complained of a headache and soreness to the touch she stated she prescribed Tylenol. NP stated Resident # 1 was agreeable to take the tylenol and rest, as Resident # 1 stated she did not want to participate in therapy due to her head hurting. <BR/>In an interview on 7/28/2023 at 3:49pm with the DON, revealed Resident # 1required a mechanical lift and that Resident # 1 was a two-person assist. The DON stated staff have access to PCC (Point Click Care) system in which staff could review to know what the care needs were for the residents. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. <BR/>In an interview with the ADM on 7/28/2023 at 4:43pm, revealed Resident # 1 was hit on the is of her face by one of the arms from the mechanical lift. The ADM stated the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care system for the resident's care needs. The ADM reported that the staff was agency staff and that he advised that the staff could not return to the facility. <BR/>Review of progress notes reflected no incident report completed of the incident. <BR/>Policies reviewed:<BR/>Review of facility policy Resident rights dated Dec. 2016 reflect the following: <BR/>Residents have to right to be free from neglect<BR/>This was determined to be an (IJ) Immediate Jeopardy (IJ) on 7/28/2023 at 6:45pm. The ADM was notified. The ADM was provided with the IJ template on 7/28/2023 at 6:45PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 7/29/2023 at 6:22PM <BR/>Plan of Removal: Immediate Jeopardy <BR/>The notification of Immediate Threat states as follows:<BR/>F600 The facility failed to ensure that the resident was free from neglect. <BR/>Statement of Deficient Practice:<BR/>All residents who require a Mechanical lift could be at risk of harm and injury from neglect. <BR/>Action Item 1<BR/>Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff<BR/>Target date: 7/31/2023<BR/>Action Item 2<BR/>Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee<BR/>Target date: 7/28/23<BR/>Action Item 3<BR/>Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee<BR/>Target date: 7/28/2023<BR/>Action Item 4<BR/>All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23.<BR/>Target date: 7/28/2023<BR/>Action Item 5<BR/>All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance<BR/> Target date: 7/28/2023<BR/>Action Item 6<BR/>Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant <BR/>Target date: 7/28/2023<BR/>Action Item 7<BR/>Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations<BR/>Target date: 7/28/2023<BR/>Action Item 8 <BR/>Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care [NAME] to identify resident needs. DON or designee<BR/>Target date: 7/29/2023<BR/>Action Item 9<BR/>Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee<BR/>Target date 7/31/2023<BR/>Action Item 10<BR/>Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee.<BR/>Target date: 7/31/2023<BR/>Action Item 11<BR/>The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator<BR/>Target date: 7/31/2023<BR/>Monitoring: 7/30/2023<BR/>Observation on 7/30/2023 at 11:00am, observed CNA D and CNA F complete a resident transfer using the mechanical lift. Staff were observed using appropriate hand hygiene, staff observed talking with Resident # 2 and explaining the process as they started. CNA D and CNA F were able to complete a successful transfer from the bed to the wheelchair. <BR/>Observation on 7/30/2023 at 11:30am, observed CNA C and CNA G completed a transfer for a Resident # 3 from her wheelchair into her bed. Staff were able to complete the transfer successfully, Resident # 3 stated she felt safe. <BR/>Interview on 7/30/2023 at 11:50am with CNA D, revealed she worked the 6am to 6pm shift, she stated she was facility staff not agency. She had been trained on how to use the mechanical lift and abuse/neglect she stated she used the [NAME] in PCC to see what the care needs are for residents. CNA D was able to explain the process of how to use the mechanical lift. <BR/>Interview on 7/30/2023 at 11:55am with CNA G, revealed she was agency staff, she stated she had been trained on how to use the mechanical lift safely and abuse/neglect She reported she had also been trained on how to access the PCC system to review the care needs for each resident. <BR/>Interview on 7/30/2023 at 12:00pm with CNA F, revealed she worked through a (staffing agency) she stated it was her second day at the facility. CNA F stated she had been in-serviced on how to use the mechanical lift safely, abuse/neglect, and how to access PCC for resident's care needs. <BR/>Interview on 7/30/2023 at 2:30pm with Resident # 2 revealed, she was doing fine and stated she felt safe at the facility. <BR/>Interview on 7/30/2023 at 3:00pm with Resident # 3 revealed, he felt safe at facility. <BR/>Record review on 7/30/2023 of in-services on abuse/neglect, Mechanical lift competency checklist dated 7/29/2023 reflected 20 staff had completed the training. <BR/>The ADM was informed the Immediate Jeopardy was removed on 7/30/2023 at 5:00PM. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records.<BR/>The facility failed to ensure LVN C documented any follow-up observations or assessments of Resident #2 after she initiated treatments for his uncontrolled coughing.<BR/>This failure could result in errors in care and treatment.<BR/>Findings included:<BR/>Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), disturbances of salivary secretion, and unspecified dementia.<BR/>Review of Resident #2's quarterly MDS assessment, dated 11/25/24, reflected a BIMS score of 7, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected he did not receive tracheostomy care.<BR/>Review of Resident #2's quarterly care plan, dated 09/27/24, reflected he had a tracheostomy stoma with an intervention of covering the trach with dry gauze and securing with tape. <BR/>Review of Resident #2's progress notes, dated 12/14/24 at 1:32 PM and documented by LVN C, reflected the following:<BR/>At about 9:29 am this writer was notified by [Resident #2]'s roommate that [Resident #2] is coughing. Upon assessment [Resident #2] seen coughing none [sic] stop, form [sic] like secretion coming out of his trach. Vital signs taken T 97.9, O2 97, P 134. BP 131/74. [Resident #2] C/O of dizziness and tiredness. NP on call called 9:29 am, called back 9:30 am, she ordered stat guanfacine 20mls. Stated should cont to suction and monitor the resident, PRN Levalbuterol HCl Inhalation Nebulization Solution, was given. Med was mild effective, [Resident #2] continue to cough with secretions from his trach and pulse rate still on [sic] 120's, [Resident #2] looks weak, NP notified again on the res condition @ 12:20 pm, called back at 12:23 pm ordered to send [Resident #2] to emergency room for further evaluation .<BR/>During a telephone interview on 12/16/24 at 1:59 with, LVN C stated she worked with Resident #2 on the morning of 12/14/24. She stated he was coughing non-stop, having secretions from his stoma that were foam-like, and was in respiratory distress. She stated she contacted the NP on-call (NP D) and she provided her with orders for a nebulizer treatment, suctioning of his stoma, continuing to monitor him, and calling her back if his oxygen levels dropped. She stated the suctioning helped with the secretions and saw an improvement with his condition with the nebulizer treatment. She stated he was not in respiratory distress and his cough had subsided. She stated approximately three hours later, she noticed Resident #2 looked more tired and was complaining of feeling dizzy. She stated his heart rate was elevated and he did not look normal. She stated she then contacted NP D again who gave her orders to send him to the ER. She stated she was not sure why she had not documented that his condition had changed but remembered she had written it as one note in his progress notes.<BR/>During an interview on 12/16/24 at 3:00 PM, the DON stated she remembered getting called by LVN C regarding Resident #2's condition on 12/14/24. She stated she had communicated to her about his improving condition and then when his condition worsened again, she sent him to the ER. She stated she would expect for all of the times she assessed Resident #2 to be documented in his progress notes to ensure he was receiving timely and appropriate care.<BR/>During an interview on 12/19/24 at 10:18 AM, Resident #2 stated on the morning of 12/14/24 he could not stop coughing and that was why he was sent to the hospital. He stated the nurse had given him a breathing treatment and he was taken good care of. He stated the nurse did what she was supposed to do, and she did not wait too long to send him to the hospital.<BR/>Interviews with NP D were attempted on 12/16/24 and 12/19/24. A returned call was not received prior to exiting. <BR/>Review of the facility's Change of Condition Policy, dated 2003, reflected when to notify the NP of a resident's change in condition. It did not have anything related to nursing documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #1) of 5 residents reviewed for informed consent for treatment options.<BR/>The facility failed to:<BR/>1. obtain a signed informed consent for the use of Seroquel for Resident #1 by her MPOA<BR/>2. obtain a signed informed consent for the use of ABH gel for Resident #1 by her MPOA <BR/>This failure could affect all residents by placing them at risk of receiving psychotropic medications without informed consent which could cause decrease quality of life and increase the risk of injury and violate the rights of residents to make informed decisions related to care.<BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM.<BR/>Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis .<BR/>In an interview on 02/10/24 at 2:00 pm with FAM, she stated that she was told the doctor wanted to start Resident #1 on Seroquel, but FAM wanted to research the medication before signing consent. She stated she never signed consent for the use of Seroquel for Resident #1. She also stated she never consented to use of ABH gel (Ativan, Benadryl, Haldol). <BR/>In an interview on 02/11/24 at 2:45 pm with MD she stated that she had a duty to treat Resident #1 and had verbal consent for the use of seroquel by FAM and the medication was put on hold when the consent was not signed after several days.<BR/>Record review of Resident #1's Orders revealed an order for QUEtiapine Fumarate (Seroquel) Tablet 25 MG Give 0.5 tablet<BR/>by mouth at bedtime for behavioral disturbance; the order was started 01/29/24 at 8:00 pm. Further review revealed an order for Lorazepam-Diphenhydramine-Haloperidol mg (ABH Gel); Apply to skin topically every 2 hours as needed for agitation for 14 Days, order started 01/15/24.<BR/>Record review of Resident #1's MAR, January/February of 2024, revealed she was administered Seroquel on the following dates;<BR/>1/29/24<BR/>1/30/24<BR/>1/31/24<BR/>2/1/24<BR/>2/2/24<BR/>2/3/24<BR/>2/4/24<BR/>Further review revealed the medication was marked as on hold starting 02/05/24.<BR/>Further review of Resident #1's MAR, January of 2024, revealed she was administered ABH gel on the following dates:<BR/>01/15/24<BR/>01/17/24<BR/>01/18/24 (x2)<BR/>01/19/24<BR/>01/20/24<BR/>01/21/24 (x2)<BR/>Record review of Resident #1's progress notes revealed a note by the MD on 01/29/24 at 4:26 pm that reflected that FAM was agreeable to start quetiapine (Seroquel). A progress note dated 02/05/24 at 8:47 am stated that FAM had not signed consent so medication was not given.<BR/>Record review revealed a consent for Seroquel that was not signed by FAM.<BR/>Record review revealed no signed consent for ABH gel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #1) of 5 residents reviewed for psychotropic drug use.<BR/>The facility failed to:<BR/>1. ensure Resident #1 was prescribed Seroquel and ABH gel for a specific diagnosis and instead prescribed it for behavioral disturbance at bedtime<BR/>This failure could affect all residents by placing them at risk of receiving psychotropic medications without a specific diagnosis and rather being prescribed psychotropic medication for behavior; this could cause decrease quality of life and increase the risk of injury.<BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM.<BR/>Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis .<BR/>In an interview on 02/10/24 at 2:00 pm with FAM, she stated that she was told the doctor wanted to start Resident #1 on Seroquel, but FAM wanted to research the medication before the Seroquel was administered to Resident #1. <BR/>In an interview on 02/11/24 at 2:45 pm with MD stated she had a duty to treat Resident #1's behaviors while awaiting signed consent from FAM.<BR/>Record review of Resident #1's Orders revealed an order for QUEtiapine Fumarate (Seroquel) Tablet 25 MG Give 0.5 tablet<BR/>by mouth at bedtime for behavioral disturbance; the order was started 01/29/24 at 8:00 pm. Further review revealed an order for Lorazepam-Diphenhydramine-Haloperidol mg (ABH Gel); Apply to skin topically every 2 hours as needed for agitation for 14 Days, order started 01/15/24.<BR/>Record review of Resident #1's MAR, January/February of 2024, revealed she was administered Seroquel on the following dates;<BR/>1/29/24<BR/>1/30/24<BR/>1/31/24<BR/>2/1/24<BR/>2/2/24<BR/>2/3/24<BR/>2/4/24<BR/>Further review revealed the medication was marked as on hold starting 02/05/24.