Arbor Oaks Healthcare And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to convey a resident's personal funds to the individual or representative administering the individual's estate within 30 days for two (Resident #212 and Resident #213) of three residents reviewed for whom the facility maintained trust accounts.
The findings include:
On [DATE] at 10:55 AM, the Business Office Manager (BOM) provided a document titled [Facility Name] Trust - Current Account Balance as of [DATE]. A review of the [Facility Name] Trust - Current Account Balance as of [DATE] document, indicated a closing trust account balance for Resident #212 of $914.06, and a closing trust account balance for Resident #213 of $893.91.
On [DATE] at 12:03 PM, a review of the form titled “Notice of Transfer, indicated that Resident #212 was transferred to the hospital on [DATE].
On [DATE] at 12:05 PM, a review of Resident #212's Nursing Progress Notes dated [DATE], indicated the coroner called to notify the facility of the death of Resident #212, at 1:37AM.
On [DATE] at 12:04 PM, a review of the form titled Notice of Transfer indicated that Resident #213 was transferred to the hospital on [DATE].
On [DATE] at 12:30 PM, a review of Resident #213's Social Progress Notes dated [DATE], indicated the Social Director spoke with Resident #213’s family member who stated, Resident #213 had passed away at the hospital, after 5:00 AM.
On [DATE] at 1:20 PM, the BOM provided a document titled [Facility Name] General Notes, for Resident #212 and Resident #213’s trust account, that indicated what facility staff had done to try and return the money for Resident #212 and Resident #213's trust balance to the Social Security Administration and how it was returned to them by Social Security Administration.
On [DATE] at 12:53 PM, during an interview the BOM indicated the facility had no more than 30 days to return a resident's money from a trust account when a resident discharges or expires. The BOM indicated that Resident #212 was discharged on [DATE], and Resident #213 discharged on [DATE]. The BOM indicated that the Social Security Administration (SSA) advised them to keep both residents’ funds for 5 years, then return to State Recovery. The BOM was unable to provide any documentation to show that the Social Security Administration had advised the facility to keep Resident #212 and Resident #213 funds for 5 years.
On [DATE] at 1:44 PM, during an interview the Administrator indicated funds should be returned within 30 days after a resident has discharged or expired. The Administrator indicated that she was not sure of the process of who returned the money, she left it up to her BOM and Human Resources.
On [DATE] at 3:45 PM, the Administrator indicated they did not have a policy regarding resident personal funds.

Based on observation and interview, the facility failed to post and make readily accessible to residents and visitors, the daily nurse staffing log in a clear and readable format to include the facility name, date, total census, total number, and actual hours worked by nursing staff.
The findings include:
On 07/01/25 at 1:30 PM, during an observation of the front lobby, the nurse's station, the main dining room, and 100, 200 and 400 halls, this surveyor did not observe daily staffing information posted.
On 07/02/25 at 9:10 AM, during an interview, the Administrator indicated the facility posted the daily staffing logs for licensed and unlicensed nursing staff in the employee break room. This surveyor accompanied the Administrator to the employee break room and was shown a form titled “Daily Staffing Log.” This form included the name of the facility, the date, and day shift was circled. This form did not contain the census number or total number and actual hours worked for the Registered Nurses (RNs), the Licensed Practical Nurses (LPNs) and the Certified Nursing Assistants (CNAs) who were responsible for patient care. This surveyor asked the Administrator if the facility posted staffing information that included the total hours worked by RNs, LPNs, and CNAs where it was visible to the residents and family. The Administrator indicated she would check and see if this was being done and let this surveyor know.
On 07/02/25 at 10:10 AM, during an interview, the Administrator indicated she did not have any additional information on posting of daily nurse staffing. She also indicated the facility used the daily staffing logs for time keeping purposes, but the logs were kept in the staff break room and not posted where they are available for residents and family to review. The Administrator stated the facility did not have a policy on posting nurse staffing information.

Based on observation, interview, and facility policy review, the facility failed to ensure foods stored in the freezer, refrigerator, and dry storage area were covered; one of two ice scoop holders were maintained in a sanitary manner, expired food items were promptly removed and discarded on or before the expiration or use by date; and that dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for two of two meals observed.
The findings include:
On 06/29/25 at 10:15 AM, during an observation, an opened bag of bread was on a rack on top of the food preparation counter, exposing it to air. The Dietary Manager (DM) stated it was supposed to be sealed to prevent something crawling in it.
On 06/29/25 at 10:21 AM, during an observation, Dietary Aide (DA) #1 placed a mop in the Janitor's closet, contaminating her hands. Without washing her hands, she picked up the pans to use in transferring cooked food for lunch and placed them on the utility cart by the steam table, with her thumb inside the pan.
On 06/29/25 at 10:24 AM, during an observation and concurrent interview, DA #1 picked up a bowl with her fingers inside the bowl, poured dry cereal in the bowl, and placed her bare hand over the cereal to be served to a resident. DA #1 was asked what she should have done after touching dirty objects and before handling clean equipment. DA #1 stated that she should have washed her hands.
On 06/29/25 at 10:27 AM, the following observations were made in the walk-in refrigerator:
- An opened bag of cheese was on a shelf in the walk-in refrigerator. The bag was not sealed, leaving it exposed to cross contamination.
- An opened bag that contained slices of ham was on a shelf. The bag was not sealed, leaving it exposed to cross contamination.
On 06/29/25 at 10:35 AM, DA #1 separated the tray cards and placed them on the counter. Without washing her hands, she picked up dishes and placed them on the counter with her fingers inside the dishes and portioned food into the dishes to be served to residents for lunch. DA #1 stated that she should have washed her hands.
On 06/29/25 at 10:44 AM, the following observations were made around the food preparation area in the kitchen.
- An opened box of crackers was on a shelf in the storage room. The box was not covered or sealed.
- An opened box of tea was on a shelf in the kitchen. The box was not covered or sealed. The DM stated they were supposed to be closed to prevent something from crawling in it.
During an observation and current interview on 06/29/25 at 10:50 AM, the scoop holder, on the wall by the ice machine, had water standing in it, with white flaky residue floating on the water, and the ice scoop resting on it. The DM stated the scoop holder was dirty, had standing water with white residue on it, and that the kitchen used it for the beverages served to the residents.
On 06/29/25 10:53 AM, DA #1 pushed a cart towards a rack that contained clean glasses. Without washing her hands, she picked up glasses by the rims and placed them on the cart. DA #1 then poured beverages into each glass to be served to the residents with their lunch meal. DA#1 stated that she should have washed her hands.
On 06/29/25 at 10:59 AM, the following observations were made in the nutrition room refrigerator on the 100-hall:
-A bottle of chocolate milk on a shelf had an expiration date of 06/20/25.
-A bag of bread on a shelf had an expiration date of 05/15/25.
On 06/29/25 at 11:44 AM, DA #2 wore gloves while using scissors to cut open the plastic wraps that covered the lids on the cream pie trays, contaminating her gloves in the process. Without changing her gloves or washing her hands, she then used the same contaminated gloves to place slices of pie onto individual plates. DA #2 stated that she should have removed the gloves and washed her hands after touching dirty objects and before handling food items.
A review of the facility policy titled, Hand washing and glove usage in food service, indicated hands should be washed before starting work, after leaving and returning to the kitchen preparation area and after touching anything else such as dirty equipment and work surfaces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review the facility failed to report an allegation of sexual abuse to the State Survey Agency within the required 2-hour time period for one (Resident #2) of three sampled residents reviewed for abuse.
The findings include:
Review of the Medical Diagnosis portion of Resident #2 ' s electronic health record revealed diagnoses which included right hip fracture, anxiety, and depressive disorder.
The discharge Minimum Data Set (MDS) with an Assessment Reference Date of 12/26/24, revealed Resident #2 had a Staff Assessment for Mental Status assessment score of 0, which indicated memory was okay, and was independent. The MDS also indicated no behaviors were exhibited, and that Resident #2 was occasionally incontinent of bladder.
Review of a, OLTC [Office of Long-Term Care] Incident and Accident Report, dated and with a discovery date of 12/26/2024 at 3:03 AM, and submitted on 12/26/24 at 8:20 AM, indicated Resident #2 alleged Certified Nursing Assistant (CNA) #3 fondled Resident #2's groin area and breast while assisting the resident to the bathroom. Resident #2 reported that while they were standing and holding onto a bathroom handrail, CNA #3 reached around and fondled Resident #2's groin and breast, before leaving the room without providing assistance. Resident #2 reported they used their wheelchair to exit their room, find a nurse, and report the incident.
During an interview on 06/17/2025 at 9:20 AM, Resident #2 ' s family member revealed Resident #2 was brought to the facility on [DATE] for skilled nursing care. On 12/26/2024 between 2:00-3:00 AM, Resident #2 called and asked to be picked up. Resident #2 was described as emotional and alleged CNA #3 touched Resident #2 inappropriately. Resident #2 was picked up after 3:00 AM and family arranged home health services.
During an interview on 06/17/2025 at 10:38 AM, Licensed Practical Nurse (LPN) #5 revealed no knowledge of any physical or sexual abuse allegations but would ask questions and report suspicions to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) right away. LPN #5 revealed the facility had 24 hours to report sexual or physical abuse allegations.
During an interview on 06/17/2025 at 12:05 PM, CNA #4 reported not being aware of any abuse complaints, but would report suspicions to the charge nurse right away, to report within 24 hours.
During an interview on 06/17/2025 at 2:19 PM, the DON stated the alleged abuse was discovered on 12/26/2024 at 3:03 AM but was not reported to the Administrator until later, for an unknown reason. The DON indicated that the alleged perpetrator was sent home right away on suspension, and family and police were notified immediately. Resident #2 refused to go to the emergency room and the facility offered to arrange skilled care at another facility. The alleged perpetrator had no history of inappropriate behavior and answers to a charge nurse. The DON confirmed sexual abuse allegations should be reported in 2 hours. I do not know what time the Administrator was notified.
On 06/18/2025 at 3:05 PM during a phone interview, this surveyor spoke with CNA #3. CNA #3 stated All I did was help this person go to the bathroom and set Resident #2 up, holding onto the handrail, assisted in pulling down their pants, guide them to the commode and instructed them on how to use the bathroom call light and left the room. CNA #3 revealed assisting Resident #2 pull down the resident ' s pants while standing behind Resident #2. CNA #3 confirmed that their hands stayed on top of Resident #2's clothing. CNA #3 indicated training in abuse was completed annually. CNA #3 knew to report suspicions of abuse right away. CNA #3 denied touching Resident #2 inappropriately.
During an interview on 06/18/2025 at 3:30 PM, the Administrator revealed staff did not call to report the allegation, and stated, someone texted the Administrator ' s phone on 12/26/2024 at 3:03 AM. An allegation of abuse was submitted to the Office of Long-Term Care on 12/26/2024 at 8:20 AM because, we did not feel abuse occurred, this was why it was not reported in 2 hours. The Administrator revealed the DON, ADON, and Administrator were responsible for investigating and reporting allegations of abuse. An investigation was completed and the allegations against CNA #3 were unfounded, witness statements did not support the allegation. Staff were trained on abuse and neglect on 12/26/2024.
During an interview on 06/18/2025 at 3:45 PM, the Medical Director (MD) said that someone called when the allegation of abuse occurred. The MD indicated that an assessment was not done because a family member picked Resident #2 up right away and they were going to the emergency room. Assistance with finding another facility to go to for skilled care was declined. The MD stated, It was an unusual situation, and there was no bodily injury to my knowledge.