<BR/>Further review of Resident #1's MAR, January of 2024, revealed she was administered ABH gel on the following dates:<BR/>01/15/24<BR/>01/17/24<BR/>01/18/24 (x2)<BR/>01/19/24<BR/>01/20/24<BR/>01/21/24 (x2)<BR/>Record review of Resident #1's diagnoses list, on 02/10/24, revealed no diagnosis of psychosis, schizophrenia nor bipolar disorder, and her only mental health diagnoses were anxiety, depression, and insomnia (she also has a diagnosis of dementia).<BR/>Record review of Resident #1's progress notes revealed a note by the MD on 01/29/24 at 4:26 pm that reflected that FAM was agreeable to start quetiapine (Seroquel). A progress note dated 02/05/24 at 8:47 am stated that FAM had not signed consent so medication was not given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1(Resident # 1) of 7 residents reviewed for accidents and supervision.<BR/>Staff attempted to use the mechanical lift to transfer Resident # 1 from her wheelchair to her bed with one person. As a result, the mechanical lift fell on top of Resident # 1, causing injury and pain to her head in which she was prescribed medication for the pain.<BR/>This failure placed all residents who require the use of a mechanical lift at risk for accidents, harm, and injuries.<BR/>An (IJ) Immediate Jeopardy was identified on 7/31/2023 at 1:35pm. While the (IJ) Immediate Jeopardy was removed on 7/31/2023 at 5:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, mechanical lifts and the effectiveness of their systems.<BR/>Findings included: <BR/>Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain)., WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and BODY MASS INDEX [BMI] 50.0-59.9,<BR/>In an interview on 7/28/2023 at 3:00pm with Resident # 1 revealed on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated the CNA A did not know how to appropriately use the mechanical lift or he would have known that he needed another person to safely operate the machine. Resident # 1 stated CNA A went to the other side of the bed and attempted to pull her from the mechanical lift onto the bed. She stated she fell on the bed and the mechanical lift fell on top of her, and the grab bar from the lift hit her in the head. Resident # 1 stated she had a headache, and her head was sore in the spot where the bar struck her in her head. She stated she was prescribed Tylenol for her pain. <BR/>Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. <BR/>Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. <BR/>In an interview on 7/28/2023 at 5:42pm with CNA C, revealed she recently started working at the facility. She stated she had not been trained on how to use the mechanical lift at this facility. Stated if they needed to transfer a resident using the mechanical lift stated they would get another person to assist with the transfer while using the lift. <BR/>In an interview on 7/28/203 at 6:09pm with CNA B revealed she was agency staff. She stated the facility had not trained her on how to properly use the mechanical lift. However, stated whenever they needed to do a list using the mechanical lift, they needed two people to use the lift. <BR/>In an interview on 7/28/2023 at 3:49pm with the DON, revealed she could not find any of her in-services for the month of July. The DON stated she thought she did a training on mechanical lifts. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. <BR/>In an interview on 7/28/2023 at 4:43pm with the ADM, he revealed the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care for the resident's care needs. The ADM stated it was the DON's responsibility for the care staff to be trained, however reported that agency staff have to be trained and worked as a CNA for a year before being able to work for the agency. He stated they had completed trainings through the agency but was not able to indicate if this training had been completed. <BR/>Record review of MDS reflected there are 14 other residents that require the of a mechanical lift. <BR/>Review of progress notes reflected no incident report completed of the incident. <BR/>Policies reviewed:<BR/>Review of facility policy Resident rights dated Dec. 2016 reflect the following: <BR/>Residents have to right to be free from neglect<BR/>The facility does not have a Mechanical Lift policy<BR/>This was determined to be an Immediate Jeopardy on 7/31/2023 at 1:35-m. The ADM was notified. The ADM was provided with the IJ template on 7/31/2023 at 1:35pm. <BR/>The following Plan of Removal submitted by the facility was accepted on 7/31/2023 at 5:30pm.<BR/>Plan of Removal: Immediate Jeopardy<BR/>The notification of Immediate Threat states as follows:<BR/>F689 The facility failed to ensure that the resident that the resident received adequate supervision and assistive devices to prevent accidents.<BR/>Statement of Deficient Practice:<BR/>All residents who require a Mechanical lift could be at risk of harm and injury from incidents and accidents<BR/>Action Item 1<BR/>Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff<BR/> Target date: 7/28/2023<BR/>Action Item 2<BR/>Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee<BR/>Target date: 7/28/23<BR/>Action Item 3<BR/>Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee<BR/> Target date: 7/28/2023<BR/>Action Item 4<BR/>All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23.<BR/>Target date: 7/28/2023<BR/>Action Item 5<BR/>All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance<BR/> Target date: 7/28/2023<BR/>Action Item 6<BR/>Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant <BR/> Target date: 7/28/2023<BR/>Action Item 7<BR/>Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations<BR/> Target date: 7/28/2023<BR/>Action Item 8 <BR/>Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care [NAME] to identify resident needs. DON or designee<BR/> Target date: 7/29/2023<BR/>Action Item 9<BR/>Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee<BR/>Target date 7/31/2023<BR/>Action Item 10<BR/>Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee.<BR/>Target date: 7/31/2023<BR/>Action Item 11<BR/>The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator<BR/>Target date: 7/31/2023<BR/>Plan of removal monitoring 7/31/2023<BR/>An interview on 7/31/2023 at 5:09pm with the ADON, revealed she has been trained on abuse/ neglect, resident rights, safe transfer of residents using the mechanical lift. The ADON stated the abuse/neglect coordinator is the ADM. She was able to discuss the procedures if she see or suspect abuse/neglect. The ADON stated she had never seen or suspected abuse/neglect at this facility. She stated she had completed the competency check on how to use the mechanical lift. She was able to discuss the process of using the mechanical lift. Stated she has been able to discuss the process for reporting accidents/ incidents and assessment of the resident. <BR/>An interview on 7/31/2023 at 5:20pm with RN, revealed she had been trained on how to use the [NAME] lift, abuse/neglect, resident rights, incident and accident reports and reporting. She was able to discuss the process for reporting abuse/neglect stated the abuse/neglect coordinator is the administrator. RN was able to discuss the process and steps of using the mechanical lift. The RN was able to discuss the process for reporting incidents and accidents. Stated all incidents and accidents should be reported and documented immediately. She stated she had never seen or suspected abuse /neglect at this facility.<BR/>An interview on 7/31/2023 at 5:29pm with CNA D, revealed she worked 6pm-6am and had been in-serviced on abuse/neglect, resident rights, incidents/accidents of residents and the mechanical lift. She was the process for reporting abuse /neglect is the ensure that the resident is safe and alert a nurse to assess the resident for further injuries. Stated the administrator is the abuse/neglect coordinator stated she has never seen or suspected abuse /neglect at this facility. Staff reported the nurse complete the incident reports and they write statement of what they saw. Staff was able to discuss process in using the [NAME] lift with a resident. CNA D stated she completed the competency skills test to use the mechanical lift.<BR/>An interview on 7/31/2023 at 5:51pm with CNA E, revealed she worked 6am to 6pm shift. Stated she had been in-serviced on abuse/neglect, resident rights, incident and accidents reports, and how to operate the mechanical lift. <BR/>Record review of in-services on the following dated: 7/31/2023<BR/>Abuse/Neglect - 75%of staff and ongoing <BR/>Resident Rights - 75% staff have been in-serviced and ongoing <BR/>Incidents/Accidents- 75% staff have been in-serviced and ongoing <BR/>An (IJ) Immediate Jeopardy was identified on 7/331/2023 at 1:35pm. While the (IJ) Immediate Jeopardy was removed on 7/31/2023 at 5:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy identified because all staff had not been trained on Abuse/Neglect, resident rights, mechanical lifts and the effectiveness of their systems.<BR/>The ADM was advised that the (IJ) Immediate Jeopardy was lifted on 7/31/2023 at 5:45pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 4 of 4 residents (Residents #2, 7, 22, and 39).<BR/>The facility failed to provide Residents #2, 7, 22, and 39 with their physician ordered therapeutic diets that included fortified foods, Cardiac diet, and 2GM Sodium for the noon and evening meals on 12/12/23 and the noon meal on 12/13/23.<BR/>This failure could place residents at risk for hunger, weight loss, and chemical imbalances. <BR/>The findings included:<BR/>Resident #2 <BR/>Record review of the current care plan dated 12/13/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Repeated Falls, Dysphagia- Oral Phase (swallowing disorder) and Moderate Protein-Calorie Malnutrition (malnutrition). <BR/>Record review of the Significant Change MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of two indicating severe cognitive impairment. Further record review revealed the resident had no documented oral, dental, or swallowing issues. The resident had an active diagnosis of malnutrition. There was no documented weight loss or gain.<BR/>Record review of the current undated care plan for Resident #2 revealed a Problem of (Resident #2) is at risk for alteration in nutrition related to impaired cognition/disease process dementia, disease process GERD, dysphagia, low BMI, dietary restrictions Date Initiated: 02/09/2022. Revision on: 12/15/2022. Interventions listed were, . House Supplement 2.0 four times a day Give 120mL four times a day between meals Date Initiated: 12/15/2022. Ice cream TID // fortified foods TID Date Initiated: 12/15/2022 . Provide and serve diet as ordered. Monitor intake and record every meal. Receives Regular diet Dysphagia Puree texture, Regular consistency Date Initiated: 12/15/2022. Revision on: 12/15/2022 .<BR/>Record review of the Nutritional Risk Assessment V2 for Resident #2 dated 9/18/23 revealed the following, .C. Identification of Risk Indicators. 1. Rate of unplanned Weight Gain/Loss. stable . 2. Current Food and Fluid Intake. 25-100%, variable dependence at meals. 3. Relevant Labs. no new labs . 6. Chewing/Swallowing Difficulties . on puree - dysphagia noted . 8. Current Diet Orders .reg/puree/reg . D. Estimated Needs .5. Nutrition summary and interventions for plan of care: Resident annual assessment. BMI 16 - underweight. Resident on hospice - some decline in weight/appetite may be unavoidable due to progression. Resident likely not meeting estimated needs with oral intake at this time and underweight. Recommend continue to offer and encourage oral intake as appropriate. Goal to maintain resident comfort and honor goals of care while on hospice. RD to continue to monitor and follow up as needed .<BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Regular diet Pureed texture, Regular consistency, Ice cream TID (3 times a day) // fortified foods TID, Active 01/18/2023 . <BR/>Record review of the tray card for Resident #2 dated 12/12/23 (lunch - day 3) revealed that the resident was documented as being on a regular pur&eacute;e diet with foods listed as: Pur&eacute;ed beef enchilada with chili sauce, pur&eacute;ed cilantro lime rice, pur&eacute;ed charro beans. Notes: ice cream; fortified foods .<BR/>Observation on 12/12/23 at 11:44 AM Resident #2 was served a pur&eacute;e diet and it was also noted that the beans were flat on the plate. The pur&eacute;ed beans were a #8 scoop, pur&eacute;ed rice was a #10 scoop, pur&eacute;ed enchiladas were a #10 scoop, and they had a course or chunky appearance. No foods were identified as fortified.<BR/>On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the probable reason for Resident #2's diet was due to swallowing issues and to maintain weight. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. <BR/>Resident #7 <BR/>Record review of the current care plan dated 12/13/23 for male Resident #7 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Lymphedema, Not Elsewhere Classified (fluid buildup in lymph system), Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing (Femur Fracture), Weakness, and Age-Related Physical Debility. <BR/>Record review of the admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 12 indicating he was moderately cognitively impaired. Further record review revealed the resident was on a therapeutic diet. The resident had an active diagnosis of a hip fracture.<BR/>Record review of the current undated care plan for Resident #7 revealed no specific care plan related to nutrition or diet. There was a Problem addressed that stated, .The resident has potential to skin integrity of the related to impaired mobility. Date Initiated: 10/04/2023. An Intervention listed was documented as, .Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 10/04/2023 .<BR/>Record review of the Weight Summary for Resident #7 revealed he sustained 11.8% weight loss in 1 month from 10/04/23 he was at 309.6 lbs to 11/16/23 with the weight of 273 lbs. On 12/05/23 he gained 2 pounds up to 275 lbs. <BR/>Record review of the Nutritional Risk Assessment V2 for Resident #7 dated 10/27/23 revealed the following, .5. Pressure Injury . 4) Unstageable 5. Nutrition summary and interventions for plan of care: Resident admitted post-surgery for hip fracture. Resident has unstageable breakdown to coccyx. He states that he has lost a lot of weight in past 6-8 months He states he has been eating very sparingly. PO intake potentially inadequate due to skin breakdown/increased needs. Recommend Fortified Meal Plan be added to increase kcal (calories) & pro (protein) intake. Goal healing of skin, stable wt .<BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of No Salt on Tray (NSOT) diet Regular texture, Regular consistency, fortified meal plan at all meals for Nutrition, Active 10/27/2023 .<BR/>Record review of the tray card for Resident #7 for 12/12/23 (lunch - day three) revealed the resident was on a regular, 2 g sodium diet. The menu listed, beef enchilada with chili sauce, cilantro lime rice, Charro beans . Notes: fortified foods .<BR/>Observation on 12/12/23 at 11:38 AM, Resident #7 was served #8 scoop of beans, #8 scoop of enchiladas, #8 scoop of rice, and a regular cinnamon apple dessert. No foods were identified as fortified. <BR/>Review of the tray card for Resident #7, dated 12/12/23 (supper - day three) revealed the resident was on a regular 2 g sodium diet. The menu listed: cream of tomato soup, grilled cheese sandwich, marinated vegetable salad. Notes: fortified foods.<BR/>Observation on 12/12/23 at 4:32 PM, Resident #7 was served a grilled cheese, mixed vegetable salad, and regular tomato soup. No foods were identified as fortified.<BR/>On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the reason for Resident #7's diet was the resident was possibly at risk for weight loss. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. <BR/>Resident #22 <BR/>Record review of the current care plan dated for female Resident #22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Unspecified Protein-Calorie Malnutrition (Malnutrition), Heart Failure, Unspecified, Encounter for Palliative Care, Essential (Primary) Hypertension (high blood pressure), and Pressure Ulcer of Sacral Region, Stage 3 (pressure ulcer - tissue injury). <BR/>Record review of the annual MDS assessment for Resident #22 dated 11/22/23 revealed that the resident had a BIMS score of 13 indicating the resident was cognitively intact. The resident had documented active diagnoses of hypertension, malnutrition, and heart failure. There was no documented weight loss or weight gain.<BR/>Record review of the current undated care plan for Resident #22 revealed a Problem of the resident has cardiac disease related to Heart Failure. Date Initiated: 08/26/2023. Revision on: 09/24/2023. No interventions were listed related to nutrition or diet. There was an intervention listed related to a care plan for the resident's diabetes mellitus that stated, .Encourage . compliance with dietary restrictions .Date Initiated: 09/24/2023 . <BR/>Record review of the Nutritional Risk Assessment V2 for Resident #22 dated 9/18/23 revealed the following, C. Identification of Risk Indicators. 1. Rate of unplanned Weight Gain/Loss. -4% (loss) in 30 days, +11% (gain) in 90 days, stable in 180 (days), diuretic .8. Current Diet Orders. 2g NA/mech soft/reg .5. Nutrition summary and interventions for plan of care: Resident readmit after hospitalization for sepsis pneumonia (infection). Edema noted 09/14. Diuretic (water pill) noted - fluid shifts may impact weight trends <BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of 2g Na Diet, diet Mechanical Soft texture, Regular consistency, for Heart Failure, Active 08/25/2023 . The diet was updated 12/12/23 at 12:27 PM to 2g Na Diet Regular texture, Regular consistency, for diet please include broth with each meal .<BR/>Review of the tray card for Resident #22 dated 12/12/23 (lunch-day 3) revealed the resident was on a regular, 2 g sodium diet with menu foods listed as: chop beef enchilada with chili sauce, cilantro lime rice with salsa, Charro beans. Note: need assistance with meals. <BR/>Observation on 12/12/23 at 11:55 AM revealed Resident #22, who was on a 2 g sodium diet, received a #8 scoop of rice, #8 scoop of beans, and a #8 scoop of enchiladas. No defined 2gm sodium menu foods.<BR/>Record review of their tray card for Resident #22dated 12/12/23 (supper-day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: Cream of tomato soup, grilled cheese sandwich, soft cooked broccoli. Notes: needs assistant with meals .<BR/>Observation on 12/12/23 at 4:44 PM revealed Resident #22 received broccoli, regular tomato soup, grilled cheese sandwich, and a brownie. The resident did not receive any broth. No identified 2gm sodium menu foods.<BR/>On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the reason for Resident #22's diet could be for sodium reduction due to blood pressure and cardiac issues. She added the broth could be for an upset stomach. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. <BR/>Resident #39 <BR/>Record review of the current care plan dated for female Resident #39 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Alzheimer's Disease, Unspecified(dementia), Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris (heart disease), Presence of Cardiac Pacemaker (heart rhythm regulating device), and Unspecified Protein-Calorie Malnutrition (Malnutrition). <BR/>Record review of the quarterly MDS assessment for Resident #39 dated 11/3/23 revealed that the resident had a BIMS score of 6 indicating that she had severe cognitive impairment. Active diagnosis listed was Alzheimer's disease, coronary artery disease, hypertension, and malnutrition. There was no documentation of known weight loss or weight gain.<BR/>Record review of the current undated care plan for Resident #39 revealed a Problem of The resident has potential nutritional problem. r/t poor intake and impaired cognition as evidence by diagnosis of protein calories malnutrition Date Initiated: 04/24/2023. Revision on: 05/24/2023. Interventions listed were, Provide and serve diet as ordered. Date Initiated: 05/24/2023. Provide and serve supplements as ordered. Date Initiated: 05/24/2023. Revision on: 05/24/2023. Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 05/24/2023 .<BR/>Record review of the Nutritional Risk Assessment V2 for Resident #39 dated 4/22/23 revealed the following, 8. Current Diet Orders. cardiac, reg, thin liquids . 5. Nutrition summary and interventions for plan of care: Resident recently admitted . Able to feed self primarily, varied intake of meals <BR/>Record review of the Weight summary for Resident #39 revealed her weight was stable at 171lbs.<BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Cardiac diet Regular texture, Regular consistency. Active 04/11/2023 . ensure or boost supplement with each meal with meals for malnutrition, Active 05/04/2023 .<BR/>Record review of the tray card for Resident #39 dated 12/12/23 (lunch - day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: beef enchilada with chili sauce, cilantro lime rice, Charro beans. Notes: house shake. <BR/>Observation on 12/12/23 at 11:34 AM revealed Resident #39 was served a #8 scoop of rice, #8 scoop of regular beans, #8 scoop of enchiladas, and a cinnamon apple dessert. No health shakes were observed served.<BR/>Review of the tray card for Resident #39, dated 12/12/23 (supper - day three) revealed the resident was documented as being on a regular 2 g sodium diet with menu foods listed as: cream of tomato soup, grilled cheese sandwich, marinated vegetable salad. Notes: house shake.<BR/>Observation on 12/12/23 at 4:31 PM revealed Resident #39 was served regular tomato soup, mixed vegetable salad, and a grilled cheese. No health shakes were observed served.<BR/>On 12/14/23 at 11:56 AM an interview was conducted with the DON regarding resident diets. She stated the probable reason for Resident #39's diet was due to her increased walking activity as a dementia resident and needing additional calories from a supplemental drink. She stated by residents not receiving their therapeutic diet, it could affect them depending on the diagnosis and the reason for the diet. <BR/>Observation on 12/12/23 at 11:20 AM revealed Dietary staff A served and took temperatures of the noon meal foods on the service line. No foods were identified as fortified. No health shakes were observed served during the meal.<BR/>On 12/12/23 at 4:15 PM a kitchen observation and interview were conducted. Observation of the service line at this time revealed temperatures were taken, and foods were served by Dietary staff D on the steam table. No foods were identified as fortified. No health shakes were observed served during the meal.<BR/>On 12/12/23 at 4:47 PM an interview was conducted with Dietary staff D regarding what she used to make the foods she served. She stated:<BR/>Mixed vegetable salad included vegetable blend and Italian dressing.<BR/>Tomato soup was canned regular Tomato Soup. <BR/>Record review of the Diet Spreadsheet, Menu . Week 1, Day: 3 - Tuesday lunch and supper revealed that there was no menu guidance listed for Cardiac diets and 2gm Na (sodium) diets.<BR/>Further documentation on the Diet Spreadsheet for Week 1 Day: 3 Tuesday revealed the following, Fortified enhanced foods: follow the consistency diet ordered and offer a minimum of one fortified food item per meal, unless otherwise directed. <BR/>On 12/13/23 at 3:35 PM an interview was conducted with Dietary staff A regarding fortified foods for the meals she prepared. She stated, I think pudding is just fortified. She identified no other food options as being fortified.<BR/>On 12/13/23 at 3:36 PM an interview was conducted with the Dietary Manager regarding therapeutic diets. He stated mashed potatoes were fortified usually. He added Dietary staff A did not make fortified foods for the noon meal on 12/12/23. He stated the fortified tomato soup was made with milk on the evening meal of 12/12/23. He stated there was a small amount of fortified mashed potatoes in a bin for the noon meal on 12/13/23. He stated, the facility ran out of shakes yesterday (12/12/23) at the noon and evening meal and none were served. He added he thought someone was taking the shakes. He also stated he did not know that Resident #22 needed broth with her meal. He stated there were issues with diet communication and at times he was not made aware of resident dietary changes in a timely manner from nursing. He further stated that the tray card and diet software had a limited amount of options regarding orders. He added that the Cardiac diet is 2 gm sodium or no added salt diet. He stated he had no other choices in the dietary department software that documents orders. He stated, regarding guidance for a 2gm sodium diet, that everything he had was low sodium and all my seasonings are low sodium. He further stated, regarding diets in the dietary software, that the diets on the menus listed were what he had, and he had no other options to match the physician orders.<BR/>On 12/14/23 at 9:56 AM an interview and observation were conducted with the Dietary Manager regarding issues in the dietary department. Observation of the pantry revealed that [NAME] Tomato Soup was present. The label on the [NAME] Tomato Soup stated that it was made with tomato pur&eacute;e, seasonings, wheat flour, and no milk products. There was no Cream of Tomato soup. Regarding the 2 gm sodium diet, the Dietary Manager stated most foods and ingredients they used was low sodium. He stated he used direct monitoring of staff to ensure that therapeutic diets were served correctly. He stated he and staff were responsible for ensuring that therapeutic diets were served correctly. He stated residents could experience heart complications, weight loss which could lead to death and malnutrition if therapeutic diets were not served correctly as ordered. He added, he tried to avoid canned vegetables to reduce the sodium. Regarding how staff knew what a 2 gm sodium diet consisted of, he stated in-services. He further stated he was unsure of the last in-service on 2 gm sodium. He stated it had been a long time. He stated, Resident #22 wanted broth because the facility lost her teeth, and she could not eat other food.