During an interview on 06/19/2025 at 10:25 AM, the Administrator stated if events or allegations do not cause abuse or bodily injury, they do not require 2-hour notice, and it was her opinion that this incident did not meet the criteria for a 2-hour reporting. The Administrator stated Resident #2 stated to the DON and [the Administrator] that CNA #3 fondled Resident #2 in the groin and breast area when taking [Resident #2] to the bathroom, and there was no serious bodily injury.
During an interview on 06/19/2025 at 12:40 PM, the ADON looked at a cellphone and revealed the ADON sent a text to Administrator on 12/26/2024 at 3:03 AM. The ADON said call logs were not available to support that the ADON called the administrator by phone. The ADON said the procedure was to send a text and to call within five minutes, if there was not a response from the administrator. I do not know if I called the Administrator or not. There are no call logs to support that a call was made.
Review of a policy titled, Abuse, Neglect, and Maltreatment, revealed the facility had a policy in place to protect residents from neglect, abuse, misappropriation, sexual abuse, exploitation and physical abuse. Background checks were done on all employees, and the facility would not knowingly employee someone with a history of abuse. In-services were done on hire and annually. When an allegation of abuse was made it should be reported to the administrator immediately, and the accused person would be removed from the facility during investigation.
Review of an in-service training on Abuse and Neglect Policy dated 12/26/2024, revealed staff were educated on the policy titled Abuse, Neglect, and Maltreatment.

Based on observation, record review and interview, the facility failed to ensure staff followed care planned intervention requiring two staff members to perform mechanical lift transfers to promote resident safety and prevent fall with injury for 1 (Resident #15) of 8 (Residents #3, #6, #10, #15, #20, #26, #33 and #46) sampled residents who required the mechanical lift for transfer. This failed practice resulted in actual harm for Resident #15, who fell and sustained a fracture, and had the potential to cause more than minimal harm for 13 residents who required transfers with a mechanical lift. The facility failed to ensure that chemicals were kept out of reach for 1 (Resident #49) sampled resident.
The findings are:
1. The Significant Change in Condition Minimum Data Set (MDS) with an Assessment Reference Date of 06/05/2024 indicated Resident #15 had diagnoses of heart failure, diabetes mellitus, arthritis, and other fracture, and that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was dependent for transfers, and had one fall with major injury.
a. The Care Plan with a revision date of 04/30/2024 indicated, .Problem: (Resident #15) has an ADL (Activities of Daily Living) self-care performance deficit .Approaches/Tasks .TRANSFER: (Resident) is dependent on total assist via Mechanical Lift with (2) staff assist for transfers with full blue sling .
b. The Care Plan with a revision date of 06/03/2024 indicated, .Problem: (Resident #15) is at risk for falls r/t (related to) bilateral lower extremity weakness & daily use of psychotropic drugs. 6/1/24- fall with injury .Goal: Will be free of falls through the review date .
c. An Incident Note dated 06/01/2024 at 6:33 PM by Licensed Practical Nurse (LPN) #11 indicated, .Nature and Description of Incident: CNA (Certified Nursing Assistant) was transferring resident back to bed using lift. While resident was in lift resident began to slowly slip out of the lift pad from the bottom. Resident was assisted to the ground by CNA to prevent hard fall. Resident states no injury and did not hit head. There is a scratch on her lower back from where she made contact with the leg of the lift .Description of Injuries: Scratch noted to lower back .Immediate Action Take: CNA was reeducated on how to position lift pad and resident while using lift and lift use safety .
d. An Order Administration Note dated 06/03/2024 at 1:05 AM indicated, .Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligram) Give 1 tablet by mouth one time only for acute pain post fall 1 Day acute pain to sacral region post fall on 06/01. Pain reports 8/10 .
e. A Nurses Note dated 06/03/2024 at 1:16 AM indicated, .Resident requested a Norco this shift r/t (related to) acute pain scale of 8/10 to lumbar/sacral region post fall on 06/01/24. Resident has an active order for Norco 7.5/325 mg tablets PRN [when needed], but none available in cart r/t (related to) expiration since Resident had not taken one since January 2024. Norco 7.5/325 mg is not available in facility e-kit, so this nurse contacted on-call provider via Access Medical for further instruction. This nurse spoke with (named provider) APRN (Advanced Practice Registered Nurse) and received orders for the following: STAT x-ray of the lumbar/sacral region and 1 x dose of Norco 5/325 mg to be administered now; call back if dose ineffective. Norco 5/325 mg was administered per orders from facility e-kit, and paperwork faxed to (Named pharmacy) pharmacy as indicated. Provider reports that he will fax to pharmacy a script to provide coverage for used dose from e-kit. This nurse attempted to input order for x-ray to (Named Radiology Company) but (named Radiology Company) site shows resident's chart as inactive and would not allow order to be processed. This nurse contacted (Named Radiology Company) and spoke with (Named radiology company employee) at 11:56 PM, who input the order manually from her end for the STAT (medical abbreviation for urgent or rush) x-ray. Resident notified of new orders. This nurse did not place a call to resident's RP (Responsible Party) at this time r/t (related to) the non-emergent nature of the clinical situation. Report left for oncoming shifts. Plan of care continues .
f. A Nurses Note dated 06/03/2024 at 3:31 AM indicated, .(Named Radiology Company) technician presented to facility, obtained x-rays, and exited facility. Results pending at this time .
g. A Nurses Note dated 06/03/2024 at 3:36 AM indicated, .results returned with the following impression noted: Suspected lower sacral nondisplaced fracture is noted denoted by cortical step deformity seen along its anterior surface. Results reported via facility secure messaging system to facility APRN, (Named APRN); response pending. Resident is resting well at this time with no complaints of pain. (Named) Director of Nursing (DON) notified via telephone correspondence. Resident notified of clinical findings. This nurse attempted to contact resident's (Responsible Party), but was unsuccessful; not able to leave a voicemail. Report left for oncoming shifts. Plan of care continues .
h. A form titled, Radiology Results Report documented, .Examination Date: 06/03/2024 .Procedure: Lumbo-sacral spine (2-3 V (View)) AP (Anterior Posterior) Lat (Lateral), Spot/Report .Impression: Suspected lower sacral nondisplaced fracture is noted denoted by cortical step deformity seen along its anterior surface .
i. A Progress Note signed by the Advanced Practice Registered Nurse [APRN], dated 06/04/2024 at 10:49 AM, indicated, .This encounter was performed using interactive video and audio communications. This visit is medically indicated to evaluate Resident for sacral pain. Resident states experiencing pain in lower back, sacrum area following a fall. Pain is becoming worse . Assessment/Plan: 1. Sacral back pain: x-ray to lumbar/sacrum. Hydrocodone 5/325 mg x 1 dose now. rx (Prescription) sent to pharmacy .
j. A Progress Note signed by the APRN dated 06/05/2024 at 7:01 PM indicated, This visit was conducted via telemedicine with audio and visual. This visit is medically necessary to review x-ray and pain. Resident with non-displaced fracture of sacral area complaining of pain to area at this time .Assessment/Plan: 1. Pain in pelvis: continue Hydrocodone. Hydrocodone 5 mg-acetaminophen 325 mg table - To be submitted on or around 6/6/24 - Take 1 tablet (s) every 6 hours by oral route for 14 days .2. Fracture of sacrum - avoid constipation - repeat x-ray in two weeks .
k. On 06/24/2024 at 1:43 PM, Resident #15 was sitting in a wheelchair in the dining room. Resident #15 was asked if experienced a fall recently? Resident #15 stated, I fell about a month ago. I was dropped out of the sling, and I broke my tail bone. He was working the lift by himself.
l. On 06/25/2024 at 4:10 PM, Licensed Practical Nurse (LPN) #11 was asked how much assistance Resident #15 needed with ADL's (Activities of Daily Living)? LPN #11 stated, Resident #15 can help roll over when in bed, but cannot get out of bed by alone. We use a total mechanical lift with two people. LPN #11 was asked if working the day Resident #15 had the fall from the lift? LPN #11 stated Yes I was working. LPN #11 was asked to describe what happened. LPN #11 stated, I was doing medication pass when [Resident #15] was being put back in bed. The CNA (Certified Nurse's Aide) came out to get another CNA. Then the other CNA came out and immediately got me. When I went into the room Resident was sitting right beside the bed between the legs of the lift. (Named CNA #6) and the Resident both said the lift pad that was divided was not under the Resident's bottom enough and when the aide went to transfer her, [Resident #15] slipped off. (The aide) said when he realized that the Resident was going down, he tried to ease [Resident] down. LPN #11 was asked when the Resident started to slip out of the lift pad, was there another aide in the room. LPN #11 stated, No it was just the one aide. LPN #11 was asked if there should there have been two aides in the room when the transfer was being done. LPN #11 stated, Yes. LPN #11 was asked, What did you do after you entered the room? LPN #11 stated, I immediately assessed the Resident. [Resident] did not want an x-ray or go to the hospital. [Resident] did not complain of any pain. Me and the other two CNAs got the Resident into the bed. I immediately told [CNA #6] he should not have done it on his own. LPN #11 was asked if all mechanical lift transfers were supposed to be done by two people. LPN #11 stated, Yes, and if they don't have a second CNA, I go with them to be the second person. LPN #11 was asked who they reported the incident to. LPN #11 stated, The Director of Nursing [DON]. LPN #11 was asked what was done after this incident occurred. LPN #11 stated, We all had to have a whole new education on how to do the lift. I was in-serviced and so was everyone else. LPN #11 was asked if the CNA that did the transfer by themselves still worked at the facility. LPN #11 stated, I didn't ask, but I have not seen him since. LPN #11 was asked, when you came to work for the facility, were you trained in the use of the lift? LPN #11 stated, Yes. LPN #11 was asked if the Resident sustained an injury from the incident. LPN #11 stated, once they did convince [Resident #15] to get an x-ray it showed a fractured sacrum.
m. On 06/25/2024 at 4:45 PM, the DON was asked if familiar with Resident #15's care. The DON stated, Yes. The DON was asked how much assistance the Resident required with ADL (Activities of Daily Living). The DON stated, [Resident #15] requires the lift for transfer but is set up with a lot of the other ADLs. The DON was asked, how long has the Resident required the lift for transfer? The DON stated, I have worked here for 6 months, and [Resident #15] has required the lift all during that time. The DON was asked how many people are required to do a mechanical lift transfer. The DON stated, Two people. The DON was asked if they were involved in the investigation when (Resident #15) fell out of the lift. The DON stated, Yes. The DON was asked to describe what happened. The DON stated, (Named CNA #6) was transferring [Resident #15], and [Resident #15] began to slip out of the lift pad. He assisted [Resident #15] to the floor. The DON was asked if CNA #6 was doing the transfer by himself. The DON stated, Upon investigation it looked like he was doing it by himself. The DON was asked how long the aide had worked for the facility at the time of the incident. The DON stated, I am not sure exactly, but I believe 2-3 months. The DON was asked what was done when the incident occurred. The DON stated, The immediate intervention was the nurse with him educated him and then he was suspended pending the investigation. The DON was asked, what day was he suspended? The DON stated, He was suspended on 06/03/2024. He was supposed to be on his days off, but we had called him in to work on the day of the incident. He was suspended as soon as I read his statement. That's when I identified he was by himself. I immediately pulled his lift check off to ensure that he was checked off prior to performing the lift transfer and he was. The Assistant Director of Nursing (ADON) and myself trained all the CNAs on the correct use of the lift and we did all new check offs on everyone. The DON was asked, how often do you do skills check offs on lift transfers on the aide staff? The DON stated, We do them on hire and then every three months. We did them again on the aides though at that time even if they had just been done. After we did the training, we, the ADON and I, did monitoring to ensure that staff were doing the procedure correctly and that there were two people at all times. The DON was asked, what happened with the CNA that did the transfer by themselves? The DON stated, He was ultimately terminated. He never worked again once he was suspended. The DON was asked, did you send a report into the state of the incident? The DON stated, No we did not. The DON then stated, We also had our service provider for the lifts (named provider) come out and check all the lifts to ensure it was not a failure with the lift. The MDS (Minimum Data Set) Coordinator also checked to make sure that every one that used a mechanical lift was appropriately marked on the kiosk. We even made a video of the correct use of the lift, and we use that with our in-service and skills check-off lists now The DON was asked if they let the Administrator know about the incident. The DON stated, Yes. Immediately.