<BR/>On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding therapeutic diet, she stated the issues occurred due to poor planning. She added, the facility had three cases of shakes on Friday, and she found out later there were no shakes available and she got some. She stated she told the Dietary Manager to take action and follow up. She stated that the Dietary Manager was responsible for ensuring therapeutic diets were served correctly. She added residents could experience weight loss and their nutrition could be affected if they did not receive their therapeutic diet.<BR/>On 12/14/23 at 1:30 PM an interview was conducted with the Dietary Manager. He stated, the facility had no specific guidance for a Cardiac Diet. He added, We only have the choices in the system (computer). He stated the diet options included Food forms - regular, mechanical soft, and pur&eacute;es. Diets are regular, mechanical soft, pur&eacute;e, low concentrated sugar, small portion and large portion.<BR/>Record review of the facility's, Diet Roster - By Texture dated 12/12/23 revealed the following documentation:<BR/>Resident #2 - Regular (diet), pur&eacute;e (texture) diet.<BR/>Resident #7 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet.<BR/>Resident #22 - Regular (diet), 2 gm sodium (diet other), mechanical soft (texture) diet <BR/>Resident #39 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet<BR/>Record review of the facility presented Recipe Listing, Corporate Recipes for the Category of fortified foods revealed that the facility had recipes for 9 fortified foods which included, fortified cereal, fortified milk, fortified milkshake, fortified potatoes mashed, fortified pudding parfait, fortified fruit smoothie, fortified creamed soup, fortified streusel topping, and Vanilla mighty shakes.<BR/>Record review of the recipe for Fortified Soup, Creamed, (assorted), Corporate Recipe - Number: 1823 revealed that the ingredients for fortified soup, consisted of assorted creamed soup, nonfat powdered milk, and bulk sour cream. Further documentation revealed the following, Notes: .2. For pur&eacute;ed: measure out desired number of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thicker if product needs thickening.<BR/>Record review of the facility recipe titled Cream of Tomato Soup, Recipe Number: 179757 revealed that the cream of tomato soup should have included the following ingredients: water, chicken base, tomato juice, chopped garlic, dried basil leaves, ground oregano, margarine, solids and milk, and parsley flakes dried.<BR/>Record review of the facility's recipe titled Pur&eacute;ed Cream of Tomato Soup, Recipe Number: 170386 revealed that the ingredients consisted of cream of tomato soup. Further documentation revealed the following, .Note . 2. If product needs thinning, gradually add an appropriate amount of liquid. to achieve a smooth, pudding, or soft mashed potato consistency. 3. If the product needs thickening, gradually add a commercial or natural food thicker. To achieve a smooth pudding or soft mashed potato consistency . <BR/>Review of the facility policy titled, Nutrition and Foodservice Policies and Procedures Manual, 2018, Section 1-3, Policy: Menu Planning. Policy Number: 01.002, Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that nutrition is an important part of maintaining the well-being and health of its residents, and is committed to providing a menu that is well balanced, nutritious and meets the preferences of the resident population. A standardize menu which meets the nutritional recommendations of the residents, in accordance with the recommended dietary allowances of the Food and Nutrition Board of The National Research Council, National Academy of Sciences will be used. Modifications for resident population and preferences may be made as appropriate. Procedure: <BR/>1. Menus will be prepared for each facility by their food vendor. Menus are updated twice each year with the Spring - Summer and Fall - Winter cycles and updated intermittently based on resident preferences. The menus will be for a five-week cycle and will include a week at a glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide .<BR/>Record review of the Long-Term Care Diet Manual, 2017 Edition, revealed the following documentation, 2 g Sodium Diet. Indications for use: the 2 g sodium diet is provided for individuals needing a significant reduction in sodium to control blood pressure and/or fluid retention for the treatment of hypertension, chronic or congestive heart failure, renal failure, or other conditions where fluid retention is a problem . General Principles and Guidelines: <BR/>1. The 2 g sodium diet is planned using the menu components as outline in Section 2: Guidelines For Menu Planning. <BR/>2. The 2 g sodium diet is planned to provide 2000-2300 mg of sodium per day. <BR/>3. The 2 g sodium diet does not use salt at the table or on meal trays. <BR/>4. The 2 g sodium diet limits the use of very high sodium foods to the limit of 2000 mg to 2300 mg per day. <BR/>5. Recipes should be followed carefully when cooking .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and puree) for 4 residents (Residents #2, 7, 22 and 25) reviewed during mealtime.<BR/>The facility failed to ensure Residents #2, 7, 22, and 25 received their meals according to the menu.<BR/>This failure could place residents at risk for unwanted weight loss and hunger.<BR/>The findings included:<BR/>Resident #2:<BR/>Record review of the current care plan dated 12/13/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Repeated Falls, Dysphagia, Oral Phase (swallowing disorder) and Moderate Protein-Calorie Malnutrition (malnutrition). <BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Regular diet Pureed texture, Regular consistency, Ice cream TID // fortified foods TID, Active 01/18/2023 . <BR/>Resident #7:<BR/>Record review of the current care plan dated 12/13/23 for male Resident #7 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Lymphedema, Not Elsewhere Classified (fluid buildup in lymph system), Displaced Intertrochanteric Fracture Of Right Femur, Subsequent Encounter For Closed Fracture With Routine Healing (Femur Fracture), Weakness, and Age-Related Physical Debility. <BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of No Salt on Tray (NSOT) diet Regular texture, Regular consistency, fortified meal plan at all meals for Nutrition, Active 10/27/2023 .<BR/>Resident #22:<BR/>Record review of the current care plan dated for female Resident #22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Unspecified Protein-Calorie Malnutrition (Malnutrition), Heart Failure, Unspecified, Encounter for Palliative Care, and Pressure Ulcer Of Sacral Region, Stage 3 (pressure ulcer - tissue injury). <BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of 2g Na Diet, Mechanical Soft texture, Regular consistency, for Heart Failure, Active 08/25/2023 .<BR/>Resident #25:<BR/>Record review of the current care plan dated for female Resident #25 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as Encephalopathy, Unspecified (change in brain function), Anorexia (eating disorder), Unspecified Severe Protein-Calorie Malnutrition (Malnutrition), Weakness, Acute Kidney Failure, Unspecified, Dysphagia, Unspecified (Swallowing Disorder), Pain, Unspecified, and Pressure Ulcer of Sacral Region, Stage 4 (pressure ulcer - tissue injury). <BR/>Further record review of the current physician orders dated 12/14/23 revealed that the resident had a diet order of Puree diet Pureed texture, Regular consistency, Active 11/07/2023 .<BR/>- The following observations were made during a kitchen tour on 12/12/23 that began at 10:45 AM and concluded at 12:33 PM:<BR/>An observation was made of the service line of the following foods at 11:20 AM: <BR/>Beef enchiladas (premade in individual rolls) served with a #8 scoop.<BR/>Rice served with the #8 scoop (1/2 cup).<BR/>Refried beans serve with a #8 scoop (1/2 cup).<BR/>Pur&eacute;ed beans serve with a #8 scoop (1/2 cup).<BR/>Pur&eacute;ed enchiladas served with a #10 scoop (3/8 cup). <BR/>Pur&eacute;ed rice served with a #10 scoop (3/8 cup).<BR/>Dietary staff A served the meal. These foods were served one scoop each.<BR/>Observation on 12/12/23 at 11:38 AM revealed Resident #7 was served #8 scoop of beans, #8 scoop of beef enchiladas, and #8 scoop of rice. The resident should have received Beef enchiladas with chili sauce 2 each + 4 ounces sauce . for his regular texture diet. It was unknown if the #8 scoop of enchilada equated to 2 enchiladas with 4 ounces of sauce.<BR/>Observation on 12/12/23 at 11:39 AM revealed Resident #25 was served a #8 scoop of pur&eacute;ed beans, #10 scoop of pur&eacute;ed rice, and a #10 scoop of pur&eacute;ed enchilada. The resident should have received Pur&eacute;ed beef and enchilada with chili sauce #6 dip (2/3 cup scoop) . for her pureed texture diet. <BR/>Observation on 12/12/23 at 11:44 AM revealed Resident #2 was served a #8 scoop of pureed beans, #10 scoop pur&eacute;ed rice, and #10 scoop pur&eacute;ed beef enchiladas. The resident should have received Pur&eacute;ed beef and enchilada with chili sauce #6 dip (2/3 cup scoop) . for her pureed texture diet.<BR/>Observation on 12/12/23 at 11:55 AM revealed Resident #22 was served a #8 scoop of rice, #8 scoop of beans, and a #8 scoop of beef enchiladas. The resident should have received Chopped beef enchilada with chili sauce, two each + 4 ounces sauce . for her mechanical soft texture diet. It was unknown if the #8 scoop of enchilada equated to 2 enchiladas with 4 ounces of sauce.<BR/>On 12/14/23 at 9:56 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. Regarding following the menu, he stated Dietary staff A went to a scoop from a spatula when serving the enchiladas. He stated that with the use of the #8 scoop, it was unknown if it was two, three, or less enchiladas served in the #8 scoop serving. He added, he told Dietary staff A she needed more pans of enchiladas prepared. Regarding the incorrect scoop sizes, he stated Dietary staff A did what she wanted to do. He stated Dietary staff A aid she was a cook, but he saw indications that required more training and gave her more. He stated to ensure the menu was followed, he printed the menus, and tray card so they would know what was needed and gave staff the tools needed. He stated he and staff were responsible to ensure that the menu was followed. Regarding what could result from the menu not being followed, he stated decreased resident expectations and we get complaints.<BR/>On 12/14/23 at 11:47 AM an interview was conducted with Dietary staff A. She stated, she changed from a spatula to an #8 scoop for the enchiladas because they had gotten cooked and fell apart. She added, The #8 scoop is a normal serving. I did not want it (enchiladas) to look too messy. She stated, she used the #10 scoop instead of a #6 for the pur&eacute;ed enchiladas because the facility only had one #6 scoop. She added there were not many #10 scoops available.<BR/>On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. She stated that she was unsure why the staff did not follow the menu. She added the person responsible for ensuring the menu was followed was the Dietary Manager and the result of not following the menu could be a potential change in weight and nutrition for residents.<BR/>Record review of the facility's, Diet Roster - By Texture dated 12/12/23 revealed the following documentation:<BR/>Resident #2 - Regular (diet), pur&eacute;e (texture) diet.<BR/>Resident #7 - Regular (diet), 2 gm sodium (diet other), regular (texture) diet.<BR/>Resident #22 - Regular (diet), 2 gm sodium (diet other), mechanical soft (texture) diet, <BR/>Resident #25 - Regular (diet), pur&eacute;e (texture) diet.<BR/>Record review of the facility Diet Spreadsheet, Menu: .Week 1, Day: 3 - Tuesday Lunch revealed that residents on a regular diet should have received:<BR/>Beef enchiladas with chili sauce 2 each + 4 ounces sauce, <BR/>Cilantro Lime [NAME] #8 dip<BR/>Charro beans 4 ounce spoodle (draining ladle)<BR/>-Residents on mechanical soft diets should have received:<BR/>Chopped beef enchilada with chili sauce, two each + 4 ounces sauce.<BR/>Cilantro, lime rice with salsa #8 dip + 2 ounces<BR/>Charro beans 4 ounce spoodle (draining ladle).<BR/>-Residents on pur&eacute;e diets should have received:<BR/>Pur&eacute;ed beef and enchilada with chili sauce #6 dip <BR/>Pur&eacute;e, Cilantro Lime Rice, #10 dip.<BR/>Pur&eacute;e Charro beans #8 dip<BR/>Record review of the facility's recipe titled Beef Enchiladas with Chili Sauce, Recipe Number: 195614 revealed the following documentation. To serve: serve two beef enchiladas with 4 ounces prepared and heated chili sauce over all .<BR/>Record review of facility's recipe titled Chopped Beef Enchilada with Chili Sauce, Recipe Number: 195615, revealed the following documentation, . To serve: serve two beef enchiladas hand chopped into bite-size pieces with 4 ounces prepared and heated chili sauce over all .<BR/>Record review of the facility policy titled Nutrition and Food Service Policies and Procedures Manual, Section 3-11, Policy: Tray Service, Policy Number: 03.006 Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility believes that accurate tray service and adequate portion sizes are essential to the resident's well-being and safety. The facility will ensure that diets are served accurately, and in the correct portions, and that resident's preferences are met. Procedure . <BR/>3. For tray line service, Nutrition and Food Service staff will check each resident's tray card prior to service to ensure their preferences and dislikes are honored, the correct diet is served, portion sizes are accurate and appropriate substitutions provided . <BR/>6. The Nutrition and Food Service Manager or consultant . will conduct in-services with the nutrition, food services as needed to ensure all serving staff are familiar with portion, sizes and therapeutic and mechanically altered diets .<BR/>Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, Policy: Test Trays, Policy Number: 10.001, Date Approved: October 1, 2018, reveal the following documentation, Policy: the facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable, and served at the correct temperatures. Routine test tray will be evaluated by the Nutrition and Food Service Manager or designated employee. Procedure: <BR/>1. The Nutrition and Food Service Manager or designated employee will conduct a test tray evaluation at least once each month. The evaluation will be conducted at each meal to ensure that food temperatures, portion sizes, and that orders are followed. A sample test tray checklist is attached. <BR/>2. A test tray checklist should be completed at least monthly at each meal service site to ensure that temperatures, palatability, and accuracy are maintained at each location .