The DON then provided the Surveyor the folder with the documentation of the investigation she did after the incident and the measures that were put in place to correct the deficient practice.
n. On 06/26/2024 at 5:00 PM, the form titled OLTC (Office of Long-Term Care) Witness Statement Form provided by the Director of Nurses dated 6/1/2024 at 4:30 PM and signed by CNA #6 on 6/03/2024 indicated, .I used the mechanical lift by myself to transfer (Resident #15) from the wheelchair to the bed. While [Resident #15]was in the air, [Resident] began to slip out of the lift pad from the lower body. It was too late to correct the problem, so I placed my arms underneath [Resident] and gradually lowered [Resident] to the ground to prevent a hard fall. Once [Resident] was on the ground, I asked if [Resident] was okay, and [Resident] responded that [Resident] was not hurt. I went and got (named LPN #11), the nurse and (named staff member), CNA to further assist me with getting (Resident) up from the ground. I believe the cause of this accident is that I did not tuck the lift pad enough under her body to keep [Resident] from slipping out. I used the light blue lift pad with 6 strings .
o. On 06/26/2024 at 8:50 AM, the Assistant Director of Nursing (ADON) was asked if familiar with Resident #15's care. The ADON stated, Yes. The ADON was asked how much assistance does Resident #15 require with ADL's. The ADON stated, [Resident #15] is a total assist for transfer so two people. Dressing can be done by one person. The ADON was asked if aware of the incident that happened with the lift on June 1st? The ADON stated, Yes. The ADON was asked how became aware of the incident. The ADON stated, It happened over the weekend, so I did not know about it until I came to work on Monday. Before the morning meeting, I always look at the incident and accident reports and that is when I saw [Resident #15] had an incident with the lift. We saw [Resident] had an x-ray and it showed [Resident] had a fracture. The ADON was asked what was done at that point. The ADON stated, We spoke with the Resident and called the CNA. We did an in-service and he was put on leave after we had him write a statement. After we did the rest of the investigation the CNA was terminated. The ADON was asked how they ensure that staff were doing the lift transfers correctly. The ADON stated, The Director of Nursing and I monitored lift transfers for the next two weeks to make sure there were two people and that the staff did the lift transfer correctly.
p. On 6/26/24 at 9:30 AM, the Administrator was asked when they became aware that Resident #15 had fallen from the lift. The Administrator stated, It happened on 06/01/2024. I became aware of the incident on 6/3/2024. The Administrator was asked how they become aware of the incident. The Administrator stated, The Resident started complaining of pain and [Resident #15] had an x-ray done and I think [Resident' s] tail bone was injured. The incident and accident report did not say anything about [Resident] complaining of pain and it did not say anything about him doing it (the transfer) by himself. The Administrator was asked what was done to investigate the incident. The Administrator stated, We did interviews. That is when we discovered that he did the transfer by himself. We did in-service for all staff. We did check off lists for lift transfers on staff and put a monitor in place to be sure staff were doing the transfers correctly. The employee was terminated for not following policy, but we checked first to make sure he had done the lift skills list prior to doing lift transfers and he had. The Administrator was asked if all lift transfers are supposed to be done by two people. The Administrator stated, Yes.
r. On 06/26/2024 at 12:00 PM, the Administrator was asked for a policy on mechanical lift transfers.
s. On 06/26/2024 at 12:05 PM, the Director of Nursing stated, We do not have a policy on lift transfers, we refer to the Manufactures Guidelines
2. The Medical Diagnoses portion of Resident #49's electronic health record revealed diagnoses of Alzheimer disease, vascular dementia, and anxiety disorder.
a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2024 documented Resident #49 scored 03 (00-07 indicates severely impaired cognition) on the Brief Interview for mental Status (BIMS)
b. Review of the Care Plan with a revision date of 02/09/2024 revealed Resident #49 re-arranges furniture and pulls out drawers in his/her room and will also place it in bathroom related to dementia and poor safety awareness.
c. On 06/24/2024 at 10:14 AM, the surveyor observed in Resident #49's bathroom a can of disinfectant spray and a can of cleaning spray solution.
d. On 06/24/2024 at 3:55 PM, the surveyor observed in Resident #49's bathroom a can of disinfectant spray and a can of cleaning spray solution.
e. On 06/25/2024 at 8:35 AM, the surveyor observed in Resident #49's bathroom a can of disinfectant spray and a can of cleaning spray solution.
f. On 06/26/2024 at 8:41 AM, the surveyor observed in Resident #49's bathroom a can of disinfectant spray and a can of cleaning spray solution.
g. On 06/26/2024 at 10:18 AM, Certified Nursing Assistant (CNA) #7 was asked to describe the facility protocol for allowing residents to keep cleaning agents and disinfectant sprays in their room. CNA #7 stated they are not supposed to have them in their rooms, we are supposed to lock them up in the shower room. CNA #7 was asked if residents wander into other resident's rooms. CNA #7 replied, Yes, all the time. CNA #7 was asked who is responsible for making sure chemicals and disinfectants aren't left out in resident ' s rooms. CNA #7 replied, The CNA's, nurse, housekeeping, and anyone who goes in the room. CNA #7 was asked how often the rooms checked to assure chemicals are not left out in a resident ' s room. CNA #7 replied, Every shift.
The Surveyor took CNA #7 into the Resident's room to the bathroom and asked her to describe what she saw. CNA #7 identified a can of disinfectant and a can of cleaning spray.
On 06/26/2024 at 10:36 AM, LPN #8 was asked to explain the facility protocol for having chemicals and disinfectants in a resident's rooms. LPN #8 replied, They should never have it in their room. LPN #8 was asked who is responsible for making sure that these chemicals are not in the residents rooms. LPN#8 replied, All the staff. CNAs should check the room every shift but anyone who goes in the room should be checking. The Surveyor took LPN #8 to Resident #49 ' s bathroom and asked her to describe what she saw. LPN #8 said there is a can of cleaning spray and a can of disinfectant. LPN #8 was asked if this was safe to be in this room. LPN #8 replied, No, it isn't. LPN #8 was asked how often rooms should be checked to assure that chemicals are not in the residents rooms. LPN #8 replied, When you first arrive on the shift and after housekeeping leaves to assure, they didn't leave a can of something in the room.
On 06/26/2024 at 10:50 AM, the DON was asked for the facility protocol regarding having chemicals and disinfectants in a resident ' s room. The DON replied, They are not allowed to have them in their rooms. The DON was asked if residents wander into other residents rooms. The DON replied, Yes, all the time. The DON was asked who is responsible for making sure that chemicals are not left in a resident's rooms. The DON replied that every person who goes in that room should be checking and if found remove them. The DON was asked how often are rooms checked to ensure there are no chemicals in residents rooms. The DON replied, They are checked a minimal of every 2 hours or when someone goes in the room.
On 06/26/2024 at 2:48 PM, the facility was asked to provide a policy and surveyor was informed they did not have a policy.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of residents for 1 of 1 meal observed. This failed practice had the potential to affect 36 residents who received regular diets, 23 mechanical soft diets, and 2 residents who received pureed diets from 1 of 1 kitchen.
The findings are:
1. The menu for the 06/24/2024 noon meal documented all diets were to receive cake, residents who received pureed diets were to receive 6 ounces of pureed chicken fajita (2/3 cup) and all residents were to receive sour cream pound cake.
2. On 06/24/2024 at 11:25 AM, Dietary [NAME] (DC) #1 used a #16 scoop (2 ounces) (1/4 cup) to place 6 servings of chicken fajita into a blender, with no tortilla or bread, (DC)#1 added chicken broth and pureed. At 11:27 AM, DC #1 poured the pureed chicken fajita into a pan and placed it in the oven.
3. On 06/24/2024 at 12:30 PM, DC #1 used a #8 scoop (1/2 cup) to serve a single portion of pureed chicken fajita with no tortilla or bread to the residents on pureed diets. The menu specified for each resident on pureed diets to receive a #6 scoop of pureed chicken fajita (2/3 cup).
4. On 06/24/2024 at 1:15 PM, no cake served to residents during the lunch meal. On 06/25/24 at 7:50 AM, the surveyor asked Dietary Aid (DA)#2 the reason cake was not served to the residents. DA #2 stated, I totally forgot. I thought it was supposed to be peaches.
5. On 06/24/2024 at 1:16 PM, the surveyor asked DC #1 what scoop size she had used to portion out chicken fajita for the residents who required pureed diets. She stated #16 scoop. The surveyor asked DC #1 how many servings of chicken fajita she prepared for the residents on pureed diets. DC #1 stated, I put 6 servings. The surveyor asked Dietary [NAME] #1 what scoop size she used to serve pureed chicken fajita and how many servings each resident received. Dietary [NAME] #1 stated, I used a #8 scoop, and I gave one serving each. The surveyor asked DC #1 the reason tortilla was not used pureed. DC #1 stated, They may choke on it. I should have used bread.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets.
The findings are:
1. On 06/24/2024 at 10:36 AM, Dietary [NAME] (DC)#1 used a #8 scoop to place 6 servings of refried rice into a blender, added beef broth and pureed. DC #1 poured the pureed refried rice into a pan and placed it in the oven. The consistency of the pureed refried rice was runny. At 11:35 AM, DC #1 added thickener into a pan of pureed rice that was on the steam table and mixed it with a spoon, which created lumps of thickener that were not completely dissolved in the mixture.
2. On 06/24/24 10:50 AM, DC #1 used a #8 scoop to place 4 servings of refried beans into a blender and pureed. DC #1 poured the pureed refried beans into a pan and placed it in the oven. The consistency of the pureed refried was thick.
3. On 06/24/2024 at 11:57 AM, the surveyor asked DC #1 to describe the consistency of the pureed refried rice and pureed refried beans. DC #1 stated, Pureed refried beans was thick. I added thickener on refried rice because it was thin, and it left lumps.
4. On 06/24/2024 at 12:50 PM, the surveyor asked Certified Nursing Assistant (CNA) #3 who was assisting residents in the unit dining room with their meal to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, They were thick.
5. On 06/24/2024 at 12:55 PM, the surveyor asked (Licensed Practical Nurse) LPN #4 to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed refried beans was thick, pureed refried rice was sticky and thick, and both pureed regular peaches and pureed peaches with cottage cheese were thin.
6. On 06/25/2024 at 7:51 AM. the surveyor asked DC #1 to describe the consistency of the pureed sausage served to the residents on pureed diets for breakfast. DC #1 stated It was lumpy, it was supposed to be smooth.

Based on observation, record review, and interview, the facility failed to ensure food items stored in the freezer were sealed or covered, food items stored in the storage room were stored in accordance with the manufacturer's instructions; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; expired products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria,
failed to ensure hot foods was maintained at or above 135 degrees Fahrenheit (F.) while awaiting to be served to prevent potential food borne illness, and failed to ensure leftover food items were not used for residents who received meals from 1 of 1 kitchen to maintain food quality and prevent the growth of bacteria. These failed practices had the potential to affect 62 residents who received meals from the 1 of 1 kitchen.
The findings are:
1. On 06/24/24 at 9:40 AM, the following observations were made in the kitchen.
a. Dietary [NAME] (DC)#1 picked a spatula from the edge of the grill she had used to stir food items on the grill. Without washing her hands, she used her bare hand to pick up slices of bacon and placed them on the tray to be used for the breakfast meal on 06/25/24. The surveyor asked DC#1 what should have been done after touching dirty objects and before handling food items? DC#1 stated, I should have washed my hands.
b. There were 5 glasses that contained lemonade, 5 glasses with punch and 13 glasses with tea that did not have lids on them, exposing them to possible air contamination or pests. The surveyor asked the Dietary Manager should those glasses be covered. She stated, Yes. They should be covered.
c. The floor tile in front of the freezer was peeling off. The area that was peeled off had a red color to it that caused the shoe to stick on it.
2. On 06/24/24 at 9:48 AM, an opened bottle of syrup was on a shelf in the refrigerator. There was no opened date on the bottle to ensure first in and first out.
3. On 06/24/24 at 9:51 AM, the following observations were made in the refrigerator:
a. There was a container of leftover mushrooms on a shelf. The container had a date of 06/12/2024. The surveyor asked DC #1 how long the leftover food items should be kept in the refrigerator? DC#1 stated, We keep them for 7 days.
b. A gallon of soy sauce on a shelf in the refrigerator had an expiration date of 05/29/2024.
4. On 06/24/2024 at 10:01 AM, a container of ground mustard on the spices rack in the kitchen had an expiration date of 06/16/2024.
5. On 06/24/2024 at 10:13 AM, the following observations were made in the dish washing machine room.
a. The edges, the planes, and the inside of the vent hood in the dish washing machine has an accumulation of built up of rust on them.
b. The wall in the dish washing machine room had discoloration of sage color on it. The Dietary Manager stated, There was mold build up. They needed to be stained.
6. On 06/24/2024 at 10:18 AM, an opened box of loose tea was on a shelf below the tea maker. The box was not covered or sealed.
7. On 06/24/2024 at 10:20 AM, DC #1 picked up a dirty pan and took it to the dish washing machine room and placed it on a dirty shelf to be washed. Without washing her hands. She picked up clean dishes and stacked them on a shelf with her fingers on the inside of the plates.
8. On 06/24/24 at 10:29 AM, the following personal items were on the food preparation counter by a zip lock bag that contained slices of green bell pepper:
a. A telephone, cigarette lighter bag and a water bottle. The surveyor asked DC #1 if a telephone, cigarette lighter bag and personal cup were supposed to be on the food preparation table. DC #1 stated, No.
9. On 06/24/2024 at 10:32 AM, the shelf below the food preparation counter where clean pans were stored had loose food particles.
10. On 06/24/2024 at 10:35 AM, Dietary Aide (DA) #2 turned on the hand washing sink faucet and washed her hands. As she finished washing her hands, she turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, DA #2 picked up glasses by the rims and stacked them on a shelf to be used in serving beverages to the residents for the lunch meal. DA #2 also picked up dishes with her long fingernails with nail polish inside of the plates.
11. On 06/24/2024 at 10:47 AM, DC #1 grabbed a surveyor on her arms with her bare hands, contaminating her hands. Without washing her hands, she picked up a clean blade and attached it to the base on the blender to be used in pureeing food items to be served to the residents on pureed diets. The Dietary Manager informed DC #1 to rewash the blade and the blender before using it.
12. On 06/24/2024 at 10:55 AM, an opened box of cobbler crust dough shell was on a shelf in the freezer. The box was not covered or sealed.
13. On 06/24/2024 at 10:58 AM, the following observations were made in the storage room:
a. An opened bottle of soy sauce was on a shelf in the storage room. The manufacturer specification on the bottle documented, Refrigerate after opening.
b. 18 boxes of corn starch on a shelf in the storage room with expiration dates of 06/16/2024.
14. On 06/24/2024 at 11:15 AM, the spout of a pitcher in the refrigerator that contained punch was not covered, exposing it to air or cross contamination.
15. On 06/24/2024 at 11:57 AM, DC #1 checked and read the temperatures of the hot food items that had been placed on the serving line on the steam table in preparation for the lunch meal service. The temperature was ground chicken fajita at 128 degrees Fahrenheit. At 12:20 PM, the chicken fajita was not reheated before being served to the residents on mechanical soft diets. On 06/25/24 at 07:52 AM, the surveyor asked Dietary Manager and DC #1 What should you do when food items are not hot enough on the steam table? Dietary Manager stated, We should have pull it out and reheated it.
16. The facility policy titled, Hand Washing and Glove Usage in Food Service, provided by the Dietary Manager on 06/25/2024 at 08:26 AM on documented, When food handlers must wash their hands: ·Before starting work .After touching anything else such as dirty equipment and work surfaces or cloths .

Based on observation, record review and interview, the facility failed to report to the State Survey Agency a fall from the mechanical lift that resulted in major injury for 1 (Resident #15) sampled resident that occurred when a staff member failed to follow care planned intervention requiring two people for lift transfers.
The findings are:
1. The Significant Change in Condition Minimum Data Set (MDS) with an Assessment Reference Date of 6/5/24 indicated Resident #15 had a diagnoses of heart failure, Diabetes Mellitus, arthritis, and other fracture, the Resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was dependent for transfers, and had one fall with major injury.
a. The Care Plan with a revision date of 04/30/2024 indicated, .Problem: (Resident #15) has an ADL (Activities of Daily Living) self-care performance deficit .Approaches/Tasks .Transfer: (Resident) is dependent on total assist via Mechanical Lift with (2) staff assist for transfers with full blue sling .
b. The Care Plan with a revision date of 06/03/2024 indicated, .Problem: (Resident #15) is at risk for falls r/t [related to]bilateral lower extremity weakness & daily use of psychotropic drugs. 06/01/2024- fall with injury .Goal: Will be free of falls through the review date .
c. An Incident Note, dated 06/01/2024 at 8:33 PM, by Licensed Practical Nurse (LPN) #11 indicated, .Nature and Description of Incident: CNA (Certified Nursing Assistant) was transferring Resident back to bed using lift. While Resident was in lift Resident began to slowly slip out of the lift pad from the bottom. Resident was assisted to the ground by CNA to prevent hard fall. Resident stated there was no injury at the time and head was not hit. There is a scratch on [Resident's] lower back from where contact was made with the leg of the lift .Description of Injuries: Scratch noted to lower back .Immediate Action Take: CNA was reeducated on how to position lift pad and Resident while using lift and lift use safety .
d. An Orders-Administration Note, dated 06/03/2024 at 12:05 AM indicated, .Hydrocodone- Acetaminophen Oral Tablet 5-325 MG (milligram) Give 1 tablet by mouth one time only for Acute pain post fall for 1-day acute paint to sacral region post fall on 06/01. Pain reports 8/10
e. A Nurses Note, dated 06/03/2024 at 1:16 AM indicated, .Resident requested a Norco this shift r/t (related to) acute pain scale of 8/10 to lumbar/sacral region post fall on 06/01/24. Resident has an active order for Norco 7.5/325 mg tablets PRN, but none available in cart r/t expiration since Resident had not taken one since January 2024. Norco 7.5/325 mg is not available in facility e-kit, so this nurse contacted on-call provider via Access Medical for further instruction. This nurse spoke with (named provider) APRN (Advanced Practice Registered Nurse) and received orders for the following: STAT x-ray of the lumbar/sacral region and 1 x dose of Norco 5/325 mg to be administered now; call back if dose ineffective. Norco 5/325 mg was administered per orders from facility e-kit, and paperwork faxed to (Named pharmacy) pharmacy as indicated. Provider reports that he will fax to pharmacy a script to provide coverage for used dose from e-kit. This nurse attempted to input order for x-ray to (Named Radiology Company) but (named Radiology Company) site shows Resident's chart as inactive and would not allow order to be processed. This nurse contacted (Named Radiology Company) and spoke with (Named radiology company employee) [at 11:56 PM], who input the order manually from her end for the STAT x-ray. Resident notified of new orders. This nurse did not place a call to Resident's RP (Responsible Party)/daughter, (named daughter), at this time r/t (related to) the non-emergent nature of the clinical situation. Report left for oncoming shifts. Plan of care continues .
f. A Nurses Note, dated 06/03/2024 at 3:31 AM indicated, . (Named Radiology Company) technician presented to facility, obtained x-rays, and exited facility. Results pending at this time
g. A Nurses Note, dated 06/03/2024 at 3:36 AM indicated, .results returned with the following impression noted: Suspected lower sacral nondisplaced fracture is noted denoted by cortical step deformity seen along its anterior surface. Results reported via facility secure messaging system to facility APRN, (Named APRN); response pending. Resident is resting well at this time with no complaints of pain. (Named) Director of Nursing (DON) notified via telephone correspondence. Resident notified of clinical findings. This nurse attempted to contact the Resident ' s daughter/RP, (Named RP), but was unsuccessful; not able to leave a voicemail. Report left for oncoming shifts. Plan of care continues .
h. A form titled Radiology Results Report indicated, .Examination Date: 06/03/2024 .Procedure: Lumbo-sacral spine (2-3 V (View)) AP (Anterior Posterior) Lat (Lateral), Spot/Report .Impression: Suspected lower sacral nondisplaced fracture is noted denoted by cortical step deformity seen along its anterior surface .
i. A Progress Note signed by the Advanced Practice Registered Nurse [APRN], dated 06/04/2024 at 10:49 AM, indicated, . This encounter was performed using interactive video and audio communications. This visit is medically indicated to evaluate Resident for sacral pain. Resident stated has pain to lower back, sacrum area following a fall. Pain is becoming worse . Assessment/Plan: 1. Sacral back pain: x-ray to lumbar/sacrum. Hydrocodone 5/325 mg x 1 dose now. RX (Prescription) sent to pharmacy .
j. A Progress Note signed by the [APRN] dated 06/05/2024 at 7:01 PM indicated, This visit was conducted via telemedicine with audio and visual. This visit is medically necessary to review x-ray and pain. Resident with non-displaced fracture of sacral area complaining of pain to area at this time . Assessment/Plan: 1. Pain in pelvis: continue Hydrocodone. Hydrocodone 5 mg-acetaminophen 325 mg table - To be submitted on or around 06/06/2024 - Take 1 tablet (s) every 6 hours by oral route for 14 days . 2. Fracture of sacrum - avoid constipation - repeat x-ray in two weeks .
k. On 06/24/2024 at 1:43 PM, Resident #15 was sitting in wheelchair in the dining room. Resident #15 was asked if had experienced a fall recently. Resident #15 stated, I fell about a month ago. I was dropped out of the sling, and I broke my tail bone. Resident #15 was asked do you have any pain now from the injury to the tail bone. Resident #15 stated No, it is healing really well.