Based on observation, interview, and record review the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 1 of 1 meal reviewed for palatability.<BR/>1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (12/14/23 lunch). <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings included:<BR/>During confidential individual interviews 1 of 12 residents voiced concerns related to food palatability. During a confidential interview on 12/12/23 at 9:50 AM, a resident stated she did not like to eat in her room for meals because the food was cold by the time it got to her. The resident stated staff would warm up the food for her if she asked, but it would still be cold at times. The resident stated she had complained about this issue before, but nothing was changed. <BR/>On 12/13/23 at 10:54 AM, an interview was conducted with the Dietary Manager, and he was informed of a test tray request for hall carts. <BR/>Observation on 12/13/23 at 11:19 AM revealed Dietary staff E took temperatures on the service line with the following results: <BR/>Seasoned [NAME] beans, 206&deg;F.<BR/>Mashed potatoes 208.4&deg;F. <BR/>Smothered Pork chops with gravy 193.4&deg;F. <BR/>Pur&eacute;e seasoned green beans 204&deg;F.<BR/>Pur&eacute;e pork chops 204&deg;F. <BR/>Ground pork chop 195&deg;F. <BR/>Pur&eacute;ed bread no temperature taken and stored at room temperature.<BR/>Hall tray meal service started at 11:27 AM on 12/13/23. <BR/>Observation revealed the last Pod B (JH) unit tray was prepared at 11:41 AM. The sample tray preparation began at 11:41 AM and ended at 11:42 AM. The unheated cart left the kitchen at 11:44 AM. The cart arrived at Pod B unit at 11:47 AM. The service for B100 pod trays started at 11:48 AM and ended at 11:51 AM. At 11:51 AM the cart arrived on the B200 pod and staff began serving trays at 11:52 AM and the doors were open on the cart. The staff were checking and identifying trays on the cart and uncovering trays. The doors were closed on the cart at 11:56 AM. The cart left for the B300 unit at 11:56 AM. It arrived on the unit at 11:57 AM and staff started serving at 11:57 AM and the doors were left open. The doors were left open to the cart until 12:01 PM. The last tray for the B unit was served to Resident #15 at 12:02 PM. The resident began eating at 12:08 PM.<BR/>The test observation began on 12/13/23 at 12:11 PM with the following results: <BR/>Seasoned [NAME] beans - 120&deg;F bland.<BR/>Smothered Pork chop with gravy - 122&deg;F bland and dry<BR/>Mashed potatoes - 130&deg;F bland and had an instant flavor.<BR/>Ground pork with gravy on top - 128&deg;F had an off flavor unlike pork, tangy, old/stale flavor.<BR/>Pur&eacute;ed pork - 115&deg;F. There were bits and pieces of whole pork. <BR/>Pur&eacute;ed bread - 102&deg;F had a tangy off flavor unlike bread.<BR/>Pur&eacute;ed seasoned green beans - 110&deg;F Cold, flat on the plate and had elevated pepper flavor.<BR/>Seven of nine foods tested had palatability issues of temperature, flavor, and appearance.<BR/>On 12/14/23 at 9:50 AM an interview was conducted with the Dietary staff E. She stated that she was unsure why the pork chops were dry. She stated she followed the recipe on the pork chops, but the thyme was missing. She added she used chicken base, onions, and heavy cream and the mashed potatoes were a powder mix. <BR/>On 12/14/23 at 9:56 AM an interview was conducted with the Dietary Manager regarding issues in the dietary department. He stated he told staff to follow the recipe and had told them many times. He stated, green beans may have gotten cold by sitting there and got cold after being prepared. He added staff may have turned the steam table off. He stated, he monitored the palatability of foods by tasting the food and monitor staff. He further stated he and the staff were responsible for the palatability of food. He stated he was not present in the kitchen all day. He added he would attend resident counsel if invited. He stated the last Resident Council meeting he attended was in June 2023. He added he addressed grievances individually. He stated unpalatable food could affect residents happiness and decrease independence. He added, good food made residents happy.<BR/>On 12/14/23 at 12:06 PM an interview was conducted with the Administrator regarding issues found in the facility. She stated that she was unsure why the food palatability issues occurred. She added the person responsible for food palatability was the Dietary Manager and the result of these issues could be possible weight loss and residents not eating the food.<BR/>Record review of the Resident Council Minutes dated 9/18/23 revealed a resident comment that stated, Food Service - stop making (resident) eggs hard .<BR/>Record review of the Resident Council Minutes dated 10/23/23 revealed resident comments that stated, Old Business. Dietary . would help to get plate warmers, not cold food. Food does come cold often.<BR/>Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, Policy: Test Trays, Policy Number: 10.001, Date Approved: October 1, 2018, reveal the following documentation, Policy: the facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Routine test tray will be evaluated by the Nutrition and Food Service Manager or designated employee. Procedure: <BR/>1. The Nutrition and Food Service Manager or designated employee will conduct a test tray evaluation at least once each month. The evaluation will be conducted at each meal to ensure that food temperatures, portion sizes, and that orders are followed. A sample test tray checklist is attached. <BR/>2. A test tray checklist should be completed at least monthly at each meal service site to ensure that temperatures, palatability, and accuracy are maintained at each location .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 2 of 2 residents (Resident #17 and #44) reviewed for infection control.<BR/>The facility failed to ensure MA performed proper hand hygiene and sanitized equipment between residents when passing medications to Residents #17 and #44. <BR/>This failure could place residents at risk for development of communicable diseases and infections. <BR/>Findings included: <BR/>Record review of Resident #17's undated face sheet, reflected she was an [AGE] year-old female admitted [DATE] with diagnoses of Encephalopathy (brain disfunction), Acute Respiratory Failure, Diabetes, Pneumonia, Anxiety, and Major Depressive Disorder. <BR/>Record review of Resident #17's Quarterly MDS assessment dated Dec. 25, 2024, reflected a BIMS score of 06, which indicated the resident's cognitive ability was severely impaired. <BR/>Record review of Resident #17's Care Plan, reflected a Focus area was initiated for Acute Infection on 11/21/24 with a goal for the infection to resolve without complications.<BR/>Record review of Resident #44's undated face sheet, reflected she was a [AGE] year-old female admitted [DATE] with diagnoses of Dementia, Depression, High Blood Pressure, and a Personal History of Urinary Tract Infections. <BR/>Record review of Resident #44's Quarterly MDS assessment dated Dec. 24, 2024, reflected a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. <BR/>Record review of Resident #44's Care Plan, reflected a Focus area was initiated for Resident is at risk for infection-Covid 19 with a goal to not exhibit signs and symptoms of Covid-19. <BR/>Observation on 1/29/25 at 9:03 a.m., revealed MA removed a blood pressure cuff from the top of the medication cart and entered the resident's room to take the blood pressure of Resident #17. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #17 in the resident's room. She returned to the medication cart and moved to the next resident without performing hand hygiene or cleaning the blood pressure cuff. <BR/>Observation on 1/29/25 at 9:15 a.m., revealed MA removed the un-sanitized blood pressure cuff from the top of the medication cart and proceeded to take the blood pressure of Resident #44. Afterwards she placed the un-sanitized cuff back on the top of the medication cart. She then proceeded to prepare the medications and to administer the medications to Resident #44 in the resident's room. She returned to the medication cart and moved the cart back to the nurse's station where she left it. The blood pressure cuff was left on top of the first medication cart and was never sanitized. Hand hygiene was not done until MA moved to a different cart, where she performed hand hygiene before starting on the new cart. <BR/>In an interview on 01/29/25 09:44 a.m., MA stated she forget the hand hygiene between Resident #17 and Resident #44 but does not know why. She stated that she did not clean the blood pressure cuff between residents. She stated she usually keeps the hand sanitizer near her on the cart and does do it. She stated it was important to do hand hygiene and clean the cuff to avoid spreading infections from resident to resident. She stated that the negative outcome to residents if it was not done, was they could develop infections and get sick. <BR/>In an interview on 1/30/25 at 9:54 a.m., the DON stated, the policy for hand hygiene during medication administration was to clean hands before and after each resident and as needed.<BR/>She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this is important for infection control and to not spread germs between residents which could give a resident an infection and make them sick. She said it was the responsibility of the DON, the Scheduler, and the ADON to train staff on this when staff is hired and at yearly competencies. <BR/>In an interview on 1/30/25 at 10:28 a.m., RN, she stated the policy for hand hygiene on medication administration was to sanitize hands before and after each resident and as needed.<BR/>She stated the policy on cleaning equipment like blood pressure cuffs, was to clean between residents. She stated this was important for minimize risk of spreading bacteria to other residents and causing cross contamination. She stated if this was not done, residents could get infections and become sick. She stated it was the responsibility of the DON, ADON and nurse management to train staff on this. <BR/>In an interview on 1/30/25 at 10:38 a.m., the ADM stated the policy for hand hygiene on medication administration was to clean hands before and after each resident. He stated the policy on cleaning equipment like blood pressure cuffs was to clean between residents. He stated this is important for infection control and to prevent giving a resident an infection which could make them sick. He stated it is the responsibility of the DON and ADM to train staff on this.<BR/>A record review of the facility policy titled, Handwashing/Hand Hygiene 2001 Med-Pass, Inc with a last revision date of 2019 reflected the following: <BR/>The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. <BR/>Hand Hygiene is indicated before and after direct contact with residents and before handling medications. <BR/>Hand Hygiene is indicated after handling contaminated equipment.<BR/>A record review of the facility's undated policy titled, 9. Medication and Preparation Administration-9.2 Preparation of Medication reflected the person administering medications adheres to good hand hygiene, which includes washing or sanitizing hands:<BR/>Before beginning a medication pass.<BR/>Prior to handling any medication.<BR/>After coming into direct contact with a resident.<BR/>When returning to the medication cart or preparation area.<BR/>After each room. <BR/>A record review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment version 2.0 in the 2001 Med-Pass, Inc with a last revision date of 2022 reflected the following:<BR/>Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).