l. On 06/25/2024 at 4:10 PM, Licensed Practical Nurse (LPN) #11 was asked how much assistance Resident #15 needs with ADL's (Activities of Daily Living). LPN #11 stated that Resident #15 can help roll over when in bed but cannot get out of bed by alone. We use a total mechanical lift with two people. LPN #11 was asked if they were working the day Resident #15 had the fall from the lift. LPN #11 stated, Yes. I was working. LPN #11 was asked to describe what happened. LPN #11 stated, I was doing medication pass when [Resident #15] was being put back in bed. The CNA (Certified Nurse Aide) came out to get another CNA. Then, the other CNA came out and immediately got me. When I went into the room the Resident was sitting right beside the bed between the legs of the lift. (Named CNA #6) and the Resident both said the lift pad that was divided was not under the Resident's bottom enough and when the aide went to transfer [Resident] slipped off it. The aide said when he realized the Resident was going down, he tried to ease [Resident]down. LPN #11 was asked, when the Resident started to slip out of the lift pad, was there another aide in the room? LPN #11 stated, No it was just the one aide. LPN #11 was asked if there should have been two aides in the room when the transfer was being done. LPN #11 stated, Yes. LPN #11 was asked what they did after entering the room. LPN #11 stated, I immediately assessed the Resident. Resident did not want an x-ray, go to the hospital, and did not complain of any pain. Me and the other two CNAs got the Resident into the bed. I immediately told [CNA #6] that he should not have done it on his own. LPN #11 was asked if all mechanical lift transfers were supposed to be done by two people. LPN #11 stated, Yes, and if they don't have a second CNA, I go with them to be the second person. LPN #11 was asked if they knew how long the CNA did the transfers alone and how long has the CNA worked at the facility. LPN #11 stated, I am not sure. I did not work with him on a frequent basis, but I don't think it was very long. LPN #11 was asked who they reported the incident to. LPN #11 stated, The Director of Nursing. LPN #11 was asked what was done after this incident occurred. LPN #11 stated, We all had to have a whole new education on how to do the lift. I was in-serviced and so was everyone else. LPN #11 was asked if the CNA that did the transfer by themselves still worked at the facility. LPN #11 stated, I didn't ask, but I have not seen him since. LPN #11 was asked if they were aware of any other incidents with the use of the mechanical lift. LPN #11 stated, No. LPN #11 was asked, when they came to work for the facility, if they were trained in the use of the lift. LPN #11 stated, Yes. LPN #11 was asked if Resident #15 had an injury from the incident. LPN #11 stated, once they did convince [Resident #15] to get an x-ray it showed a fractured sacrum. LPN #11 was asked if Resident #15 required pain medication following the incident. LPN #11 stated, [Resident #15] did end up taking pain medication, but that was for a short period of time. I can look in the record and see when [Resident] last took something. The nurse looked in the electronic record and stated, [Resident] took one dose of Hydrocodone on Sunday the 23 rd of June.
m. On 06/25/2024 at 4:45 PM, the Director of Nurses (DON) was asked if they were familiar with Resident #15's care. The DON stated, Yes. The DON was asked how much assistance Resident #15 required with ADL's. The DON stated, [Resident #15] requires the lift for transfer but is set up with a lot of [Resident's] other ADL's [Activities of Daily Living] . The DON was asked how long has the Resident required the lift for transfer? The DON stated, I have worked here for 6 months, and [Resident] has required the lift all during that time. The DON was asked how many people are required to do a mechanical lift transfer. The DON stated, Two people. The DON was asked if they were involved in the investigation when Resident #15 fell out of the lift. The DON stated, Yes. The DON was asked to describe what happened. The DON stated, (Named CNA #6) was transferring [Resident #15], and [Resident] began to slip out of the lift pad. He assisted [Resident] to the floor. The DON was asked if CNA #6 was doing the transfer by himself. The DON stated, Upon investigation it looked like he was doing it by himself. The DON was asked how long CNA #6 had worked for the facility at the time of the incident. The DON stated, I am not sure exactly, but I believe 2-3 months. The DON was asked what was done when the incident occurred. The DON stated, The immediate intervention was that the nurse that was with him educated him, and then he was suspended pending the investigation. The DON was asked what day CNA #6 was suspended. The DON stated, He was suspended on 06/03/2024. He was supposed to be on his days off, but we had called him in to work on the day of the incident. He was suspended as soon as I read his statement. That's when I identified he was by himself. I immediately pulled his lift check off to ensure that he was checked off prior to performing the lift transfer and he was. The Assistant Director of Nursing and myself trained all the CNAs on the correct use of the lift and we did all new check offs on everyone. The DON was asked how often skills check offs on lift transfers for the aide staff were performed. The DON stated, We do them on hire and then every three months. We did them again on the aides though at that time even if they had just been done. After we did the training, we .the ADON (Assistant Director of Nursing) and I .did monitoring to ensure that staff were doing the procedure correctly and that there were two people at all times. The DON was asked what happened with the CNA that did the transfer by themselves. The DON stated, He was ultimately terminated. He never worked again once he was suspended. The DON was asked if a report was sent to the state regarding the incident. The DON stated, No, we did not. The DON was asked if there had been any other incidents with lift transfers. The DON stated, No. The DON was asked if the Administrator was made aware of the incident. The DON stated, Yes. Immediately.
n. On 06/26/2024 at 5:00 PM, the form titled OLTC (Office of Long-Term Care) Witness Statement Form provided by the Director of Nurses dated 06/01/2024 at 4:30 PM and signed by CNA #6 on 06/03/2024 indicated, .I used the mechanical lift by myself to transfer (Resident #15) from [the] wheelchair to [the] bed. While [Resident #15] was in the air, [Resident] began to slip out of the lift pad from the lower body. It was too late to correct the problem, so I placed my arms underneath [Resident] and gradually lowered [Resident] to the ground to prevent a hard fall. Once [Resident] was on the ground, I asked if [Resident] if okay, and [Resident] responded that [Resident] was not hurt. I went and got (named LPN #11), the nurse and (named staff member), CNA to further assist me with getting [Resident] up from the ground. I believe the cause of this accident is that I did not tuck the lift pad enough under [Resident's] body to keep [Resident] from slipping out. I used the light blue lift pad with 6 strings .
o. On 06/26/2024 at 8:50 AM, the Assistant Director of Nursing (ADON) was asked if they were familiar with Resident #15's care. The ADON stated, Yes. The ADON was asked how much assistance [Resident] required with ADL's. The ADON stated, [Resident] is a total assist for transfer so two people. Dressing can be done by one person. The ADON was asked if they were aware of the incident that happened with the lift on June 1st. The ADON stated, Yes. The ADON was asked how they became aware of the incident. The ADON stated, It happened over the weekend, so I did not know about it until I came to work on Monday. Before the morning meeting I always look at the incident and accident reports and that is when I saw [Resident #15] had an incident with the lift. We saw [Resident] had an x-ray and it showed [Resident] had a fracture. The ADON was asked what was done at that point. The ADON stated, We spoke with the Resident and called the CNA. We did an in-service and he was put on leave after we had him write a statement. After we did the rest of the investigation the CNA was terminated. The ADON was asked if anything was done with the other staff members. The ADON stated, We did a lift in-service and lift check off's on all nursing staff. The ADON was asked how they ensured that staff were doing the lift transfers correctly. The ADON stated, The Director of Nursing and I monitored lift transfers for the next two weeks to make sure there were two people and that the staff did the lift transfer correctly. The ADON was asked if a report was done and sent into the state regarding the incident. The ADON stated, Not that I am aware of.
p. On 06/26/2024 at 9:30 AM, the Administrator was asked when they became aware that Resident #15 had fallen from the lift. The Administrator stated, It happened on 06/01/2024. I became aware of the incident on 06/03/2024. The Administrator was asked how they became aware of the incident. The Administrator stated, Resident #15 started complaining of pain and [Resident] had an x-ray done and I think [Resident's] tail bone was injured. The incident and accident report did not say anything about [Resident] complaining of pain and it did not say anything about him doing it (the transfer) by himself. The Administrator was asked what they did to investigate the incident. The Administrator stated, We did interviews. That is when we discovered that he did the transfer by himself. We did in-service for all staff. We did check off lists for lift transfers on staff and put a monitor in place to be sure staff were doing the transfers correctly. The employee was terminated for not following policy, but we checked first to make sure he had done the lift skills list prior to doing lift transfers and he had. The Administrator was asked if all lift transfers supposed to be done by two people. The Administrator stated, Yes. The Administrator was asked, When you discovered that the Resident had an injury from the fall, did you do a report and send it into the state? The Administrator stated, I did not. I didn't even think about it honestly.
q. On 06/26/2024 at 12:00 PM, the policy titled, Abuse, Neglect, and Maltreatment Investigation and Reporting provided by the Administrator indicated, .Policy: The facility will endeavor to protect Residents/Elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of Resident/Elder property .Identifying, Investigating, & Reporting: 1. Immediate reporting. All incidents of alleged or suspected Resident/Elder maltreatment, including neglect, or abuse and misappropriation of Resident/Elder property must be reported immediately to the Administrator . The administrator will shall conduct a preliminary review of the circumstanced to determine if an allegation of abuse or neglect exists. Following this determination, the Administrator or designee will initiate actions to report incidents as required by State law or regulation, including the Office of Long-Term Care as well as the registry and/or licensing board .Definitions: Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .

Based on observations, interviews, and record review, the facility failed to ensure residents who required extensive assistance with personal hygiene were regularly offered trimming or shaving of facial hair to maintain good grooming and hygiene for 3 (Resident #23, #49, and #53) of 3 sampled residents reviewed for activities of daily living (ADLs), and the facility failed to provide continent care every 2 hours for 1 (Resident #53) reviewed for continent care.
The findings are:
1. Review of the Medical Diagnosis portion of Resident #23 ' s electronic health record revealed diagnoses of legal blindness, obsessive compulsive disorder, and anxiety disorder.
a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/2024 documented Resident #23 scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS).
b. The Care Plan with revision date of 04/16/2024 indicated that Resident #23 (R #23) will be clean and well-groomed daily.
c. On 06/24/2024 at 10:21 AM, surveyor observed R#23 up in wheelchair with 1/4-inch white hair to chin and around mouth.
d. On 06/24/2024 at 1:44 PM, surveyor observed R#23 with 1/4-inch white facial hair to chin and around mouth.
e. On 06/25/2024 at 8:37 AM, surveyor observed R#23 with 1/4-inch white facial hair to chin and around mouth.
f. On 06/26/2024 at 8:41 AM, observed R#23 with 1/4-inch white facial hair to chin and around mouth.
g. Activities of daily living (ADL) sheet provided by facility did not indicate R#23 was shaved.
2. Review of the Medical Diagnosis portion of Resident #49 ' s electronic health record revealed diagnoses of dementia, Alzheimer disease, and anxiety disorder.
a. The Quarterly MDS with an ARD of 05/22/2024 documented Resident #49 scored 03 (00-07 indicates severely cognitively impaired) on the BIMS.
b. The Care Plan with revision date of 05/24/2024 indicated that R#49 will shower/bathe self: Requires supervision assist of 1 staff. If bathing refused, give him an option to return later for bath/shower.
c. On 06/24/2024 at 10:14 AM, surveyor observed R#49 in room with 1/4-inch white facial hair on both facial cheeks and chin.
d. On 06/24/2024 at 1:44 PM, surveyor observed R#49 with 1/4-inch white facial hair to both facial cheeks and chin.
e. On 06/25/2024 at 8:35 AM, surveyor observed R#49 with 1/4-inch white facial hair to both facial cheeks and chin.
f. An Activities of Daily Living (ADL) Sheet was provided by facility but did not indicate that R#49 was shaved.
3. Review of the Medical Diagnosis portion of Resident #53 ' s electronic health record revealed diagnoses of Alzheimer ' s disease, psoriasis, and dementia.
a. The Quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/25/2024 documented R#53 scored 99, (00-07 indicates severely impaired). Brief interview for mental status (BIMS).
b. The Care Plan with revision date of 05/30/2024 indicated that R#53 has an ADL self- care performance deficit due to cognitive decline and indicates R#53 will be clean and well-groomed daily. R#53 He requires partial assistance x 1-2 staff for bathing. If he refuses his bath, please return later to offer bath again.
c. On 06/24/2024 at 10:00 AM, surveyor observed R#53 with 1/2 inch black and white facial hair to both facial cheeks and chin.
d. On 06/24/2024 at 2:36 PM, surveyor observed R#53 with 1/2 inch black and white facial hair to both facial cheeks and chin.
e. On 06/24/2026 at 3:12 PM, Certified Nursing Assistant (CNA) #10 was asked when R#53 ' s brief was last changed. CNA #10 replied, Earlier this morning. CNA #10 was asked to observe R#53 and asked to describe what was seen. CNA #10 replied, Urine has soaked through the pajama bottoms and is on the back of the Resident ' s shirt, and the specialty chair cushion is soaked. CNA #10 was asked if R#53 should go this long without having a brief changed. CNA #10 stated, No they shouldn't, but it is just me back here and I didn't get time to change him earlier.
f. On 06/25/2024 at 8:37 AM, surveyor observed R#53 with 1/2 inch black and white hair to both facial cheeks and chin.
g. On 06/26/2024 at 8:41 AM, surveyor observed R#53 with 1/2 inch black and white hair to both facial cheeks and chin.
h. Activities of daily living (ADL) sheet provided by the facility did not indicate R#53 had been shaved.
i. On 06/24/2024 at 10:18 AM, CNA #7 was asked to describe the facility protocol for changing a resident. CNA #7 replied, Every 2 hours and depending on the resident, I may check them every hour. CNA #7 was asked why it is important to make sure residents are changed frequently. CNA #7 replied, Residents don't need to sit in soiled brief, smell and can cause skin breakdown. CNA #7 was asked how often a resident should be checked if they were unable to tell report needing changed. CNA #7 replied, Every 2 hours or even hourly if needed. CNA #7 was asked if it is appropriate for a resident to go an entire shift without having their brief changed. CNA #7 replied, Oh, my goodness no, it should be changed every 2 hours. CNA #7 was asked if a resident should be left in a brief that has soaked through residents clothing and has saturated the back of the resident's shirt and the cushion in the chair has so much urine it was liquid on the top of it. CNA #7 replied, No that means they have been in the same brief for all day at least and that can cause skin issues and odors. CNA #7 was asked how often the residents are showered. CNA #7 replied 3 times a week. How often are the residents shaved? CNA #7 replied 3 times a week. When is this done? CNA #7 replied, when they get their shower, they should be shaved. What is the facility protocol for residents who refuse their showers or to be shaved? CNA #7 replied, I go tell my nurse then I try to ask them again before the end of the shift. and then I document it in the kiosk.
j. On 06/26/2024 at 11:18 AM, CNA #9 was asked how often a resident's brief should be checked. CNA #9 replied, Every 2 hours. CNA #9 was asked why it is important to make sure that a resident gets changed regularly. CNA #9 replied, So they don't sit in a soiled brief. CNA #9 was asked if it is appropriate for a resident to go 6 to 8 hours without having their brief changed. CNA #9 replied, No, that should never happen. CNA #9 was asked if a resident should be left in a brief that has soaked through their pants and soaked the back of their shirt their seat cushion has a puddle of wet substance in it. CNA #9 replied, Never ever.
j. On 06/26/2024 at 10:36 AM, Licensed Practical Nurse (LPN)#8 was asked how often the residents get showered. LPN #8 replied, 3 times a week. LPN #8 was asked how often the residents get shaved. LPN #8 replied, They get shaved when they get showered and there are orders for them to be shaved on Sundays. LPN #8 was asked who is responsible for shaving the residents. LPN#8 replied, The CNA's do. LPN #8 was asked who is responsible for assuring that shaving is getting done. LPN#8 replied, Well, the nurse is, I guess. LPN #8 was asked why it is important to make sure a resident gets a bath and shaved. LPN#8 replied, They look and feel better, helps with spreading of germs. LPN #8 was asked for the facility ' s protocol when a resident refuses a shower or shave. LPN#8 replied, The CNA will tell me, then I go and attempt to get them to shower if no luck then I will call the family and document that I called them.
k. On 6/26/2024 at 10:50 AM, the Director of nursing (DON) was asked for the facility protocol for changing residents. The DON replied, Every 2 hours or more if needed. The DON was asked why it is important that residents are changed every 2 hours. The DON replied, Dignity and health. The DON was asked how they ensured that residents are being changed every 2 hours. The DON replied, I go round frequently in the building and check them. The DON was asked If a resident is unable to tell you they need changed, how often should they be checked. The DON replied, Every 2 hours and as needed. The DON was asked if it was appropriate for a resident to go 6 hours without having their brief changed. The DON replied, No ma'am, that is a dignity issue and can cause skin issues. The DON was asked if a resident should be left in a brief that has soaked through their pants and the back of their shirt and the cushion in the chair had a puddle of liquid on it. The DON replied, Absolutely not. The DON was asked how often the residents get showered. The DON replied, 3 times a week or more if needed or if they ask to be showered more often. The DON was asked how often the residents are shaved. The DON replied, When they receive a shower or if their hair grows fast more often if needed. The DON was asked who is responsible for making sure showers and shaving are done. The DON replied, The CNA's are. The DON was asked for the facility protocol if a resident refuses to be showered or shaved. The DON replied, The CNA will tell the nurse, then they are asked 3 times by different staff members and then if they still will not allow us to shower or shave them, we call the family and notify them. The DON was asked why it is important that a resident receives showers and is shaved. The DON replied, Good hygiene. The DON was asked if it is appropriate for a resident to have 1/4-1/2-inch facial hair. The DON replied, No, I don't.
4. On 06/26/2024 at 1:38 PM, the facility was asked for a policy on Activities of Daily Living (ADL). The surveyor was informed the facility did not have a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident assessment accurately reflected a level II Preadmission Screening and Resident Review (PASARR) evaluation for 1 (Resident #36) of 4 (Residents #30, #36, #38 and #43) sampled residents. The findings are:
Resident #36 had diagnoses of Anxiety Disorder, Bipolar Disorder and Delusional Disorders. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/23 documented the resident was not currently considered by the state Level II PASARR process to have serious mental illness and/or intellectual disability or a related condition.
1. On 07/25/23 at 11:50 AM, the Administrator provided documentation of a Level 1 PASARR dated 12/31/20.
2. On 07/26/23 at 9:28 AM, the Surveyor asked the Administrator for the Level II PASARR documentation. The Administrator replied, I'm still digging for it.
3. On 07/27/23 at 9:07 AM, the Surveyor called [State Designated Professional Associates] office and spoke with a representative regarding Resident #36's Level II PASARR evaluation. The [State Designated Professional Associates] representative informed the Surveyor that Resident #36 was approved for a Level II on 01/7/2021, but their office had not been notified with a date of admission to a long-term care facility. The Representative further explained that the [State Designated Professional Associates] office had only received documents from the hospital that had completed the application.
4. On 07/27/23 at 9:38 AM, the Surveyor asked the Administrator for any documentation for Resident #36's PASARR II from [State Designated Professional Associates]. The Administrator answered, I have talked to the MDS Coordinator, and they found where they had submitted the application paperwork to [State Designated Professional Associates] but haven't heard anything back yet. We even emailed them yesterday and we still haven't heard back from them. The Surveyor asked for a copy of the application paperwork the facility had submitted to [State Designated Professional Associates]. She answered, I will ask the MDS Coordinator for a copy and get it to you right away.
5. On 07/27/23 at 9:45 AM, the Administrator provided documentation including an admission record to the facility dated 03/03/2021 from a third party requesting items for Resident #36's Medicaid eligibility and the Evaluation of Medical Need Criteria (Form703).
6. On 07/27/23 at 11:35 AM The Surveyor asked the MDS Coordinator for a copy of approval letter for Level II PASARR from [State Designated Professional Associates] office. She stated We haven't gotten it yet. I've emailed and contacted [State Designated Professional Associates] office, but they are so backed up we haven't heard anything back yet.
7. On 07/27/23 at 3:42 PM, the Administrator provided a letter from [State Designated Professional Associates] dated 07/27/23 stating that Resident # 36 does not require specialized services.
8. On 07/28/23 at 8:50 AM, the Surveyor asked the MDS Coordinator to review section A1500 from the MDS dated [DATE]. The Surveyor asked the MDS Coordinator what it said. The MDS Coordinator replied, 0 [No]. The Surveyor asked the MDS Coordinator if Resident #36 had a Level II PASSAR. The MDS Coordinator replied, No, She's not a Level II PASSAR. The Surveyor asked the MDS Coordinator if the MDS was coded correctly for Level II PASSAR. The MDS Coordinator answered, Yes, because the Level II PASSAR letter wasn't here until yesterday so until that time it would have been no.
9. On 07/28/23 at 9:00 AM, the Surveyor asked the DON if it was important that the MDS be coded correctly. The DON answered, Yes. The Surveyor asked why it was important. The DON answered, So they can get care outside of the facility if they need it. The Surveyor asked the DON what could be the outcome if it's not coded correctly. The DON answered, They don't get special services and it could be a pause in their care.
11. The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's [NAME] Version 1.17.1 October 2019 documented, .The RAI process has multiple regulatory requirements . and require that (1) The Assessment reflects the resident's status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report into a resident's Care Plan to facilitate needed care for 1 (Resident #36) of 4 (Residents #30, #36, #38 and #43) sampled residents. The findings are:
Resident #36 had diagnoses of Anxiety Disorder, Bipolar Disorder and Delusional Disorders. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/09/23 documented the resident was not currently considered by the state Level II PASARR process to have serious mental illness and/or intellectual disability or a related condition.
1. The Comprehensive Care Plan did not address Resident #36's Level II PASARR determination, evaluation, and recommendations.
2. On 07/28/23 at 8:50 AM, the Surveyor asked the MDS Coordinator if the PASSAR Level II evaluation and recommendations were incorporated into the care plan. The MDS Coordinator answered, Yes. The Surveyor asked if there was a care plan specifically for the PASSAR Level II evaluation and determination. The MDS Coordinator answered, There is a specific one for those recommendations and that's what we've been working on. The Surveyor asked if the care plan should include the Level II PASARR determination and recommendations. The MDS Coordinator answered, Right. That's what we've been working on.
3. On 07/28/23 at 9:00 AM, the Surveyor asked the DON if it is important to care plan correctly for residents and why it was important. The DON answered, Yes, so that staff and families know how to care for the resident. The Surveyor asked if the facility had a policy for Care Planning. The DON answered, I'll have to get back with you on that.