<BR/>Durable medical equipment is cleaned and disinfected before reuse by another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of three residents reviewed for notification of changes, in that:<BR/>The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. <BR/>An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.<BR/>This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. <BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. <BR/>Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission.<BR/>Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred.<BR/>Review of Resident #1's NP progress note, dated 11/14/23, reflected the following:<BR/>Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities.<BR/>Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis.<BR/>Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days.<BR/>Review of Resident #1's physician order, dated 11/14/23, reflected the following:<BR/>Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days.<BR/>Review of Resident #1's physician order, dated 11/14/23, reflected the following:<BR/>Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. <BR/>Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following:<BR/>[Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today.<BR/>Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following:<BR/>Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . <BR/>Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following:<BR/>Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture.<BR/>Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following:<BR/>Description of Allegation:<BR/>The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff.<BR/>Initial Investigation:<BR/>Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). <BR/>[CNA B], worked 11/10/23 10p - 6am<BR/>[CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication.<BR/>[LVN C], worked 11/10/23 10p - 6am<BR/>[LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident.<BR/>[CNA D], worked 11/11/23 6a - 10p <BR/>[CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated.<BR/>[RN E], worked 11/11/23 6a - 6p<BR/>[RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C].<BR/>[CNA A], worked 11/13/23 6a - 10pm<BR/>[CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds.<BR/>[LVN G] worked 11/13/23 6a - 10pm<BR/>[LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. <BR/>[CNA A], worked 11/15/23 6a - 10pm<BR/>[CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound.<BR/>[RN E], worked 11/15/23 6a - 6pm<BR/>[RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER.<BR/>Immediate actions taken: <BR/>Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture.<BR/>Post actions taken:<BR/>- Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP.<BR/>- Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls.<BR/>- Pain assessment conducted on all residents in Memory Care Unit with no concerns noted.<BR/>- [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON.<BR/>- All falls and discharges are to be reported to DON in a timely manner. <BR/>Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc.<BR/>Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following:<BR/>When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse.<BR/>At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident.<BR/>Failure to comply will lead to disciplinary action up to termination.<BR/>Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following:<BR/>When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols:<BR/>- Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing.<BR/>- Follow physician instructions.<BR/>- Notify DON/ADM.<BR/>- Notify family.<BR/>- Do proper documentation - incident report, nursing notes, pain and fall evaluation. <BR/>- If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation.<BR/>Failure to follow these procedures will lead to disciplinary action up to termination.<BR/>Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls.<BR/>During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. <BR/>During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding.<BR/>During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP.<BR/>During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse.<BR/>During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. <BR/>During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. <BR/>An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. <BR/>An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. <BR/>Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following:<BR/>1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):<BR/>a. accident or incident involving the resident;<BR/>b. discovery of injuries of an unknown source<BR/> .<BR/>8. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and neglect.<BR/>On 7/5/2023 at 9:00pm, CNA A attempted to transfer Resident # 1 from her wheelchair to her bed using a mechanical lift. CNA A attempted the transfer with one person, although Resident # 1 required two-person assistance. As a result, the mechanical lift fell on top of Resident # 1 and the cross bar struck Resident # 1 in head causing a bump, soreness, headache causing injury to her head in which she had to take medication. <BR/>An (IJ) Immediate Jeopardy was identified on 7/28/2023 at 6:45pm. While the (IJ) Immediate Jeopardy was removed on 7/30/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed all residents who require the use of a mechanical lift at risk to be neglected. <BR/>Findings included: <BR/>Review of Resident #1 face sheet dated 7/28/2023, reflected Resident # 1 was a 70- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with UNSPECIFIED OSTEOARTHRITIS (typically affects the hips, spine, hands, and knees, causing joint stiffness and pain), WEAKNESS (the state or condition of lacking strength), UNSPECIFIED FALL (falls due to slipping or tripping), SEQUELA (a condition of a previous injury of infection) and body mass index of 50.0-59.9.<BR/>Review of care plan dated 6/20/2023, reflected Resident #1 required a mechanical lift for transfers. <BR/>Review of quarterly MDS dated [DATE] reflected Section G functional section indicated Resident # 1 required extensive assist with bed mobility and transfers, Mechanical lift 2x person assist. <BR/>In an interview on 7/28/2023 at 3:00pm with Resident # 1 stated on 7/5/2023 at 9:00pm the CNA A (agency staff) was attempting to transfer her from her wheelchair to her bed. She stated she asked CNA A where the other staff was to assist him, she stated CNA A responded, don't worry he was going to do it himself and that he didn't have anyone to help him at the time. Resident # 1 stated she didn't think that CNA A knew what he was doing. Resident # 1 stated when she was up in the sling, that CNA A went to the opposite side of the bed leaning across the bed to pull her from the sling onto the bed. She stated once he pulled her, she went down on the bed and the mechanical lift came down on top of her on the bed. Resident # 1 stated when the mechanical lift fell over the grab bar struck her in her head causing her head to hurt. <BR/>In an interview on 7/28/2023 at 1:34pm with NP, revealed Resident # 1 had a faint bruise to the right side of her forehead. NP stated the incident occurred on 7/5/2023, she stated Resident # 1 reported that CNA A was trying to transfer her using the mechanical lift and the lift fell on top of her. The NP stated Resident # 1 stated she was hit in the head with the bar from the mechanical lift causing her head to hurt. She stated she assessed Resident #1 on 7/6/2023. The NP stated Resident #1 complained of a headache and soreness to the touch she stated she prescribed Tylenol. NP stated Resident # 1 was agreeable to take the tylenol and rest, as Resident # 1 stated she did not want to participate in therapy due to her head hurting. <BR/>In an interview on 7/28/2023 at 3:49pm with the DON, revealed Resident # 1required a mechanical lift and that Resident # 1 was a two-person assist. The DON stated staff have access to PCC (Point Click Care) system in which staff could review to know what the care needs were for the residents. The DON stated they have a competency checklist that they use for the mechanical lift but stated she had not completed this form with any of the staff. The DON stated she has gone over the checklist with staff but was not able to state which staff or any documentation where the checklist had been completed with any staff. <BR/>In an interview with the ADM on 7/28/2023 at 4:43pm, revealed Resident # 1 was hit on the is of her face by one of the arms from the mechanical lift. The ADM stated the facility does not have a formal process in which agency staff are oriented to the facility or resident needs. The ADM stated the staff had access to Point Click Care system for the resident's care needs. The ADM reported that the staff was agency staff and that he advised that the staff could not return to the facility. <BR/>Review of progress notes reflected no incident report completed of the incident. <BR/>Policies reviewed:<BR/>Review of facility policy Resident rights dated Dec. 2016 reflect the following: <BR/>Residents have to right to be free from neglect<BR/>This was determined to be an (IJ) Immediate Jeopardy (IJ) on 7/28/2023 at 6:45pm. The ADM was notified. The ADM was provided with the IJ template on 7/28/2023 at 6:45PM. <BR/>The following Plan of Removal submitted by the facility was accepted on 7/29/2023 at 6:22PM <BR/>Plan of Removal: Immediate Jeopardy <BR/>The notification of Immediate Threat states as follows:<BR/>F600 The facility failed to ensure that the resident was free from neglect. <BR/>Statement of Deficient Practice:<BR/>All residents who require a Mechanical lift could be at risk of harm and injury from neglect. <BR/>Action Item 1<BR/>Direct Care Staff, including agency, to be in-serviced on 2-person transfer and how to identify transfer status of residents. Direct Care Staff will be in-serviced before the start of their shift. Results will be reported to and reviewed by the QAPI committee monthly x3 months starting in August. RNC or Designee Regional Nurse Consultant has been onsite and is providing in-service education to direct care staff<BR/>Target date: 7/31/2023<BR/>Action Item 2<BR/>Direct Care Staff, including agency, to provide return demonstration and competency on Hoyer lift transfers. RNC or Designee<BR/>Target date: 7/28/23<BR/>Action Item 3<BR/>Facility staff and agency staff will be in-serviced on Abuse and Neglect and proper reporting process, Includes Administrator and Director of Nursing. RNC and Designee<BR/>Target date: 7/28/2023<BR/>Action Item 4<BR/>All current Residents who require Hoyer lift transfer will be assessed by licensed nurses for injury. All resident current and future will have weekly skin assessments completed to assess for injury. RNC or Designee Regional Nurse Consultant is onsite and conducted assessments with assistance of charge nurses on 7/28/23.<BR/>Target date: 7/28/2023<BR/>Action Item 5<BR/>All facility Hoyer lifts will be inspected to assure safe operation. Director of Maintenance<BR/> Target date: 7/28/2023<BR/>Action Item 6<BR/>Regional Nurse Consultant to in-service Administrator and Director of Nursing on Incident Accident Process. Including reporting allegations of abuse. Regional Nurse Consultant <BR/>Target date: 7/28/2023<BR/>Action Item 7<BR/>Regional Nurse Consultant and Regional Director of Operations to in-service Administrator and Director of Nursing on process for agency staff orientation to facility and resident needs. Regional Nurse Consultant and Regional Director of Operations<BR/>Target date: 7/28/2023<BR/>Action Item 8 <BR/>Agency staff will be provided orientation on facility and residents needs per facility process. Orientation will include a check off form that include but is not limited to essential job functions, facility tour and procedures, medical and emergency equipment, specialty equipment, assignment sheets, point click care [NAME] to identify resident needs. DON or designee<BR/>Target date: 7/29/2023<BR/>Action Item 9<BR/>Facility staff and agency staff will be in-serviced on a) Abuse, Neglect, Exploitation and Misappropriation Prevention, and Resident Rights. RNC and designee<BR/>Target date 7/31/2023<BR/>Action Item 10<BR/>Facility and agency Licensed Nurses nursing staff will be in-serviced on proper completing of Incident and Accident process, identification, documentation and notification. All staff and agency will be in-serviced on reporting of incidents and accidents. RNC and Designee.