5. The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's [NAME] Version 1.17.1 October 2019 documented, .The RAI process has multiple regulatory requirements . and require that (1) The Assessment reflects the resident's status . The document further states the services provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination and the evaluation report should be addressed in the plan of care.

Based on observation, record review and interview, the facility failed to ensure nail care was regularly provided to maintain good hygiene and prevent potential injuries or infections for 3 (Residents #13, #30 and #43) of 15 (Residents #2, #4, #8, #9, #13, #18, #30, #31, #36, #37, #38, #43, #44, #49 and #50) sampled residents who required assistance with nail care. This failed practice had the potential to affect 24 residents on the [NAME] Unit who were dependent for nail care as documented on a list provided by the Director of Nursing (DON) on 07/26/23 at 11:31 AM. The findings are:
1. Resident #13 had diagnoses of Alzheimer's Disease and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy.
a. A Care Plan with an initiated date of 12/06/21 and a revision date of 06/23/22 documented Resident #13 required maximum assistance with personal hygiene and staff were to keep his nails trimmed and filed.
b. On 07/25/23 at 9:41 AM, Resident #13 was lying in bed watching TV. His fingernails were approximately 1/4 inch past his fingertips and uneven. The fingernail on his left little finger was sharp and jagged.
c. On 07/25/23 at 3:35 PM, Resident #13 was lying in bed awake. His fingernails remained approximately 1/4 inch in length past his fingertips and uneven. The fingernail on his left little finger was sharp and jagged.
d. On 07/26/23 at 10:38 AM, Resident #13 was lying in bed awake. The Surveyor asked if he had a shower this week. Resident #13 answered, I really want a bath, not a shower. His fingernails remained approximately 1/4 inch past his fingertips and uneven. The fingernail on his left little finger was sharp and jagged. The Surveyor asked if he had his nails trimmed. Resident #13 answered, That little one needs to be trimmed. The Surveyor asked if he liked his nails that long. Resident #13 answered, No.
e. On 07/26/23 at 10:54 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #3 to Resident #13's room and asked her to describe Resident #13's fingernails. LPN #3 answered, They need to be trimmed, you got a sharp edge on the left pinky, it's really sharp. The Surveyor asked if there was anything else that she could describe more specifically. LPN #3 answered, They need to be cleaned and trimmed. This one really needs to be clipped. Resident #13 stated, That little one needs to be trimmed.
2. Resident #30 had a diagnosis of Neurocognitive Disorder with Lewy Bodies.
a. A Care Plan with an initiated date of 01/08/19 and revision date of 7/21/23 documented the nurse was to check Resident #30 ' s nail length and trim when bathed and to keep his nails trimmed and filed to minimize jagged edges.
b. On 07/25/23 at 8:15 AM, Resident #30 was lying in bed awake with her left hand resting on her left cheek. The fingernails on her left hand were various lengths with the index and 4th fingernails approximately 1/4 inch past her fingertips with a brown substance under them.
c. On 07/25/23 at 2:23 PM, Resident #30 was sitting up in a chair in her room. Resident #30's left hand was resting in her lap. The fingernails on her left hand were various lengths with the index and 4th fingernails approximately 1/4 inch past her fingertips with a medium to dark brown substance under them.
d. On 07/26/23 at 9:45 AM, Resident #30 was lying in bed awake. Resident #30's left hand was resting on her left cheek. The fingernails on her left hand were various lengths with the index and 4th fingernails approximately 1/4 inch past her fingertips with a medium to dark brown substance under them.
e. On 07/26/23 at 10:57 AM, Resident #30 was sitting up in a chair in her room. The Surveyor accompanied LPN #3 to Resident #30's room and asked LPN #3 to describe Resident #30's nails. LPN #3 answered, They are uneven, they need to be clipped and cleaned. The Surveyor asked how she would describe what is under Resident # 30's fingernails. LPN #3 answered, Brown discoloration, but not under all of them. The Surveyor asked who was responsible for nail care. LPN #3 answered, The CNA's but I'm supposed to check and make sure they are done. The Surveyor asked how often nails should be checked. LPN #3 stated, Every day. The Surveyor asked what could happen if nails are not checked and nail care is not done. LPN #3 answered, Infection or she could scratch herself or someone else.
3. Resident #43 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia.
a. A Care Plan with an initiated date of 12/24/21 and a revision date of 07/23/23 documented Resident #43's fingernails were to be cut and filed.
b. On 07/24/23 at 10:45 AM, Resident #43 was lying in bed asleep. Resident #43's fingernails were approximately 1/4 inch past his fingertips with a medium brown substance under them.
c. On 07/25/23 at 9:49 AM, Resident #43 was lying in bed his fingernails were approximately ¼ inch past his fingertips with medium and dark brown substance under them.
d. On 07/26/23 at 9:42 AM, Resident #43 was sitting up on the side of the bed in his room. His fingernails were approximately 1/4 inch past his fingertips with a medium and dark brown substance under them.
e. On 07/26/23 at 10:48 AM, the Surveyor accompanied LPN #3 into Resident #43's room where he was lying in bed awake. The Surveyor asked LPN #3 to look at Resident #43's fingernails and describe what she saw. LPN #3 answered, They are dirty. They need to be cleaned, but he dips [smokeless tobacco]. You can clean him, you can come in, and it will be dirty again. The Surveyor asked who was responsible for the resident's nail care. LPN #3 answered, The CNA's [Certified Nursing Assistants], but I'm supposed to check and make sure they do them. The Surveyor asked when residents should receive nail care. LPN #3 answered, As needed, anytime that you see it needs to be done. The Surveyor asked how often nails should be checked. LPN #3 answered, Every time they need it. We should be checking daily. The Surveyor asked what can happen if nail care isn't done for residents on a regular basis. LPN #3 answered, He could scratch himself and get an infection or put them in his mouth and get an infection.
f. On 07/26/23 at 11:02 AM, the Surveyor asked the Director of Nursing (DON) who was responsible for resident nail care. The DON answered, It depends. CNA's if the resident is not Diabetic. The Nurses if Diabetic. The Surveyor asked what could happen if residents are not given nail care as needed. The DON answered, Infections, or skin tears. The Surveyor asked how often residents should be checked to receive nail care. The DON answered, Every day.
g. On 07/26/23 at 11:31 AM, the DON informed the Surveyor that there was no facility policy for nail care.

Based on observation of the Medication Pass, record review, and interview, the facility failed to ensure medications were removed from the top of the medication cart and the cart was locked when outside of the nurse's line of sight, to prevent the potential for accidents. This failed practice had the potential to affect 10 residents who received medications from the East Hall medication cart as documented on a list provided by the Administrator on 07/26/23 at 9:22 AM. The findings are:
1. On 07/26/23 at 8:00 AM, Licensed Practical Nurse (LPN) #2 retrieved a resident's medications from the medication cart and placed them in a clear plastic medication cup. Without locking the medication cart, LPN #2 knocked on the resident's door and entered the room, leaving the medication cart outside of the LPN's field of vision.
2. On 07/26/23 at 8:05 AM, LPN #2 removed another resident's medication from the cart and placed them in a clear plastic medication cup. Without locking the medication cart, LPN #2 knocked on the door and entered the resident's room, which was outside of the nurse's line of sight. LPN #2 returned to the medication cart and retrieved an inhaler and another cup medication with water from the top of the cart. Without locking the cart, LPN #2 returned to the resident's room, leaving the cart outside of the nurse's line of sight.
3. On 07/26/23 at 8:20 AM, The Surveyor asked LPN #2 what could happen if you leave medications on top of the cart. She answered, Someone could get it and take it. The Surveyor asked what should you do when you leave the direct line of sight from your cart. She answered, I should lock the cart. The Surveyor asked what could happen if you don't lock the cart and leave the direct line of sight. She answered, Someone could get on it and take stuff.
4. On 07/26/23 at 9:15 AM, the Surveyor asked the Director of Nursing (DON) if medications should be on top of the medication cart when the cart is out of the nurse's line of sight. She answered, No. The Surveyor asked what could happen if medications are left on top of the medication cart when the cart is out of the nurse's line of sight. She answered, Someone could take them. The Surveyor asked what should a nurse do before leaving a cart out of the line of sight. She answered, Make sure there are no medications on top. Lock the cart. The Surveyor asked what could happen if a nurse left the cart unlocked and out of the line of sight. She answered, Anyone could get in the cart.
5. A facility policy titled, Specific Medication Administration Procedures, provided by the Administrator on 07/26/23 at 9:22 AM documented, .Security: All medication storage areas (carts .) are locked at all times unless in use and under the direct observation of the medication nurse .

Based on observation, record review and interview, the facility failed to ensure oxygen was administered at the prescribed rate for 2 (Residents #9 and #43) sampled residents and failed to follow the resident preference for no humidifier bottle for 1 (Resident #43) of 4 (Residents #8, #9, #18, #43) sampled residents who had a Physician's Order for oxygen. This failed practice had the potential to affect 11 residents who had a Physicians Orders for oxygen as documented on a list provided by the Administrator on 07/26/23 at 7:44 AM. The findings are:
a. On 07/24/23 at 2:06 PM, Resident #9 was in bed with eyes closed with oxygen at 2.5 liters per minute (LPM) via nasal cannula.
b. On 07/25/23 at 8:39 AM, Resident #9 had oxygen at 2.5 LPM via nasal cannula in use. Resident #9 stated, I do change the rate on occasion. I have not changed it lately. It's supposed to be set on 4 liters and I know it's not. I can tell when it's not right.
c. A Physicians Order dated 06/25/23 documented Resident #9 was to receive oxygen at 4 LPM via nasal cannula as needed.
d. A Care Plan with an initiated date of 05/12/13 documented Resident #9 was to receive oxygen at 4 LPM via NC as needed. The Care Plan did not address the resident adjusting her own settings.
e. On 07/27/23 at 8:10 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 if a resident has a physician's order for oxygen at 4 liters, what should the concentrator be set on. LPN #2 answered, It should be set on 4 liters. The Surveyor asked what could happen if the rate was set on 2.5 liters. LPN #2 answered, They wouldn't get enough oxygen.
f. On 07/27/23 at 8:20 AM, the Surveyor asked the Director of Nursing (DON) if a resident has a physician's order for oxygen at 4 liters what should the concentrator be set on. The DON answered, Four liters. The Surveyor asked what could happen if the rate was set on 2.5 liters. The DON answered, They wouldn't get enough oxygen.2. Resident #43 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with Hypoxia.
a. On 07/25/23 at 9:49 AM, Resident #43 was lying in bed receiving oxygen at 1.5 LPM via nasal cannula. A humidifier bottle dated 7/21 was attached to the concentrator.
b. On 07/25/23 at 1:41 PM, Resident #43 was sitting up on the side of the bed in his room receiving oxygen at 1.5 LPM via nasal cannula. A humidifier bottle dated 7/21 was attached to the concentrator.
c. A Physicians Order dated 07/20/23 documented Resident #43 was to receive oxygen at 2 LPM via NC as needed with no humidified sterile water per preference.
d. A Care Plan with an initiated date of 12/31/21 and was last revised on 04/20/23 documented Resident #43 was to receive oxygen administration at 2 LPM via NC and prefers NOT to have humidified water. Licensed nursing staff to verify oxygen liters every shift and as needed.
e. On 07/25/23 at 1:42 PM, the Surveyor asked LPN #4 what Resident #43's oxygen flow meter setting was. LPN #4 answered, It's supposed to be set on 2 liters, but it looks like 1.5. The Surveyor asked who was responsible for checking oxygen flow meter settings. LPN #4 answered, The nurses. The Surveyor asked how often flow meter settings should be checked. LPN #4 answered, At least once daily. The Surveyor asked what could happen if flow rates are not checked and set at the correct flow rate that has been ordered. LPN #4 answered, He has COPD so his oxygen can just drop.