<BR/>Target date: 7/31/2023<BR/>Action Item 11<BR/>The facility has a system to evaluate and improve safety for all residents who reside at the facility. The incident accident system is used as a tool to track facility incidents that have been reported to the facility QAPI where the safety of the facility is assessed, and action plans developed. Administrator<BR/>Target date: 7/31/2023<BR/>Monitoring: 7/30/2023<BR/>Observation on 7/30/2023 at 11:00am, observed CNA D and CNA F complete a resident transfer using the mechanical lift. Staff were observed using appropriate hand hygiene, staff observed talking with Resident # 2 and explaining the process as they started. CNA D and CNA F were able to complete a successful transfer from the bed to the wheelchair. <BR/>Observation on 7/30/2023 at 11:30am, observed CNA C and CNA G completed a transfer for a Resident # 3 from her wheelchair into her bed. Staff were able to complete the transfer successfully, Resident # 3 stated she felt safe. <BR/>Interview on 7/30/2023 at 11:50am with CNA D, revealed she worked the 6am to 6pm shift, she stated she was facility staff not agency. She had been trained on how to use the mechanical lift and abuse/neglect she stated she used the [NAME] in PCC to see what the care needs are for residents. CNA D was able to explain the process of how to use the mechanical lift. <BR/>Interview on 7/30/2023 at 11:55am with CNA G, revealed she was agency staff, she stated she had been trained on how to use the mechanical lift safely and abuse/neglect She reported she had also been trained on how to access the PCC system to review the care needs for each resident. <BR/>Interview on 7/30/2023 at 12:00pm with CNA F, revealed she worked through a (staffing agency) she stated it was her second day at the facility. CNA F stated she had been in-serviced on how to use the mechanical lift safely, abuse/neglect, and how to access PCC for resident's care needs. <BR/>Interview on 7/30/2023 at 2:30pm with Resident # 2 revealed, she was doing fine and stated she felt safe at the facility. <BR/>Interview on 7/30/2023 at 3:00pm with Resident # 3 revealed, he felt safe at facility. <BR/>Record review on 7/30/2023 of in-services on abuse/neglect, Mechanical lift competency checklist dated 7/29/2023 reflected 20 staff had completed the training. <BR/>The ADM was informed the Immediate Jeopardy was removed on 7/30/2023 at 5:00PM. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that:<BR/>The facility failed to ensure Resident #1 was properly assessed after being found on the floor of her room on 11/10/23. Resident #1 was picked up by CNA B, there was no assessment documented by the nurse, the on-coming nurse nor NP were notified of the fall. On 11/15/23 she was sent to the ER and diagnosed with a left hip fracture requiring surgery. <BR/>An Immediate Jeopardy (IJ) existed on 11/16/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.<BR/>This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. <BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including fracture of right humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow), dementia, and unspecified protein-calorie malnutrition. <BR/>Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected she required supervision or touching assistance with transferring and chair/bed-to-chair transfers. Section J (Health Conditions) reflected she had not had any falls since admission.<BR/>Review of Resident #1's quarterly care plan, revised 09/24/23, reflected she was at risk for falls with an intervention of educating resident/family/caregivers about safety reminders and what to do if a fall occurred.<BR/>Review of Resident #1's NP progress note, dated 11/14/23, reflected the following:<BR/>Today, [Resident #1] was seen in the day room, sitting up in her WC. AAOx3 with mild impairment. [Resident #1] reports her legs hurt x 4 days. She describes it being a constant, deep/dull pain, ranging from the hips to above the knees. [Resident #1] reports she has never had this feeling before. [Resident #1] can't remember if she fell or not over the weekend. There were no reports of any falls from staff, but [Resident #1] does have new bandages on both elbows. No new bruises on [Resident #1]'s body. Staff reports that the pain has been very disabling to [Resident #1]. [Resident #1] normally would be a [NAME]-by or contact assist with ADLs, but today, [Resident #1] has been having difficulties transferring to toilet from WC d/t pain in her lower extremities.<BR/>Abdominal swelling generalized: Ordered ultrasound of abdomen and pelvis.<BR/>Pain in right and left leg: Order x-ray of femur. Added Tylenol 500mg tid for pain x 7 days.<BR/>Review of Resident #1's physician order, dated 11/14/23, reflected the following:<BR/>Acetaminophen tablet 500 MG - Give 1 tablet by mouth three times a day for pain for 7 days.<BR/>Review of Resident #1's physician order, dated 11/14/23, reflected the following:<BR/>Muscle Rub External Cream 10-15% (Menthol-Methyl Salicylate) - Apply to thighs and knees topically two times a day for pain. <BR/>Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 10:57 AM, reflected the following:<BR/>[Resident #1] appears comfortable but with distended abdomen and a bulging area on the left side of the abdomen. Has order for abdominal ultrasound which has not been done . Called and notified NP and asked if [Resident #1] can be sent to ER for evaluation, she objected to that. Called (x-ray company) for ETA for the procedures and the don't have any at this time but will come today.<BR/>Review of Resident #1's progress notes in her EMR, dated 11/15/23 at 4:21 PM, reflected the following:<BR/>Returned to the floor following lunch break at 3:30 PM and received a note that the ultrasound tech called and will not be coming in to perform the procedure today. No specific date or time was given. Called NP and rec'd phone order to send [Resident #1] to ER for evaluation/treatment . <BR/>Review of Resident #1's progress notes in her EMR, dated 11/16/23 at 7:19 AM, reflected the following:<BR/>Called (hospital ER) this morning and was informed that [Resident #1] was admitted and will be going for surgery this morning - left hip fracture.<BR/>Review of the facility's investigation regarding Resident #1's injury, dated 11/16/23, reflected the following:<BR/>Description of Allegation:<BR/>The facility was informed of a fracture of left hip of [Resident #1] on morning of 11/16 by hospital staff.<BR/>Initial Investigation:<BR/>Upon investigation, [CNA A] informed Administrator that she was informed by [CNA B] on morning of 11/17 that on 11/12 [Resident #1] had slid out of bed during her shift with [LVN C] being informed of incident. The fall was reported to have happened in the early hours of Saturday (11/11/23). <BR/>[CNA B], worked 11/10/23 10p - 6am<BR/>[CNA B] stated that around midnight she witnessed [Resident #1] sitting next to her bed with her left hip against the bed and she (Resident #1) had been in bed previously. [CNA B] tried to locate [LVN C] but was unable to at that time due to resident care. [CNA B] placed [Resident #1] in wheelchair with no complaints of pain. Shortly thereafter, [Resident #1] complained of pain with [LVN C] giving her medication.<BR/>[LVN C], worked 11/10/23 10p - 6am<BR/>[LVN C] stated that it was reported to her that [Resident #1] had slid out of bed and had been placed in wheelchair when she was notified of incident. [LVN C] stated that [Resident #1] had tried to get out of bed without help. [LVN C] stated she assessed [Resident #1]'s left leg/hip and vitals with no concerns. [LVN C] noted two skin tears that she treated on [Resident #1]'s elbow. [Resident #1] agreed to take pain medication. [LVN C] reported having message the physician and passed along to the following nurse. [LVN C] admitted that no incident report was generated, or nurses note made regarding the incident.<BR/>[CNA D], worked 11/11/23 6a - 10p <BR/>[CNA D] noted [Resident #1]'s change with mobility however did not report change to nurse. Educated that all changes need to be investigated.<BR/>[RN E], worked 11/11/23 6a - 6p<BR/>[RN E] stated she was unaware of fall and was not informed of any changes with [Resident #1] from [LVN C].<BR/>[CNA A], worked 11/13/23 6a - 10pm<BR/>[CNA A] informed NP that she noticed [Resident #1] having change of mobility during her rounds.<BR/>[LVN G] worked 11/13/23 6a - 10pm<BR/>[LVN G] received an order for Acetaminophen TID, and a muscle rub cream medication continued to be given. <BR/>[CNA A], worked 11/15/23 6a - 10pm<BR/>[CNA A] stated that [Resident #1] still had difficulty with mobility and was aware we were waiting on x-ray and ultrasound.<BR/>[RN E], worked 11/15/23 6a - 6pm<BR/>[RN E] contacted (x-ray company) as ultrasound of abdomen and x-ray of bilateral hips had not been conducted. At approximately 3:30pm, [RN E] received a message that they will be unable to perform ultrasound. [RN E] notified NP of issue with ultrasound and was notified to send to ER.<BR/>Immediate actions taken: <BR/>Pain medication ordered for comfort and effective. Abdominal ultrasound and x-rays of both hips ordered, however was unable to obtain. [Resident #1] has a history of bruising easy with NP stated she noted swelling in the abdomen, however, did not visualize anything during assessment that would even suggest a fracture.<BR/>Post actions taken:<BR/>- Nursing staff educated on change of condition and reporting expectations, ensuring that nurses are informed of any pending procedures/orders at shift change, completing of incident report, notification of DON, Physician, and RP.<BR/>- Skin assessments completed on all residents in Memory Care Unit with no skin findings to falls.<BR/>- Pain assessment conducted on all residents in Memory Care Unit with no concerns noted.<BR/>- [LVN C] was terminated due to failure to complete incident report, pass on information during shift transfer, and notify physician, family, and DON.<BR/>- All falls and discharges are to be reported to DON in a timely manner. <BR/>Review of an in-service entitled Incident and Accident Reporting, dated 07/31/23, reflected CNA B and LVN C had been in attendance for the in-service given on notifying the ADM and DON for all incidents and accidents, all falls, etc.<BR/>Review of an in-service entitled CNA Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected CNAs were in-serviced on the following:<BR/>When a resident is on the floor, whether witnessed or not witnessed, at no point should you lift resident off the floor or move them without a nurse assessing that resident. If resident complains of pain when moving resident, leave resident and follow fall protocol through the nurse.<BR/>At no circumstance should a CNA or MA lift a resident from the floor without a nurse assessing the resident.<BR/>Failure to comply will lead to disciplinary action up to termination.<BR/>Review of an in-service entitled Nurse Fall Procedure, dated 11/16/23 and conducted by the ADON, reflected nurses were in-serviced on the following:<BR/>When a CNA reports a fall, whether witnessed or un-witnessed, nurse need to follow the following protocols:<BR/>- Assessment of resident, head to toe, vitals, and range of motion. If resident is in pain or cannot bear weight, call for help and call on-call for order to either transfer the resident to the hospital of non-weight bearing.<BR/>- Follow physician instructions.<BR/>- Notify DON/ADM.<BR/>- Notify family.<BR/>- Do proper documentation - incident report, nursing notes, pain and fall evaluation. <BR/>- If reside is in pain and cannot get x-ray on time, get order to send resident out for further evaluation.<BR/>Failure to follow these procedures will lead to disciplinary action up to termination.<BR/>Review of an in-service entitled Fall Precautions and Interventions, dated 11/16/23, reflected all staff were in-serviced on fall precaution educating and fall interventions to reduce falls.<BR/>During an interview on 12/02/23 at 12:11 PM, the DCO stated she did meet with the NP on 11/14/23 after she assessed Resident #1 but she did not make the situation sound as dire as it had been documented in the progress note. She stated the aide should have never gotten Resident #1 off the floor without notifying a nurse first so that appropriate assessments could have been conducted. She stated the nurse (LVN C) admitted to not completing an incident report. She stated it was unacceptable that Resident #1 did not receive the proper care or treatment due to the fall not being reported. She stated LVN C was terminated and the staff were in-serviced on fall precautions, who to notify, and what assessments needed to be done after a witnessed or un-witnessed fall. <BR/>During an interview on 12/02/23 at 1:46 PM, CNA H stated she had been in-serviced on falls and notifying nurses of changes-in-condition. She stated she would never try to pick a resident up off the floor if they had fallen. She stated she would get a nurse immediately. She stated the nurses needed to conduct their assessments to ensure residents were not hurt or bleeding.<BR/>During an interview on 12/02/23 at 2:32 PM, LVN I stated she expected CNAs to notify her when there was any kind of change-in-condition regarding a resident, especially a fall. She stated when a resident falls, she assessed them, checked their range of motion, completed an incident report, documented in the resident's chart, and notified the NP and resident RP.<BR/>During an interview on 12/02/23 at 2:41 PM, LVN J stated of a resident was found on the ground by an aide, she would expect the aide to notify her immediately. She stated she would check vitals, conduct a full-body assessment, conduct neuro checks, notify the NP, complete an incident report, and ensure she notified the on-coming nurse.<BR/>During an interview on 12/02/23 at 2:49 PM, CNA K stated if she found a resident on the ground, she would immediately notify a nurse. She stated a nurse needed to be notified so they could ensure the resident was not bleeding or had a broken bone. <BR/>During an interview on 12/04/23 at 2:05 PM, Resident #1's NP stated she was never notified of the fall that occurred. She stated she saw Resident #1 on Friday 11/10/23 and she was doing great - she was acting completely normal, making jokes, and there were no issues. She stated on Tuesday 11/14/23, staff informed her that Resident #1 was having difficulty with transferring. She stated Resident #1 was usually able to transfer herself with minimal assistance. She stated the resident was complaining of pain whenever she moved her legs. She stated she did a skin assessment and noted no bruising. She stated the only thing that could have suggested she had a fall were two bandages on her elbows that were dated 11/11/23. She stated she asked the charge nurse who was working who stated he had not heard of Resident #1 sustaining a fall over the weekend. She stated it was her expectation that she be notified of every fall. She stated even if a resident falls over the weekend, their on-call team should be notified. She stated she ordered x-rays on 11/14/23 and was not aware they had not gotten done that day until she was called in the morning of 11/15/23 by a nurse requesting to send Resident #1 to the hospital because she was complaining of pain. She stated she did not want her to go to the hospital since she had personally called the x-ray order to put in the order and she had PRN pain medication. She stated the nursing staff from the night before on 11/15/23 should have followed up on the x-rays because they should have been done that day. She stated it was unacceptable they were not followed-up on or at least should have called the on-call medical team. She stated when she calls in a STAT x-ray, she had rarely seen it take over an hour for them to get to the facility. She stated once she was notified later in the day on 11/15/23 that the x-rays still had not been done, she requested Resident #1 be sent to the ER immediately. <BR/>An attempt to interview CNA B was made on 12/04/23 at 3:08 PM. A returned phone call was not received. <BR/>An attempt to interview CNA B was made on 12/04/23 at 3:13 PM. A returned phone call was not received. <BR/>Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following:<BR/>1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):<BR/>a. accident or incident involving the resident;<BR/>b. discovery of injuries of an unknown source<BR/> .<BR/>8. The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that:<BR/>The facility failed to ensure LVN A confirmed Resident #1 consumed her morning medication on 04/03/24 as she was witnessed spitting her medication into the trashcan. <BR/>This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, type II diabetes, major depressive disorder, acute kidney failure, and hypertension (high blood pressure).<BR/>Review of Resident #1's annual MDS assessment, dated 01/31/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected she did not have any swallowing disorders.<BR/>Review of Resident #1's quarterly care plan, revised 02/05/24, reflected she had impaired cognitive function with an intervention of administering medications as ordered.<BR/>Observation on 04/03/24 at 9:24 AM in the MCU, revealed Resident #1 wandering around the living area and walking over to a trash can and spitting out her medication. LVN A was by the medication cart and saw the incident. <BR/>During an interview on 04/03/24 at 9:26 AM, LVN A confirmed she did see Resident #1 spit out her medication and was glad none of them were narcotics. When asked if she was supposed to ensure all residents consumed their medications after administering them, she stated it was her first day in the MCU and was not aware Resident #1 had a history of pocketing/spitting out her medication. She stated she had mixed her medications with apple sauce and maybe it was too tart, and she was going to try again with chocolate pudding.<BR/>During an interview on 04/03/24 at 11:45 AM, the DON from their sister facility stated her expectation during medication pass when a nurse or MA administered medication was that they wait with each resident to ensure they took them. She stated one negative outcome could be another resident could consume them, which could adversely affect them. She stated another negative outcome could be the resident who was supposed to be taking the medication might not get any therapeutic benefit. She stated there was also a concern of aspiration (choking) if a resident consumed their medication alone. <BR/>Review if the facility's undated Medication and Preparation Administration Policy reflected the following:<BR/>During medication administration, the facility staff should . confirm resident consumption of the medication.

Based on interview, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use, for the entire facility. <BR/>The facility failed to monitor residents' antibiotic use.<BR/>This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.<BR/>Finding included:<BR/>In an interview on 10/20/22 at 04:45 p.m., the DON stated they do not have an Infection Control Preventionist at this time. The DON stated they are going to start training someone on Monday, 10/24/22. The DON stated they have not been tracking or trending antibiotic stewardship. She said the ADON who quit was supposed to be doing the ICP, but she did not, and she was no longer (working) there. Infection Control policy/antibiotic stewardship was not given to surveyor. DON stated they did not have one and there was no tracking/trending being done at that time.<BR/>Facility failed to provide a policy on Infection Control/Antibiotic Stewardship prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that:<BR/>The facility failed to ensure LVN A confirmed Resident #1 consumed her morning medication on 04/03/24 as she was witnessed spitting her medication into the trashcan. <BR/>This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, type II diabetes, major depressive disorder, acute kidney failure, and hypertension (high blood pressure).<BR/>Review of Resident #1's annual MDS assessment, dated 01/31/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected she did not have any swallowing disorders.<BR/>Review of Resident #1's quarterly care plan, revised 02/05/24, reflected she had impaired cognitive function with an intervention of administering medications as ordered.<BR/>Observation on 04/03/24 at 9:24 AM in the MCU, revealed Resident #1 wandering around the living area and walking over to a trash can and spitting out her medication. LVN A was by the medication cart and saw the incident. <BR/>During an interview on 04/03/24 at 9:26 AM, LVN A confirmed she did see Resident #1 spit out her medication and was glad none of them were narcotics. When asked if she was supposed to ensure all residents consumed their medications after administering them, she stated it was her first day in the MCU and was not aware Resident #1 had a history of pocketing/spitting out her medication. She stated she had mixed her medications with apple sauce and maybe it was too tart, and she was going to try again with chocolate pudding.<BR/>During an interview on 04/03/24 at 11:45 AM, the DON from their sister facility stated her expectation during medication pass when a nurse or MA administered medication was that they wait with each resident to ensure they took them. She stated one negative outcome could be another resident could consume them, which could adversely affect them. She stated another negative outcome could be the resident who was supposed to be taking the medication might not get any therapeutic benefit. She stated there was also a concern of aspiration (choking) if a resident consumed their medication alone. <BR/>Review if the facility's undated Medication and Preparation Administration Policy reflected the following:<BR/>During medication administration, the facility staff should . confirm resident consumption of the medication.

Based on interview, the facility failed to designate an Infection Preventionist that was qualified by education, training, experience or certification, and who completed specialized training in infection prevention and control, for the entire facility. <BR/>The facility did not have a designated, qualified Infection Preventionist.<BR/>This failure could affect residents by placing them at risk of cross contamination and infection.<BR/>Findings included:<BR/>In an interview on 10/20/22 at 04:45 p.m., the DON stated they did not have an Infection Control Preventionist at this time. She said the ADON who quit was the ICP at the facility. Infection Control policy/antibiotic stewardship was not given to surveyor. DON stated there was no tracking/trending being done at that time. <BR/>Facility failed to provide policy on Infection Preventionist and the job description of Infection Preventionist prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for one of one (Resident #1) of two residents reviewed for Comprehensive Care Plans, in that:<BR/>The facility failed to schedule a care plan meeting with FAM and Resident #1 that involved a multidisciplinary team and instead documented a phone call between FAM and the Social Worker as the care plan meeting.<BR/>This failure could place residents at risk of not receiving the highest practicable interventions, treatments and care by not involving the resident and FAM (MPOA) of a care plan meeting.<BR/>Findings included:<BR/>Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM.<BR/>Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis.<BR/>Record review of the assessment titled Multidisciplinary Care Conference - V2 with an effective date of 12/28/23 revealed the meeting was 12/28/23 at 11:40 am and it was marked as the quarterly care conference. The only staff marked in attendance was the social worker. None of the l7 areas to be addressed per the form were marked as addressed, all were left blank. Under summarize discussion of the care plan conference there was a note stating FAM had a question about Resident #1's fall and the SW encouraged her to get with nursing about questions related to that. The SW said she was going to activities and the SW was making a referral to dental. It was further marked that the family member attended by phone and the only staff member who signed was SW.<BR/>In an interview on 02/10/24 at 2:00 pm with FAM she stated that she had never attended a care plan meeting. She said she had called near the end of December (2023) about her Resident #1 having a fall that required stitches, but nothing else was discussed. She was not told in advance about a care plan meeting so she could attend . She also said her mother was not present on the phone call with SW.<BR/>In an interview on 02/11/24 at 4:00 pm with the DON, she stated that a care plan meeting should be scheduled and include staff from all departments, the resident and the resident representative .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that:<BR/>The facility failed to ensure LVN A confirmed Resident #1 consumed her morning medication on 04/03/24 as she was witnessed spitting her medication into the trashcan. <BR/>This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, type II diabetes, major depressive disorder, acute kidney failure, and hypertension (high blood pressure).<BR/>Review of Resident #1's annual MDS assessment, dated 01/31/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected she did not have any swallowing disorders.<BR/>Review of Resident #1's quarterly care plan, revised 02/05/24, reflected she had impaired cognitive function with an intervention of administering medications as ordered.<BR/>Observation on 04/03/24 at 9:24 AM in the MCU, revealed Resident #1 wandering around the living area and walking over to a trash can and spitting out her medication. LVN A was by the medication cart and saw the incident. <BR/>During an interview on 04/03/24 at 9:26 AM, LVN A confirmed she did see Resident #1 spit out her medication and was glad none of them were narcotics. When asked if she was supposed to ensure all residents consumed their medications after administering them, she stated it was her first day in the MCU and was not aware Resident #1 had a history of pocketing/spitting out her medication. She stated she had mixed her medications with apple sauce and maybe it was too tart, and she was going to try again with chocolate pudding.<BR/>During an interview on 04/03/24 at 11:45 AM, the DON from their sister facility stated her expectation during medication pass when a nurse or MA administered medication was that they wait with each resident to ensure they took them. She stated one negative outcome could be another resident could consume them, which could adversely affect them. She stated another negative outcome could be the resident who was supposed to be taking the medication might not get any therapeutic benefit. She stated there was also a concern of aspiration (choking) if a resident consumed their medication alone. <BR/>Review if the facility's undated Medication and Preparation Administration Policy reflected the following:<BR/>During medication administration, the facility staff should . confirm resident consumption of the medication.