3. On 07/25/23 at 1:50 PM, the Surveyor asked the DON who was responsible for checking oxygen flow meter rates to make sure they were on the correct setting as ordered. The DON answered, Nurses are responsible. The Surveyor asked what could happen if flow meters were not set at the correct ordered rate. The DON answered, Possibly some type of harm could happen. The Surveyor asked when flow rates should be checked. The DON answered, Anytime a nurse or Certified Nursing Assistant (CNA) enters a room. A CNA can report it to the nurse if the setting isn't right. The Surveyor asked how often flow rates should be checked. The DON answered, Every day, 2 to 3 times daily.
4. A facility policy titled, Oxygen Administration, provided by the Administrator on 07/26/23 at 7:44 AM documented, .To administer oxygen safely to the Resident/Elder when insufficient oxygen is being carried by the blood to the tissues . Procedure Humidifiers may or may not be used for low-flow oxygen administration . 1. Check physician's order for liter flow and method of administration . 8.adjust liter flow as ordered .

Based on observation, interview and record review, the facility failed to ensure unauthorized personnel were monitored by a licensed nurse when in 1 (Nurses Station) of 2 (Nurses Station and Light House Unit) Medication Rooms. The findings are:
1. On 07/24/23 at 2:10 PM, the Maintenance Director and an outside vendor approached the Nurses Station and asked Licensed Practical Nurse (LPN) #5 to let them into the Medication Room for repairs. LPN #5 opened the door allowing outside vendor into the medication room and returned to her chair facing away from the medication room. The Maintenance Director was speaking through the door to the repairman and then walked over and propped himself in the open-door frame. The Surveyor did not observe LPN #5 checking on activity in the medication room.
2. On 07/24/23 at 2:15 PM, during an interview with the Maintenance Director and the outside vendor, the outside vendor said, I am downloading the database to the computer for the call light system. The Maintenance Director said, I do not have keys to the medication room, and we were making repairs.
3. On 07/24/23 at 9:44 AM, the Surveyor asked LPN #5 what medications were in the medication room. LPN #5 said, Just some over the counter medications, insulin and a locked narcotic box. The Surveyor asked why should you limit access to the medication room, who is responsible when you let someone into the medication room, and does maintenance have a key. LPN #5 said, There are medications in there. LPN #5 asked other staff if maintenance had a key to the medication room, then said, No, and I guess I am responsible if I let someone into the medication room. I didn't just walk off and leave them in there.
4. On 07/26/23 at 1:25 PM, the Surveyor asked the Director of Nursing (DON) what the procedure or process was for allowing repairmen into the medication room to make repairs. The DON said the nurse that allows the repairman into the medication room should stay in there with them an keep an eye on them. It is not appropriate for a nurse to let someone into the medication room and sit in a chair with their back to the medication room. They could pocket a medication.
5. On 07/28/23 at 8:15 AM, the DON said, Everyone in the building can get medications out of the main Medication Room [Nurses Station].
6. A facility policy titled, Medication Storage in the Facility, provided by the Administrator on 07/26/23 at8:15 AM documented, .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are
locked when not attended by persons with authorized access .

Based on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets, and food was prepared appropriately to meet the needs of the residents to conserve nutritive value, flavor, and encourage adequate nutritional intake for 1 of 1 meal observed. This failed practice had the ability to affect 5 residents who have a Physician's Order for a pureed diet according to a list provided by the Dietary Supervisor on 07/27/23 at 11:41 AM. The findings are:
1. On 07/25/23 at 11:10 AM, Dietary Employee (DE) #1 placed 5 servings of baked chicken breasts with barbeque sauce into a blender and pureed. At 11:11 AM, she poured the pureed meat into a pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed chicken was gritty and not smooth.
2. On 07/25/23 at 11:18 AM, DE #1 used a spatula to place 5 servings of potato salad into a blender, added milk and pureed. At 11:20 AM, she poured the pureed potato salad into a pan, covered it with foil and placed it in the refrigerator to be served to the residents on pureed diets. The consistency of the pureed potato salad was lumpy, not smooth and had pieces of potato visible in the mixture.
3. On 07/25/23 at 11:35 AM, DE #1 placed 5 servings of rolls into a blender, added whole milk and pureed. At 11:37 AM, she poured the pureed dinner rolls into a pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed dinner rolls was lumpy and not smooth.
4. On 07/25/23 at 12:04 PM, a pan of pureed baked beans was on the steam table. The consistency of the pureed baked beans was runny.
5. On 07/25/23 at 1:00 PM, the Surveyor asked DE #2 to describe the consistency of the pureed food served to the residents on pureed diets. She stated, Pureed potato salad was chunky and not smooth. Pureed beans were runny and has lumps and pureed chicken was gritty and was not smooth and pureed bread was thick and has lumps.

Based on observation, record review and interview, the facility failed to ensure freezer temperature was maintained at 0 degrees Fahrenheit or below and all foods were frozen solid to prevent the potential for food bore illness; foods stored in the freezer were sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 30 residents who received meals from the kitchen (total census: 57) as documented on a list provided by Dietary Supervisor. The findings are:
1. On 07/24/23 at 10:10 AM, in the freezer was a box of Orange Cream Bars and a box of frozen orange/cherry/grape popsicles that were opened and undated.
2. On 07/24/23 at 10:10 AM, the Dietary Manager (DM) said, They had a party or activity the other day. That is not supposed to be in the freezer without a date on it. The Assistant DM said, Sometimes staff puts things in the refrigerator or freezer, and they forget to put a date, but we know when these were opened.
3. On 07/25/23 at 10:41 PM, the following observations were made in the freezer in the kitchen:
a. The temperature in the freezer was 27 degrees Fahrenheit.
b. A ziplock bag of grapes dated 6/16/23.
c. A ziplock bag of liquid butter milk pie dated 6/14/23 was not frozen.
d. A box 6 ice cream sandwiches was melted.
4. On 07/25/23 at 10:54 AM, Dietary Employee (DE) #1 removed a packet of ham and placed it on the counter. She then used a rag to wipe off the counter. She removed gloves from the glove box and placed them on her hands. She opened the packet of ham, then untied the bread bag. Without changing gloves and washing her hands, she removed slices of bread from the bag and placed them on top of the bread bag. She then removed slices of ham and placed them on the bread to be served to the residents who requested a ham sandwich with their lunch meal. At 10:56 AM, DE #1, still wearing the same gloves removed a bag of bread from the bread rack and placed it on the counter. She picked up a container of peanut butter and placed it on the counter. She went to the Storage Room, removed packets of grape jelly, and placed them on the counter, contaminating her gloved hands. Without changing gloves and washing her hands, she untied the bag of bread, removed slices of bread placed then on the plate and spread peanut butter and grape jelly on the bread to be served to the resident who requested a peanut butter and jelly sandwich.
5. On 07/25/23 at 11:13 AM, DE #1 opened the refrigerator and removed a container of potato salad and placed it on the counter. She removed a gallon of whole milk from the refrigerator and placed it on the counter. She used a rag to wipe off the counter. At 11:16 AM, she picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents on pureed diets.
6. On 07/25/23 at 11: 25 AM, DE #1 picked up the water hose with her bare hand, used it to spray leftover food from dishes, contaminating her hands. She placed the dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents on pureed diets for lunch. The Surveyor asked DE #1 what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands.
7. On 07/25/23 at 11:40 AM, on a shelf in the Storage Room were 3 containers of corn starch with an expiration date of 7/19/2023.
8. On 07/25/23 at 12:04 PM, the temperature of pureed bread with milk when checked on the steam table by DE #1 was 95 degrees Fahrenheit.
9. On 07/26/23 at 10:44 AM, DE #1 picked up the water hose with her bare hand, used it to spray leftover food from dishes, contaminating her hands. She placed the dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents on pureed diets for lunch.
10. On 07/26/23 at 1:25 PM, the Surveyor asked the Director of Nursing (DON) if she expected staff to follow dietary procedures when they store resident food items in the kitchen. During the interview the DON said, Yes, I absolutely expect them to follow procedures. It causes a risk for cross contamination.
11. On 07/26/23 at 3:00 PM, the Administrator said, We do not have a food storage policy.
12. The facility policy titled, Hand Washing and Glove Usage in Food Service, provided by the Dietary Supervisor on 07/27/23 at 11:41 AM documented, When food handlers must wash their hands: ∙ starting work . ∙ touching anything else such as dirty equipment and work surfaces or cloths .

Based on observation and interview, the facility failed to ensure the call light system was maintained in proper working order to assure residents could call for assistance when needed for 2 (Residents #23 and #51) of 6 (Residents #23, #38, #49, #50, #51 and #259) sampled residents who resided on the Light House Unit. The findings are:
1. On 07/24/23 at 11:00 AM, the call light above the door of Resident #23 and #51's room was flashing continuously. Certified Nursing Assistant (CNA) #2 said, The call light is broken in the bathroom. The parts are on order. The Surveyor asked how Residents #23 and #51 call for help from the bathroom. CNA #2 said, If the resident pulls the cord in the bathroom, it will still alarm. Only the light is not functioning. No response was given when CNA #2 was asked how long the call light had been malfunctioning.
2. On 07/25/23 at 1:43 PM, the call light above the door of Resident #23 and #51's room was no longer flashing. The Surveyor entered the bathroom and pulled the call light cord and observed the red light flashing in the hallway above the door, but no alarm was heard.
3. On 07/25/23 at 2:00 PM, Resident #51 was washing her hands in the bathroom with the door held open with a wheelchair. The call light remained lit up above the door.
4. On 07/25/23 at 2:16 PM, CNA #2 responded to the call light. The Surveyor asked if the call light had been fixed, and if he saw the bathroom light flashing outside the door or if he heard the alarm between 1:43 PM and 2:16 PM. CNA #2 said, I never heard an alarm. [Resident #23] and [Resident #51] use the bathroom.
5. On 07/25/23 at 2:20 PM, the Surveyor asked the Director of Nursing (DON) what could be the consequences of Resident #23 and Resident #51 not having a working call light in the bathroom. The DON said, There are bad consequences, and I am paging the Maintenance Director right now. The Surveyor asked for a call light policy, and a purchase order showing where parts had been ordered.
6. On 07/25/23 at 2:22 PM, Licensed Practical Nurse (LPN) #1 said, I saw maintenance working on the alarm earlier today. I cannot hear well, so he probably would not ask me to test the alarm for him. A resident could go to the bathroom unattended during the night. It could be bad.
7. On 07/25/23 at 2:28 PM, the Maintenance Director said, The volume was turned off. It was supposed to be turned off because, the light was flashing continuously, and the alarm was driving everyone crazy. The Surveyor asked if administration and staff were aware the volume was turned off. He said, The nurses and CNAs knew.
8. On 07/26/23 at 9:44 AM, the Surveyor pulled the bathroom call light cord, flashing red light above the outer door, and the alarm sounded. CNA #3 said, I think they fixed the call light.
9. On 07/26/23 at 3:00 PM, The DON said, We do not have a call light policy. We do not have a purchase order because we have not been billed yet. I do not know the date or time, but we called the repairman with [Company] and asked for parts to fix the call light.